Building a Learning Culture in the ED: Why It Matters and How to Make It Happen.

This week I am in Gabarone at the African Emergency Medicine conference. It’s such a privilige to be here and to learn from the wonderful delegates and speakers. I would highly recommend you make the journey if you can. You will be assured of a fabulous welcome and a great time. I’m honored to speak on learning cultures, something that I’m really interested in and which I’ve had so much fun developing alongside many others in the online and wider Virchester team.

I still love emergency medicine. It’s my home away from home and despite a few years in the business I still genuinely love it. There are no doubts that it’s tough at the moment with seemingly never enough space, staff or support to do the job that I really want to do, but to some extent it’s always been like that and I (perhaps rather strangely) thrive on a little bit of chaos, and so do many of my EM colleagues.

One of the things that I especially like about EM is that fact (and it is a fact) that it is a rich environment for teaching and learning, two things which I love,. It’s worth remembering at this point that teaching and learning are different. Teaching is what we do to facilitate learning in others,. Learning is really what we hope to achieve for them and also for ourselves. Emergency medicine gives so many opportunities for learning and without doubt this will continue until the day I leave the speciality (if that ever happens). I’m also a huge fan of ‘unlearning’ and #dogmalysis, those moments in life when you suddenly realise that new evidence has arrived that means that what you were doing in the past was wrong and we need to change. Sure, those moments might be thought of as frustrating, but I find them so exciting and just love sharing them with others (hence St Emlyn’s), and I know that others in the #FOAMed world feel the same. My happiest days are paradoxically when I’ve just been proved wrong and learned something new.

Over the years I’ve held quite a few senior educator roles and it’s always struck me as surprising that there seemed to be little correlation between the satisfaction that doctors felt in their jobs, as compared to how busy the department was. In fact workload had no correlation whatsoever with satisfaction. We proved this by plotting overall satisfaction scores against different elements of the GMC survey in the UK. I don’t think we ever published this and it’s a few years past, but I’ll let you into a few insights.

This is a graph of the correlation between overall satisfaction in a training post and workload. It comes our with an R2 of 0.10 which is pretty much next to nothing. Perceived workload did not correlate with overall satisfaction

However, if you look at elements like clinical supervision you get a much better correlation, and this was consistent across those elements related to teaching and learning. I repeated this the following year and got the same results (though annoyingly I can’t find that data on my computer). Wow I thought, maybe we’ve been looking at the wrong things to try and change to increase satisfaction for trainees. Workload may not be the most important thing, experience is probably more important.

Maybe it’s not just about space and patient numbers, perhaps satisfaction comes from learning, teaching and feeling as though you are developing. Maybe I did not need the data to tell me that, but having seen it then and now, it makes so much sense. We are all busy to one degree or another, but if we derive value from being there it’s a much better experience. More importantly, we can’t change how busy we are, but we can change how we teach and learn. This blog post hopes to help you on that journey and to find ideas that can help you and your colleagues lead better careers and lives together.

Learning Cultures

Let’s get onto a bit of theory and then think about what we can practically do, and maybe pick out some themes that you can take away and play with. A learning culture is one that embraces continuous improvement, open communication, and resilience within teams. This is all good for staff, but it’s also good for patients. A learning culture isn’t just about scheduled training sessions or feedback (although these are important); it’s a fundamental shift in how we work, learn, and support each other in real time.

What Is a Learning Culture, Really?

A learning culture is an environment that actively encourages curiosity, growth, and knowledge sharing. In the ED, this means promoting an atmosphere where everyone, from the most experienced consultant to the newest resident, feels empowered to ask questions, learn from mistakes, and discuss ways to improve care. Mistakes aren’t seen as failures but as learning moments, and collaboration is prioritized over hierarchy.

Imagine an ED where team members feel comfortable sharing ideas and asking questions without fear of judgment. After a challenging case, the team gathers for a brief discussion, focusing not on blame but on what went well, what didn’t, and what they might do differently next time. In a true learning culture, these moments of reflection are embedded into the daily routine, turning every shift into an opportunity to learn and grow.

A learning culture in the ED revolves around four key principles:

1. Psychological Safety: People feel comfortable speaking up, even about mistakes.
2. Commitment to Continuous Improvement: Each case, whether routine or complex, is a chance to learn.
3. Open Communication: Ideas and feedback flow freely across all levels.
4. Reflection and Accountability: Teams routinely pause to reflect on their actions, taking responsibility for growth.

Amy Edmondson, a professor at Harvard Business School, found that psychological safety—where team members feel secure to ask questions and admit errors—is foundational to high-performing teams. Although that was in different teams of office workers rather than in EM. That said, there are common themes with us all understanding that some teams work better than others and often there are links to how they behave and learn together.

Why Does a Learning Culture Matter in Emergency Medicine?

In emergency medicine, we operate in a decision dense environment. We also deal with huge amount of uncertainty and under significant time pressures amd with a great deal of uncertainty and judgement in what we do. We can only effectively function as part of a team that constantly learns and support each other in that learning. The range of conditions that we deal with combined with the pace of evidence changes from the literature and from the lived experience of clinicians and patients is also vast. We simply cannot do that on our own and we if we are to be the best that we can for our patients and health economies then we simply have to be part of a culture that embraces life long learning. We know that our ED’s are unpredictable spaces and that our teams need to be resilient, adaptable, and able to learn quickly from every situation.

Psychological Safety is Key to Growth

Psychological safety means everyone in the ED feels comfortable admitting when they’re unsure or need help. Edmondson’s research highlights that people learn faster and work more effectively when they feel safe to make mistakes and ask questions (Edmondson, 1999). In the ED, this openness can make the difference between catching a potential error and letting it go unnoticed or finding it, resolving it and then sharing what we know so that others can benefit too. This process, and the degree of altruism required to highlight errors is really important in learning cultures. It only happens if people feel that it is something they can do without harm to themselves. Often people think that we can’t do this, or that by having an entirely open culture we don’t have censure, and that’s simply not true. In a really great system people feel OK admitting error as they know that they will be supported through a process of reflection, training and improvement. So it’s still painful to admit errors, but it’s not harmful in the long run. Rather it is a development tool.

Continuous Improvement Enhances Patient Safety

A learning culture isn’t just a safety net for mistakes; it’s a proactive approach to improving care. Instead of waiting for errors, a culture of continuous improvement means consistently looking for ways to enhance patient care. Studies show that this mindset reduces errors and improves patient safety outcomes (Sutcliffe & Vogus, 2003). I like this a lot and it’s a strong reason why we introduced the concept of A&A (Awesome and Amazing) alongside M&M (Mortality and Morbidity). Clinicians often want to have meetings about cases that go wrong (and that’s fine), but why not also embrace times when things go really really well. Shouldn’t we learn from them too? They both enhance patient care and can make differences in the future. Try this at your next M&M by squeezing in a case that highlights great practice or a new idea.

Other examples would be at shift end/starts (typically handovers in the ED). The team might hold a short debrief to discuss what went well and where they could improve. By making continuous improvement a routine, the ED team can adapt to new challenges and refine processes over time. The ‘routine’ element here is really important. Embedding the culture of reflection and learning and not just saving it for the exceptional makes a difference. Now, we have to be a little bit careful here because no-one wants an in-depth discussion at the end of a tough night shift, or when something terrible has just happened, but a little and often can make the difference. It builds a culture that ‘this is the way we do things here’.

Openness Strengthens Team Resilience

The ED is a demanding environment, and work stress is a real risk, with many studies suggesting that EM folk lead the ranking on this (sadly). A learning culture, where team members openly share experiences, can foster resilience and connection. Open communication and shared learning might might mitigate work stress (or burnout as some call it) and strengthen team bonds as a result. When teams share both challenges and successes, it brings them together and better equips them for the future. My personal view is this is like compound interest. As you start developing an open team approach, it becomes easier to be an open team, which in turn puts more energy back into the system making it better and better. Along the way it’s likely that there will be times when any system’s resilience and openness is challenged and/or undermined and to some extent that is to be expected, In those times a return to good practice is dependent on how much energy you already have stored in the system and how well those will influence re-engage and re-energise.

So How do I Build a Learning Culture in my ED?

A great question, and not always easy to answer as there will always be some local factors, some tricky personalities and a lot of history! However, the key point here is that all of these issues can be overcome and to a large extent you can create a learning culture. It is not something that just happens, it’s something that needs a little curation, from yourself and perhaps a few other interested colleagues. The bottom line is that you can make a difference.

Start with Psychological Safety

Psychological safety begins with leadership but requires everyone’s participation. Leaders can set the tone by showing vulnerability, openly discussing mistakes, and encouraging team members to do the same. In their study on hospitals, leaders who model openness foster environments where team members feel empowered to share ideas and admit mistakes. If the bosses aren’t taking part and showing that they too want a learning culture this will be a problem. However, in my experience you don’t need everyone to come on board at the beginning. It is likely that you will have some senior clinicians who don’t want to get involved, or who do not want to be as open as you would like. This is fine. Don’t fight them, just get others to do instead and wait for them to catch up. All innovations will have early adopters, and late adopters. Don’t try and take everyone with you at the beginning, they can catch up later 😉 .

Make Reflection Part of the Routine

Reflection doesn’t need to be formal or time-consuming. Even a quick five-minute debrief after a challenging case can have a profound impact. Weekly case reviews, daily debriefs, or quick post-shift reflections help embed learning into the ED’s routine. There are lots of papers out there showing that some form of structured reflection, even brief ones, enhances team performance and fills knowledge gaps.

Encourage Knowledge Sharing

We also call this the amplification principle. If you have something to share then do so, and not just the negatives, but in fact really makes sure you amplify positive learning. We use social media groups such as St Emlyn’s publically, and WhatsApp groups within the department to share and share and share what we learn (with careful and explicit rules about what can and what cannot be shared – there is some good research from South Africa on this very topic, but please do adhere to your local and national guidelines). These are great tools that are open to everyone. We also use these group discussions to highlight topics for in-situ simulation sessions. At this point it’s probably also worth mentioning the concept of educational contamination, by which I mean that in a learning culture you don’t have to teach everyone everything, you just need to reach enough people with information that they then feel empowered to share with others in practice, on line and face to face. Think of your new infdiormation as a virus and your educationally active colleagues as vectors! Find and nurture those who are most likely to infect others.

Commit to Continuous Improvement

Continuous improvement doesn’t require major changes; it’s about finding small ways to enhance processes every day. The Model for Improvement, developed by the Institute for Healthcare Improvement, emphasizes testing small changes, reflecting on results, and iterating as needed. In the ED, this could mean trying a new protocol for patient handoffs and adjusting it based on team feedback.

Things to try

At this point you may want to know what you can get started on in your own department to build your learning culture and I’m going to say that I don’t know for two reasons. I will give you a few ideas in a moment, but first yhou need to take a step back at the wider picture of building cultures, which is rarely about changing just one thing, but rather a series of events and a change of attitude around those events.

Firstly, you know your people better than I do, and you’ll be able to have a really good feel for what might or might not work locally. Secondly, I really don’t think it matters what you do, but rather how you do it. Below are a series of ideas that I’ve seen work over the years. Some we still do today, but many others have come and gone as enthusiasm for them has waxed and waned, and that is 100% OK. I love trying new things out, and that inevitably means that some old ideas fade away. However, new ideas bring new people on board and new ways to do things. So never by worried or ashamed about this being a perpetual journey where some ideas last and others don’t, that’s arguably all part of the fun, and it really should be fun.

Some ideas to give a try. Follow the links to learn more.

1. Post it pearls
2. Board rounds
3. Hot-debriefs
4. Social media in emergency medicine
5. WhatsApp groups
6. Awesome and Amazing rounds
7. Feedback cards (Teaching, Banter and Feedback cards)

Bringing It All Together

Building a learning culture in the ED is a gradual process, requiring commitment and consistent effort. However, the benefits for patients, teams, and individual well-being make it worthwhile.

In a true learning culture, curiosity, openness, and continuous improvement become part of daily life. This mindset not only enhances patient outcomes but also builds stronger, more resilient teams. Next time you finish a shift, think about one small thing you could do to foster a learning culture in your ED. It could be a quick debrief, an encouraging word, or an insight shared. Over time, these small actions add up, creating a culture where every team member can thrive.

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References

1. Edmondson, A. C. (1999). “Psychological safety and learning behavior in work teams.” Administrative Science Quarterly, 44(2), 350-383.
2. Purdy E, Alexander C, Caughley M, Bassett S, Brazil V. Identifying and Transmitting the Culture of Emergency Medicine Through Simulation. AEM Educ Train. 2019 Feb 27;3(2):118-128. doi: 10.1002/aet2.10325. PMID: 31008423; PMCID: PMC6457353.
3. Carley S, Morris H, Kilroy D. Clinical teaching in emergency medicine: the board round at Hope Hospital emergency department. Emerg Med J. 2007 Sep;24(9):659-61. doi: 10.1136/emj.2005.033811. PMID: 17711947; PMCID: PMC2464654.
4. Simon Carley, “Be a better Resuscitationist at #iMEDconference12,” in St.Emlyn’s, October 4, 2020, https://www.stemlynsblog.org/be-a-better-resuscitationist-at-imedconference12/.
5. Bouter C, Venter B, Etheredge H. Guidelines for the use of WhatsApp groups in clinical settings in South Africa. S Afr Med J. 2020 Apr 29;110(5):364-368. doi: 10.7196/SAMJ.2020.v110i5.14558. PMID: 32657718.
6. Riddell J, Patocka C, Lin M, Sherbino J. JGME-ALiEM Hot Topics in Medical Education: Analysis of a Multimodal Online Discussion About Team-Based Learning. J Grad Med Educ. 2017 Feb;9(1):102-108. doi: 10.4300/JGME-D-16-00067.1. PMID: 28261403; PMCID: PMC5319607.
7. Amazing and Awesome RoundsFischer, Lisa M.Annals of Emergency Medicine, Volume 69, Issue 5, 655
8. Education as Culture: The Amazing and Awesome Case Conference. Eve Purdy, MD, MSc; Rob Roseby, MD; Manuela Brinkmann, MD; Elizabeth Blackmore, MD; Chris Meyer, MD; Daniel Cabrera, MD. J Grad Med Educ (2021) 13 (1): 18–21.
9. Carley S, Beardsell I, May N, Crowe L, Baombe J, Grayson A, Carden R, Liebig A, Gray C, Fisher R, Horner D, Howard L, Body R. Social-media-enabled learning in emergency medicine: a case study of the growth, engagement and impact of a free open access medical education blog. Postgrad Med J. 2018 Feb;94(1108):92-96. doi: 10.1136/postgradmedj-2017-135104. Epub 2017 Oct 20. PMID: 29054933.
10. Carley S, Laing S. How can emergency physicians harness the power of new technologies in clinical practice and education? Emerg Med J. 2018 Mar;35(3):156-158. doi: 10.1136/emermed-2017-207239. PMID: 29463635.
11. Simon Carley, “Be a better learner – Part 1. St.Emlyn’s,” in St.Emlyn’s, September 21, 2018, https://www.stemlynsblog.org/better-learning/be-a-better-learner-part-1-st-emlyns/.
12. Simon Carley, “Be a better learner. Part 2. St.Emlyn’s,” in St.Emlyn’s, September 21, 2018, https://www.stemlynsblog.org/better-learning/be-a-better-learner-part-2-st-emlyns/.
13. Simon Carley, “Be a better learner. Part 3. St.Emlyn’s,” in St.Emlyn’s, September 21, 2018, https://www.stemlynsblog.org/better-learning/be-a-better-learner-part-3-st-emlyns/.
14. Simon Carley, “SMACC2019: The Power of Peer Review,” in St.Emlyn’s, May 30, 2019, https://www.stemlynsblog.org/smacc2019-the-power-of-peer-review/.
15. Lin, M., Battaglioli, N., Melamed, M., & Mott, S. E. (2019). “High yield didactic rounds on physician well-being.” Academic Emergency Medicine Education and Training, 3(S1), S91-S95.
16. Fanning, R. M., & Gaba, D. M. (2007). “The role of debriefing in simulation-based learning.” Simulation in Healthcare, 2(2), 115-125.
17. Aggarwal, R., Mytton, O. T., Derbrew, M., et al. (2010). “Training and simulation for patient safety.” Quality and Safety in Health Care, 19(Suppl 2), i34-i43.
18. Manser, T. (2009). “Teamwork and patient safety.” Acta Anaesthesiologica Scandinavica, 53(2), 143-151.
19. Edmondson, A. C., & Lei, Z. (2014). “Psychological safety: The history, renaissance, and future.” Annual Review of Organizational Psychology, 1, 23-43.
20. Frenk, J., Chen, L., Bhutta, Z. A., et al. (2010). “Health professionals for a new century.” The Lancet, 376(9756), 1923-1958.
21. Simon Carley, “How to cope when your registrar knows more than you do. St.Emlyn’s,” in St.Emlyn’s, April 28, 2013, https://www.stemlynsblog.org/how-to-cope-when-your-registrar-knows-more-than-you-do/.

A learning culture in practice, the start of my journey.

“Some years ago, when I was a new consultant, I was in resus with a severely injured patient come in with life-threatening injuries, clearly in shock. As we moved quickly to stabilize them, I was preparing to intubate, reaching for etomidate as the induction agent—my typical choice for trauma cases, given its reliability. Just then, a junior colleague gently suggested we use ketamine instead. At first, I was taken aback. In a lot of emergency departments, there’s a strict hierarchy that tends to stop junior team members from speaking up, especially during critical moments. In those environments, people with less experience are often expected to watch, learn, and keep their input to themselves.

But we strive for a learning culture here, where anyone—junior or senior—can speak up, so I asked them why they thought ketamine was the better choice. They explained that ketamine is less likely to drop blood pressure, which could make it a safer option given the patient’s signs of hypovolemic shock. It was a smart, well-thought-out suggestion, and exactly the right call for that situation. So, we went with ketamine, and it worked well for our patient, but more than that it

This moment reminded me why it’s so important to keep an open mind, no matter how experienced you are. Emergency medicine can make it easy to slip into autopilot, relying on what we’ve always done or what’s worked in the past. But each patient and each situation is unique, and so much of what we do depends on adapting quickly and staying curious. When we stop being curious or assume we have all the answers, we risk missing valuable insights that might be right in front of us—sometimes from the very people we’re there to teach.

Creating a learning culture isn’t just about formal teaching sessions; it’s about fostering an environment where everyone feels safe to ask questions and offer insights. If we truly want to improve patient care, we need to move beyond hierarchy and embrace an openness that allows for learning in every direction. Moments like this reinforce that growth and learning are collective goals, achieved through listening and encouraging each other to speak up, no matter our level of experience.”

That trainee was Luka Randic, and you can read more about him here.

This introduction highlights the importance of dismantling hierarchy to foster a culture of learning, as well as the role of curiosity and humility in delivering high-quality patient care.