Embedding Sustainable Second-Order Problem-Solving Behaviour in Hospital Nurses via Simulation-Based Education

To identify strategies for fostering sustainable second-order problem-solving behaviours among hospital nurses. The study evaluates the impact of an emotive audio narrative stimulus and examines barriers and enablers in a simulated clinical environment.

Mixed-methods observational study.

Eighty hospital nurses were randomly assigned to either an emotive patient-safety audio narrative or a control condition before completing two simulated tasks embedded with system-level operational failures. Real-time behaviours were coded; quantitative data were analysed using chi-square tests and logistic regression. Semi-structured interviews elicited actionable recommendations for practice implementation.

Despite widespread detection of operational failures (96.2%), second-order problem-solving behaviours remained infrequent across both tasks (overall 21.9%). While the narrative triggered strong emotional responses, it did not increase escalation or formal reporting behaviours. Nurses identified normalization of deviance, time pressure and absence of feedback loops as structural barriers to problem-solving agency. Conversely, team debriefings, audit-feedback mechanisms and simulation-based failure training were cited as enablers.

Emotional triggers raise awareness but do not bridge the awareness-action gap. Sustainable second-order problem-solving requires organizational strategies-such as team reflection, audit feedback and simulation training-that empower nurses and strengthen system learning.

To reduce patient harm from unresolved operational failures, healthcare organizations must promote failure awareness alongside redesigning work systems that facilitate escalation, interdisciplinary collaboration and empower nurses to improve flawed processes sustainably.

GRAMMS checklist.

Not applicable.