Education Theory Made Practical 2: Organizational Learning

 (From the E-i-C: Here are links to the previous chapters in this series <Zone of Proximal Development; Transformative Learning Theory; Spaced Repetition Theory; Self-Determination Theory>  We need your help. Before we publish all of these chapters as an ebook, we want the health professions community to weigh in on the confusing, missing, and disputed sections of each chapter.  Please include your comments at the bottom of the post. We will acknowledge your contribution in the forthcoming ebook.)

Authors: Nathaniel Scott, MD; Tom Davis, MD; Simran Buttar, MD

Editor: Dimitrios Papanagnou, MD

What is your Educational Theory?
Name of Theory:

Organizational Learning

Main Authors or Originators:

Chris Argyris, Donald Schon, Peter Senge

Other important authors or works:

Jean Lave, Etienne Wenger

 

Part 1: The Hook
Emergency Medicine (EM) residents and faculty gather once a month to discuss morbidity and mortality (M&M) cases in your Emergency Department (ED). You are an associate program director for the EM residency. At one of these sessions, Louis, one of your first-year residents, recounts a case in which he took care of a patient with an ankle fracture that he successfully reduced in the ED with the assistance of a senior resident.  After the reduction, he placed a splint on the patient’s extremity and discharged the patient with the plan to follow-up with orthopedics.

One week after the patient was seen in the ED, Louis and the faculty member supervising the case received a message from an orthopedic surgeon, who was evaluating the patient in her outpatient clinic.  The orthopedic surgeon was concerned that the patient had suffered skin breakdown over both malleoli, and was suffering from significant pain. She noted that only one layer of cotton padding was used for the splint, which she noted was an inadequate amount of padding.

At the M&M conference, faculty and residents in attendance also agreed that an inadequate amount of padding was used. Several faculty and residents shared instances in the past year where an inadequate amount of padding was similarly underused for splints. The collective agreed that this was an important consideration to be mindful of when applying splints in the ED.

Two months later, a different resident presents a clinical case of a distal forearm fracture, in which the splint was noted to have an inadequate amount of applied cotton padding.  One of the faculty members asks in a frustrated voice, “Didn’t we just have this discussion two months ago?”

You wonder to yourself why your residents are continuing to make this same mistake. You begin to brainstorm different approaches to address this problem.

 

Part 2: The Meat
Overview of this theory

Organizational learning has been described as “the ability of an organization to gain insight and understanding from experience through experimentation, observation, analysis, and a willingness to examine successes and failures”.1 Core tenets of organizational learning theory include that it is individuals within organizations that learn, and that the systems of learning within organization facilitate or hinder individual learning.2,3

Different authors view organizational learning from either a behaviorist or cognitivist perspective, as organizational learning can be demonstrated to have occurred either when a change in behavior in response to a stimulus is observed, or when the assumptions, beliefs, and structure that make up a cognitive structure share within the organization change.

It is important to note the issue of scale.  An organization may be a small team; a department or division; or an entire business or organization.

Background About this Theory

The concept of organizational learning was popularized in the book, “Organizational Learning: A Theory of Action Perspective,” published by Argyris and Schon in 1978.2  In laying the groundwork for organizational learning theory, the authors describe several key concepts.  They view individual members of organizations as the originators and central actors in the learning process. They also described the model of single-loop and double-loop learning (Figure 1), which has been heavily referenced in business literature.  In single-loop learning, an organization responds by changing an action or strategy that led to a specific result. In double-loop learning, the organization takes an additional step back to reevaluate assumptions, objectives, and beliefs that may have led to the action or strategy.  Argyris and Schon hold a primarily cognitivist view of organizational learning, as they maintain that for learning to occur, learning should be embedded in the images that exist in individuals’ minds or the artifacts and programs within an organization.4

Capture

Figure 1: Single-loop and double-loop learning.1

The 1990 book, “The Fifth Discipline: The Art and Practice of the Learning Organization” by Peter Senge represents another highly referenced work on organizational learning.5  Senge agrees with Argyris and Schon that learning occurs within organizations through its individuals who learn. Senge describes five disciplines which make organization learning possible: personal mastery, mental models, building shared vision, team learning, and, the most important, systems thinking.  Rather than advancing the theory of organizational learning, Senge makes the case for the importance of organizational learning, and describes steps to take to achieve this in an organization.

Wenger and Lave advanced a social perspective of organizational learning in the 1990s.6,7 These authors introduced the concept of  “communities of practice” as a fundamental unit of learning, consisting of a group of individuals that develop shared tacit knowledge by actively working and learning together. In contrast to Argryis and Schon, who primarily describe organizational learning as a cognitive process, the emphasis of Wenger and Lave on participation and collaboration recognizes the real-life processes in which organizational learning takes place.8 Wenger summarizes these implications for organizations:

“For organizations, it means that learning is an issue of sustaining the interconnected communities of practice through which an organization knows what it knows, and thus becomes effective and valuable as an organization.”9

Modern Takes or Advances to this Theory

In recent years, the application of Organizational Learning has been discussed with increasing frequency in the business literature.  In a seminal Harvard Business Review Article, a “learning organization” is one that it is skilled at creating, acquiring, and transferring knowledge, and at modifying its behaviors to reflect new knowledge and insights.10 The five elements to this process include systematic problem solving; experimentation with new approaches; learning from experience and past history; learning from experiences and best practice of others; and transferring knowledge quickly and efficiently throughout the organization.

Learning organizations actively embrace the quality movement to generate ideas and collect information to feed the rest of the cycle. They are willing to experiment and form teams to create projects that will guide new approaches for an organization. An eye to the past is required to learn from previous successes and failures, as well as to look outside the organization (i.e., to national experts) to improve methods. Once a new method is identified, then the system can move quickly to share results of previous steps to change practices.

Examples of Application to Medical Education and Healthcare

While organizational learning is routinely referenced in the business literature, the term has started to appear in healthcare literature, typically in the context of patient safety and/or quality improvement efforts. Many thought leaders have proposed that healthcare systems be viewed as ‘learning’ health systems instead of ‘centers for learning’, referencing organizational learning principles.11 The application of organizational learning specifically to medical education, however, is infrequently described. A Medline search performed in August 2017 yielded only 13 papers that referenced both “medical education” and “organizational learning” as key words.  These papers cover various topics, such as addressing continuous professional development as a method to promote organizational learning within academic medical centers, and integrating in situ simulation to achieved improved clinical outcomes in health systems.12,13

Interestingly, organizational learning can be applied broadly in medical education. The leadership of a residency program may critically analyze the results of their recruiting efforts after the match process, applying principles of organizational learning to critically reflect on the assumptions and strategies that may have influenced the results of the process, and build on that knowledge in subsequent years. A team of residents and faculty members working together during an ED shift may uncover valuable insights regarding a new triage process; ensuring that this information is shared with the entire team working on improving triage processes will help create optimal conditions for organizational learning’s impact.

Annotated Bibliography of Key Papers on this Theory

Argyris C, Schon D. Organizational Learning: A Theory of Action Perspective. Reading, MA: Addision Wesley. 1978.

Argyris C, Schon DA. Organizational Learning II. Addison Wesley; 1996.

The aforementioned books by Argryis and Schon are among the most commonly cited works related to organizational learning. These works have popularized the term, discussed it as a theory of learning, and introduced concepts that remain frequently referenced (i.e., single-loop and double-loop learning).  They are written from a business perspective, and include case vignettes that serve as helpful examples to clarify some of the challenging terminology associated with this theory.

Senge P. The Fifth Discipline: The Art and Science of the Learning Organization. New York: Currency Doubleday. 1990, 2006 (2nd edition).

Senge’s book is considered by many to be a business classic, and is more accessible than the earlier works of Argryis and Schon. Theory is discussed less in this work; however, the application of organizational learning principles to practically create a learning organization is adequately emphasized.  While this book is written from a general business perspective, once can easily link ideas and applications with education in the health professions. The book covers a broad range of topics and concepts, which are not directly related to organizational learning.

Garvin DA. Building a Learning Organization. Harv Bus Rev. 1993;71(4):78-91.

Articles discussing organizational learning in the Harvard Business Review are relatively superficial, but serve as quick, easy-to-read introductions to the concept of organizational learning, and cite real-word examples of its applications. Articles focus almost exclusively on the application of organizational learning, and do not offer a critical appraisal of the theory. These articles offer an ideal starting point for someone interested in learning more about the concept of organizational learning.

Grumbach K, Lucey CR, Johnston SC. Transforming from Centers of Learning to Learning Health Systems: The Challenge for Academic Health Centers. JAMA. 2014;311(11):1109-1110.

This article discusses organizational learning within the context of academic medical centers. While the article defines organizational learning primarily from the lens of quality improvement, it offers a cogent and concise example of the application of organizational learning principles within the healthcare landscape.

Limitations of this Theory

The term organizational learning is essentially a misnomer – organizations themselves do not ‘learn’, rather it is individuals within organizations who learn. This may be confusing to some audiences.

The popularization and perceived broad applicability of organizational learning may pose as a limitation to this theory, as it risks being a concept with little meaning if it is applied to all situations at all times.  Additionally, its substantial overlap with quality improvement methodologies may lead to confusion for individuals aiming to integrate organizational learning into traditional pedagogical formats and venues.

Lastly, it should be pointed out that the increased discussion of organizational learning in popular business literature outlets has been superficial and universal. Consequently, organizational learning has not been adequately defined. This may obscure the potential for its additional practical applications on other domains, such as higher education.

 

Part 3: The Denouement
Immediately after the most recent M&M conference, you meet with your leadership team to discuss your observation that residents are not learning from these case discussions. You specifically want to discuss that there has been no tangible outcome or effort to disseminate the learning that took place around splint placement in the ED.

You consider the application of organizational learning principles to reframe monthly M&M conferences as an educational opportunity to sustainably improve patient care. You implement a process for the resident presenting at M&M conference to share the key learning points from the discussion with all residents, reinforcing learning for those in attendance and creating learning opportunities for those not present. The presenting resident is now also responsible for documenting these learning points in a central repository that can be reviewed and referenced by faculty and residents at any time.

In preparation for the M&M conference, you now ask residents to consider a series of questions when reflecting on their case to promote double-loop learning and systems thinking.  These include questions such as, “Did the culture of our ED contribute in any way the outcome?” and “Is there a gap in our formal curriculum that should be addressed to reduce the chance of this outcome in the future?

The next month, a case of Clostridium difficile colitis following an inappropriate clindamycin prescription for lower extremity venous stasis dermatitis was discussed. While discussing the case, the presenting resident noted that there are several mimics of lower extremity cellulitis, which are not extensively covered in the formal curriculum.  The residents and faculty in attendance also noted that this differential is rarely discussed explicitly on shift. A brief reference describing mimics of lower extremity cellulitis was created and shared with the residents and faculty. The presenting resident generated several ideas for a quality improvement project related to this topic, and planned a meeting with the medical director of the ED to discuss process changes with regards to patients being prescribed antibiotics for cellulitis.

Please leave your peer review in the comments below

References:

  1. Serrat O. A Primer on Organizational Learning. In: Knowledge Solutions. Springer, Singapore; 2017:359-365.
  1. Argyris C, Schon D. Organizational learning: A theory of action perspective. Reading, MA: Addision Wesley. 1978.
  2. Argyris C, Schon DA. Organiational Learning II. Addison Wesley; 1996.
  3. Leavitt CC. A Comparative Analysis of Three Unique Theories of Organizational Learning. 2011.
  4. Senge P. The fifth discipline: The art and science of the learning organization. New York: Currency Doubleday. 1990.
  5. Wenger E. Communities of practice: Learning, meaning, and identity. Cambridge: CUP. 2000.
  6. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge University Press; 1991.
  7. Göhlich M. Theories of Organizational Learning as resources of Organizational Education. In: Organisation und Theorie. Organisation und Pädagogik. Springer VS, Wiesbaden; 2016:11-21.
  8. Wenger E. A Social Theory of Learning. In: Illeris K, ed. Contemporary Learning Theories: In Their Own Words. Routledge; 2009:209-218.
  9. Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91.
  10. Grumbach K, Lucey CR, Johnston SC. Transforming from centers of learning to learning health systems: the challenge for academic health centers. JAMA. 2014;311(11):1109-1110.
  11. Davis DA, Rayburn WF, Smith GA. Continuing Professional Development for Faculty: An Elephant in the House of Academic Medicine or the Key to Future Success? Acad Med. 2017;Publish Ahead of Print. doi:10.1097/ACM.0000000000001777.
  12. Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: a systematic review. J Contin Educ Health Prof. 2012;32(4):243-254.