December 2007 Vol 8 After Meeting.indd The Learning Organisation and Health Care Education *Rashid K Al-Abri and Intisar S Al-Hashmi THE ‘LEARNING ORGANISATION’ IS A concept that is becoming an increasingly widespread philosophy in modern health care institutions. What is achieved by this philosophy depends considerably on one’s interpretation of it and commitment to it. Much has been written about the concept of a learning organisation1,2 and some attempts, such as those by Critten, and other writers 3 have been made to translate the concept into practice. According to Peter Senge, learning organisations are: …organisations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.4 So, the concept of the learning organisation is that any successful organisation must continually learn in order to adapt to changes in the environment and grow. Any organisation that wants to implement a learn- ing organisation philosophy requires an overall strat- egy with clear, well defined goals. Once these have been established, the tools needed to facilitate the strategy must be identified. The building blocks of a learning organisation are, initially, individuals and then teams, who create, share and act on collective learning. Such an organi- sation operates an organisational learning cycle where Quality Management Department, Sultan Qaboos University Hospital, P.O.Box 38, Al-Khod 123, Sultanate of Oman *To whom correspondence should be addressed. Email: ralabri@hotmail.com SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL DECEMBER 2007 VOL 7, NO. 3, P. 207-214 SULTAN QABOOS UNIVERSITY© SUBMITTED - 16TH JULY 2007 ACCEPTED - 19TH SEPTEMBER 2007 S P E C I A L C O N T R I B U T I O N الصحية الرعاية وتعليم التعلم مؤسسة الهاشمي محمد بنت إنتصار العبري˛ خلفان بن راشد االبداع أجل من قدراتهم وتعزز مستمرة بصورة الناس فيها يتعلم ــة كمؤسس ــينج، س بيتر من وصفه أول هو مفهوم التعلم" ــة "مؤسس امللخص: هذه املنظم. والتفكير ــخصي الش االتقان الذهنية، النماذج املشتركة، الرؤية الفريق، تعلم ــية: رئيس أقسام ــة من خمس التعلم ــة تتكون مؤسس . املعرفة التي بأنه ويوصف احلقيقية، التعلم ملؤسسة ــاس األس احلجر املنظم التفكير يعتبر البعض. بعضها وتتفاعل مع ــة حركية اخلمس ــام األقس ذي موظفني انتاج أجل ــن م احلديثة باملعلومات اعضائه ــد تزوي الى الصحية الرعاية ــدف تعليم يه ــة التعلم. مؤسس في العلوم لتنفيذ ــتعمل تس أهمية النظرية التي لها والنماذج التعليم مفاهيم لذلك هناك بعض اضافة الصحية. الرعاية خدمات نوعية تدعيم مبقدورهم كفاءة وأمانة، يكون بالتفصيل. وصفها يتم التعلم سوف مؤسسة اساسيات للحصول على املراحل الالزمة االدارية. للقرارات وتستطيع تزويد أرضية التعلم، ــة ملؤسس سلبيني. مستلمني ابدا يبقون وال البيئة لتحسني باستمرار يتعلمون اعضاءا التعلم مؤسسة يدعم الذي اتمع في نرى قيادة. ممارس، طبيب الرعاية املستمرة، األدبيات ، الكلمات: مراجعة مفتاح ABSTRACT The ‘Learning Organisation’ is a concept first described by Peter Senge as an organisation where people continuously learn and enhance their capabilities to create. It consists of five main disciplines: team learning, shared vision, mental models, per- sonal mastery and systems thinking. These disciplines are dynamic and interact with each other. System thinking is the cornerstone of a true learning organisation and is described as the discipline used to implement the disciplines. In a learning organisation, health care education aims to educate its members with up to date knowledge to produce competent and safe personnel, who can promote quality in health care services. In addition, there are some educational concepts and theoretical models, which are of relevance to the learning organisation, and can provide a framework for managerial decisions. The stages required to achieve the principles of a learning organisation will be described in detail. Moreover, in a proper culture which supports the learning organisation, members continuously learn to improve the environment and never remain passive recipients. Keywords: Learning organisation; Healthcare education; Leadership. R A S H I D K A L - A B R I A N D I N T I S A R S A L - H A S H M I 208 new knowledge is created, captured, shared and implemented.5, 6 In a learning organisation, managers - supported by human resources department profes- sionals - have a key role in creating opportunities for individuals and /or teams to learn and sharing learn- ing in work. 7, 8 T H E L E A R N I N G O R G A N I S A T I O N C H A R A C TE R I STI C S O F SU C C E S SF UL TE A M S An organisation development plan is the process through which an organisation develops the internal capacity to be optimally effective in its work and to sustain itself over the long term. Organisation develop- ment interventions are divided into two basic groups: diagnosis and action or process. Team building is one type of process intervention. Team work is considered as the fundamental unit and the building block of the learning organisation. Teams and team work have been studied by many writers looking for the characteristics that make for success. Larson and LaFasto looked at high perform- ance groups as diverse as a championship football team and a heart transplant team and found eight characteristics that are always present.9 They are listed below: 1. A clear, elevating goal 2. A results-driven structure 3. Competent team members 4. Unified commitment 5. A collaborative climate 6. Standards of excellence 7. External support and recognition 8. Principled leadership TE A M F O R M ATI O N Before a team can learn, it has to be formed. In the 1970s, psychologist B. W. Tuckman identified four stages that teams had to go through to be successful. They are: 1. Forming: When a group is just learning to deal with one another; a time when minimal work gets accomplished. 2. Storming: A time of stressful negotiation of the terms under which the team will work together; a trial by fire. 3. Norming: A time in which roles are accepted, team feeling develops and information is freely shared. 4. Performing: When optimal levels are finally reached in productivity, quality, decision mak- ing, allocation of resources, and interpersonal interdependence.9 FI V E D I S C I PL I N E S C RU C I A L TO A L E A R N I N G O R G A N I SATI O N There are five disciplines which are crucial to a learning organisation and should be encouraged at all times.4,10 These are as follows, as shown in Figure 1. Team Learning Teams, not individuals, are the fundamental learn- ing units and unless a team can learn the organisation cannot learn. Consequently, team learning focuses on the learning ability of the group. Mature people learn best from each other by reflecting on how they are addressing problems, questioning assumptions and receiving feedback from their team and from their results. Through team learning, the learning ability of the group becomes greater than the learning ability of any individual in the group. The discipline of team learning starts with ‘dia- logue’, the capacity of members of a team to suspend assumptions and enter into a genuine ‘thinking to- gether’. To the Greeks dialogos meant a free-flowing of meaning through a group, allowing the group to discover insights not attainable individually. It also in- volves learning how to recognize the patterns of inter- action in teams that undermine learning.4 Shared Visions In order to generate a shared vision, large numbers of people within the organisation must draft it, thus em- powering them to create a single image of the future. To become reality all members of the organisation must understand, share and contribute to the vision. People will then do things out of personal commit- ment, not because of external pressure. Mental Models These are deeply ingrained assumptions, generalisa- tions, or even pictures and images, that influence how we understand the world and how we take action.4 Every human being has an internal image of the world, with deep-rooted assumptions. Therefore, in- dividuals will behave according to the true mental model that they subconsciously hold and usually not TH E L E A R N I N G O R G A N I S AT I O N A N D H E A LT H C A R E E D U C AT I O N 209 according to the theories in which they claim to be- lieve. If group members can constructively challenge each others’ ideas and assumptions, they can begin to recognise their mental models and to change these to construct a shared mental model for the team. This is essential as the individual’s mental model will control what they think can or cannot be done. Personal Mastery Personal mastery is one of the core disciplines for building a learning organisation. It refers to an indi- vidual commitment to life-long learning; it is a con- tinuous and never-ending process. 4 Personal mastery can be defined as the process of continually clarifying and deepening an individual’s personal vision. This is a matter of personal choice for the individual and involves persistently assessing in an objective manner the gap between their current and desired proficiencies, and practising and refining skills until they are internalised. This would develop self- esteem and creates the confidence to deal with new challenges. Personal mastery has three important elements: commitment to truth, personal vision and creative tension. Personal mastery allows individuals to look at their current reality and desired future (commitment to truth and reality), continually focus and clarify their personal vision for the desired future (personal vision) and use these gaps to create the dynamic energy to get to their desired future (creative tension). Systems Thinking The foundation of any learning organisation is the fifth discipline - systems thinking. This is the ability to see the bigger picture, to look at the interrelationships of a system as opposed to simple cause-effect chains thus allowing continuous processes to be studied rather than single snapshots. Also, this discipline shows us that the essential properties of a system are not de- termined by the sum of its parts, but by the process of interactions between those parts. This is why sys- tems thinking is fundamental to any learning organi- sation as it is the discipline used to implement the disciplines. Without it, each of the disciplines would be isolated and consequently not achieve their objec- tive. Systems thinking enables the formation of an in- tegrated system, whose properties exceed the sum of its parts. Nevertheless, all of the other four disciplines mentioned above are required to successfully imple- ment systems thinking. System thinking is the mainstay of a true learning organisation, integrating the above disciplines and is a way of discovering solutions to complex problems. This discipline enables interrelationships between systems and teams; at the same time, it allows the organization, through linear and logical thinking, to understand the source of and the solutions to modern problems. In summary, the five factors identified are dynamic in the way they interact with each other. For instance, when people are given genuine freedom and are trusted to handle their jobs through adequate support from other team members and appropriate resources, innovation and diversity of ideas will increase.11 This will cultivate a sense of the bigger picture and increase their capacity to know and act upon the events. Figure 1: The five disciplines of a learning organisation R A S H I D K A L - A B R I A N D I N T I S A R S A L - H A S H M I 210 T H E L E A R N I N G O R G A N I S A T I O N A N D H E A L T H C A R E E D U C A T I O N The aim of professional health care education is to educate health care personnel with up to date knowl- edge and skills, either by theoretical learning through attending courses or practical through training pro- grammes. The core purpose of health care education is to promote quality in health care service by having competent and safe personals. TR A I N I N G A N D L E A R N I N G I S SUE S Training can help shape ideas and aspirations, because it involves learning new things. Depending on the type of training, it can be the most effective way of learning. The difference between training and learning is that in- dividuals are different when it comes to learning. This can lead to a number of unpredictable outcomes, such as increased motivation and self-confidence, changing attitudes and insights which shape future actions.12, 13 E D U C ATI O N A L C O N C E P TS A N D TH E O R E TI C A L MO D E L S The use of the term theory in education does not need to imply something remote from the day to day expe- rience of the teacher. It is suggested that there is no real dichotomy between theory and practice. Also, to some extent, theory serves to provide a rationale for decision-making. Managerial activity is enhanced by an explicit awareness of the theoretical framework un- derpinning practice in educational institutions.14 The- ory is useful as long as it has relevance to practice in education. Theodossin clarifies that academics tends to want understanding for knowledge, while managers seek understanding for action.15 In discussing the rel- evance of educational concepts to the learning organi- sation the following should be taken into account:16, 17 Awareness Organisations must be aware that learning is neces- sary and must take place at all levels, not just the man- agement level. Once the educational institution has accepted the need for change, it is then responsible for creating the appropriate environment in order for this change to occur. Environment Centralised, mechanistic structures do not create a good environment as individuals do not have a com- prehensive picture of the whole organisation and its goals. This causes political and parochial systems to be set up which stifle the learning process. Therefore a more flexible and a flatter structure, which encourages innovations, would be more suitable. The flatter struc- ture also promotes the passing of information between workers, so creating a more informed work force. It is necessary for management to embrace a new philosophy: to encourage openness, reflectivity and accept error and uncertainty. Staff members need to be able to question decisions without the fear of repri- mand. This questioning can often highlight problems at an early stage and reduce time consuming errors. One way of overcoming this fear is to introduce ano- nymity so that questions can be asked or suggestions made, but the source is not necessarily known. Leadership In a learning organisation, leaders are designers, stew- ards and teachers. They are responsible for building organisations.4 Leaders should promote the systems thinking concept and encourage learning to help both the individual and the organisation in learning. It is the leader’s responsibility to help change the individu- al views of team members. For example, they need to help the teams understand that competition is a form of learning, not a hostile act. Management must provide commitment for long- term learning in the form of resources. The amount of resources available (money, personnel and time) determines the quantity and quality of learning. This means that the organisation must be prepared to sup- port this. Leaders have to generate and manage crea- tive tension – especially around the gap between vi- sion and reality. Mastery of such tension allows for a fundamental shift. It enables the leader to see the truth in changing situations. Empowerment ( flatter hierarchies) Empowerment has been variously defined, but its core idea is based on creating an environment where oth- ers are equipped and encouraged to make decisions in autonomous ways and to feel that they are in control of the outcomes for which they have accepted respon- sibility. The locus of control shifts from managers to workers (‘empowerment’) thus making workers re- sponsible for their actions, but the managers do not lose their involvement. They still need to encourage, enthuse and co-ordinate the workers. Empowerment can help organisations tackle the uncertainties of today’s changing world by drawing out the creative potential of the people who make up the organisation. TH E L E A R N I N G O R G A N I S AT I O N A N D H E A LT H C A R E E D U C AT I O N 211 Learning from mistakes Staff members need to find out what failure is like so that they can learn from their mistakes in the future. The managers are then responsible for setting up an open, flexible atmosphere in their organisations to en- courage their workers to follow their learning example. Anonymity can be achieved through electronic confer- encing; this type of conferencing can also encourage different sites to communicate and share knowledge. Finally, the fifth discipline (systems thinking) has close theoretical linkages with single-loop (adaptive) and double-loop (generative) learning.18 Adaptive learning routines can help health care professionals to follow pre-set pathways, detect and correct errors. This is also referred to as single-loop learning, an ex- ample being the clinical audit. Single-loop learning is the method of learning where you find a better way to do a process and it is comparable to the idea of contin- uous quality improvement. Double-loop learning goes a step further and asks, ‘why are we doing the proc- ess in the first place?’ The self-generating behaviour resulting from adaptive learning is determined by the operating norms or standards that guide it. Develop- ing evidence-based practitioners may be one way to facilitate double-loop learning.19 The learning-loop concept takes into account the cognitive and behavioural aspects of human develop- ment; together they form the theoretical foundation of the organisational learning framework.20 At the centre of these approaches is the importance of promoting creative individualism within organisations, so as to make people feel empowered. Consequently, employ- ees will be challenged to find better ways of meeting organisational goals and values.21, 22 H E A LTH C A R E PR O FE S SI O N A L S ’ F O R M S O F K N OW L E D GE A N D H E A LTH C A R E Q UA L I T Y Organisational learning and knowledge management are two concepts that have developed in parallel and are often linked in their definitions and practice.23 Or- ganisational learning is referred to as changes in the state of knowledge and involves knowledge acquisition, dissemination, refinement, creation and implementa- tion: the ability to acquire diverse information and to share common understanding so that this knowledge can be exploited.24, 25 Organisational knowledge is stored partly in individuals in the form of experience, skills and personal capability, and partly in organisa- tions, in the form of documents, records, rules, regula- tions and standards, etc.26 Therefore, the main task for the management is to create a learning environment between individuals and the organisation in order to facilitate the interaction and strengthening of each other’s knowledge.27 Thus, organisational learning is collective learning. Health care professionals are obligated both to ac- quire and maintain the expertise needed to undertake their professional tasks. Additionally, they are also ob- ligated to undertake only those tasks that are within their competence and to acquire technical knowledge in their field of work. Other forms of knowledge (list adapted from Nut- ley and Davies,19) which can be gained by health care professionals (HCP) from their learning organisation are: 1. Formal knowledge, such as structured pro- grammes and written procedures. This can be gained through attending courses, conferences and workshops. 2. Informal knowledge, such as that learned from different informal situations. Also, people learn skills and acquire knowledge beyond their specific job requirements. This enables them to appreciate or perform other roles and tasks. 3. Tacit knowledge arising from the capabilities of people, particularly the skills that they have devel- oped over time. 4. Cultural knowledge relating to the customs, val- ues and relationships with clients and other stake- holders. These are: celebration of success, absence of complacency, tolerance of mistakes, recognition of tacit knowledge, mutual trust, belief in human potential and staff empowerment. By being aware of their role and importance in the whole organisa- tion, the workers are more motivated to ‘add their bit’. This encourages creativity and free-thinking, hence leading to novel solutions to problems. All in all, there is an increase in job satisfaction and health care quality standards. Other important issues related to knowledge and high quality service are: 5. Flexibility at work allows workers to move freely within departments and enables them to choose their own speciality, whilst at the same time it re- moves the barriers associated with rigidly struc- tured training programmes and promotes creativ- ity. 6. Knowledge and accountability. Denyes et al.28 state that scientific accountability is a character- istic of a profession. Knowledge, skill and attitude are considered the most basic pre-requisites for R A S H I D K A L - A B R I A N D I N T I S A R S A L - H A S H M I 212 accountability. Responsibility must be given or taken to carry out an action and then authority is legitimised power, i.e. the legal right to carry out the responsibility.29 An example of this is the im- plementation of a staff appraisal system. 7. Knowledge and empowerment Equal participa- tion must be allowed at all levels so that members can learn from each other simultaneously. In the UK, the government ensures that the national quality standards are applied consistently within lo- cal practice or units through a system of clinical gov- ernance. The key characteristics of clinical govern- ance are the importance and interaction of extended life-long learning and modernised professional self- regulation.30, 31, 32 The combination of all three work- ing well will serve good clinical practice and deliver the requirements of the General Medical Council for good medical practice.33 First, clinical governance is a process by which each part of the UK National Health Service (NHS) quality-assures its clinical decisions, backed by a new statutory duty of quality. Second, life- long learning allows NHS staff to identify the training needs across professions to aid clinical team working. Third, professional self-regulation provides clinicians with the opportunity to help set standards. The concept has some parallels with the more wide- ly known corporate governance, in that it addresses those structures, systems and processes that assure quality, accountability and proper management of an organisation’s operation and delivery of service. How- ever, clinical governance applies only to health and social care organisations, and only to those aspects of such organisations that relate to the delivery of care to patients and their carers; it is not concerned with the other business processes of the organisation, except in so far as they affect the delivery of care. The concept of ‘integrated governance’ has emerged to refer jointly to the corporate governance and clinical governance duties of healthcare organisations.34 C R E A T I N G A C U L T U R E T H A T S U P P O R T S T H E L E A R N I N G O R G A N I S A T I O N Learning organisations embrace change and constant- ly create the reference points to precipitate an ever- evolving structure that has a vision of the future built in to it. According to Richard Karash, learning organi- sations are healthier places to work because they: 1. Garner Independent Thought 2. Improve Quality 3. Develop a More Committed Work Force 4. Increase our Ability to Manage Change 5. Give People Hope that Things Can Get Better 6. Stretch Perceived Limits 7. Are in Touch with a Fundamental Part of our Humanity.35 One of the biggest challenges that must be over- come in any organisation is to identify and breakdown the ways people reason defensively. Everyone must learn that the steps they use to define and solve prob- lems can be a source of additional problems for the organisation.36 H O W T O A C H I E V E T H E P R I N C I P L E S O F A L E A R N I N G O R G A N I S A T I O N The first step is to create a timeline to initiate the types of changes that are necessary to achieve the principles of a learning organisation; these changes are described in details by Gaphart as follows:37 STA GE O N E To create a communication system to facilitate the ex- change of information, which is the basis on which any learning organisation is built. The use of technology has and will continue to alter the workplace by ena- bling information to flow freely and to “provide uni- versal access to business and strategic information.” STA GE T WO To organize a readiness questionnaire, which acts as a tool to assess the distance between where an organisa- tion is and where it would like to be, in terms of the following seven dimensions: 1. Providing continuous learning 2. Providing strategic leadership 3. Promoting inquiry and dialogue 4. Encouraging collaboration and team learning 5. Creating embedded structures for capturing and sharing learning 6. Empowering people toward a shared vision 7. Making systems connections The questionnaire is completed by all employees or a TH E L E A R N I N G O R G A N I S AT I O N A N D H E A LT H C A R E E D U C AT I O N 213 sample of them; its results are then analysed to form an assessment profile, used to design the learning or- ganisation initiative. STA GE TH R E E To commit to developing, maintaining and facilitating an atmosphere that garners learning. STA GE F O UR With the help of all employees, is to create a vision of the organisation and write a mission statement. STA GE FI V E Through training and awareness programmes, is to try to expand employees’ behaviours to develop skills and understanding attitudes needed to reach the goals of the mission statement, including the ability to work well with others, become more verbal, and net- work with people across all departments within the organisation.38 STA GE SI X To communicate a change in the company’s culture by integrating human and technical systems. STA GE SE V E N To initiate the new practices by emphasizing team learning and contributions because employees will then become more interested in self-regulation and management, and be more prepared to meet the chal- lenges of an ever-changing workplace. STA GE E I GH T To allow employees to question key business practices and assumptions. STA GE N I N E To develop workable expectations for future actions.38 STA GE TE N To remember that becoming a learning organisation is a long process and that small setbacks should be ex- pected. C O N C L U S I O N A learning organisation encourages its members to improve their personal skills and qualities, so that they can learn and develop. They benefit from their own and other people’s experience, whether they are positive or negative. In a learning organisation, there are more opportunities to be creative and this helps ensure that any individual will be able to cope rapidly with a changing environment and move freely within the organisation. Effective leadership is the foremost requirement for the creation of a learning organisation, which is not based on traditional hierarchy, but based on a mix of different people from all levels of the system leading in different ways.39 Technological development may replace human resources in some other sectors, but not in the health sector. In the health field, there are very few options for equipment to replace humans. 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