“The hallmark of a good system is a strong culture of learning from failure”.
This quote is from a BMJ Blog published last December by R. Lloyd. I copied it at the time and have gone back and looked at it often. The reason I was so taken with the concepts was at the time I was working on ways to help nurses develop confidence and competence in their thinking and decision making. There is a great deal of research about errors and I had focused upon clinical reasoning and how to develop strategies to approach nursing in a logical, stepwise manner to come to decisions.
Certainly, the fact that errors in clinical judgement and decision making are said to account for more than half of adverse clinical event was something I emphasised, but how we deal with our colleagues and selves was not really addressed in my approach at the time.
So I was interested in this author’s statement: “Error is heavily stigmatised in our workplace because the public expects perfection. So when the inevitable mistakes do occur and we fear being implicated, a strategy for deflecting attention is to turn on each other. Even when there is no risk of being implicated, we still can’t resist the urge to point the finger of blame (or gossip about the incident behind the back of the guilty party) because somehow it soothes open wounds from previous public humiliations”.
This author was writing about Emergency Department behaviour but I would suggest that every one of us can identify these behaviours reflecting on our experience in any health environment. I certainly can. I have often complained about how nurses frustrated with a colleague will insist “they are not competent” when in fact they have been found to be competent by their registering authority. It is a dangerous accusation as it can rebound on the speaker should the problem be lack of experience, inappropriate delegation, poor support and inadequate education. Nurses, I feel are not very forgiving.
By expressing anger or strong disapproval of what may at first appear to be incompetence we fail to actually address the problem. Humiliation is closely linked to bullying but the need for leaders to analyse and understand the causes of failures (or in our nursing clinical language, errors) is critical. We can undertake every type of education and put in every procedure and protocol but it is inevitable that mistakes will happen. Health systems are complex, the organisations are complex, patients are complex and no doubt about it, nursing is complex.
Perhaps rethinking our patterns of response and jettisoning old cultural beliefs and stereotypical notions while embracing failure’s lessons is a solution. Nurses can begin by understanding how the blame game gets in the way. In health care, a culture that makes it safe to admit and report on failure can coexist with high standards for performance. It is not a case of dismissing or accepting the inevitability of an error.
Amy C. Edmondson writing for the Harvard Business Review proposed a Spectrum of Reasons for Failure, which lists causes ranging from “deliberate deviation to thoughtful experimentation”. She wondered which of these causes involved blameworthy actions. “Deliberate deviance, first on the list, obviously warrants blame. But inattention might not. If it results from a lack of effort, perhaps it’s blameworthy. But if it results from fatigue near the end of an overly long shift, the manager who assigned the shift is more at fault than the employee. As we go down the list, it gets more and more difficult to find blameworthy acts. In fact, a failure resulting from thoughtful experimentation that generates valuable information may actually be praiseworthy”.
What has been your experience? Do we take time to analyse? It is not just a matter of cause and effect, if it has gone wrong and is an error or a failure, of course, we can see the effect but instead of dropping on the culprit like a ton of bricks and wallpapering over the disaster with a report can we learn from the whole story? The energy spent on the blame game might be better spent on exploring and correcting the situation that gave rise to the problem.
There are some fabulous webinar recordings by Pam Savage regarding Nurses and the Law on the Nurses for Nurses Network. The Nurses for Nurses Network provides good information and CPD on an array of nursing topics in a range of easy learning ways including webinars and quizzes on the latest information that Nurses need to know – remember the Nurses for Nurses Network was created by Australian Nurses for Nurses! www.nursesfornurses.com.au