Aim To establish a middle‐range theory of organizational learning in hospitals. Design A realist review of the literature, conducted according to established standards for realist and meta‐narrative evidence syntheses. Middle‐range theory development was performed according to Smith and Liehr's recommendations. Data sources Two comprehensive scientific databases and six discipline‐focused databases spanning health care, life sciences, business, sociology, and psychology were searched from inception to 12 May 2016. Review methods Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms, and outcomes associated with organizational learning. Results The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes. Conclusion This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals, and provides a middle‐range theory of organizational learning in hospitals. Impact This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle‐range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning.
Introduction: Providing high-quality care to every patient is challenging, particularly in critical care units (CCUs). However, this standard can be achieved through organizational learning. Unfortunately, the process of organizational learning in CCUs is not well understood. Objective: The objective of this study is to describe the developmental progression of a cardiac intensive care unit (CICU) to reach its current state of reliably excellent clinical performance. Methods: The method selected for this study was a learning history. A total of 43 individuals with experience working on the CICU participated in small group interviews. Participants included nurses, surgeons, unit clerks, administrators, nursing assistants, a pharmacist, a respiratory therapist, and an administrative assistant. Relevant artifacts, including unit performance data, were also gathered to complement interview data. Results: The CICU progressed through 4 distinct developmental stages to reach its current state. The CICU’s early development involved establishing psychological safety on the unit, which prepared the unit for increased accountability, improved performance, and the pursuit of reliability. Discussion/Conclusion: The findings validate the relationship between psychological safety and organizational learning, offer insight into how CCUs become high-reliability organizations, and provide clinical leaders with guidance for achieving high reliability in their organizations. The findings also help validate the American Association of Critical-Care Nurses position that a healthy work environment is essential to achieving clinical excellence. Critical care unit teams should use these findings as a framework for collective reflection and planning to achieve their desired future. Further research is needed to validate the applicability of these findings and to continue building the evidence base for organizational learning in hospital units.
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