The main findings provide a measure of the extent to which healthcare staff trained in RCA actually participated in subsequent investigations in the workplace. It is clear in this study that a majority has yet to do so with the greatest proportion of trained but inexperienced staff being based out-with the acute care sector. This is a concern given the resources committed to RCA training and the implications in terms of lost opportunities to improve patient safety and organizational learning, as well as the potentially discouraging impact on staff morale and attitudes. Previous research has reported concerns from RCA-trained staff that they may lack ‘personal control’ over participation in subsequent incident investigations which is likely, for many, to be a decision for local managers in their organisations and heavily dependent upon workload priorities [16–18, 20].
The ‘failure of work schedules’ to provide staff with protected time for RCA investigations was cited as the major difficulty by Braithwaite et al. . Edmonson (2004) suggests that leadership has a critical role in this regard in developing an environment of ‘psychological safety’ to encourage a greater willingness for transparency, questioning and sharing of concerns, and also in ‘supporting and empowering’ team learning across the organisation . Nicoloni et al. (2011) also suggest that leaders need to openly endorse RCA (or a variant) as an improvement method and the staff who have been trained to implement it . Without this type of approach then it is possible that local leaders will continue to forfeit opportunities to learn from RCA by occasionally or even frequently assigning a low priority to investigations or blocking participation in the process by trained staff.
Most respondents with RCA experience report multiple exposures to incident investigations. Similar to previous research [9–11, 16–19, 21, 22], a clear majority also report that their recommendations to make care safer are at least partly or fully implemented in their organisations, although determining how effective these potential improvements actually were was not a study aim but nonetheless should be a subject of further research given the limited evidence.
It is possible, perhaps even likely, that RCA investigators will be subject to some form of ‘criticism’ or ‘conflict’ from ‘powerful’ individuals or groups, or those with vested interests, within a healthcare organisation . It should also be remembered that in essence RCA involves healthcare professionals ‘not just scrutinizing each other but scrutinizing each others’ errors’. Many respondents encountered a range of organizational barriers to conducting RCA investigations similar to those reported previously . A few significant differences were apparent, however, with respondents in our study more likely to adopt a post-training RCA leadership role and also report less difficulty with some of the organizational barriers outlined. One interpretation is that the differences indirectly hint at a slightly more positive organizational safety culture being reported in our study, which is possible given the large-scale national initiatives to improve patient safety in the Scottish health service over recent years . However a more likely explanation is that the Australian study  is more than five years older and so associated cultural factors such as the prevailing attitudes and behaviours towards RCA investigations and patient safety in general may have improved over time to match those in our study findings – not that the results reported here offer some type of benchmark.
Similar to other studies, our RCA-experienced respondents were generally positive about the training they received and the cost-benefits of this investigation technique in terms of the ‘advancement of safety in healthcare’ and being a ‘good use of staff time and resources’ [16, 18, 20]. Respondents displayed mixed views - supported by seemingly logical arguments on both sides - on whether non-clinical colleagues and patients should have a role in incident investigations. However, many risk managers are non-clinical and this does not seem to have been a barrier to them leading on RCA training or advising on, or participating in, related investigations. The involvement of patients and relatives in these investigations is strongly encouraged in national policy [12–15], but the reality is that this appears to be a rarity perhaps because of the many sensitivities and difficulties outlined by our respondents, even if many were positive about the prospect.
Most respondents had a sufficient ‘understanding/confidence’ in conducting RCA and indicated that their work practices and reporting of errors have changed since being trained. A follow-up training session and the use of confidential peer feedback on RCA reports were viewed as potentially beneficial educational interventions, suggesting that many respondents may have a level of insight into the need for further learning around the often complex and problematic issues involved in applying the technique. The inconsistent quality of RCA attempts and the need for additional post-training support has been noted previously [17, 19]. The study by Wallace et al. (2009) reports high levels of satisfaction with RCA training, but low levels of correct responses when study participants were subsequently tested on their acquired knowledge of RCA using pre-designed vignettes .
Overall the evidence demonstrates that the standard of incident analysis and report writing is frequently variable [7, 16, 17, 19]. Given that the written report is a key proxy for the quality of the investigation undertaken then it is likely that some type of educational feedback intervention is necessary. Offering developmental support and mentorship, particularly to guide less experienced staff confronting and dealing with some of the aforementioned barriers to RCA, and when writing comprehensive unambiguous reports that offer realistic recommendations for improvement (either during training or after training or both), arguably makes sense in closing this educational gap. Taken together the combined evidence from this and other studies cited may point to an organisational learning need for continuous development and feedback for RCA-trained staff, or at least in the short-term [7, 16, 18, 20].
The study findings are not generalisable beyond the RCA training practices in this single health authority. But given the degree of congruence with Braithwaite et al.  and specific findings in previous research [9–11, 16, 17, 19, 21, 22], it is possible that similar issues would be uncovered in other regions and countries with comparable training arrangements, particularly with regard to the significant proportion of trained staff who do not gain any post-training investigation experience. A key consideration, therefore, will be the cost-benefits involved in taking healthcare staff out of frontline clinical duties to provide them with RCA training and then failing to utilize or support them in the post-training phase.
One potential option is to better select staff for more intensive RCA training, while training less staff numbers so that organisations develop a strong core grouping with the requisite experience, expertise and leadership skills - augmented by the provision of continuous developmental support. Potentially this offers a number of advantages over current arrangements. A better trained and dedicated RCA staff group which is afforded greater opportunities to gain experience may retain and strengthen their analytical knowledge and skills and also benefit from shared peer-to-peer learning – leading to more meaningful and effective incident investigations. In developing this ‘expert community of practice’, these individuals (or as a group) may also become better equipped to highlight and challenge existing institutional barriers to engaging in and learning from incident investigation and start to make progress in developing a more positive safety culture. However, this will require organisations – and, perhaps more specifically, local healthcare leaders - to give greater priority to investigations and provide some element of protected time for these staff to continue to develop related experience and expertise when necessary. In some cases this may require a paradigm shift in local middle management and executive level attitudes and behaviours towards improving patient safety that goes beyond purely rhetorical endorsement of this concept as the single most important healthcare priority. A recent high profile media exposure of inconsistencies around serious patient safety incident investigation practices across NHSiS may have some impact in this regard .
Strengths and limitations
Our survey generated a moderate response rate although respondent numbers were still significantly large enough for useful statistical inferences and adding to our knowledge and understanding in this topic area. A number of limitations are associated with this type of descriptive cross sectional survey. It is likely that a proportion of non-respondents will have changed posts and therefore email addresses since RCA training and so could not be tracked using the online survey system. There may have been response bias as we were unable to compare and explore the characteristics of responders and non-responders as well as recall bias given the time lag between training and completing the questionnaire experienced by some. Also, self-report data may not be fully reliable as there is no means of independent verification. Caution should therefore be exercised when extrapolating these findings for more general purposes.