In his book titled Black Box Thinking: Why Most People Never Learn from Their Mistakes-but Some Do Matthew Syed recounts the following:
"In 2004, Amy Edmondson, a professor at Harvard Business School, and colleagues conducted an influential study into the consequences of a blame culture.
"In her six-month investigation, Edmondson focused on eight different units in two hospitals. She found that some of these units, across both hospitals, had tough, disciplined cultures. In one unit, the nurse manager was “dressed impeccably in a business suit” and she had tough discussions with the nurses “behind closed doors.” In another, the manager was described as “an authority.”
"Blame in these units was common. Nurses said things like: “The environment is unforgiving; heads will roll,” “You get put on trial” and “You’re guilty if you make a mistake.” The managers thought they had their staff on a tight leash. They thought they had a disciplined, high-performance culture. Mistakes were penalized. The managers believed they were on the side of patients, holding the clinicians to account.
"And, at first, it seemed as if these managers were right. Blame seemed to be having a positive impact on performance. Edmondson was amazed to discover that the nurses in these units were hardly ever reporting mistakes. Remarkably, at the toughest unit of all (as determined by a questionnaire and a subjective survey undertaken by an independent researcher), the number of errors reported was less than 10 percent of another unit’s.
"But then Edmondson probed deeper with the help of an anthropologist and found something curious. These nurses in the so-called disciplined cultures may have been reporting fewer errors, but they were making more errors. In the low-blame teams, on the other hand, this finding was reversed. They were reporting more errors, but were making fewer errors overall.
"What was going on? The mystery was, in fact, easy to solve. It was precisely because the nurses in the low-blame teams were reporting so many errors that they were learning from them, and not making the same mistakes again. Nurses in the high-blame teams were not speaking up because they feared the consequences, and so learning was being squandered."
Is there anything to be learned from this story?
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KEVIN J. BROWNE
Philosopher / Educator
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2022 Reading Challenge
Kevin has read 12 books toward his goal of 63 books.