The Field Guide › Paper
Observational study of 26 nurses across nine hospitals, documenting how frontline workers routinely encountered operational failures — missing supplies, wrong information, broken equipment — and responded with first-order problem-solving (workarounds) rather than second-order learning (fixing the system). The structural inhibitors were time pressure, lack of psychological safety to escalate, and a management culture that rewarded individual heroics over system improvement. One of the most cited papers connecting PS to organisational learning in healthcare, and a direct empirical ancestor of PSIRF's shift from individual incident investigation to systemic learning.