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TLO 18,6 From blaming to learning: re-framing organisational learning from adverse incidents 438 Dee Gray Grays, Caernarfon, UK, and Sion Williams Bangor University, Bangor, UK

Abstract Purpose – This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting and learning approach from adverse incidents, could contribute towards individual and organisational approaches to patient safety. Design/methodology/approach – The study formed part of a series of six iterative action research cycles involving the collaboration of students (all National Health Service (NHS) staff) in the co-creation of knowledge and materials relating to understanding and learning from adverse incidents. This fifth qualitative study involved (n ¼ 20) anaesthetists who participated in a two phase teaching intervention (n ¼ 20 first phase, n ¼ 10 second phase) which was premised on transformative learning, value placed on learning from adverse incidents and reframing the learning experience. Findings – An evaluation of the teaching intervention demonstrated that how students learned from adverse incidents, in addition to being provided with opportunities to transform negative experiences through re-framing learning, was significant in breaking out of practices which had become routine; propositional knowledge on learning from adverse incidents, along with the provision of a safe learning environment in which to challenge assumptions about learning from adverse incidents, were significant factors in the re-framing process. The testing of a simulated dual learning/reporting system was indicated as a useful mechanism with which to reinforce a positive learning culture, to report and learn from adverse incidents and to introduce new approaches which might otherwise have been lost. Practical implications – The use of a “re-framed learning approach” and identification of additional leverage points (values placed on learning and effects of dual reporting and learning) will be of significant worth to those working in the field of individual and organisational learning generally, and of value specifically to those whose concern is the need to learn from adverse incidents. Originality/value – This paper contributes to individual and organisational learning by looking at a specific part of the learning system associated specifically with adverse incidents. Keywords Reframing learning, Transformative learning, Value of learning, Adverse incidents, Individual and organizational learning, Learning organizations, Health services sector, Learning methods Paper type Research paper

1. Introduction British government reports from Organisation with a Memory (DOH, 2000), onwards have continued to underline the importance of learning from mistakes, but the practical application of policy recommendations has proved hard to achieve in practice (DOH, The Learning Organization 2002, 2003; NPSA, 2005). The National Audit Office (NAO, 2005) identified that Vol. 18 No. 6, 2011 pp. 438-453 organisational learning (OL) was key to patient safety, fundamental to this was the q Emerald Group Publishing Limited reporting of adverse incidents, as this would enable the discovery of patterns of risk; 0969-6474 DOI 10.1108/09696471111171295 under-reporting from health care staff is an international problem (Evans et al., 2006), in Britain this has been reported by a media that claimed doctors and nurses were not From blaming reporting either due to a lack of feedback from the National Patient Safety Agency to learning (NPSA), or because they thought that they were the only person who knew about the incident or near-miss, and so did not think there was any need to let anyone else know (Guardian, 2009). Under-reporting became a political priority and by May 2009 death rates were published for the first time from every hospital in England; after the scandal of poor quality care provided at Stafford Hospital in the West Midlands, this was 439 supplemented by a demand for “new levels of transparency” (The Independent, 2009). However, under-reporting is not the whole story. The literature that contributes to what is known about individual and organisational learning from mistakes, in the British National Health Service (NHS), illuminates a failure to learn for reasons that include a surface approach to learning and a blame learning culture. The former results in only temporary acquisition of information, which translates into performance that is at best ill informed, and the latter operates to perpetuate a learning system populated by “things which cannot be discussed”, which are in effect fear, shame and personal trauma (DOH, 2000; Ramsden, 1992; Prosser and Trigwell, 1999; Senge, 1990; Senge and Scharmer, 2001; Argyris and Scho¨n, 1978; Alberti, 2001). The learning culture which surrounds learning from error is often compounded by the adoption of strategic defence routines, used to pretend that learning has occurred when in actuality there has been little understanding and/or a covering up of mistakes, in order to avoid “embarrassment” or “threat”. These defence routines become normative over time and lead to a range of unwanted consequences, such as the repetition of mistakes (Grieves et al., 2006, p. 97). Such routines become “mechanisms for psychological survival” and in themselves cause an impediment to the flow of learning in the organisation, so that achieving interconnectedness between all systems (the “primacy of the whole”) is impossible (Grieves et al., 2006, p. 97; Senge, 1990). Determining the flow of knowledge in an organisation requires us to look at the whole organisational learning system, including those associated with mistakes (Wendy, 2009). In the NHS, mistakes that have the unintended outcome of harming another are also known as “adverse incidents”. In the context of OL from adverse incidents, learning often emphasises what has gone wrong, this provides what Goffman (1974) might refer to as a “master frame” for learning from adverse incidents; this “master frame” basically sets the scene by which any learning associated with adverse incidents will be accorded a value that resonates with negative connotations to learning, and contributes to an overall negative learning culture (Benner, 1984; Vincent et al., 2000). Reversing this negative culture requires those involved in OL to move away from “re-constructing a world which IS problematic a world of deficits, failure, and blaming” and re-frame learning by identifying the positive learning aspects in an adverse event (Hosking and Morley, 2004 p. 11). This type of learning is deemed deep and transformative, resulting in changes that equate with a sense of responsibility instead of blame in error causation (Marton and Sa¨ljo¨, 1984; Mezirow, 1991; Donovan et al., 2007); in the context of this study, transformative learning means re-framing learning around adverse incidents and bringing into the new frame improvements or innovation borne out of an adverse incident experience (Goffman, 1974). The quality improvement through questioning and analysis (QIQA) framing approach (the intervention in this study) is not unlike that used in appreciative inquiry (AI), in which individuals are encouraged to generate knowledge from the standpoint TLO of positive regard within a given system, this is deemed to generate knowledge and 18,6 movement towards achieving full potential of that system (Cooperider et al., 2003; Whitney et al., 2010). QIQA draws on this, and the “wholeness” expounded by Senge et al. (1995), to guide individual learning holistically in an attempt to reverse the effect of a blame learning culture that seeks an individual to blame. The new re-framed positive learning culture makes errors acceptable, if those making them are prepared to 440 and allowed to learn from them. Finally, hidden knowledge associated with the adverse incident which might lead to prevention of recurrence, and/or a change of practice, is more accessible.

2. QIQA QIQA was located within a series of action research (AR) cycles which formed part of a larger research project about risk management in the NHS (Lewin, 1947a, b). As an AR intervention, QIQA incorporated re-framing learning from adverse incidents so that NHS staff could creatively explore work-based practices in a shared learning environment, and celebrate and communicate what they were doing right (Lewin, 1947a, b; Culvenor, 1997; Cooperider et al., 2003). The processes included reflective thinking and dialogue in which there was no “significant embarrassment or threat”, so that covering up of events was avoided and learning was achieved (Appelbaum and Goransson, 1997, p. 116). Combining transformative learning and “re-framing” with an AR methodology worked well due to the points of convergence between processes which either cause a “stirring up”, “flooding out” or the “disorientating dilemma” that precedes learning at a “deep” level (Lewin, 1947a, b, 1952; Goffman, 1974; Mezirow, 1991; Biggs, 1987; Marton and Sa¨ljo¨, 1984). The QIQA approach linked individual learning with a systems (organisational) centred approach to learning from adverse incidents, achieved by including learning content on organisational systems and through experiential learning of a simulated dual reporting and learning system based on current NHS reporting systems (Senge et al., 1995; Donovan et al., 2007). The QIQA approach was designed to: . Provide an environment that allowed for open discussion about adverse incidents – pivotal to achieving this was a sense of personal safety so there were no ramifications from discussing adverse incidents in order to learn from them. . Foreground and reinforce learning with a positive frame of reference - this was important so participants would move out of any negative routineised ways of thinking about adverse incidents, and move towards a new frame that encouraged learning from mistakes. . Ensure new frames of reference were born out of understanding and questioning previous experiences.

The QIQA content was designed to: . Relate to and draw on real work situations, such as reported adverse events and “undiscussables” (situations or events that students felt were not open to critical review) (Ramsden, 1992; Argyris and Scho¨n, 1978; Alberti, 2001). . Align to existing knowledge and experience of reporting and learning from adverse incidents (Miller, 1956; Tsoukas, 1994; Taylor, 1985; Prosser and Trigwell, 1999). . Be kept to a manageable amount to achieve “de-routinisation” of existing From blaming learning frames (also known as schemata) (Eraut, 1994). In essence this meant to learning that the way the students understood how they learned from adverse incidents was open to change, through a process in which existing knowledge no longer applied and a new frame (schemata) could be constructed.

3. Methodology and study design 441 QIQA was pilot tested as an educational intervention designed to improve patient safety and conducted at the “local” level so that “sociohistorically” constructed realities were accessed ((Braithwaite et al., 2006; Guba and Lincoln, 1989). Analysis of QIQA as a transformational learning intervention included establishing whether it could operate as a mechanism with which to re-frame learning from adverse incidents, the potential of re-framing would be to rebalance a field rife with a negative learning culture and re-state positive values of learning from adverse incidents (Goffman, 1974; Cooperider et al., 2003; Whitney et al., 2010; Lewin, 1947a, b; Bourdieu, 1989). There were two phases to the QIQA learning intervention. Phase one attracted (n ¼ 20) students, who answered pre/post teaching intervention questionnaires relating to patient safety. The phase one intervention included propositional knowledge on types of learning; for example single, double and triple loop learning identified by Argyris and Scho¨n (1978) was considered an important inclusion because it would introduce the students to the double loop process of challenging assumptions (their own and others) about how they learned from adverse incidents, and to the process of influencing how their colleagues learned from adverse incidents, through triple loop learning (learning how to learn). Phase one also included opportunities for dialogue and experiential learning, and an introduction to “mindfulness” in bringing about changes in practice. This was achieved in a learning environment that removed conditions that might create defensive routines, so that questioning “cultural norms and prescriptive rules” associated with organisational learning from adverse events was able to take place – all of which is “considered paramount to clinical risk management” (Elliott et al., 2000; Argyris and Scho¨n, 1978; Argyris, 1995, 1999; Mathews and Thomas, 2006, p. 186). The pre- and post-intervention questionnaire had three open-ended qualitative questions: (1) Do you think understanding how things go wrong can contribute towards a safety climate? If you have answered yes, please say why. (2) Do you think understanding how we learn can contribute towards a safety climate? If you have answered yes, please say why. (3) Do you think a learning culture contributes to a safety climate? If you have answered yes, please say why.

Phase two of QIQA required students to participate in a simulated dual reporting/learning system for adverse incidents (n ¼ 10 of the original n ¼ 20 students took part). The process required the participant to think reflectively about an adverse incident using the “frame” of searching for positive improvements and innovation in practice (Goffman, 1974). The “new learning system” is distinct from AI processes as it incorporated and used a worldview that included something that held negative connotations (an adverse incident); the process then provided the opportunity TLO to report the adverse incident alongside either a positive learning outcome from the 18,6 disclosed incident, or disclose something alongside the reported adverse incident, where they had learned from an incident that had no adverse consequences (termed a critical learning event (Benner, 1984; Eraut, 1994). An emphasis was placed on moving away from what had gone “wrong” in practice, and moving towards a mindset of what was going right. The implication behind the approach is that individuals who process 442 and learn from incidents (adverse and critical) in this way, re-construct their mental schema (individually and then collectively), thereby disconnecting the learning process from a blame culture and connecting to learning in a positive light; all of which may in some way break the pattern of a “recursive relationship” with previous negative experiences, so that the blame learning loop in which NHS staff often find themselves is broken, allowing for a new positive recursive relationship to emerge (Harkema, 2003, p. 344). When considering reporting an incident the participants were asked to reflect on the incident using three key questions used in phase one to introduce mindfulness in learning from adverse incidents, these were: . What did I do? (Reflective.) . How did I do it? (Reflective.) . Was there any way I could have done it better? (Reflective/visioning.) The objective of the QIQA pilot was to test and develop theories of how to positively influence learning from adverse incidents, to come up with practical workable solutions that might enable the flow of learning from adverse incidents, and to re-frame thinking born out of a new understanding that positive learning outcomes can come from adverse incidents achieved through actual experience “within and in relation to action (organisational intervention)” (Argyris and Scho¨n, 1978, p. 43). In order to identify early indications of transformative learning the students (n ¼ 10) were asked to comment on the effect of having the opportunity to report a positive as well as a negative incident, responses were added to data collected from their pre and post intervention questionnaires (Mezirow, 1990). The (n ¼ 10) students worked on their own through this process, recording information separately.

4. Sample A process of snowball sampling identified a purposeful (Blaxter et al., 1996) overall sample of n ¼ 20 participants (reducing to n ¼ 10 for phase two) and although not generalisable to a larger population as “good” informants“(Morse, 1991, p. 132), they provided a depth and quality to the data collected. Declaring the students good informants was based on the criteria that they belonged to a single professional group and body (anaesthetists), worked together in the same organisation, had exposure to the same working conditions and risks and had undergone the same professional education, the only differentiation among the students related to levels of professional seniority. Permission to conduct the proof of concept study was gained through agreement with the NHS Trust. In line with good ethical practice, all the participants as “QIQA students” were informed prior to the teaching session that this teaching intervention had developed from the research associated with the larger risk management project; voluntary participation in research activities was reinforced, so that students as participants could choose to withdraw at any time and were welcome to stay for their own continuing professional development (CPD). Confidentiality of From blaming data and participant anonymity were assured. All data provided from phase one and to learning two were transcribed verbatim.

5. Validity and reliability Validity of findings is provided by transparency of the research process in naturalistic enquiry, particularly my own role in interpretation of findings; for example I make 443 explicit the “lens” I am looking through is focused on evidence of supports and barriers to individual and organisational learning, a lens gained through repeated reflective turns of the AR cycle (Greenaway, 1995, Baskerville and Wood-Harper, 1996). Reliability was assured through the cross-checking of interpretations and construction of data analysis tools with academic and NHS colleagues.

6. Data analysis 6.1 Phase one An initial content analysis was conducted compiled against each pre and post list of questions; during this interrogation a significant number of negative experiences were identified to learning from adverse incidents, this sensitised the second interrogation to search for indications of positive and negative learning experiences, (later categorised as “supports” and “barriers” to learning) (Guba and Lincoln, 1989; Reason and Bradbury, 2001). To enable identification of any post teaching intervention indications of “re-framing”, the data were collated using a devised analysis framework which represented a “case” or “profile” for each student (Hosking and Morley, 2004). The analysis framework categorised responses from the students “original frame” to include whether they had a positive or negative experience of learning from adverse incidents (thereby identifying possible supports or barriers to learning), and whether their responses were single, double or triple loop type; post intervention, they were then categorised as being in the “same-frame” (unchanged) or “re-framed” to represent something new. The data was then scrutinised for values as these might determine not only the nature or tensions within the field of learning from adverse incidents, but also levers with which to influence the field; the values that emerged from the data were used to determine the original (and subsequent) student frames (Bourdieu, 1989; Lewin, 1947a, b; Bourdieu and Wacquant, 1992; Gherhardi and Nicollini, 2000; Goffman, 1974). The emergent student values were: . Value 1 ¼ a value placed on learning itself. . Value 2 ¼ a value placed on changing practice. . Value 3 ¼ a value placed on wider implications of learning.

6.2 Phase two Phase two students (n ¼ 10) provided data that were scrutinised for evidence of learning constructs which occurred/developed from the named incident(s) and whether “dual reporting” had influenced mental schemas associated with reporting and learning from adverse incidents. The data were clustered under headings of, “adverse learning incident”, “critical learning incident” and “effect” to reflect the reporting streams provided for the students, the latter was used to discover any effects the experience may have had on the student. TLO 7. Reflexive appraisal of findings 18,6 The findings below are represented under the headings of “Phase one” and “Phase two”, pre and post intervention data which corresponded with the “values” of “learning”, “changing practice” and “wider implications” is clustered under these headings. 444 7.1 Phase one Being able to accommodate and construct new schemata in relation to learning from adverse incidents is a vital part of the learning change process. Without the ability or the opportunity to challenge existing knowledge and construct new schemata (frame) with which to recognise and retrieve knowledge, there is the potential for mistakes to remain hidden in single loop learning (Mezirow, 1991; Elliott et al., 2000; Grieves et al., 2006; Argyris and Scho¨n, 1978). Exploring whether QIQA (phase one) may influence schemata associated with learning from adverse incidents meant establishing the student’s schemata/frame of learning and patient safety; the findings (n ¼ 20) demonstrated schemata/frames that included understanding how errors are made and (n ¼ 19) how a learning culture contributes to a safety climate. The biggest change in student thinking came with understanding how they learned to contribute towards a safety climate (n ¼ 13 pre increasing to n ¼ 16 post), as students 8 þ 18 who previously answered “don’t know” and student 15 who previously answered “no” post QIQA demonstrated, a frame that indicates an appreciation of understanding how we learn from adverse incidents is important: [...] yes – by sharing our experiences of events with others- the same mistakes are less likely to be made (Student 8). [...] yes – concentrate on these aspects first to encourage learning þ identification of risk factors. Currently unlikely to speak up for fear of persecution (Student 15). [...] yes positive learning encourages good behaviour as well as discouraging bad behaviour/activities (Student 18). Of the n ¼ 4 remaining students, Student 9 who had previously answered “No” pre intervention answered “Possibly” post intervention. In addition, Student 6 demonstrated post-QIQA a new frame of thinking that regarded learning from adverse incidents in a positive light and, importantly for organisational learning, had moved from individual learning (single loop) to shared learning (double loop): [...] yes, understanding how things go wrong can give a positive outcome of learning to both the person who made or was involved in the mistake and those learning about the mistake and therefore avoid repeating the same mistake (Student 6). Values and barriers. The values located within students’ individual schemata relating to learning from adverse incidents, demonstrated leverage points with which to bring about individual and organisational learning (Bourdieu, 1989; Lewin, 1947a, b; Meadows, 1999; Bradbury, 2001; Ramsden, 1992; Prosser and Trigwell, 1999; Senge et al., 1995). Barriers to actioning leverage points form tensions within the field, and were closely associated with student values; identifying values and barriers which would decide future action (Lewin, 1952) are considered below. Value 1: learning. Clinicians are often exposed to systemic conditions and teaching From blaming practices that encourage surface learning approaches which promote single loop to learning learning (Øvretviet, 2000). This represents a dysfunctional learning system which seriously hampers clinicians’ ability to progress from novice to expert (Audit Commission, 1999; Vincent et al., 2000; Vincent, 2004; Benner, 1984; Eraut, 1994). Actioning a lever associated with valuing learning meant establishing whether students were interested in double and triple loop learning, a system that encouraged 445 this and a positive culture of learning from adverse incidents. This was initially demonstrated through a willingness to participate in the teaching intervention (which incorporated learning about learning) and was identified in post intervention responses: . Q.1 “having an understanding can lead to appreciation of adverse events and possible reparation” (Student 12). . Q.2 “yes positive learning encourages good behaviour as well discouraging bad behaviour/activities” (Student 18). . Q.3 “a learning culture, and that is a positive experience will enhance what is learnt and retained and then used in practice” (Student 6).

Indicating a desire to do more than surface learn is important in determining the quality of what is learned and the flow of knowledge in an organisation. Too often, clinical knowledge is gained in crisis situations with little time to reflect and understand not just what has been learned, but also how it has been learned. The result is that learning is not fully realised and remains (single loop) within the individual so the flow is limited (Eraut, 1994; Bransford et al., 2000). A deep approach to learning is one in which there is individual and group reflection in a shared learning (a learning community for example) experience, the students demonstrated that shared learning was important to them: [...] by sharing our experiences of events with others- the same mistakes are less likely to be made (Student 8). Value 2: changing practice. Change is often not an easy process, changing one’s own (or another’s) practice that operates within a closed system can prove difficult, it requires courage on the part of the change agent, as conflict and “turf wars” frequently result in disruption of equilibrium (Lewin, 1947a, b, 1952; East and Robinson, 1994; Elliot, 1991; Jacobson, 2003). Any change starts with an individual’s recognition and desire for change; the students’ desire for change came through the recognition that learning about adverse incidents enabled them to improve on their practice. This may be represented as a double loop or “second order” change of mental model, as the students were in the process of constructing new mental models where learning from an adverse incident is seen in a positive light (Jacobson, 2003, p. 36): . Q.2 “yes, If you can improve learning and therefore have more knowledge then your work practice should be improved” (Student 5). . Q.3 “yes as it gives you the right working environment in which you can improve what you are doing” (Student 9). TLO Value 3: wider implications. The collaborative model expounded in AR has positive 18,6 implications in overcoming resistance to change, in this instance by bringing together a network of people working towards the same goal(s) in a learning community, constructed as being interdependent and connected to the organisational learning system (DoH, 2006; Mathews and Thomas, 2006; Lewin, 1947a, b; Jacobson, 2003). Students who recognised the wider implications (interconnectedness) of learning from 446 adverse incidents were those who related learning at an individual and organisational level which could be achieved in a variety of ways: [...] especially through small group discussion and sharing information e.g. via departmental meetings (Student 19). Barriers. Perceived barriers to learning from adverse incidents included internal (cognitive) barriers relating to the quality of adult learning being provided, recognising that there are different learner needs and how they were learning: [...] we need to gain information in way that we can remember it so will actually use again (Student 13). Barriers were identified in locating learning opportunities: [...] positive learning cultures can and do exist, though it is often not widespread and this means finding a place where you can learn. It can be hit and miss (Student 2). The students in this study spend a lot of time learning in the “hot conditions” of clinical practice so that they have little time dedicated to making sense of the learning experience. This means that knowledge is not developed in a way that reflects accurately what has happened, or is surface learnt so that vital information is lost quickly, either of which often translates into sub-optimal care delivery (Benner, 1984; Eraut, 1994; Lipshitz, 1993; Klein, 2008). Not having time to learn was the most often cited barrier to learning and therefore the most valuable resource: [...] but like everything it has to be properly resourced which means devoting time in order to develop it (Student 1). Barriers associated with a blame culture included fear of speaking up, being in a threatening environment, and not being able to learn lessons because of repercussions. Students were open to changing this through a positive learning culture: A positive learning culture that would embrace learning from events that have had adverse consequences as well as positive consequences would be a fairer system (Student 13).

[...] yes – if it is a positive learning culture would do something to remove the pervasive blame culture in which everyone suffers (Student 15). Blame cultures are often the cause of under-reporting and remove the opportunity for de-briefing and group learning from adverse incidents. This means that knowledge and insight gained from experiencing an adverse incident often remains of the single loop variety (remaining with the individual), and causes an overall loss of organisational knowledge; errors are repeated and the individual who is unable to discuss adverse incidents may find future practice is based on inaccurate models of care standards (DOH, 2000; Singer and Edmondson, 2006). Learning schemas associated with blame cultures are reinforced in learning systems that perpetuate the importance of “what” and not considering “how” it is learnt (Prosser and Trigwell, From blaming 1999; Bransford et al., 2000). to learning 7.2 Phase two Students who participated in phase two of the intervention may have experienced a “de-briefing process in which one [...] evaluates one’s own practical performance” (Tripp, 1998, p. 39); through this de-briefing the students reflected on their own practice 447 in a shared environment, each knowing the other was divulging an experience in which they had felt “virtually individual responsibility” for an adverse incident (Frieidson, 1971, p. 134). This may well prove to be unusual practice in itself as in the NHS a “horizontal” team is not often embraced, instead the emphasis “is on knowing thy place” (Pilgrim and Sheaff, 2006, p. 8). While the students did not share the content of the adverse incidents with each other, they were sharing the opportunity to revisit an experience that may have left a sense of guilt and failure. This demonstrated trust that a safe learning environment had been provided and with colleagues who would know that they had been involved in an adverse incident; as an overt process this may do something to subvert an underground management practice which covertly endorses a status quo to cover up mistakes (Mcardle et al., 2003; Argyris, 1995, 1999). All of the students who had participated were given the opportunity to report an adverse incident and something positive that had come out of it, or, report an adverse incident and report a critical learning event with positive outcomes with no adverse connotations attached, n ¼ 9 of the students fell into the latter category all reporting a positive learning experience distinct from the adverse incident they reported. This may be significant in that at this stage they could not think of a positive learning outcome from an experience that involved an adverse event. Only one student reported an adverse incident (accepting inferior judgement from a colleague) with a subsequent positive learning experience (safe assessment of airway for intubation). All students, however, experienced QIQA as a reflective/reflexive process in which reporting and learning from error was framed in such a way that it became associated with success (Histed et al., 2009). The importance of this relates to the more recent research on brain plasticity and learning, indicating that humans do not immediately learn from failure, especially if failure is not immediately detected or if there is no time to reflect on actions. Aligning a negative with a positive experience makes sense with regard to learning from error, and has been endorsed in professional teaching practice for some considerable time (Fontana, 1996; Light and Cox, 2001). Under the category of learning from adverse incidents, the types of errors reported were associated with administration of medicines, errors associated with technical expertise/judgement and error associated with accepting advice from colleagues. Learning from critical incidents appeared to be associated with times in practice where the clinician had been working solo, where they had demonstrated technical skill and judgement and where they had successfully challenged the opinion of colleagues, all of which had produced safer patient outcomes. Learning from these experiences suggested learning had taken place when students had to cope and perform well after working solo, or where they had been able to demonstrate superior technical skill and judgement. Student responses (n ¼ 7) regarding thoughts related to the exercise were mixed. Four found the experience positive and rewarding: I feel good and buoyed by acknowledging what I have done well (Student 18). TLO The students who found the experience more challenging may be on the road to 18,6 challenging assumptions about learning from adverse incidents, the first step is often traumatic as it “stirs things up” and is part of the transformational learning process (Lewin, 1947a, b, 1952; Mezirow, 1991): Exposes differences of how I learnt in each instance. The first did not feel good (Student 6). 448 The opportunities for learning from adverse incidents at the point of reporting are as yet untapped, the ability to do this already exists within NHS OL systems (DATIX for example), but would require adaptation to ensure tacit knowing and innovation is captured for the whole organisation (Harkema, 2003). Wider implications from this study may influence other organisations/industries, apart from the NHS, where reporting and learning from adverse incidents is required and where there is a prescient blame learning culture (Whittingham, 2003). The students (n ¼ 10) who participated in phase two indicated that learning can be re-framed through a dual reporting/learning process, all of which should contribute towards a positive reporting and learning culture

8. Conclusion Using the QIQA approach could provide important outcomes for the NHS. First, a strong message is sent throughout the organisation that individuals have the opportunity to demonstrate how they are improving on practice through the medium of continuous learning, in adverse incident situations this removes some of the stigma attached to the adverse incident itself. As a proof of concept QIQA demonstrated significant potential as a teaching and learning intervention designed to positively affect quality of health care provision (Braithwaite et al., 2006). QIQA facilitated re-framing learning from adverse incidents towards a more positive mindset, while phase one introduced the frame of learning from adverse incidents in a positive way, Phase Two directed and re-framed learning at a part of the overall learning system that is often not even considered to hold valuable stocks of knowledge relating to innovation or improvement on practice (Goffman, 1974; Cooperider et al., 2003; Hosking and Morley, 2004). If phase two of QIQA could be made more tangible by utilising existing NHS reporting and learning structures/systems such as DATIX this would harness co-creation from NHS staff towards achieving “solving the problem within, rather than a solution imposed from outside or above” (Patrick and Dotsika, 2007, p. 396). Arguably this would capture innovation and improvements borne out of learning from personal experience and used for the benefit of the organisation as a whole. The study supports the view that transformative learning is the mechanism by which real learning from adverse incidents can take place. In order to achieve this, attention has to shift to a more holistic way in which learning opportunities in relation to adverse incidents are developed and delivered (Mezirow, 1991; Marton and Sa¨ljo¨, 1984; Bransford et al., 2000; Cooperider and Srivastva, 1987). Creating a learning environment (Senge and Scharmer, 2001) and providing leverage (Meadows, 1999) with which to overcome barriers are fundamentally important in sustaining this deep approach to individual and organisational learning. 8.1 Practical implications From blaming The concepts and findings that have developed from the use of a “re-framed learning to learning approach”, and identification of additional leverage points, should be of significant worth to those working in the field of individual and organisational learning generally, and specifically for those enabling the learning from adverse incidents. For managers and leaders who are working towards the development of a positive learning culture from adverse incidents this approach will harness organisational knowledge which 449 often remains hidden. While the approach is not prescriptive, the steps followed in QIQA are cost effective, simple to implement and align with tried and tested methodologies and methods known to bring positive change through re-framing (Cooperider et al., 2003; Whitney et al., 2010). QIQA could be taken up by those responsible for organisational learning, organisational development and governance in both public and private sectors and utilised with knowledge management systems within those sectors. The approach offers real opportunities for the workforce to rethink and re-frame learning so that innovation, change and improved performance can manifest in organisational practice. The study also illuminates the complexity of learning from adverse incidents by demonstrating that factors which shape, influence and perpetuate learning systems can be re-framed. The implications of this for teaching and learning either in an academic or workplace context, lies in the potential QIQA has to harness organisational knowledge embedded in adverse incidents.

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About the authors Dee Gray, RGN LLB Hons, Mphil, PGCE, tHE, is a doctoral student (PhD submitted Spring 2011) and Director of Grays, a business dedicated to learning from adverse incidents. Dee was formerly a Research Fellow in the Research Institute for Enhancing Learning, School of Education, Bangor University and Senior Manager in Organisational Development for the Welsh Assembly Government. Her PhD has been conducted under the auspices of the School of Healthcare Sciences at Bangor University. Sion Williams, RCBC is a Senior Health Career Research Fellow at the College of Health and Behavioural Sciences, School of Healthcare Sciences, Bangor University.. A particular aspect of Dr Sion Williams’ work is the development of qualitative methodologies through a participatory approach, using modified grounded theory, narrative research and testimony. A key strand of this work involves a programme of constructivist grounded theory studies. Sion Williams is the corresponding author and can be contacted at: [email protected]

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