Department of Health Sciences, University of Leicester, Leicester, UK.
Cumming School of Medicine, University of Calgary, Calgary, Canada.
Soc Sci Med. 2017 Nov;193:8-15. doi: 10.1016/j.socscimed.2017.09.036. Epub 2017 Sep 22.
Much policy focus has been afforded to the role of "whistleblowers" in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included "quiet words", bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. But they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.
政策制定者非常重视“举报者”在提高医疗保健环境中患者护理质量和安全性方面的作用。然而，大多数人员有机会发现并处理这些问题，更可能是在日常工作中更上游的日常平凡互动中。通过对 19 个英国重症监护病房（ICU）的 900 多个小时的民族志观察和 98 次访谈的定性数据分析，我们研究了人员如何表达对患者安全或不良实践的关注。我们观察到，在病房的日常运作中，存在大量的低水平社会控制，经常使用挑战和制裁措施来防止或解决错误和规范违反问题。当患者面临直接风险时，会采取先发制人的措施进行干预，包括温和提醒、使用幽默和尖锐的语言等策略。纠正性干预措施包括教育和基于证据的论证，而当出现安全漏洞时，会采取制裁措施，包括“私下谈话”、调侃、公开曝光或羞辱、责骂和严厉斥责。这些形式的社会控制通常能有效地维持安全实践。但它们并非始终有效，有时还会强化不符合患者安全和高质量医疗保健目标的规范和特殊行为。此外，在跨专业边界或等级制度提出挑战有时也会出现问题。我们的研究结果表明，将正式报告或沟通培训作为表达安全关注的解决方案是过于简单化的；需要更深入地理解社会控制。
