Reflective Systems Learning

Warning: this blog is free range. 

The image is of me running down our dusty gravel road in a bath towel shouting “Eureka! Eureka!”

Caveat emptor. 

My advance apologies to the kangaroos who bear silent witness to my unathletic exertions!

It may come as no surprise to those around me because of the far-away look in my eyes, but I have been pondering lately. 

I wasn’t even aware of the answer taking shape in my brain until this afternoon whilst putting out hay to the cattle. 

Perched on the back of the truck flinging biscuits of compressed dry grass over the side to the thankful snorts of cows with calves afoot, I discovered an urgent desire for a pen and some paper. 

Obviously having none within cooee, I opted for the next obvious choice. 

I licked my finger and etched in the dust on the hood of the truck the following statement:


I couldn’t write more because my throat was dry, but what I had written was enough. 

If I had more spit I could well have finished off my logic equation:



So simple. 

I had been spending the last few days exploring Claire Cox’s brilliant work on her ‘Ten Minute MET Meeting’. 

It didn’t take long to come to the realisation that our pathways and experiences bore many similarities, and that if I looked closely enough, a reproducible DNA for clinician-led change mechanics may emerge. 

I thought back to the original conversation between John and I in Recovery that fateful day, and the words that unwittingly popped into my mind were:

“Reflective Learning”

John and I were both familiar with the reflective learning journals undergraduate nurses keep as part of their coursework, journals which fall by the wayside as they become enmeshed in the rigours of clinical practice. 

But in no way until now have I considered that the process we undertook to arrive at our solution was, in fact, no more than reflective practice in action!

So our real accomplishment, it seems, was to matriculate reflective practice into something I have temporarily coined ‘Systems Learning Innovation’ which is a fancy way of saying that if a patient safety system is to ‘learn’ or evolve, then one way it can do so is by organically finding ways to integrate innovation arising from shared reflective practice narratives amongst clinicians. 

So there you go. 

From this simple precept we can develop an architecture that opens up a pathway to both high performance teams AND a clinician led safety culture. 

That’s not just cool;

That’s Safety Phenomenal!



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