Over time, decision-making becomes culture.

💡 If more team-members spoke up, more effectively and more often, how many disasters, scandals and failures could be averted?

I was asked recently to help a team whose workplace ended up looking like a disaster-zone, because of the failure of the team – collectively – to make the right decision on how to solve a problem, support a service user, and satisfy their client.

On the call with the manager of the team, I got a flashback to a chapter in Malcolm Gladwell’s book Outliers which discussed Korean Air flight 8509 and its crash near an English village more than 20 years ago.

The image above is of Korean Air 8509 after its crew flew it sideways into the ground in Great Hallingbury near Stanstead, on December 22, 1999.

Korean Air had more plane crashes than almost any other airline in the world for a period at the end of the 1990s. It was suggested that a culture based on seniority, and lack of effective communication between the team at critical moments when action was needed to avert a disaster, was to blame.

One issue (amongst many identified) was that the first officer in the cockpit had not challenged the captain’s actions when instrumentation, warning alarms and the flight engineer all registered that the aircraft was about to crash.

In their formal recommendations, British investigators called on Korean Air to revise its company culture and training, “to promote a more free atmosphere between the captain and the first officer.”

In the UK we are coming to understand that poor cultures of care are consistently revealed through secret filming by BBC Panorama, or Channel 4 Dispatches, resulting in a consistent line of scandals – Winterbourne View, Whorlton Hall and most recently the Edenfield Centre in Manchester for example.

These are environments where the team isn’t seeing the disaster looming in front of them, as they continue to work, deaf to the warning tones and blind to the flashing lights alerting them to poor ethical standards in their service.

There are at least three traps – a sort of triple-threat – which work to compound each other to result in these issues.

1. the absence of supervisors to model desirable professionalism, values and ethos which would guide a team faced with crucial decisions and
2. a culture of deflecting responsibility for decision-making during key moments to others – usually the higher-ups (”its what they get paid for – I am paid to do only what I’m told”) and finally
3. hesitation amongst team members to correct each other when mistakes or poor decisions are being made in-the-moment.

Values in Action: Do Something

These all underline the importance of what is called ‘Ethical Intervention’ or ‘Bystander Mobilisation’ in any workplace (terms used by Vistelar for when staff take a stand based on their values and put them into action).

Vistelar founder Gary Klugiewicz can often be heard repeating that “in our world today, there are no innocent professional bystanders”

Gary recommends that staff working in any setting where difficult decisions need to be made to keep everyone safe must:

1. Assist your fellow staff members.
2. Fix something if it is going wrong.
3. Stop something if it is wrong.

…and in all cases, staff must write a report which records what they observed.

Gary references the strength of character, the dilemma faced and the actions of Hugh Thompson Jnr. who intervened and ended the My Lai massacre in South Vietnam on March 16, 1968, saving many lives by taking decisive action against the behaviour of people who were otherwise his compatriots, team-mates and brothers-in-arms.

Sometimes, our colleagues make poor decisions and embark on courses of action which will lead to dark places, poor outcomes and difficult futures. The question Gary poses is that, in the critical moment, what are we going to do about it?

We have shared in the past a video called “How to respond when someone spits in your partner’s face” – this is an example of how to incorporate ethical intervention and bystander mobilisation into your training. By getting ahead of the problem and actually practicing it in training, we might be able to save careers, reputations and appearances on Panorama, or Dispatches…

In the moment, Slow Down

Sometimes, events seem to take on a sense all of their own. Although present, staff can feel like they are being swept along in a current of activity, somehow robbed of their own agency in the moment.

Amply described in the video below by Gordon Graham, the pressures of modern connected communication systems, the pressure of being observed and the need to “be seen to do something” – a kind of professional embarrassment caused by a void in the team’s mental model for the problem facing them – can usher teams towards a rapid decision, but one which is rash and is more likely to result in a negative outcome.

In these situations, it is critical to “Slow Down”:

💡 “You only get one chance to get it done right – slow down! Remember, you can be efficient, and still not be effective.” – Gordon Graham

In less-dramatic events than those of the My Lai massacre though, such as the day-by-day activities of care staff, police, ambulance teams or other public-facing staff, decisions are made in a more mundane setting.

Poor decisions, repeated, become ‘the way we do business’ and before long, a toxic culture.

Don’t always follow the leader

Often we see a more-experienced or more senior member of the team leading the way down a dark path. Often they are strong characters, popular amongst the rest of the team, perhaps even looked-up-to by the rookies they are leading.

The other two officers present when George Floyd was killed were “rookies, barely off probation”…

Philip Zimbardo, in his excellent book ‘The Lucifer Effect’ discussing at length how social context can radically transform a normal person’s behaviour towards negative ends, points to leadership:

“In some groups we are made leaders, while in others we are reduced to being followers. We come to live up to or down to the expectations others have of us. The expectations of others often become self-fulfilling prophecies. Without realizing it, we often behave in ways that confirm the beliefs others have about us. Those subjective beliefs create new realities for us. We often become who other people think we are, in their eyes and in our behavior.”

In resisting these expectations – and the power of the group or the pressures of the situation – to have us conform, that we can change outcomes.

💡 “To be a hero you have to learn to be a deviant —because you’re always going against the conformity of the group.”

– Philip Zimbardo

There’s a further lesson than Zimbardo’s extensive writings about the power of calling out senior staff when they deviate from safe practice – you should note the story of Checklists in reducing ICU patient admissions in hospitals in the USA, as described by Atul Gawande in his book The Checklist Manifesto (and partially described in his article here)

“The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.”

Where we enable staff at all levels to check and call out safety (or ethics, or compassionate care, or physical intervention) violations, then we can be more sure that when managers are not looking over their shoulders, staff will do the right thing.

A prospective hindsight approach?

Perhaps another way to prevent poor decisions becoming a regime of care, or a culture of efficient ineffectiveness, could be to carry out what cognitive psychologist Gary Klein refers to as a ‘Premortem’.

In this exercise, the assembled team imagines that there has already been an “adverse outcome” in their service and makes suggestions as to how it may have come about. Through this process, insights come to light about the nature of the issue in front of the team, and a better plan may emerge as to how to proceed.

In healthcare environments, we might have a pre-mortem exercise which considers:

• a named service user in our facility has died subsequent to a physical restraint intervention
• a service user’s placement in our service has broken down and they are transferring to another service
• a service user in our facility has ended their life while under our care
• a service user has absconded

This type of ‘red-teaming’ exercise, where we try to find the weaknesses in our approach and open the discussion with our team about what those weaknesses might be, helps to create a culture where voices are heard and respectful conflict is valued to drive quality improvements and prevent our team, our service and our organisation from the professional embarrassment of scandal, tragedy or disaster.

💡 “A premortem may be the best way to circumvent any need for a painful postmortem.”

– Gary Klein

Gathering up concerns

Your service will have a whistle-blowing policy, of course. OFSTED, CQC and Local Authorities will have mechanisms in place for your people to report to them about concerns they have about care and treatment in your service.

We have found, however, that the conflict management and physical intervention training is a really good part of the induction and ongoing development of your people to introduce both the values mentioned above, the practice and acceptability of interrupting risky practices in a positive way and one other tool – a tool that lets someone raise their hand and ask for attention to an issue.

One of our clients has successfully rolled out what might be the simplest tool for opening up communications in a service that we know of – an electronic form that any staff member can use at any time to raise their hand and say “I’m concerned”. The staff member can add their name if they wish (or not) and can add as much detail as they wish. Their concern could be about their own responses to an encounter, or about someone else’s (including a service user).

The training and development team are tasked with regularly checking the log for this reporting tool, and then taking action on the issue raised, whether by supporting a team mate, or bringing an issue to the team meeting, or raising a concern to management, and (this is key) doing it VISIBLY and TRANSPARENTLY.

In rolling out the tool, the team have transformed the service culture from one of secrecy, fear of failure and expectations of sanction, to one where the focus is on openness and improvement. The service reduced their restrictive practices by a significant amount through this and other work on communications. To read the case study about how we helped this service to reduce their reliance on restrictive practices, please visit

Restraint Reduction

Gerard O’Dea is the Director of Training at Dynamis – a leading provider of conflict management, personal safety and physical intervention training for services in the UK, Ireland and the UAE. He is the European Representative for Vistelar, a global provider of conflict management training. In partnership with Loughborough University, Dynamis has been involved with the College of Policing’s redevelopment of Public and Personal Safety Training for police services in the UK.