Latest / Safe As Podcast / E48: Blame fixes ... something ???

Transcript

E48: Blame fixes ... something ??? · Safe As Podcast

• 0:07
  Blame fixes nothing, so goes the popular mantra.
• 0:11
  But given that this well intentioned battle cry is also
• 0:15
  an empirical claim, how does it hold up to scientific testing?
• 0:19
  Can blame actually fix something?
• 0:21
  Good day everyone. I'm Ben Hutchinson and This is
• 0:25
  Safe as a podcast dedicated to the thrifty analysis of safety,
• 0:30
  risk and performance research. Visit safetyinsights.org for
• 0:34
  more research. Today's study is from Van
• 0:37
  Morrick ET al 2023 titled Mitigating Work Conditions that
• 0:43
  Can Inhibit Learning from Errors, Benefits of Error
• 0:47
  Management, Climate Perceptions, and Frontiers in Psychology.
• 0:52
  It's studied how certain work conditions can prevent
• 0:54
  professionals from learning from their errors and our perceptions
• 0:58
  of an organisation error management, climate, they call
• 1:01
  it EMC, can help counteract these negative effects.
• 1:04
  The authors emphasise that errors in the workplace are
• 1:07
  unavoidable. Therefore, effective error
• 1:10
  management necessitates not only preventing errors, but also the
• 1:15
  subsequent learning from the errors.
• 1:16
  Learning from errors is characterised as an effortful
• 1:20
  process that requires time and resources and vulnerability.
• 1:25
  The central premise in this study is that professionals
• 1:27
  don't always learn from their mistakes because their
• 1:30
  experience of errors in their work environment can actively
• 1:34
  hinder this learning. The study focuses on 4 specific
• 1:38
  audit related conditions that could negatively impact error
• 1:41
  learning. So errors with minor
• 1:44
  repercussions may be perceived as less learn worthy.
• 1:47
  Ignoring their learning potential might lead to
• 1:49
  repetition and future escalation.
• 1:52
  Also, routine type errors might inhibit learning since they're
• 1:55
  easily attributed to simple things like inattention rather
• 1:59
  than a lack of knowledge or the environmental conditions The way
• 2:03
  that work is designed and structured.
• 2:05
  Strong negative emotions might also impact learning.
• 2:08
  Feelings such as shame, fear, or guilt can consume cognitive
• 2:12
  resources, impeding the information processing which is
• 2:16
  crucial for learning. That can also result in
• 2:19
  professionals withdrawing or prioritising emotional relief
• 2:23
  over problem solving. Also, professionals under
• 2:26
  intense time pressure might prioritise urgent tasks over
• 2:30
  learning, or they might externalise the errors
• 2:34
  contributing or causal factors leading to superficial analysis.
• 2:38
  To mitigate these inhibitory learning factors, the study
• 2:41
  examines the moderating role of perceived error management
• 2:45
  climates. The EMC.
• 2:47
  EMC encompasses the beliefs, norms and practises related to
• 2:52
  how errors are dealt with that are shared within an
• 2:54
  organisation. The study differentiates between
• 2:57
  two facets of the error management climate.
• 3:00
  The EMC. IT has an open EMC.
• 3:03
  The open EMC is a climate characterised by a high
• 3:06
  tolerance for errors, provided that learning occurs and errors
• 3:10
  are not repeated. An open EMC promotes
• 3:12
  opportunities for learning from errors, but in my view, the
• 3:16
  premise of not repeating errors is still pretty optimistic and
• 3:20
  not very representative of human performance variability.
• 3:23
  But whatever. The authors hypothesise that an
• 3:26
  open EMC would help mitigate or weaken the negative effects of
• 3:30
  those four learning condition inhibitions that I mentioned
• 3:32
  before. What was interesting is that
• 3:34
  they also used a blame EMC. In a blame EMC, errors are
• 3:41
  considered unacceptable and therefore should be penalised to
• 3:44
  prevent recurrence. It typically leads to errors
• 3:47
  being seen as a personal failure and can result in formal and
• 3:50
  informal sanctions. And expectedly, it was
• 3:53
  hypothesised that a blame EMC would exacerbate or strengthen
• 3:58
  the negative effects of those learning inhibitions I mentioned
• 4:01
  before. The data came from 141 Dutch
• 4:04
  auditors using an experiential questionnaire approach.
• 4:08
  As a proviso, I'm using this study's terminology of error
• 4:12
  just for simplicity, but note that there's a whole research
• 4:16
  movement that is very critical of the whole enterprise of human
• 4:20
  error, particularly from the normative and judgmental
• 4:23
  perspective. So what did they find?
• 4:27
  Well, some of the core findings is that, as expected, the open
• 4:31
  EMC helps with strong negative emotions.
• 4:34
  So perceptions of an open EMC where found to mitigate the
• 4:37
  negative relationship between negative emotions and error
• 4:40
  learning. What this means is that if your
• 4:43
  workplace encourages learning from mistakes and doesn't punish
• 4:46
  them, of course you're more likely to learn from your errors
• 4:49
  even if you feel particularly bad or ashamed or scared about
• 4:52
  them. Supportive environment helps you
• 4:54
  process the error despite your feelings.
• 4:57
  An open EMC also helps with high time pressure.
• 5:00
  So perceiving an open EMC helps mitigate the negative
• 5:04
  relationship, specifically a high or medium open EMC.
• 5:09
  So the air management climate increase reported learning from
• 5:13
  errors, particularly under conditions of high time
• 5:15
  pressure. So what this means is that even
• 5:18
  when orders were under a lot of pressure, if they felt their
• 5:21
  workplace had an open culture about errors, they still learned
• 5:25
  more from their mistakes. This means a good supportive
• 5:28
  environment can help you learn even when you're really busy.
• 5:32
  Now. Surprisingly, though, a blame
• 5:35
  EMC, a blame climate can encourage learning from small
• 5:39
  errors. So contrary to the initial
• 5:42
  expectation that a blame EMC would be really particularly
• 5:46
  worse, and it would exacerbate any negative effects, the study
• 5:50
  found that blame Emcs actually mitigated the negative
• 5:53
  relationship between small error consequences and error.
• 5:57
  This means that more error learning takes place regardless
• 6:01
  of consequences when participants experience a blame
• 6:04
  EMC. The authors suggest that some
• 6:06
  blame oriented values might actually create a sense of
• 6:10
  urgency to learn from the smaller errors, as people want
• 6:13
  to prevent reoccurrence. So you might think a blame
• 6:17
  climate would make people feel less safe, less enabled to
• 6:21
  learn. But surprisingly, the study
• 6:25
  found that in a blame focused environment, audits were more
• 6:28
  likely to learn from small mistakes.
• 6:31
  It's like the fear of being blamed for small errors pushed
• 6:33
  them to learn to prevent them from becoming bigger problems.
• 6:37
  What this means is that when there's not too much blame in
• 6:40
  the workplace environment, auditors learned effectively
• 6:43
  from their mistakes, no matter how strong their negative
• 6:46
  feelings were. It shows that simply not having
• 6:48
  a strong blaming environment can help people learn from errors.
• 6:52
  So there seems to be a sweet spot with the degree of
• 6:55
  perceived blame climate. Although some people may argue
• 6:59
  that this conflates blame with forward looking accountability.
• 7:03
  They also found that time pressure has an inverted U
• 7:06
  effect on learning. So this implies that medium
• 7:09
  levels of time pressure can be beneficial for reported learning
• 7:13
  from errors, while higher levels of time pressure has an adverse
• 7:16
  effect. So simply there is seems to be a
• 7:20
  bit of a moderate sweet spot. The time pressure, that's good
• 7:23
  for learning, but if the time pressure gets too high it
• 7:27
  becomes bad for learning, making it harder to reflect and
• 7:30
  understand mistakes. So what can we make of the
• 7:33
  findings? That's obviously quite a lot of
• 7:35
  stuff I just dumped on you. The author suggests a few
• 7:38
  practical implications. Explicitly communicate the
• 7:41
  values of all errors, including those with minor consequences,
• 7:46
  and emphasising that they all have some level of value for
• 7:50
  learning. Now.
• 7:51
  Importantly, while exercising caution regarding a full blown
• 7:55
  blame climate, recognise that communicating error
• 7:58
  repercussions according to this research can help create a sense
• 8:02
  of urgency and potentially encourage learning from smaller
• 8:06
  errors because people want to prevent their reoccurrence.
• 8:09
  So organisations should really aim to strike a balance between
• 8:13
  the components of both an open and a blame error management
• 8:16
  climate, especially since orders reported more learning from
• 8:20
  errors accompanied by strong negative emotions when in an
• 8:24
  open EMC. And given that excessive time
• 8:27
  pressure leads to lower levels of error learning, and time
• 8:30
  pressure is often inherent in workplaces, organisations must
• 8:33
  find ways to cope with the threat.
• 8:35
  They suggest that fostering an open EMC is potentially
• 8:39
  beneficial in mitigating the negative effects of high time
• 8:42
  pressure, and leaders play a key role in learning from error.
• 8:47
  Leaders should act as role models for learning from their
• 8:50
  own errors and provide the opportunities and structures
• 8:53
  within the organisation so people can feel empowered to
• 8:57
  report errors. Leaders should actively listen
• 9:00
  and assist in the analysis and mitigation of future errors and
• 9:03
  performance. Leaders need to establish clear
• 9:06
  expectations for managing errors within their teams and hold team
• 9:10
  members accountable for contributing to an open EMC.
• 9:14
  For leader behaviours to be effective, their underlying
• 9:17
  values and beliefs must be aligned with the organisation
• 9:20
  structures, systems and retains. So what were some limitations?
• 9:25
  There was a few. I think the main one to draw out
• 9:27
  though is that this was based on self reported perceptions via
• 9:31
  questionnaires and in a single professional Dutch setting.
• 9:36
  And there's of course a lot of nuance around their concept of
• 9:40
  the blame climate. That's it on safe as I'm Ben
• 9:45
  Hutchinson, please help share, rate and review and check out
• 9:49
  safety insights.org for more research.
• 9:52
  Finally, feel free to support Safe As by shouting a coffee
• 9:56
  link in the show notes.