If you have determined that your organization’s work involves the interaction of complex technical, mechanical, legal or social systems, and small mistakes can lead to much larger, far-reaching and even catastrophic events, then you are likely in need of a high reliability culture.
The right kind of culture for your organization is determined by your goals. If you need to be “cutting-edge” to thrive in your market space, then a culture of innovation is appropriate. If you are in an industry with highly complex operations and need to avoid failure at any cost, then a high-reliability culture may be more appropriate.
In one way or another, culture helps to shape nearly everything that happens in and around an organization. As important as it is, though, it can be equally as confusing and hard to control. Work cultures seem to emerge as an unexpected by-product of randomness — a brief comment made by a manager, misinterpreted by direct-reports, propagated during water cooler conversations, and exaggerated by unrelated management decisions to downsize, reassign, promote, terminate, etc.
As we are all aware the oil and gas industry is currently deeply entrenched in a global downturn rooted in an enormous glut of oversupplied crude. It seems that each and every day we hear a different expert give their analysis of when this downturn will end and prices will rise but the consistent message is that we will not see rising crude prices until we can start burning a lot more than we produce, and for an extended period. While we at The RAD Group don’t participate in the speculation of crude prices, we certainly understand the impact that a weak sector can have on profits, morale, and just about every other KPI that companies measure. You may not be directly effected by this current downturn but you’ve probably been through one in your own industry or will at some time in your career. As you may also be aware as one of our readers, we do focus on the application of Human Factors science to improve the performance of individuals, teams, and entire organizations. To this end, let’s take a look at how organizations could use Human Factors principles to survive, and even thrive, in a market downturn.
As I write this, the Houston area is dealing with the aftermath of a 500-year flood that has left several feet of water in areas that have never flooded before. Some areas received 15- to 20-inches of rain in less that 6-hours which left all of the creeks and bayou’s overflowing their banks and inundating residential areas, displacing several thousand people and shutting down travel in much of the area. As I watched live television coverage of this event from my non-flooded home I was saddened by the impact on the lives of so many, but initially struck by the “stupidity” of those who made decisions that put their lives at risk and in a few cases cost them their lives. I began to try to make sense of why these individuals would make what appeared to be such fool-hearty decisions. What could they have been thinking when they drove past a vehicle with flashing lights right into an underpass with 20 feet of water in it? What could they have been thinking when three people launched their small flat-bottom, aluminum boat to take a “sight-seeing” trip down a creek that was overflowing with rushing waters and perilous undercurrents only to capsize, resulting in them floating in the chilly water for 2+ hours before being rescued by the authorities? As I reflected on it, and after my initial incredulous reaction, my conclusion was that it made perfect sense to each of them to do what they did. In the moment, each of their contexts led them to make what to me seemed in hindsight to be a very foolish and costly decision. You may be asking yourself….” What is he talking about? How could it make sense to do something so obviously foolish?” Let me attempt to explain. Context is powerful and it is the primary source we have when making decisions. Additionally, it is individual-centric. My context, your context and the context of the individual who drove around a barricade into twenty feet of water are all very different, but they are our personal contexts. In my context where I am sitting in my living room, watching TV, sipping a cup of coffee, with no pressure to get to a certain location for a specific purpose is most likely completely different from the man who drove around a police vehicle, with flashing lights, in a downpour, with his windshield wipers flashing, on his way to check on someone he cares about and who could be in danger from the rising water. What is salient to me and what was salient to him are very different and would most likely lead to different decisions. His decision was “locally rational”, i.e. it made perfect sense in the moment. We will never know, but it is very likely that his context precluded him from even noticing the flashing lights of the police vehicle or the possibility of water in the underpass. It is also possible that “human error” was present in the tragic deaths of at least 6 people during the flood, but human error is not a sufficient explanation. We can never really understand what led to their decisions to put themselves at risk without understanding the contexts that drove those decisions.
This is what we really need to focus on when we are investigating incidents in the workplace so that we can impact the aspects of contexts that become salient to our workers. The greater impact we have on minimizing the salience of contextual factors that lead to risk taking and increasing the salience of contextual factors that minimize risk, the greater opportunity we will have to end “senseless” injury and death in the workplace, and on rain swollen highways. This approach will have a lot more positive impact than just chalking it up to “stupidity”!
There are a lot of organizations working hard to create an organizational culture including a safety culture that will help ensure a productive and safe workplace. The quest to build from scratch or transform your organizational culture will prove costly if the process stops at quantifying, qualifying and communicating desired results. The essential next step is to ensure alignment of all the elements of the organization that will produce the desired results. What is “Alignment”? Alignment is simply ensuring that every aspect of the organization (people, teams, surroundings, and systems) works together to create desired results. We have previously introduced the concept of “local rationality”; i.e., people make decisions to perform in various ways as a result of the local context in which they find themselves. This context includes factors such as Self (motivation, ability, knowledge, habits, attention, emotion), Others (help, pressure, modeling), Surroundings (equipment, climate, layout) and Systems (rules, rewards/punishments, procedures). The person’s view of that context will impact how they act, which will impact the results that they get. Effective organizational leaders understand this and work to create a context (or “culture”) that increases the chances that their employees will decide to perform in ways that lead to accomplishment of the organizational mission. For example, when changing organizational policy on some issue like “incentive pay” (System), effective leaders will attempt to evaluate the impact of the policy on decision making at all organizational levels. If the policy provides incentive to produce at a higher rate, then it could lead to shortcuts in approved procedures and perhaps even create an incentive to cheat or perform in a less than safe manner. While increasing production, the policy would be “mis-aligned” with other desired results and thus become counter to overall organizational effectiveness.
Culture Alignment We have had the opportunity to help leaders evaluate this type of alignment on several occasions. We call our process “Culture Assessment & Diagnostics” and it involves three primary phases (Diagnosis, Design and Intervention).
Diagnosis If not already done, we have senior management articulate their desired “formal” organizational culture by defining the values and behaviors that they feel will support accomplishment of their mission. We then review Systems (policies and procedures) and Surroundings in light of their alignment with the desired culture. This is followed by interviewing a cross-section of employees at all organizational levels and segments to determine the real “informal” culture that exist. This information allows us to determine if “alignment” currently exists between people, systems and processes. We then deliver a report to senior management with our findings and recommendations.
Design The results of the Diagnostic Phase will provide the information needed to guide the design of any necessary change. Few organizations have perfect alignment and therefore most require some changes to achieve alignment. Management determines what changes are needed and then they design a plan to make those changes.
Intervention Every organization is different and thus needs different “interventions” to bring about the desired culture. Some organizations need training programs to impact employee knowledge and ability. Some need accountability systems to ensure consistent adherence to the desired cultural values and behaviors. Some need to change reporting structure. Once the plan has been determined, it is implemented and the appropriate changes will hopefully lead to greater alignment and thus greater effectiveness.
What’s the point? Whether you use a process like the one just described or not, continuous evaluation of alignment between formal and informal cultures is needed to remain or become an effective and safe organization. This is especially true if your organization is not currently getting the results that are expected.
I can’t claim to be an avid follower of college basketball. In fact, until this past Sunday I had not watched an entire game all season and certainly couldn’t tell you who the top teams or any of the players were. But that was until I discovered that my undergraduate alma mater (Stephen F. Austin) was playing Notre Dame in the second round of the NCAA basketball tournament. “March Madness” had struck me! I ended up watching college basketball all afternoon and evening, yelling at the television and even though my alma mater lost (by 1-point in the last 1.5 seconds of the game) I will be watching college basketball for the next couple of weeks. While some of you who are reading this are probably die-hard college basketball fans, many of you are like me and only become interested when the stakes are high (e.g., your team is playing to advance) or something else, like sitting in a sports bar with friends, makes watching more likely. As I started thinking about writing this blog, it hit me that safety observation and intervention are a lot like “March Madness”. Both normally occur under specific contextual conditions. Both are triggered by a change in the salience of certain aspects of the context that lead to watching and responding. My interest in watching college basketball changed when I learned that SFA was playing Notre Dame. Basketball became much more salient in my context, important to me personally and as a result changed my television viewing behavior. Watching the game led me to “intervene” even if it was simply yelling at the television and talking with my wife about the “great 3-point shot” or the “terrible call by the referee”. As a matter of fact, that change in salience led to me watching continuous basketball until it ended that Sunday and increased the likelihood that I will watch the rest of the tournament. Isn’t that what we want in our workplaces……employees predictably watching each other’s backs and intervening when they see something unsafe? While this analogy doesn’t perfectly translate to the workplace, it would seem to be close enough to provide some help.
So how can we translate this to increasing safety observations and interventions in the workplace?
Remember, I contracted “March Madness” upon learning that the stakes had increased for me, i.e. my alma mater was playing. It would seem that something analogous must happen in the workplace. First there must be an understanding that the stakes are high if we don’t watch each others’ backs. Our research indicates that this is already present in most workplaces. People consistently report that they feel a “moral responsibility" to keep each other safe, so simply reminding employees regularly of their role as a way to increase salience should be all that is necessary.
Secondly, just like I “watched” the games, we need for our employees to attend to the risks and behaviors of others in their contexts. While I don’t need to learn how to watch television, I do need to be aware of the rules of the game, pay attention to the screen and interpret what I see. This has happened for me over time, but in the workplace we need to teach employees what situations and behaviors are high risk in an attempt to increase the salience of those situations and behaviors. This requires training, but also regular reminders through safety and pre-job meetings. While watching basketball on television I have the announcers constantly predicting and interpreting play which acts to direct my attention. That should be the role of each employee, but especially the on-site supervisor. That person’s primary job is to direct attention for their employees.
But what about intervention? I don’t need any training on how to yell at the television when there is a bad call or cheer for my team when they make a good play. But our research indicates very clearly that employees for the most part, while mindful of their role in intervention, don’t necessarily feel competent to do so. They know that “yelling” at each other has a high probability of leading to defensiveness and anger. In other words, while we can get “March Madness” into our workplaces from a motivational and observational perspective, getting the right kind of intervention does not come naturally. Our research and experience demonstrate that providing employees with the right kind of intervention skills increases their competence while simultaneously leading to an increase in confidence and an increase in intervention frequency and success.
The NCAA basketball tournament only happens once a year but safety observation and intervention are a year round necessity. Maybe we can replicate the “March Madness” process to improve safety all the time!
Have you ever observed someone acting in an unsafe manner and immediately attributed their action to lack of motivation to perform safely? Research, including our own demonstrates that we tend to do exactly that more than 80% of the time, but when we personally act unsafely we attribute our decision to outside, situational forces rather than internal dispositional forces over 90% of the time. Attribution theories of motivation are explanations of how we attempt to understand our environment, including the behavior of others, and ourselves, by attributing/inferring causes to behavior that we observe. These theories are helpful in explaining how we attempt to understand performance, but the fact that we do attribute such causes to behavior is not really helpful in our personal understanding of motivation. In fact in many cases this tendency causes us to inaccurately infer cause and then react to the action of others incorrectly, i.e. commit the Fundamental Attribution Error. The attributional approach typically does not take into account many other potential causes of unsafe action including situational/contextual contributors. Competence theories of motivation, on the other hand are based on the premise that individuals want (are intrinsically motivated) to interact effectively with their environments. Psychological researchers such as Albert Bandura (Social Cognitive Theory, 2001) and Edward Deci and his associates (Self-Determination Theory, 2000) have helped us understand what really produces our motivation to perform in certain ways. They propose that we are trying to effectively engage our environments in ways that make sense given our current understanding of the components of that those environments. Interestingly, according to Self-Determination Theory we are seen as primarily intrinsically motivated to be simultaneously autonomous and competent and the more successful we are at both of these, the more intrinsically motivated we become.
So why is this important? How do these theories relate to motivating people to minimize risk and work more safely?
Simply attributing internal motivational causation (Attribution Theories) to unsafe performance creates the opportunity for execution of the Fundamental Attribution Error which is usually negative, often wrong and often leads to blame. Additionally, it doesn’t help us understand where the motivational state came from in the first place or how to control it. Viewing the individual as a complex entity who is actively attempting to understand and engage his environment (Competence Theories) would seem to be much more fruitful. If we “engineer” that environment (context) to increase intrinsic motivation we would have a greater opportunity of developing employees who are competent, take initiative and work more effectively together. Consider the following. What if we allowed participation (autonomy) in decision making about those aspects of context that are open to input? What if we explained the reasons for safety rules, limits, etc so that autonomy could be supported? What if we made sure that consequences for what turns out to be intentional rule breaking are clearly understood? The idea is to create a work context where people will adhere to safety rules and procedures, not because they are coerced to do so, but because they feel autonomous and competent in doing so; their reason for doing so is their own and they accept responsibility for doing so. They are intrinsically motivated to be safe. Not many people want to get hurt, so capitalizing on the intrinsic desire for safety would seem to make a lot of sense. Deci’s research (1995) demonstrates that the more controlled people feel (i.e., the less autonomous they feel) the more likely they are to engage in risky behavior. Isn’t it ironic that most safety programs attempt to control behavior when it is just the opposite that has been shown to motivate behaviors that lead to safety?
As our world and workplaces grow in complexity, and as failures in these complex systems become increasingly calamitous, how do we take the insights that have been given us by so many dedicated and brilliant individuals, and make things better for the people who, whether we want to think about it or not, will suffer and die if we don’t adapt? It’s a heavy question, and one that’s been on our minds for a while.
You might not have known but, between blog posts and our day jobs, we’ve been writing a book. In fact, we are now in the final phases of writing this book called, “The Safety Switch℠,” which aims to tie together our research and the priceless contributions made by scholars and practitioners from a wide range of disciplines.
We thought it was about time to introduce the premise.
The Safety Switch℠ is a way of thinking about how we can adapt to a new world — one in which organizations are understood as complex systems, and the ever-increasing complexity of these systems presents new challenges.
The “Switch” happens at two levels.
First, it is a micro-level, personal, in-the-moment switch between two mental Modes. Our default setting, Mode 1, is powered by mental shortcuts (called “heuristics”) and distortions (called “biases”) and often leads us to fix upon human error as the cause of safety problems. While we may be “wired” to stay in this default mode, we can deliberately switch to a second Mode. When in this Mode 2, we take a rigorous, effortful, sometimes counterintuitive, and often winding path to understand and address persistent safety challenges.
Second, there is a macro-level, organizational switch. It involves activating within the organizational system an inherently dynamic layer of protection — it’s people — positioning humans as a unique and requisite response to growing complexity.
But here’s the catch: You can’t flip the second switch until you flip the first.
We have to learn when and how to switch from Mode 1 to Mode 2 in the moment and on the fly if we are going to generate the capacity to flip the second switch, and energize within our organizations this vital, dynamic and fully integrated layer of protection — the people.
Neurological research has helped us better understand some of the developmental and age related changes in cognitive functioning and performance, including risk tolerance (see Complexity, Age and Performance). We have proposed that these findings provide additional support for the need to have older and younger workers learn to work together so as to capitalize on their age-related strengths, i.e., older workers + younger workers = better decisions. The problem is that there are also very strong age related stereotypes that inhibit the effectiveness of this suggestion. Therefore, we need to understand the role that stereotypes play in the interactions of various age groups in the workplace so that we can create environments where negative stereotypes are minimized or overcome. Stop for a moment and describe the characteristics of people who are 20 years of age, 40 years of age, 60 years of age, and 75 years of age. If you are honest with yourself, you will have some overlap in your descriptors, but you will also have differences and if you are also honest you will find that there are more negative characteristics identified for age groups to which you do not currently belong. If you think about it you will also most likely find that your descriptions don’t necessarily accurately describe every person that you know within each of those age groups. We all function with age related stereotypes but we also know that there are individual differences. The problem is that until we know a given individual, our stereotypes tend to guide our perceptions and expectations of that person. In fact, when our expectations are strong, we will overlook invalidating evidence of our stereotypes and foster what is called a “self-fulfilling prophecy (SFP)” through our actions toward the other person. In other words, our stereotypes will tend to override our search for individual differences, or exceptions, and simultaneously help create the behavior that we expected in the other person. For example, research has demonstrated that performance is improved when it follows an interaction driven by a positive stereotype but decreased when it follows an interaction driven by a negative stereotype (e.g., Hausdorff, et al, 1999). Likewise, the behavior resulting from the interaction will strengthen our stereotype and if that behavior is perceived negatively, e.g., inflexible, know-it-all, etc., we will likely become less willing to work with or listen to the other person and this makes our objective of “better decisions” more difficult to attain.
So how do we overcome the negative impact of our stereotypes?
We have been helping supervisors and managers deal with the impact of their negative stereotypes for the past 30+ years and the process, while simple requires understanding and effort. First, we help them evaluate and understand their stereotypes, especially their negative stereotypes and the role that they personally play in creating SFP’s. Second, we help them think about specific individuals with whom they interact and then have them honestly evaluate the role of negative stereotyping on both their expectations of the person and the impact of their interaction on the behavior of the person. In other words, we help them understand that because everyone is different we need to look for those individual differences rather that viewing everyone of a certain age as the same. Third, we have them evaluate the positive aspects of these individuals, especially those characteristics that can be beneficial to other team members and the organization. Finally, we have them commit to a regular review of their stereotypes and evaluation of how those stereotypes are impacting their relationships. Our objective is to improve interactions and relationships by minimizing the impact of negative age related stereotypes. If we are going to create “better decisions” through the interaction of older and younger workers we will first need to positively impact stereotypes that are currently leading to reduced respect and willingness to listen, learn and depend on each other.
We live and work in environments that are continuously increasing in complexity, which puts an even greater strain on our ability to make quick, accurate decisions. (See Human Error and Complexity: Why your safety “world view” matters). Among the many important considerations for organizational leaders is how age affects people’s decisions and performance in these complex environments. Though the cognitive and socio-emotional skills of younger workers (under 25 years of age) are still developing (see Protecting Young Workers from Themselves), this group is at its peak performance with respect to speed of information processing and physical abilities…including vision, hearing, strength, flexibility and reaction time.
On the other hand, the opposite is generally true of the 55+ age group, even though there are individual differences. Aging tends to bring with it a decline in just about all of these physical abilities as well as some cognitive abilities. (Note that we are talking about “normal” aging, absent significant pathology such as Alzheimers and Dementia.)
While research has demonstrated that aging has little or no effect on general intelligence, it can impact other aspects of cognition. The aging brain is slower to shift attention to new stimuli in the environment and also slower to recall uncued relevant information. Additionally, short term (“working”) memory functions less efficiently with age. While an older worker might make fewer mistakes in decision making, he or she will normally require more time to make those decisions. So when a task is complex and requires the manipulation of information or ignoring irrelevant information, there may be age related decline in performance (e.g., Balota, et al, 2000), especially when the older person is under pressure to perform. In short…
Complexity + Time Pressure = Kryptonite for the Aging Brain
Left at that, it would be bad news for the aging worker in our increasingly complex and fast-paced world. HOWEVER, as with nearly everything in life, there are more pieces to this puzzle. Two of these pieces are experience and contextual cues. Research has shown that older adults tend to perform well on recognition tasks where contextual cues are present. This could help explain their lower incident rate relative to younger workers, since older adults recognize and process contextual cues effectively because of their past experience. They are more likely to recognize a hazard as a hazard because they have experienced it in the past. In short…
Contextual Cues + Experience = The Great Equalizer
Adolescents and young adults don’t have the experience with contextual cues that older adults do, so they are less likely to recognize them and respond to them. Younger workers’ higher speed of processing is offset by their lack of experience with contextual cues…and vice versa with older workers. These findings provide additional support for the need to have older and younger workers learn to work together so as to capitalize on their age-related strengths. In short…
Older Workers + Younger Workers = Better Decisions
Unfortunately, there are common and misguided stereotypes about both younger and older workers, which can keep us from honestly exploring the many ways that they may contribute to organizational success. Understanding the truth about the developing brain of younger workers and the aging brain of older workers may just be a key to thriving in our increasingly complex world.
Change is in the air, or at least on the minds of American football fans, political junkies, and those looking at making that big New Year’s resolution. It seems that change has always and will always be a hot topic. In other words, nothing has changed in regards to change. So why is it that change is so intriguing yet elusive to us all? Oddly enough, the answer may be found in a topic at the forefront of American culture, college football. While there is a long history of teams in the Midwest, particularly the Big Ten, being powerhouses, this hasn’t been the case in recent years. In fact, most recently the landscape of college football has been dominated by a couple of teams on the West Coast and, to a larger extent, in the Deep South. Looking at the era from 1998-2013, the national champions have resided either in Southern California or the South 15 of 16 years, with the lone exception being Ohio State in 2002. If you asked the experts, this was less of a cyclical trend and more of a shift into what the future of college football would look like from now on. However, the last two years shows that may be changing.
What’s Behind It?
One reason that so many struggle with change is that they fail to understand the basic mechanisms behind it, simply floating adrift in the winds of change with no means for navigation. Let’s looks at three very basic mechanisms of change and how we can use them in driving change in our own lives and organizations.
Acceptance of Change
We all tend to be change adverse at some level. Some of the best organizations in the world have entire departments who do nothing more than manage change within the company. One of their main functions is to determine when people are resistant to change and how to compel them to accept the change the organization is wanting to make. We’ve all had that moment in our own lives that we realized that we simply can’t keep doing things the way we’ve always done them and expect to get different results, but that doesn’t make it any easier to accept that we need to make big changes.
Over the last decade warm weather schools have dominated college football. Not only did they have a deep pool of talent located close by, they were getting some of the best players from the North to come down to warmer climates. Warm weather schools have an embarrassment of riches in talent, and they used these talents to evolve the spread offense to such impressive levels that football scores started to resemble basketball scores. Meanwhile the Big Ten continued to lag their friends to the South in recruiting and offensive numbers. The powers-that-be at these Big Ten institutions knew they had to make big changes or risk the game leaving them relevant only in history books.
Change is Rooted in Complexity
Anybody that tells you that making a change is simple and you need to just do one simple thing fails to understand what is driving the performance of people. If you’ve read many of our blogs you have seen the term complexity used quite often. Simply put, human performance happens in response to multiple stimuli. No one thing, by itself, is salient enough to sustainably drive a change in performance, instead multiple factors are almost always at play when lasting change takes effect. In fact, the performance itself is simply a byproduct of the stimuli in which people find themselves. In our blog Complexity and Local Rationality we detail that people don’t behave in certain ways simply because that’s what they want to do but because that’s what seems to be the logical thing to do given their context. In other words, getting people to want to change is far less important than helping them see that change is actually the logical thing to do and helping them understand that when the change is made it will take changing several factors to make the change stick.
In 2014 Ohio State was ranked #16 in the first College Football Playoff Poll. After an opening week loss to Virginia Tech they had become an afterthought in terms of playing for a national championship. Two months later they soundly beat an Oregon team to win the national championship, stopping a 7 year streak of SEC teams winning the national title. In the 2015 season not only Ohio State, but Michigan State, Iowa, and Northwestern are ranked in the top 14 teams in the country at the end of the regular season, making the Big Ten arguably the dominant conference in college football. Where did this change come from so fast? The answer is nebulous but can be argued that many things led to this change. Former Northwestern Graduate Assistant coach Kenji Jackson says he saw several things happen over the last few years that has changed the way Big Ten football recruits players and performs on the field.
- Several assistant coaches hired from the South brought their recruiting networks with them
- Satellite camps from Big Ten schools held in the Deep South in Summers to recruit the best from that region
- Lowering of academic standards in some Big Ten schools
- Social media and video sharing tools such as Twitter and Hudl where recruits could gain instant access to college coaches around the country
- A change in offensive philosophies in the Big Ten that has coupled the fast paced spread offense with the traditional smash mouth run game.
These were just a few of the examples that Coach Jackson immediately saw happening in the Big Ten the last few years. While there is no measurable correlation, each of these probably have impacted the resurgence of Big 10 football.
Agents of Change
To drive change in organizations you have to have the right person/people at the wheel. This doesn’t necessarily mean you have to have a CEO that drives the change throughout the organization, you simply have to identify the right people, the social centers of gravity, that will intentionally drive the change. This could be senior leadership, front line supervisors, key front line employees, or any combination of the above. However, you have to find the right person/people who know the vision of where the organization wants to go and who have the hearts and minds of the masses to make them follow.
In the case of the Big Ten nobody has driven this change more than Urban Meyer. Coach Meyer has been successful at every stop, from Bowling Green, to Utah, to Florida, and ultimately Ohio State. He not only brought a fresh perspective for running a cutting edge new offense to the league, he brought new blood with his coaches and players that he recruited from outside the region, and viewership that meant more TV dollars that help all of the teams in recruiting.
One of the biggest aspects of change that Coach Meyer brought to Ohio State was the willingness to change. Braxton Miller was the starting QB when the season started in their championship season of 2014 but missed the majority of the season due to injury. When he returned in 2015 he was asked to move to receiver and did so. Now none of us on the outside know how that change was received at first but the change was made and Braxton Miller has played exceptionally well at the position and will probably be playing receiver in the NFL next season. He built the blueprint for winning in the Big Ten in modern day football and other teams have benefited by following that blue print while putting their own tweaks in the plan itself.
The Real World
What does this have to do with making change in my own life or in my company you may ask. This analogy is not just the musings of a college football fan but a case study in how we can all drive big change in performance across dynamic and complex organizations. There are more aspects to change than just these three points but if we can start to understand how a loosely jointed group of higher learning institutions changed the way America views their football programs we can start to understand how we get our organization to be better at changing HR software programs or adhering to a new company policy on environmental record keeping.
First, understand that people tend to be resistant to change. This isn’t merely a weakness of the human spirit, but more likely a weakness in organizational context. We can and should compel, encourage, and reward people to accept positive change, but we can’t expect change to stick until we understand the context in which people work.
Next, understand that making change is not a one off effort. People are doing things because the context in which they work makes it locally rational to do it that way. You can’t change any one thing and create sustainable change. In Step 1 above you have encouraged your team to accept change and begun to understand the context that is driving their resistance. It will take effort and resources across the board to make changes to this context and make the change stick.
Lastly, identify the right agents of change. It may be a senior leader, a committee of front line leaders or even your front line workers but you have to find the people who see the vision, understand the strategy for making change, and who people will follow to make the change sustainable.
In a recent blog (Protecting Young Workers from Themselves) we discussed some of the reasons for the relatively high risk tolerance of young (15-24 years old) workers compared with older workers. We concluded that while there is still cortical structure development during this developmental period that this alone does not explain why this age group is at a higher risk of engaging in unsafe actions and suffering the consequences of those actions. The research demonstrates that the less developed limbic system which is involved in both social and pleasure seeking behavior can at times override the logical capabilities of the young workers and stimulate them to engage in risky behavior. Because educational programs designed to provide the young workers with the knowledge necessary to effectively interpret their contexts has not proven overly successful, we proposed that one way to impact their risk taking in the workplace is to remove social stimuli such as peers from their work teams and replace them with older, more risk averse and experienced workers, especially those in the 55+ age group. We suggested that these older workers who understand and can interpret the various workplace contexts could provide mentoring and coaching for the younger workers. This however introduces another set of issues that must be addressed if this approach is to have the desired impact. These issues include the perceptions/stereotypes/expectations of each cohort group by the other and the skills necessary to impact those perceptions/stereotypes/expectations. We all have a tendency to focus on actions and traits of other people that fit with our expectations and stereotypes of the groups to which that person belongs, including the person’s age. We also tend to behave toward that person based on what we perceive them doing and they do likewise to us. The problem is that what we “see” is driven by what we “expect to see” and often results in a phenomenon known as the “Self-Fulfilling Prophecy (SFP)” which also reinforces our stereotypes and thus our future interactions. For example, an older worker observes a younger worker engage in some risky behavior and because the older worker views younger workers as thinking they are “bullet proof” he immediately criticizes the younger worker for his failure to “think”. The younger worker who did what he thought was the right thing in the situation becomes defensive toward the “judgmental/rude” older worker and “smarts off” to him. This causes the older worker to become defensive and the cycle continues, reinforcing the SFP and strengthening the stereotypes held by both individuals (see “Your Organization’s Safety Immune System (Part 2): Strengthening Immunity” for a more in-depth discussion of defensiveness).
The question is how do we utilize the older workers as coaches for the younger workers without the negative impact of the SFP? The key is to change the expectations that both age groups have of each other and this requires training. Facilitated, interactive training programs that address the common impact of the SFP, help people of all ages understand the role of individual differences in performance, teach people how to deal with the Defensive Cycle™, and give them opportunity to interact successfully with each other tend to produce environments where both older and younger workers can capitalize on the strengths that each bring to the table. While younger workers bring less socioemotional maturity and experience, they also bring creativity, physical strength and a fresh view of the work context. Older workers bring the experience and a broader understanding of the work context that can help younger workers make better, less risky decisions. The key is mutual understanding and mutual respect which come from less stereotyping, less defensiveness and more teamwork.
Can we all agree that people tend to make fewer mistakes when they slow down and, conversely, make more mistakes when they speed up? And people tend to increase their speed when they feel pressure to produce? Personal experience and research both support these two contentions. Deadlines and pressure to produce literally change the way we see the world. Things that might otherwise be perceived as risks are either not noticed at all or are perceived as insignificant compared to the importance of getting things done. Pressure and Perception
A famous research study by Darley & Batson (1973), sometimes referred to as “The Good Samaritan Study”, demonstrated the impact of production pressure on people’s willingness to help someone in need:
Participants were seminary students who were given the task of preparing a speech on the parable of the Good Samaritan — a story in which a man from Samaria voluntarily helps a stranger who was attacked by robbers. The participants were divided into different groups, some of which were rushed to complete this task. They were then sent from one building to another, where, along the way, they encountered a shabbily dressed “confederate” slumped over and appearing to need help. The researchers found that participants in the hurry condition (production pressure) were much more likely to pass by the person in need, and many even reported either not seeing the person or not recognizing that the person needed help.
Even people’s deeply held moral convictions can be trumped by production pressure, not because it has eroded those convictions, but because it makes people see the world differently.
The Trade Off
One reason for this is that many of our decisions are impacted by what is known as the Efficiency-Thoroughness Trade-off (ETTO) (Hollnagel, 2004, 2009). It is often impossible to be both fast and completely accurate at the same time because of our limited cognitive abilities, so we have to give in to one or the other.
When we give in to speed (efficiency) we tend to respond automatically rather than thoughtfully. We engage what Daniel Kahneman (see Hardwired to Jump to Conclusions) refers to as “System 1” processing — we utilize over-learned, quickly retrieved heuristics that have worked for us in the past, even though those approaches cause us to overlook risks and other important subtleties in the current situation. This is how we naturally deal with the ETTO while under pressure from peers, supervisors or organizational systems to increase efficiency.
Conversely, when we are not under pressure to increase efficiency, but, rather, pressure to be completely accurate (thorough), we have a greater tendency to engage what Kahneman calls “System 2” processing — we are more thorough in how we manage our efforts and account for the factors that could impact the quality of what we are producing. In these instances, we will notice risks, opportunities and other subtleties in our environments, just as the “non-rushed” participants did in the “Good Samaritan Study.”
So what is the point?
Most of our organizations are geared to make money, so efficiency is very important; but how do we bolster the thoroughness side of the tradeoff to support safety and minimize undesired events? To answer this, we have to take an honest look at the context in which employees work. Which is more significant to employees, efficiency or thoroughness? And what impact is it having on decision making?
Some industries (e.g. manufacturing) have opted to streamline and automate their processes so that this balance is handled by interfacing humans more effectively with the machines. Some industries can’t do this as well because of the nature of their work (e.g., construction). We worked with a client in this later category that had a robust safety program, experienced employees and well intentioned leaders, but which was about to go out of business because of poor safety performance…and it had everything to do with the Efficiency-Thoroughness Trade-off. The contracts that they operated under made it nearly impossible to turn a profit unless they completed projects ahead of schedule. As they became more efficient to meet these deadlines, the time-to-completion got shorter and shorter in each subsequent contract until “thoroughness” had been edged out almost entirely. For this company, preaching “safety” and telling people to take their time was simply not enough to outweigh the ever-increasing, systemic pressure to improve efficiency. The only way to fix the problem and balance the ETTO was to fix the way that contracts were written, which was much more challenging than the quick and illusory solutions that they had originally tried.
Every organization is different, so balancing the ETTO will require different solutions and an understanding of the cultural factors driving decision making at all levels of the organization. Once you understand what is salient to people in the organization, you can identify changes that will decrease the negative impact of pressure on performance.
Looking back at your younger self, did you ever do something that now seems foolish and excessively risky? We have talked about the phenomenon of “local rationality” several times in the past, which is how our reasoning and decisions are heavily influenced by our immediate context. We are all subject to its impact, including yours truly (see “A Personal Perspective on Context and Risk Taking”), but perhaps even more so when we are young, especially between the ages of 15 and 24. The data are clear. Adolescents and young adults are more likely to engage in risky behaviors than are adults (especially older adults) and workplace incidents are more frequent among this age group.
So is it because young workers are less experienced, poorer decision makers or inherently more risk tolerant? The answer is likely “yes” to all of these questions, but it is more complicated than that. Understanding why young workers do risky things requires an understanding of the neural mechanisms that are at play in these types of situations. While it's a heady topic (forgive the pun), understanding neural development can be of extreme importance when attempting to protect our younger workers.
It has been suggested that the adolescent brain's (cortical) structures - those involved in logical reasoning and decision making - aren't completely developed, which contributes to risky decisions and behaviors. While it is true that the frontal cortex continues development into young adulthood, research demonstrates that, by age 15, logical reasoning abilities have already development equal to those of adults. In fact, 15-year olds are equal to adults at perceiving risk and estimating their vulnerability to that risk (Reyna & Farley, 2006).
In light of this type of evidence, Steinberg (2004; 2007) has proposed that risk taking is the interaction of both logical (cognitive) reasoning and psychosocial factors such as peer pressure. Unlike the logical reasoning abilities that have developed by age 15, the psychosocial capacities that impact logical reasoning have not developed until the mid-twenties and therefore interfere with real-world decision making and risk aversion. In other words, the mature decision making processes of adolescents and young adults my be interfered with by the immature psychosocial processes of this group, and reasoning only shows maturity when these psychosocial factors are minimized...for example, when there are no peers around to pressure them.
Additionally, the limbic system, which is integral to socioemotional processing and also the center for experiencing pleasure, is less developed and highly sensitive in adolescence. Because of this, they will put themselves in high risk situations in the hope of experiencing the “high” that comes from a dopamine rush. Even though the frontal cortex (executive function) is more advanced, the “thrill” that comes from the risk can overpower the logical functions of the brain and lead to risk taking, especially when under stress or fatigue. In other words, at this age, the attraction to rewards causes young adults to do exciting and perhaps risky things while their poor self-control makes it hard for them to slow down and think before acting, even when they know that the risk is present.
So what does this mean for protecting this age group. According to Steinberg (2004), attempts to reduce risk taking in this group by improving their knowledge, attitudes or beliefs have generally failed. Changes to their decision making contexts, by removing peers from the team and having older adults observe them, have had a much greater impact on reducing risk taking behaviors. Rearranging teams, so that young workers are not with their peers, minimizes the impact of negative psychosocial factors on their decisions and is a first step in protecting young workers from their own developing brains. Additionally, teaming young workers with older workers, who have been trained to observe and effectively intervene in their younger counterparts' unsafe performance, will also reduce incidents among this age group. It is, however, very important that mutual respect be nurtured so that coaching does not trigger defensiveness. Creating contexts that minimize the impact of negative psychosocial factors on logical decision making is one way to protect young workers from themselves.
In our last blog, we explored how team members can support each other by intervening effectively in unsafe situations. [Your Organization’s Safety Immune System (Part 2): Strengthening Immunity] Now we will look into something slightly different: How coworkers can prevent risks by supporting each other. In other words, how helping each other improves safety performance. There are clear safety implications when, for example, an experienced employee goes out of her way to teach a new-hire how to use a tool correctly, or when an employee drops what he is doing to help a coworker lift a heavy object. While the organization's culture can impact people's helpfulness (or lack thereof), people either do or don’t help for other reasons as well.
It is generally recognized that there are two forms of helping behavior, both of which are present in the workplace. One is referred to as "egoistic helping," in which the helper does so because he either wants something in return or desires the positive feeling that comes from helping. The other form is referred to as "altruistic helping" because the helper expects nothing in return and helps only to benefit the other person.
Altruistic Helping: The helper adopts the perspective of the other person (which is called "empathy") and helps out of a desire to benefit or reduce any negative impact on that person. For example, people donate money to a disaster relief effort because they empathize with and want to alleviate the suffering of those affected.
When team members truly care about each other's wellbeing, altruistic helping is more likely to occur. This is sometimes referred to as "active caring" and it is an important foundation for teamwork and team support. Organizations that take steps to increase empathy among team members will likely see an increase in altruistic helping behavior.
Egoistic Helping: The helper does not adopt the perspective of the other person, but helps in an attempt to further his own positive feelings, secure personal gain or create indebtedness. For example, people donate money to a disaster relief effort because the donation is tax deductible and it feels good to support the cause. Egoistic helping isn't bad...just less "noble" looking than altruistic helping.
Research has shown that positive emotional states increase helping behavior (e.g., Cunningham, 1979). Workplaces that produce pleasant, optimistic, hopeful feelings (in other words, "high employee morale") will have people helping each other more often. An explanation for this phenomenon is that people want to maintain their good mood, and helping others is one way of accomplishing that desire. As such, a workplace that promotes positive feelings also appears to increase egoistic helping behavior.
The Point: If an organization wanted to increase helping behavior within it's workforce, it would do well to set its sights on (1) interpersonal empathy and (2) employee morale. It might at first seem that these are too "wishy-washy" to have any place in safety management, but there are quite tangible steps that can be taken to improve both.
*Looking back on our previous blog, we see implications for safety intervention as well. Interpersonal empathy and employee morale may also increase the likelihood that people will intervene in unsafe situations; but neither is sufficient. Even when people want to intervene, most will not until they are confident that they can do so effectively and without creating social tension. People also need to learn how to intervene.
In a recent blog (Your Organization’s Safety Immune System) we talked about people being the “white blood cells” of our "safety immune system", but also that we have to help them become competent to do so. People care about the safety of others, but most people do not have the natural ability to conduct a successful intervention discussion. Isn’t it ironic that most organizational leaders assume that their employees have that very ability when they tell them to intervene when they see something unsafe. It takes skill to successfully tell someone that their actions could lead to injury. Many times people don’t intervene because they are afraid of reactance/defensiveness on the part of the other person. Having the skills to deal with defensiveness is essential to being willing to enter into this potentially high stress conversation in the first place. Success involves understanding where defensiveness comes from, how to deal with it before it arises and what to do when we encounter it both in others and in ourselves. The intervention conversation is not a script, but rather a process that involves understanding the dynamics of the inhibiting forces and development of a set of skills that lead to effective communication. Defensiveness. We have all experienced defensiveness both in ourselves and in other people. Defensiveness arises because we perceive that we are under attack. We are naturally inclined to defend our bodies and our property from danger, but we are also naturally inclined to protect/defend our personal dignity from criticism and our reputation from public ridicule. When we perceive that our dignity or reputation are threatened, we defend either internally by retreating/avoiding or externally by pushing back either physically or verbally. Thus we enter the Defensive Cycle™.
When we see someone doing something undesirable, such as acting in an unsafe manner we automatically attempt to understand why they are doing it and most of the time we automatically attribute it to something internal to the person. This leads to the well-documented phenomenon of the “Fundamental Attribution Error” (FAE), whereby we have a tendency to attribute failure on the part of others to negative personal qualities such as inattention, lack of motivation, etc., thus leading to the assignment of causation and blame. When you fall victim to the FAE you will likely become frustrated or even angry with the other person, and if you enter into a conversation, you will likely come across as blaming the person, whether you mean to or not. When the other person perceives you blaming, they will most likely guess that you are attacking their dignity or reputation, whether you mean to or not. When this happens they naturally become defensive. In turn, if the person gets quiet (defends internally), you will guess that you were right and they took your words to heart so you will expect performance changes which may or may not occur. If, on the other hand, the person becomes aggressive (defends externally), you will guess that they are attacking your dignity or reputation and you will then become defensive and either retreat or push back yourself. And the cycle goes on until someone retreats, or until you are able to stop the defensiveness and focus not on the person but on the context that created the unsafe performance in the first place. You have to change your intent from blame to understanding and you have to communicate that intent to the other person.
Recognizing that we are in the Defensive Cycle™ is the first step to controlling defensiveness and conducting a successful intervention. It is at this point that we need to stop and remember that when people engage in unsafe actions it is because it makes sense to them (local rationality) given the context in which they find themselves. When we commit the FAE we are limiting the possible causes of their decision to act in an unsafe manner to their motivation and/or other internal attribute and then allowing that guess to create frustration which causes us to come across as blaming the person. Recognizing that there could be other contextual factors driving their decision will reduce our tendency to blame, stop the defensive cycle before it begins and significantly increase our chances of having a successful intervention discussion.
Over the past decade we have trained many frontline workers and supervisors/managers in the skills needed to deal with defensiveness, hold an intervention discussion and create sustained behavior change. We have also found that following training, interventions increase and incidents decrease as a result of simply creating competence which leads to confidence, thus strengthening the “white blood cells” needed for the "safety immune system" to work.
Have you ever considered that organizations in many ways are like living organisms? While there are obvious differences between organizations and living organisms, the metaphor can be helpful in understanding how to keep people safe in the workplace. Like a living organism, organizations are made up of complex, interacting components and systems that allow the organization to survive, flourish and grow. One of those systems in a living organism is its immune system which is needed to help it fight off external and internal attacks. Organizations also need an immune system to help it defend itself from danger. An immune system is composed of many different types of barriers against disease, some static and some dynamic. Your body’s immune system includes static components like your skin, blood vessels, thymus, spleen, bone marrow, liver, etc., each designed to act as a barrier to defend your body against various dangers that could cause damage to you. Organizations also rely of various static barriers to defend themselves against injury. These include rules, policies, procedures and various mechanical safeguards, such as personal protective equipment, machine guards, etc. While unquestionably useful, these defenses are also inherently insufficient. No matter how well designed or assimilated, these devices simply cannot prevent all incidents in complex workplaces because they are static and slow to change. As such, there is a need for something different. Something more naturally suited to mitigate risk in our highly complex work environments. Something that is more agile than our usual tools. Something ubiquitous, reactive and creative. The immune systems of living organisms contain something that is more agile than the static structures and barriers listed above. They include white blood cells that move around the body and create various types of antibodies needed to fight off invaders. Our organizations also have “white blood cells”…. the people that work there. The individuals that are moving around, observing and intervening to activate safeguards or remove others from danger. The difference between the white blood cells of our immune system and the people in our organizations is that white blood cells “naturally” intervene when danger is observed. People on the other hand don’t necessarily always intervene. White blood cells have the natural ability to detect danger and intervene. Most people on the other hand don’t have the natural ability to intervene and as we have discussed in other articles (Hardwired Inhibitions), they are actually predisposed not to intervene. To overcome this inhibition people have to be trained. They have to learn how to not only recognize hazards but how to effectively speak up and also deal with the possible defensiveness that can arise when they do so. Is your organization's immune system fully functional. Do your organization's “white blood cells” know how to intervene. If not, then your organization is very possibly at serious risk of injury.
In a recent blog we discussed Peer Pressure, Conformity and Safety Culture. As with peer pressure, authority pressure and the resulting obedience can be either good or bad. It is hard to imagine a functioning society without obedience to police officers or successful organizations without obedience to supervisors. It is also not hard to imagine the negative impact of power hungry, authoritarian police or over zealous, production oriented supervisors. The study of obedience to authority has its roots in the famous research of Stanley Milgram (1963). His research was stimulated by the Nazi atrocities seen during WWII. The question he attempted to answer was…how could seemingly moral people follow instructions to kill innocent civilians simply at the command of a superior officer? The experimental conditions that he utilized involved a series of subjects who were required to “administer” electric shocks to a confederate when the confederate failed to answer a question correctly. In reality no shock was actually administered but the test subjects were unaware of this and thought that they were actually administering increasingly powerful shocks to the confederate. If the test subjects balked at administering the shocks, they were directed/commanded by the experimenter (in white lab coat) to continue. The “shocks” began at 15-volts and progressively increased to a maximum of 450-volts which could in reality kill the confederate if actually administered. The results indicated that a majority (62.5%) of test subjects went all the way up to the maximum shock when directed to do so by the authority figure. Many of the test subjects showed signs of distress, indicating that they did not agree with the directive, but the majority did so anyway.
Perhaps even more concerning is recent research that indicates that even having a resistant ally did not stop others from being obedient to authority (Burger, 2009). The power of authority pressure can be extreme. While the Milgram studies are focused on the negative effects of bad authority pressure, obedience which leads to prosocial behavior ultimately contributes to culture and organizational success. It is difficult to achieve success in social groups whether it be society or organizations without obedience. Understanding the powerful influence that leaders have on the performance of their employees and establishing cultural norms and developing the leadership skills that lead to desired performance can have a profound impact on how these individuals lead and on how their employees respond when pushed to perform in an undesired manner whether that performance relates to production, ethics or safety.
Research and personal experience both demonstrate that people are less likely to intervene (offer help) when there are other people around than they are when they are the only person observing the incident. This phenomenon has come to be known as the Bystander Effect and understanding it is crucial to increasing intervention into unsafe actions in the workplace. It came to light following an incident on March 13, 1964 when a young woman named Kitty Genovese was attacked by a knife-wielding rapist outside of her apartment complex in Queens, New York. Many people watched and listened from their windows for the 35 minutes that she attempted to escape while screaming that he was trying to kill her. No one called the police or attempted to help. As a matter of fact, her attacker left her on two occasions only to return and continue the attack. Intervention during either of those intervals might have saved her life. The incident made national news and it seemed that all of the “experts” felt that it was "heartless indifference" on the part of the onlookers that was the reason no one came to assist her. Following this, two social psychologists, John Darley and Bibb Latane began conducting research into why people failed to intervene. Their research became the foundation for understanding the bystander effect and in 1970 they proposed a five step model of helping where failure at any of the steps could create failure to intervene (Latane & Darley, 1970).
• Step 1: Notice That Something Is Happening. Latane & Darley (1968) conducted an experiment where male college students were placed in a room either alone or with two strangers. They introduced smoke into the room through a wall vent and measured how long it took for the participants to notice the smoke. What they found was that students who were alone noticed the smoke almost immediately (within 5 seconds) but those not alone took four times as long (20 seconds) to notice the smoke. Just being with others, like working in teams in the workplace can increase the amount of time that it takes to notice danger.
• Step 2: Interpret Meaning of Event. This involves understanding what is a risk and what isn’t. Even if you notice that something is happening (e.g., a person not wearing PPE), you still have to determine that this is creating a risk. Obviously knowledge of risk factors is important but when you are with others and no one else is saying anything you might think that they know something that you don’t about the riskiness of the situation. Actually they may be thinking the same thing (pluralistic ignorance) and so no one says anything. Everyone just assumes that nothing is wrong.
• Step 3: Take Responsibility for Providing Help. In another study, Darley and Latane (1968) demonstrated what is called diffusion of responsibility. What they demonstrated is that as more people are added the less responsibility each assumes and therefore the less likely any one person is to intervene. When the person is the only one observing the event then they have 100% of the responsibility, with two people each has 50% and so forth.
• Step 4: Know How to Help. When people feel competent to intervene they are much more likely to do so than when they don’t feel competent. Competence engenders confidence. Cramer et al. (1988) demonstrated that nurses were significantly more likely to intervene in a medical emergency than were non medically trained participants. Our research (Ragain, et al, 2011) also demonstrated that participants reported being reluctant to intervene when observing unsafe actions because they feared that the other person would become defensive and they would not be able to deal with that defensiveness. In other words, they didn’t feel competent when intervening to do so successfully, so they didn’t intervene.
• Step 5: Provide Help. Obviously failure at any of the previous four steps will prevent step 5 from occurring, but even if the person notices that something is happening, interprets it correctly, takes responsibility for providing help and knows how to do so successfully, they may still fail to act, especially when in groups. Why? People don’t like to look foolish in front of others (audience inhibition) and may decide not to act when there is a chance of failure. A person may also fail to act when they think the potential costs are too high. Have you ever known someone (perhaps yourself) who decided not to tell the boss that he is not wearing proper PPE for fear of losing his job?
The bottom line is that we are much less likely to intervene when in groups for a variety of reasons. The key to overcoming the Bystander effect is two fold, 1) awareness and 2) competency. 1) Just knowing about the Bystander effect and how we can all fall victim to this phenomenon makes us less likely to do so. We are wired to be by-standers, but just knowing about this makes us less likely to do so. 2) Training our employees in risk awareness and intervention skills makes them more likely to identify risks and actually intervene when they do recognize them.