Learning from our mistakes
Dee Gray looks at developing learning cultures in organisations that need to learn from workplace errors
The costs of workplace injury within the European Union are estimated to amount to around €20bn. The UK's Health and Safety Executive has estimated that 500,000 of those injured through workplace errors have also suffered 'new' work-related illness such as stress, depression and anxiety1.
The link between workplace stress and the occurrence of error is well-established, as is an understanding that we do not immediately learn from error. This is especially true where there is insufficient time for us to reflect on what has happened, and indicates two things: that, as a result of being involved in a workplace error, there is the distinct possibility that we will also experience stress and that, if we experience stress, we are more likely to be involved in a workplace error2. This has been demonstrated through research on brain plasticity and learning, which shows stress has the potential to alter both the structure of the brain and how we perform.
When we learn something new, we need to find ways to utilise this to ensure others can benefit from our newly acquired knowledge. To ensure knowledge is accurate, we also need to engage in discussion and reflection. To increase the impact of learning on ourselves and the places in which we work, we need to find formal ways to share what we have learned.
Enhancing our professional performance may be achieved by encouraging a mind-set and practice that comes from a positive starting point3. This may be facilitated through developing skills that help to negotiate complex changing environments by identifying and maintaining a strong locus of control. Having a strong locus or 'core' of who we are means being able to identify with the 'core' of your organisation and finding within it a safe space in which to learn.
This 'safe space' does not appear out of thin air; having one requires educational leadership within the organisation, a leadership that has sufficient power, influence and authority to influence change. There also has to be a supportive infrastructure to ensure 'psychological safety' for staff to develop the cultural norms that facilitate the sharing of learning from workplace errors. Developing a supportive learning culture takes time; it requires nurturing, sponsorship and championing4.
So how do we develop a supportive learning culture and how much do we need to know about the science of learning in order to make sure what we do is effective? Let's start with the latter. Those who have responsibility in an organisation to encourage learning from workplace errors that follow a behaviourist paradigm will focus exclusively on observable behaviours and the causes that trigger them. Behaviourists use operant conditioning to reinforce or modify conscious behaviour, by rewarding and punishing employees for either getting things right or getting things wrong.
Those who follow a constructivist model will seek ways to facilitate learning, and ensure learners are active in the learning process by co-constructing learning experiences. Constructivists develop shared learning opportunities in the social work environment. Constructivists expose an individual's construction of a workplace error so a shared understanding develops.
In order to build on the effectiveness of behaviourist and cognitivist approaches, those responsible for developing a learning culture around workplace errors need to utilise affective, social and cognitive learning theories for the following reasons:
- affective theories focus on the learners' relationships with themselves; learning provokes emotional responses and develops emotional intelligence. Affective learning may result in feelings of pride and achievement or shame and loss
- social learning is about shared learning and systems thinking, developing the learner to become aware of shared situated learning experiences. Interpersonal relationships between learners are significant as they instil a sense of collegiality and support or a sense of isolation and silo mentality
- cognitive learning ensures that the learner has understood the complexities of knowledge required to perform to an appropriate standard. Instilling the belief that learning is attainable contributes to self-efficacy.
Neuroscience tells us that humans may not immediately learn from error, and that we often build up a history of making mistakes before we get it right. Although we accept that we 'will never solve the problem with the mind-set that created it', we also know now that, due to the brain's inherent plasticity, our mind-sets are not fixed, they can be changed and, by changing them, we not only see errors we have made but also find innovation and improvement5.
In order to learn from error, we need to engage in what is known as 'deep learning'. This means, in essence, that we have to slow things down, we have to stop, we have to reflect and we have to have time to think. This is because, in the field of learning from errors, we have learned that the speed and context in which we think are linked with positive/negative outcomes. If we have been able to detect an error and if we are to have time to challenge the assumptions underpinning the practice that contributed to it, deep learning will occur.
So what will help us to challenge the assumption that what we are doing is right? Instead of 'downloading' and imposing an existing mind-set on to complex problems, we could find an improved solution if we were to observe, and reflect, on the complex situation over a period of time. It is this 'stepping back' from the problem that allows our brains to find innovation and solution.
The science of learning could not be any clearer, as far as learning from errors is concerned: as individuals and collectives, we can all learn from workplace errors, we can all challenge our own assumptions and change the mind-sets that have contributed both to the initial error and to the recurring errors in our workplaces. In order to make sure we do so effectively, we need both the time to do this and to develop learning opportunities for employees that will incorporate a range of learning theories. If we fail to do so, learning will remain superficial and has the potential to be viewed as part of a punitive system.
What about the 'how' of developing a supportive learning culture?
We have all been saddened by the events in some of the NHS institutions charged with curing and caring for us when we are at our most vulnerable. The King's Fund report that provided further insight into the failings at Stafford laid open the issue of workforce disengagement brought about through stress and the lack of 'psychological safety' in which to learn6. Catastrophic failings in health care provision brought about through a lack of the preconditions that create 'psychological and physical safety' are not limited to the UK or to the health care sector7. A disregard for how learning cultures develop are also to be found in the banking industry: the Saltz report on the investigation into Barclays Bank identified that as there was no "consistency to the development of a desired culture"8. The one that did develop was based on chasing financial gains rather than on values and behaviours. The report recommends the promotion of "open learning" and an emphasis on social learning within groups.
The common denominator between these organisational cultures is that open and blame-free learning was absent. Instead, leadership focused on meeting financial targets and ignoring the contribution employees had to make regarding learning from workplace practices.
In order to affect the whole organisation, we need to think about not just how we learn but also how we share learning.
Achieving both horizontal and vertical impact by a positive learning culture means developing commitment, participation and action from the top of the organisation to the bottom. It means facilitating learning across departments, professional groups and faculty. A leader who is able to acknowledge and share his own mistakes demonstrates that valuable learning comes from making errors and is viewed as human and more effective by employees as a result9.
Neuroscience has shown that, while only a small percentage of our learning comes from formal classroom training, it is in this setting that we can start to create the mindset and practise the skills we will use back in the workplace. [pullquoteBuilding a psychologically safe environment in the classroom means establishing the cultural norms that we would all like to work within. These norms are not rocket science; they are about having mutual respect, being honest and open, contributing to the learning of others and having an individual willingness to learn.
Most importantly though, in establishing a learning culture, you have to ensure that everyone contributes from the very beginning to laying down the conditions in which learning will take place, and this means, from the start, asking employees what sort of learning culture they want and how they will sustain it. Once norms have been identified, values that determine organisational practices will follow.
From these classroom practices, we may be able to establish a learning culture that instils a commitment across the whole of the workplace. This, in turn, has the potential to imbue a rigorous approach to learning that contributes to how we can all learn from workplace errors.
By developing the skills and abilities to develop a positive learning culture, not only will we be engaging with work during a crucial time of change but we will also have the skills necessary to thrive. Beginning the process will require educational leadership; sustaining the new learning culture will require leadership stamina.
1 Kerr R, McHugh M, McCrory M “HSE Management Standards and stress-related work outcomes” Occupational Medicine (2009)
2 Kirschenbaum A, Oigenblick L, Goldberg A I “Wellbeing, work environment and work accidents” Social Science Medicine (2000)
3 Gray D, Williams S “Facilitating Educational Leadership: using frames to increase action” Leadership & Organization Development Journal (2012)
5 Gray D, Williams S “From blaming to learning: re-framing organisational learning from adverse incidents” The Learning Organization vol 18, 6 (2011)
6 King’s Fund Patient-centred leadership: Rediscovering our purpose (2013)
7 Lucian Leape Institute, National Patient Safety Foundation Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care Roundtable on Joy and Meaning in Work and Workforce Safety (2013)
8 Saltz A, Collins R An Independent Review of Barclays’ Business Practices (2013)
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