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From blaming & shaming to a learning organisation

Posted by Bianca Beentjes on March 1 2018
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From blaming and shaming to a learning organisation

We all know that incident reporting is not the moment for reproach. It is a learning opportunity for care professionals involved as well as for their colleagues. The question is; how do you create an open culture without “blaming and shaming” and improve safety levels within your care institution? Read this blog to see “which buttons you can press” to create safety awareness in your team.

The benefits of a Just Culture

Openness, communication and learning from one another can prevent a lot of suffering on the part of nurses, patients involved and their family. An open culture, also called a Just Culture, is often a safe culture. Moreover, an open culture enhances team effectiveness. A closed culture impedes learning from one another.

"Supervisors can create a culture in which admitting errors and assessing unsafe situations comes out in the open.”

Leadership and realizing a cultural change

Managers and team leaders show leadership by sharing their vision on safety in the healthcare sector with their team. They do this not only by engaging in conversation with their care professionals, but also by demonstrating exemplary behaviour. If supervisors do not see safety as a priority, why should their staff? If supervisors see insufficient attention for safety in their team, it is important that they create time and space to bring the matter into the open. Good leaders are interested and curious, and ask their team members what makes it difficult for them to display the safety imperative during their shift.

Behaviour demonstrating that safety is regarded as a priority should be rewarded. Compliments increase care professionals’ intrinsic motivation. They will then apply themselves even more conscientiously to show the desired behaviour with respect to safety.

“Pay compliments to staff who show positive behaviour, think along and share ideas with management.”

Creating awareness

In order to manage behaviour, it is important that organisations describe the behaviour expected at every level of the organisation. For example, request every entity throughout the organisation to draw up some “golden rules” to address the most significant safety risks. In this way, care professionals are made aware of the impact that positive behaviour can have on patient safety.

"Request every organisational entity to develop some 'golden rules' to address the most important safety risks."

Learning organisation

An Old Chinese proverb:

"Tell me and I will forget.
Show me and I will remember.
Involve me and I will understand."

If you want your team to grow as part of a learning organisation, trust is imperative. Only then can the future be worked on together. As a supervisor, it is crucial that you pay attention to both the professional and personal development of your team members. At a team level, it is all about collective competences such as cooperation, feedback and communication.

Conditional to the creation of a safety culture is that care professionals are made aware of unconscious behaviour. A good example of this is the audit during the preparation and dispense of high-risk medication such as parenterilia. During the audit, it appeared that a large proportion of nursing staff did not know that the worktop had to be disinfected during this process. They were not aware that that they were carrying out their work in an unsafe manner. Old ways of doing things have to be discarded and new behaviour must take their place.

The following interventions contribute to awareness:

  • Taking audits
  • Doing safety rounds
  • Analysing and discussing incidents within the team

“A learning organisation asks for a climate in which care professionals feel safe enough to look critically at the day-to-day display of values and assumptions – and question them.”

It is important to inspire staff to look critically at the day-to-day display of values and assumptions and encourage them to ask questions. If they do so, they can experience that this attitude is valued in and rewarded by the organisation. It is also important that managers and supervisors seize that moment to engage in conversation with care professionals about safety. The best stimulus, however, is to have management showing exemplary behaviour.

Do's and dont's on the way to a learning organisation

Do's Dont's
Delegate Mistrust each other
Bring problems out into the open Conceal problems
Radiate peace of mind Overflowing agendas
Room for dialogue The fundamentals do not work their way up
Face-to-face communication Communication on paper and by email
Management stimulates and inspires Hidden agendas
Accept that mistakes can be made Avoid risks

The importance of reports in a learning organisation

By regularly sharing transcripts of reported incidents, you can create awareness throughout the organisation. It stimulates staff to learn from incidents by doing things better.

A good example is carrying out a double check when dispensing high-risk medication. The so-called “double check” is crucial to patient safety. Care professionals ask each other to check the specifications and look critically over their shoulder, but when the care professional is busy and thinks “that’ll be okay”, the foundations for an incident or a near-miss are laid.

By sharing reports, supervisors become aware of organisational risk and are challenged to do things better or differently on their department by making more time, money, staff or resources available.

Management can decide on the basis of risk assessment to take other measures than simply adjusting values, standards or policy, whereby more attention can be paid to safety in the healthcare institution.

How can software support your learning organisation?

TPSC Cloud™ software enables every supervisor and care professional to report incidents and bring them out into the open. Reports can be generated at every conceivable level, providing real-time insight into incidents, risk and trends. This in turn creates consciousness throughout the organisation.

It is also possible to generate an overview of the theme or nature of the reported incident from the reporting module itself. This offers precise insight into where the weaker links in the chain of your organisation can be found.

Like to know more about interventions you can apply to change the organisational culture? Download the e-book 'Safety is our joint effort!' about creating a healthcare safety culture:

e-book Safety culture healthcare


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Bleeker, F., & Bruijne, de, M. (2013). Medisch Teamwork (Rev. ed.). Houten, Holland: Bohn Stafleu Van Loghum.

Creatief Denken. (n.d.). De lerende organisatie. Retrieved from 

Leren en organiseren. (2017, March). Een lerende organisatie. Retrieved from 

Nivel. (n.d.). Leren van incidenten in de zorg. Retrieved from 

Nivel. (2010). Systematisch Leren van Incidenten in de Zorg: een online handreiking voor zorgverleners, managers en kwaliteitsmedewerkers. Retrieved from 

Ridder, den, K., Tuitert, Y., Tuijn, van der, Y., & Bon, van, A. (2010). Patientveiligheid voor verpleegkundigen (Rev. ed.). Amsterdam, Holland: Elsevier Gezondheidszorg.

Senge, P. (1995). De vijfde discipline - De kunst en de praktijk van een lerende organisatie (4th ed.). Amsterdam: Scriptum Management.

Winstar Institute. (n.d.). Hoe verbeter je de veiligheidscultuur? Retrieved from 

Topics: Cultuur

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