Aveling Emma-Louise, Parker Michael, Dixon-Woods Mary
Department of health Sciences, University of Leicester, UK.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, USA.
Sociol Health Illn. 2016 Feb;38(2):216-32. doi: 10.1111/1467-9566.12370. Epub 2015 Nov 4.
An enduring debate concerns how responsibility for patient safety should be distributed between organisational systems and individual professionals. Though rule-based, calculus-like approaches intended to support a 'just culture' have become popular, they perpetuate an asocial and atomised account. In this article, we use insights from practice theory--which sees organisational phenomena as accomplished in everyday actions, with individual agency and structural conditions as a mutually constitutive, dynamic duality--along with contributions from the political science and ethics literature as a starting point for analysis. Presenting ethnographic data from five hospitals, three in one high-income country and two in low-income countries, we offer an empirically informed, normative rethinking of the role of personal accountability, identifying the collective nature of the healthcare enterprise and the extent to which patient safety depends on contributions from many hands. We show that moral responsibility for actions and behaviours is an irreducible element of professional practice, but that individuals are not somehow 'outside' and separate from 'systems': they create, modify and are subject to the social forces that are an inescapable feature of any organisational system; each element acts on the other. Our work illustrates starkly the structuring effects of the broader institutional and socioeconomic context on opportunities to 'be good'. These findings imply that one of the key responsibilities of organisations and wider institutions in relation to patient safety is the fostering of the conditions of moral community.
一场持久的争论涉及患者安全责任应如何在组织系统和个体专业人员之间分配。尽管旨在支持“公正文化”的基于规则、类似计算的方法已变得流行，但它们延续了一种非社会和原子化的观点。在本文中，我们借鉴实践理论的见解（该理论将组织现象视为在日常行动中实现的，个体能动性和结构条件是相互构成的动态二元性），并以政治学和伦理学文献的贡献为分析起点。我们展示了来自五家医院的人种志数据，其中三家位于一个高收入国家，两家位于低收入国家，我们对个人问责制的作用进行了基于实证的规范性反思，确定了医疗企业的集体性质以及患者安全在多大程度上依赖于众多人员的贡献。我们表明，对行为和举止的道德责任是专业实践中不可简化的要素，但个体并非以某种方式“置身于”“系统之外且与之分离”：他们创造、改变并受制于作为任何组织系统不可避免特征的社会力量；每个要素都对另一个要素产生作用。我们的研究鲜明地说明了更广泛的制度和社会经济背景对“做好事”机会的构建作用。这些发现意味着，组织和更广泛机构在患者安全方面的关键责任之一是营造道德共同体的条件。
