Dr Tim Marsh takes the concept of ‘nudge theory’ and explains how it is a key element of the ‘mindful organisation’ – one in which strong and proactive leadership creates a robust safety culture.
Some time ago, I was in a public toilet in Amsterdam when I saw my chance, whipped my camera out, and got the picture. “I’ve wanted a shot of one of these for ages – I’ll have great fun with this when I get home,” I thought, as the other occupants watched me in alarm. . .
The painted ceramic fly on the toilet bowl at Schiphol airport (which we men simply can’t help but aim for, and was the subject of my snapping) is easily the most famous example of a ‘nudge’ – the hugely influential social psychology concept so expertly and thoroughly detailed by Jennifer Lunt and Malcolm Staves in the November issue of the SHP.1 As it happens, I do have lots of fun with that picture at other conferences when asking: “What rules, regulations, training, or supervision could match the automatic 50-per-cent reduction in splashing and associated cleaning costs the fly delivers?”
As Lunt and Staves point out, the nudge concept has been around for years in different guises2 – for example, user-friendly paint and signage, and good ergonomics – and it is increasingly widely used by the current government. Once you know it’s around you, it’s easy to spot. The new motorway signs saying “Don’t litter – other people don’t” (a nudge with reference to social norms), the empty Police van parked strategically in the city centre, the new tax form that asks “Before you sign this off are you sure you didn’t forget anything?” Police being asked to wear uniform when travelling to work, and so on.
For what it’s worth, a significant percentage of those just about to sign, seal and post a tax form that’s not entirely true find themselves grimacing, banging the table and cursing: “Bugger it – I was home free but you got me right at the end there, you evil lot!” and reaching for the white-out. (Studies suggest that this one simple question alone will generate tens of millions of pounds of extra tax revenue!)
Used proactively and systemically ‘nudges’ are also a key element of a safety culture concept that’s gaining great credence around the world: the Australian writer Andrew Hopkins’ concept of “the mindful organisation”.3 He refers to the “shadow” that leadership throws, where apparently little things can have a big impact – for example, an event that generates the comment “and they stopped the job?!” or “and they still didn’t stop the job?!” In many respects, such critical incidents work as big nudges.
‘Mindfulness’ is not a technique, or a theory – it’s a practical and realistic mindset that can (and should) be applied to all aspects of an organisation’s safety culture and management. Following is a discussion of several key elements of a safety culture, starting with leadership and including incident analysis, communication and procurement, and concluding with how this mindset should be applied to them all.
The leadership shadow
The idea of a leadership ‘shadow’ isn’t new either, of course – I have written before in these pages on the subject of weak leadership.4,5,6 For example: starting a meeting by announcing “safety is our number-one priority” but in a manner that means “let’s get it out of the way then crack on with the important stuff”; using the word ‘but’ in the middle of a sentence such that it means “ignore what I’ve just said, as the important stuff’s coming up”; and the way that “do it safely but do it by Friday” means something entirely different to “do it by Friday but do it safely”.
I mean, has anyone ever heard the words “you’re really nice and I really like you but…” without their heart automatically sinking?!
Whether they are aware of nudge or ‘mindful’ concepts or not, many companies train their managers not to undermine the message in such ways, and then follow up the training to make sure they don’t. Some others, that are aware of the concepts, are being more proactive than that, however, and are actively looking for opportunities to throw a positive shadow (or nudge), as they know it can take years to change a company’s culture.
This is because it takes that length of time for a genuine change in senior-management attitude to percolate down and become embedded (e.g. “You’ve been saying it for years, I know, but only now am I beginning to realise you actually mean it”). Basically, a few well-designed nudges can really help accelerate this process.
Shell Scandinavia, for example, on platforms, has stopped asking the question: “Why did you feel it was necessary to switch off?” Instead, it asks: “Why did you feel it was safe to switch back on?” When you think about it, the technical information in the report generated in response to the question will be exactly the same but the shadow it throws is very different. Indeed, it’s also not so much a nudge but an almighty shove in the right direction!
I have written previously in these pages about “transactional leadership”,5 and the mindful leader is, by definition, a transactional one: always mindful to lead by example, to maximise the use of praise, to coach and involve rather than to tell and dictate, and absolutely always aware that even the little things they do or say throw a big shadow.
‘Just culture’ and mindful analysis
Hopkins makes specific reference to both “why?” and ABC analyses6 in his work and, in doing so, encourages companies to make that vital leap – from spotting that something is wrong to a mindset that always seeks to understand why it’s wrong.
For example, at the IOSH Rail Conference 2011, East Midland trains produced some graphs showing impressive safety improvements, and commented:“For us, the key was to stop treating SPADs (signals passed at danger) and the like as events in themselves but as symptoms of a more underlying issue. That shift in mindset was vital to our improvement.”
Sidney Decker, in his hugely influential Field Guide to Understanding Human Error,7 makes this point really bluntly, saying: “Human error is not the cause but the effect. Whatever the label (loss of situational awareness, inadequate resources, even complacency) human error can never be the conclusion of your investigation. It is the starting point.”
This thinking is fully in accord with Reason’s ‘just culture’ concept.5 Hopkins himself insists that it isn’t possible to be genuinely mindful without an ongoing commitment to such as the “five whys” analysis. I couldn’t agree more.
It’s a good idea to carry out ‘mindful analysis’ spot checks. For example, we can sleep easily, assured that we have an excellent incident reporting system, or we can, from time to time, pick an incident mentioned in conversation and follow it up by tracking it through that reporting system. How far did it get? What was learned? What was done with this learning? Even the best companies with highly expensive tracking systems will often find that the answers to these questions are concerning.
It’s also worth proactively looking at the trends in the reporting system. Are there divisions, shifts, or other demographics that ‘hardly ever’ report? If so, then we need to dig into it and find out what the blockages are and why – because since no one ever has anything to report, there’s a problem!
Mindfulness and ‘zero harm’
No conference is complete without a heated debate about whether ‘zero harm’ is a useful concept or genuine goal. Reason’s cheese model,8 showing how weaknesses up and down the chain effectively show how all accidents could have been prevented, is very influential to this thinking, but his recent work on the “overstretched rubber band” model has been very well received and, for me, clarifies the debate.
It describes how all companies are apt to be pulled from best practices by the challenges and issues of real life (contractors, unexpected costs and delays, etc.) so that the realistic challenge is not to be perfect but to ensure that when parts of the organisation are stretched they do not become overstretched and vulnerable.
In the real world, says this model, pockets of vulnerability will inevitably pop up from time to time and from place to place, even if the overall culture is strong and the planning thorough. The trick is to be geared to spot them soon, and respond to them effectively so that balance is quickly restored. This is entirely analogous to the key principles of HSG48 (Human Error), which says:
Following on from this, Reason suggests that safety is then best thought of as an ongoing guerrilla war and, like any such war, although we can’t actually win it we can delay the inevitable almost indefinitely. To do this, we’ll need keen intelligence, good data and to use the resources at our disposal cleverly.
In other words, we’re not asking our boards to be perfect in such an imperfect world – but we are asking them to be genuinely mindful.
Mindfully ‘following the money’
The Baker report into Texas City has often been used as a stick with which to beat behavioural safety, pointing out, as it did, that with bonuses triggered by low accident rates the eye was taken off the process-safety ball. But the Baker report doesn’t say anything like “behavioural safety bad, process safety good”; it actually says “don’t get the balance wrong and give too much weight to just one issue”.
This echoes the classic Oliver Stone film JFK, when the shadowy but deeply wise figure asks our investigative hero: “You always have to ask yourself, who most stood to benefit…?” and suggests “just follow the money”.
A proactive mindful safety trick is to do exactly that. For example, where the procurement division is rewarded for cutting costs but no one checks if any false economies result as a consequence, we often find cheap PPE that no one actually wears because it’s uncomfortable, or isn’t fit for purpose, or that cheap components fail and leak. (At Texas City itself, bonuses were paid only on lost-time incidents, so management focused on these to the detriment of process-safety issues.)
Of course, it’s always worth considering how contractors and piece workers are remunerated and selected (the term “a whole can of worms” was coined with this issue specifically in mind!) We all know full well that what the contract says and what happens on the day are not often in accord. An example: we all want our airports to be safe and secure, but how do you feel when you hear that the staff at the airport from which you’ll be flying tomorrow with your family are going to “work to rule”? Is your first thought: “Great, they’ll follow all those well-designed rules and regulations and we’ll be extra safe?”
Communication and the mindful mindset
Hopkins suggests that in 2005, BP was not a mindful organisation – in fact, “the very opposite”. Underinvestment meant that pipe work was old and leaky and maintenance wasn’t being done, but in London (HQ) they were simply unaware of the impact of their policies because of the existing climate of “only good news moved upwards” and admitted themselves they didn’t listen well to those on the front line. Hopkins suggests that this proved fatal at BP, literally and repeatedly in combination with the aggressive cost-cutting at the time.
On a more individual level I once asked an MD at a board meeting if he ever responded negatively to a safety issue being raised, and he was adamant: “Never!” I asked: “Not even with the eyes?” and the whole room burst into laughter, as he was, it transpired, notorious for this. Luckily he wasn’t a defensive man, laughed himself, and we were off.
So, the mindful leader will show a healthy paranoia by losing sleep to the thought: “How do I know XYZ won’t happen?” and this will inevitably involve lots of good, proactive communication. More than that, the organisation must seek out the many examples there will be of communication being poor, or even impossible.
A simple exercise is to ask someone a production, or quality-related question. Check the speed of the response, the facts they have at their disposal, and how keen they appear to reassure you they have everything under control. Then ask them a safety-related question of similar type. How do the responses tally with a genuinely ‘balanced scorecard’?
Similarly, if you really want to get to the core of a safety culture why not sit in on a formal appraisal without mentioning that your interest is primarily in safety. Monitor the body language of the appraiser and the appraised. Is it as intense when talking about safety items as when talking about productivity? (Or does this look like the half-time warm-up rather than the real thing?)
You should, of course, also consider the organisational structure itself. Is it easy to communicate concerns upwards, or totally impossible? (For example, if you’d need to go through the person you’re concerned about, even though you know for a fact they are not going to see this as a learning opportunity!) Also, consider if the people responsible for writing systems and procedures are empowered to ensure they are actually followed. More fundamentally, do the people who write the systems and procedures actively consult the end users as a systematic part of the design process? Any ‘no’s’ here absolutely guarantee problems down the line.
Finally, especially at this time, it’s worth considering any recent cost-cutting or “renegotiated” contracts. Were these risk-assessed really thoroughly for the ‘Law of Unintended Consequences’, or were assumptions made that ‘all will be well’? You’ll have got the idea by now that a genuinely mindful leader will be all over any such assumptions like a bad rash.
Training and a mindful mindset
To start to sum up, I hope I’ve made it clear that, for me, the key concept of the ‘mindful’ mindset is astute thought coupled with some robust digging. For example, you’ll often see companies quoting lead measures regarding the percentage of employees actually trained relative to those they planned to train (and a very impressive pie chart it can make, too!).
However, no matter how sexy and glossy the pie chart, the questions are still begged: How well designed and delivered was the training? Were the behaviours introduced on the course followed up and embedded? If they were, was some follow-up analysis made to ensure the change of behaviour genuinely benefited the company in some way?
In my experience, the answers to these questions are not always what a company would wish for. Indeed, they rarely are. There is, of course, any number of other key issues that should be considered but whatever the topic, ‘mindful’ leaders don’t take assurance from checking the files – they get out and about, talk to people in-depth, and genuinely dig.
Conclusion
So, to re-iterate, for me the key element of mindfulness is to “drill” into a subject and ask probing questions that tell you what’s really going, on especially when you suspect the answers will make you uncomfortable.
Mindfulness is always remembering that safety is a guerrilla war. To fight an effective rearguard action we need to be clever and alert and take nothing at face value, showing proactive analysis crossed with a healthy paranoia that reflects senior management’s genuine commitment to get their workforce back home unharmed every day.
As with the airport security mentioned above, much of what we are assured by in our daily lives and work is an illusion. An unspoken accommodation of make-pretend that helps us through the day. Well, usually. The genuinely mindful leader remembers this – always – because almost every time you dig into something, you’ll learn something worrying.
A final thought: I do wonder if the concept is proving so popular around the world because of the positivity of the word ‘mindful’. It’s perhaps the flip-side of the behavioural safety burden that the word ‘behaviour’ is nearly always used when we “want to talk to you about your behaviour”. So, no Mind Games please (unless it’s the classic John Lennon song) but can I sign off by sincerely wishing all readers to “please do take care and mind yourselves and your colleagues as you go”.
References
1 Lunt, J & Staves M (2011): ‘Nudge, nudge, think, think’, in SHP November 2011, Vol.29 No.11 – www.shponline.co.uk/features-content/ full/cpd-article-nudge-nudge-think-think
2 Thaler, RH and Sunstein, CR (2009): Nudge, Penguin
3 Hopkins, A (2008): Failure to learn, CCH Australia
4 Marsh, T (2010): ‘Stretch to the limit’, in SHP February 2010, Vol.28 No.2 – www.shponline.co.uk/features-content/ full/safety-culture-stretch-to-the-limit
5 Marsh, T (2010): ‘It’s A Kind of Magic’, in SHP September 2010, Vol.28 No.9 – www.shponline.co.uk/features-content/full/it-s-a-kind-of-magic
6 Marsh, T (2011): ‘Words to the wise’, in SHP February 2011, Vol.29 No.2 – www.shponline.co.uk/features-content/ full/cpd-article-words-to-the-wise
7 Dekker, S (2006): The Field Guide to Understanding Human Error, Ashgate
8 Reason, J (1997 and 2008): Managing the Risks of Organisational Accidents and The Human Contribution, Ashgate
Dr Tim Marsh is managing director of Ryder-Marsh Safety (Ltd).
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