A Description of the Learning Organisation Within the Accident and Emergency Department

The concept of a learning organization knows its roots back to Garratt in 1987, which later on in the late 90’s was revived by Peter Senge. Senge (1990) focuses on the organization acting as a unit where innovative ideas are generated and common goals are reached. Collective commitment of the team is fundamental. Furthermore, according to Senge (1990), the organization must go through 5 domains in order to reach the productivity of a learning organization: systems thinking, personal mastery, mental models, building shared vision and team learning.

Therefore it is clear that organizational learning goes beyond knowledge. This notion involves the process of action and reflection (Carroll & Edmondson, 2002) or action learning (Revans, 1979). Having members of an organization engage in this process depend on various factors such as change. Furthermore medical knowledge and routine practices are continuously evolving over time, making organizational learning more popular with healthcare (Tucker, Nebharmb & Edmondson, 2006).

A typical organizational culture such as the accident and emergency department (A&E) of Mater Dei hospital represents a chaotic setting where professionals are able to handle a variety of problems simultaneously, some being unpredictable (Smith & Feied, 1999). Being an emergency nurse involves being an all-rounder, such as being a triage nurse, a pre-hospital nurse, in-hospital emergency nurse and resuscitation nurse. Furthermore, an emergency department is the frontier of a hospital that provides immediate care to the patient. Therefore in such a complex culture expertise is a must.

As suggested by several authors experience is a valuable resource, which promotes organizational learning (Garvin, 1993; Dunphy, Turner & Crawford, 1996; Carroll & Edmondson, 2002). In fact senior staff in the A&E department (those with more than three years experience as an emergency nurse) are involved in training junior nurses, educational organizations such as the MENA that carry out seminars on a three month basis, working with other members of the multidisciplinary to organize short educative meetings approximately once a week and are a point of reference during work.

Having said this, these individuals form the basis of team learning. However, before team learning starts to progress, members of the team such as the professional development nurse help train new staff individually. This gives way for the initial steps of individual learning where the shared vision of the team can be fostered (Senge, 1990). Even though individual learning takes up more time and cost it is the bedrock of team learning (Carroll & Edmondson, 2002). In fact the NHS has made it a requirement that every professional has a Professional Development Program (Sheaff & Pilgrim, 2006).

The same is being introduced for nurses in the A&E department by the practice development nurse. Curiosity of new recruits helps them to learn at their own will. This is where individual learning translates into personal mastery. Making mistakes comes part of this process. In fact Stinson, Pearson & Lucas, 2006, mentions that learning from mistakes to be an opportunity to learn from, rather than to blame. However curiosity itself is not enough to proliferate into team learning. Limitations such as time, costs and being understaffed overshadow the use of open dialogue (Berwick, 1996).

As previously mentioned team learning is not just the sharing of knowledge but open dialogue about perceptions (mental models) of current issues, and the creation of innovative ideas as a team (O’Connor & Kotze, 2008). Mental models are powerful tools that affect what we do as they in turn affect what we see (Senge, 1990). Self-awareness comes part and parcel of individual learning. Having different people looking at the same issue but giving different opinions and knowledge fosters a learning organization – or as Stinson, et al. , 2006, says being “open to new ideas.

These characteristics also form the distinctive line between dialogue and discussion (Stinson, et al. , 2006). Unfortunately the A&E department allocates very little time to cater for open dialogue sessions. Although there is a great sense of teamwork amongst the multidisciplinary team, discussions are usually done at the managerial level. Furthermore there are instances where staff feels threatened to voice their perspective (Sheaff & Pilgrim, 2006). In fact as described by Snell, 2002, a hierarchy could be dangerous to a learning organization.

Leaders should be the gatekeepers of the organization culture making them accessible (Snell, 2002). One issue leaders of the A&E department may not be sensitive to the psychological aspect of nurses. A day full of heart touching situations can bring a surge of emotions which maybe hard for an individual to cope with. As suggested by Stinson, et al. , 2006, “ time to smell the roses”, is the opportunity where staff can find time to reflect and enjoy leisure activities together. This is also makes way for a better relationship between staff members, which in turn gives a quality patient care.

Another troublesome issue concerning the A&E is the fact that parts of the A&E department are being used as a ward. This is both creating unsafe nursing practice and is in the way of emergency nursing care. This issue is attracting media and public criticism that in turn leads to job dissatisfaction. This all creates a viscous cycle, which ultimately affects the patient care. Furthermore situations like these project high rates of sick leave and nurse turnover (Perry, 2003). High sick leave and nurse turnover rates are also present within the A&E department because booking leave its very difficult.

A&E nurses must book their leave three months ahead and may still not find the days they want. Not only this, but continuing education is also made difficult with this matter. Despite the fact that there are opportunities for nurses to continue learning, such as continuous professional development program, many are the times when staff is unable to attend. This again is due to the workload present. This leads to frustration amongst staff and has also been a source of clashes between management and staff. Therefore, the management of issues like these does not call for a one-man show.

As Dowd, 1999, states, leaders in a learning organization go beyond the traditional leader – leaders should be ready to work on the floor with other nurses and be able to critically teach others. Leadership roles should be dispersed through the organization, at different levels. Human resource management should be there whilst nurses work in this ‘unstable’ environment. There should be a relationship between such leaders and staff to help build trust. Patient’s complaints should be taken into consideration to help create innovative approaches (Gunn, 2001).

Staff should learn to look at complaints objectively and find support from others. Staff meetings, including managers should be organized to give voice to staff. Currently the Emergency Nurses Union is projecting our concerns. Suggestions such as bed managers being present on the floor of the A&E department would help facilitate deputy nursing officers workload and responsibility as well as giving them a realistic picture of what is truly happening on the A&E department floor. Along with this human resource management should boost the A&E department by granting them more staff.

Efforts by the nursing school can also be done to attract more students towards A&E care. This would make the A&E department more flexible creating more time for learning. Having this, staff should participate in this learning organization by being assertive and prioritize their time for learning (Stinson, et al. , 2006). Despite this, authors have recognized that clinicians and policy makers (including politicians) are reluctant to beat the barriers that staff face. Whilst policymakers are unwilling to reform current polices and professional clinicians continue to train their members ‘their’ way (Sheaff & Pilgrim, 2006).

Another factor this is evident within the A&E department is the fact that since there are various leaders, there is conflict between them. Having many leaders can be proven to a disadvantage. This emphasizes the need for fixed protocols and guidelines. Another factor is that some leaders are not even experienced within the emergency nursing setting that makes it hard for them to understand the nurse’s day-to-day difficulties. Therefore it is in the hands of the leaders to promote change – as the Institute of Medicine, 2001 reports “Trying harder will not work.

Changing the systems of care will”. Therefore in order to implement a learning organization leaders should be change agents. Leaders should build a rapport with their staff through empowerment and motivation. Appraisal systems as being used in the NHS help job satisfaction and in return give good quality patient care (Sheaf &Pilgrim, 2006). Acknowledging the fact that leaders are themselves busy, studies like that of Tucker, et al. , 2006, show how leaders can delegate their job of change agents to so called improvement project teams.

Project teams help by finding better practices, modify them in a way that are conducive to the learning environment and disseminate them amongst staff. Medicine involves many standardized procedures and practices. The job of the leader is not to demolish this standard but to modify it so that innovative ideas and can be created (Bartunek, 1984). Project teams can also help build the shared vision (Tucker, et al. , 2006). The shared vision of the team working in the emergency department would entail giving the best immediate care using evidence -based knowledge. Such a vision is what empowers members of the team to strive for what is best.

A shared vision also creates a sense of shared purpose for each member of the team (Carroll & Edmondson, 2002). This mends a stronger relationship between members. Evidence based knowledge helps to motivate staff letting them know that their actions are ethically and scientifically correct. None-the-less motivation is not enough. Implementation of change through policies and protocols is the best way as mentioned above (Klein, 2001). In fact the A&E department has formulated a committee that is gathering research-based knowledge to create guidelines for many procedures such as triage and cauterization.

This committee is finding its support through the ENU to be provided with material and time during work to have committee meetings. Along with this the committee is asking staff to give their input by sharing ideas or any material. This gives a sense of shared purpose as mentioned above. It is important to acknowledge that when change is implemented there will be resistance at first (Bolton, 2009). This in fact is another issue within the A&E department. Many are the times that new documentation sheets, guidelines or new equipment are introduced with few staff actually aware of this.

Being a large number of staff leaders should organize ways and means to disseminate this information. Bolton, 2009, shows how the leader should facilitate change once all analyses and conclusions have been theoretically drawn. Within an orthopedic ward, Bolton, 2009 dates a ‘time out’ day where staff gets the opportunity for staff to reflect on the protocols and guidelines, making them realize that there is the need for change. This also applies for the A&E department where all staff is gathered at convenient times, possibly, shift by shift to ponder upon the introduction of anything new.

This re-emphasizes the importance of open-dialogue sessions. Looking at the issues that emergency nurses face, projects Senge’s proposed guidelines as a utopian world (Snell, 2002). Many are the issues that pose as limitations to a learning organization. Unlike individuals, organizations are not programmed to learn (Carroll & Edmondson, 2002). Therefore such a process takes times and a collective commitment. The formulation of a common goal is fundamental (shared vision). This requires the implementation of change through the involvement of the whole team.

Ultimately the success of a learning organization such as the A&E department reflects through patient care and their satisfaction. As Preston, et al. , 1999, found that when patients see that nurses were responsive to patient’s needs good feedback was given. This in turn gives job satisfaction. Job satisfaction helps the individual grow into a motivated individual that strives to learn more and engage in the organization’s well being. Having said this, turning the A&E department into a learning organization would pose so many benefits both to leaders, staff and ultimately to the patient.

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