Discussion
This study aimed to describe healthcare professionals’ experiences with the GC method in a PACU setting 3 years post implementation, including the COVID-19 pandemic period. Our results showed that the GC method continued to be actively used but required revitalisation. Although an open communication about the PSIs was facilitated, a more interprofessional collaboration was desired. The reluctance to report PSI was increasing; PSI reporting was downscaled due to the pandemic and a desire to share more of what went well.
The healthcare professionals found it rewarding to discuss the patient safety issues in the QI meetings, which supports the findings that from their perspectives, the opportunity to discuss patient safety is the most important part of the GC method.16 Interprofessional attendance, although difficult to achieve, enhanced learning. By discussing the PSIs interprofessionally across the perioperative care pathways, they obtained different viewpoints that stimulated reflection and improved practice. They became better acquainted with each other’s work tasks and resolved misunderstandings, thereby improving the shared understanding.27
The findings add to previous research that creating spaces for reflection and improved teamwork may contribute to increased staff well-being and patient outcome.28 Interprofessional focus and effective communication are identified as contextual enablers for effective team interventions.29 Furthermore, the importance of dialogue for developing a collaborative culture and mutual understanding are highlighted as critical for QI.30 31 We argue that the GC method promotes resilience, because it facilitates the collaborative learning processes across various levels that comprise the prerequisites for resilience.32 33 However, the hospital’s reorganisation during the COVID-19 pandemic resulted in many new challenges and many new inexperienced staff members, so the GC method was downscaled; the perceived care quality was reduced, indicating decreased resilience. Although not causal, the findings are interesting. Additional research on how to accommodate an interprofessional collaborative learning in hospitals is needed.
The anaesthesiologist had ‘untapped potential’ to propose QI work and lead the QI meetings. Although anaesthesiologists’ attendance was particularly desired in the QI meetings; even if they wanted to participate, they could rarely attend, which is consistent with recent studies.34 35 The anaesthesiologists were discouraged by the discussions on topics that were mainly nursing-related and by not observing visible improvements. Historically, physicians have found it difficult to engage in QI work because of an insufficient improvement culture and the inconvenience of the day-time QI work, among other things.36 It is suggested that the physicians’ nature of work limits the use of the GC method, and that the GC method’s does not affect their patient safety culture.16 17 Due to the traditional culture of surgeons not participating much in the PACUs’ daily life, it was not even considered feasible to include surgeons in the QI meetings. This may be an area for further exploration. Physician involvement enables effective team interventions; therefore, more innovative ways to include the physicians in the QI work is necessary.29 37 38
Insufficient visible improvements increased the PACU nurses’ reluctance to report; they discussed the need for establishing a QI board and focusing on one task at the time. Contrarily, the GC method caused increased improvements in a Swedish hospital, where the QI boards were actively used.17 Often data collection happens at the expense of using it for improvement.39 We propose that a QI tool should be more explicitly linked to the GC method and that the healthcare professionals should be educated and assisted in using this.7 40 41 A prerequisite for effective team interventions is that something can be done about the problems discovered, that is, the intervention’s credibility.29 We suggest agreeing on what is feasible to enhance within the PACU-setting, to avoid any discouragement. Furthermore, the managers should initiate, delegate, mandate the QI work, and follow up on the results. This has been identified as necessary to support the GC method.16
Reporting issues that needed resolution outside the PACU aroused negative comments from both PACU nurses and other professionals. This resulted in a culture where ‘not all incidents need to be reported’. A totally green cross can signal insufficient trust in each other.16 However, it is important to capture first-hand information from clinicians close to where the incident occurred.42 Issues that need resolution outside the PACU may profit from being discussed in the QI meetings and being reported in the IRS as suggestions for improvements. This could mitigate the weaponisation of incident reporting and be an incentive for broader participation.
Additionally, during the COVID-19 pandemic, PACU nurses did not report the PSIs out of concern for the relocated staff, who more easily made mistakes due to an inadequate routine. This can be understood as a self-limiting cascade.43 Optimising the healthcare professionals’ emotional experience is as significant as enhancing performance for avoiding the PSIs.43 44 This may be done by focusing on the positive deviants, as requested by this study’s healthcare professionals, the psychological safety at work and a systems approach to improving patient safety.7 45 46 Further research is needed to determine if the GC method collectively with a focus on positive performance can improve learning and the healthcare professionals’ emotional experience simultaneously.
Strengths and limitations
This longitudinal study provides an in-depth understanding of the healthcare professionals’ experiences of the GC method implementation; it offers relevant knowledge for other similar healthcare settings. However, some limitations should be noted. As nurses make up most of the staff in this PACU-setting, the focus is more on the nurses’ experiences compared with that of other professionals. The FG interviews might have deterred the participants from speaking openly. Furthermore, although the sample reflected the true ages and occupations of the users’ of the GC method, the limited number of male informants may have influenced the results by omission of their experiences. Healthcare professionals who did not participate in the FG interviews may have disliked the GC method, or they simply did not engage with it. However, exploring this goes beyond the scope of this study.