Working on a ward, nurses quickly realise if the manager is tough and quick to assign blame if mistakes occur, is not a good learning environment.

Contrast that with a nurse manager on another unit that recognises that nurses work in a complex environment and acknowledges that no nurse would willingly seek to harm a patient.

Which unit would report the most errors and make the most errors?

It turns out that nurses with a manager that was tough and quick to assign blame reported the least errors, yet made more errors.

The other unit reported more errors but were making fewer errors overall.

This occurred because the nurses with a nurse manager who understood that nurses worked in a complex environment and did not seek to harm were reporting more errors because they learnt from the errors and were not making the same mistakes again.

The unit that had a tough nurse manger, where nurses were afraid of speaking up because they feared the consequences. The opportunity of learning from mistakes did not occur.

And errors continued to harm patients.

Most people would think that reducing the penalties for errors would lead to an increase in errors.

The complete opposite occurs when nurses believe that reporting errors and near-misses as learning opportunities.

The confidence to report an error and know that accusations and blame will not occur will lead to a reduction in insurance claims and lawsuits.

Cognitive dissonance is where there is tension when your beliefs are challenged by evidence.

Most of us would think of ourselves as rational and smart.

We think of ourselves as capable of making sound judgements.

We think that we are not easily duped.

So when an error occurs, our self-esteem is threatened.

We become uncomfortable and terrified.

After all we know that these errors can have serious consequences.

So there are two ways to deal with that.

The first is accept that our original judgement is at fault but that is threatening.

The second is denial.

You could argue that the evidence as presented is wrong, (know as reframing).

This means that you can carry on knowing that you were right all along.

And you are able to retain the reassuring sense that you are smart and rational.

Cognitive dissonance is a deeply ingrained human trait.

The greater the consequences about our judgement, the more likely it is that you will manipulate any new evidence that calls your judgement into question.

Or you will ignore it all together.

Going back to the two units from earlier, the difference could not have been more stark.

One unit had a punitive culture and the other had a learning culture.

The consequences for patient care were different.

If you said to the punitive nurse manager that changing the culture to a learning environment, would result in fewer errors.

The challenge to that nurse managers judgment is enormous.

What seemed right is wrong.

Improvements will occur only when there is a willingness to learn from failure.

No one deliberately goes out of their way to make an error.

The reasons behind the error need to be investigated thoroughly.

It is laughable how far people will go to justify their decisions despite the contradictory evidence to the contrary.

You may not realise that you do it yourself.

There are two types of deception – external and internal.

Deceiving anyone has a clear benefit.

You know that you have deceived and privately you will acknowledge it to yourself.

Maybe you will change the way you do your work to prevent a future error from occurring.

But self justifying to yourself is insidious.

It eats away at the potential to learn.

How do you learn if you have convinced yourself that an error did not occur?

There is a benefit to self justification.

You will stop agonising over it and get a good night’s sleep.

But you will learn nothing.

In order to deal with the consequences of harming patients, health professionals reframe the evidence.

This protects their self worth and justifies non disclosure.

Cognitive dissonance allows good nurses to harm those they are caring for.

Not just once but again and again.

Learning from your mistakes improves care.

All nurses should hope to work in an area that encourages just that.

To learn more about cognitive dissonance and learning from failure:

Edmondson, Amy C. “Strategies for learning from failure.” Harvard Business Review 89.4 (2011): 48-55.