the theory

Mindfulness is increasingly fashionable. But mindfulness is a word with many meanings and not all of them appear in the dictionary.

MF dictionary definition

In healthcare, most research on mindfulness refers to the therapeutic technique that helps against stress and burnout (#2 in the Google dictionary definition above). Its roots are in the Buddhist meditative tradition. This is not the meaning of mindfulness assumed in the pages of this website and associated research.

In the fields of reliability, safety and resilience, mindfulness refers to two specific theories: one about individual mindfulness as in the work of Harvard social psychologist Ellen Langer, the other is about collective mindfulness and refers to the work of organisational theorists Karl Weick, Karlene Roberts and Kathleen Sutcliffe.

Langer’s definition of mindfulness

Langerian mindfulness is about information processing. It is about cognition and interpretation of information. Being mindful is:

‘an active state of mind characterised by novel distinction-drawing that results in being
(1) situated in the present;
(2) sensitive to context and perspective; and
(3) guided (but not governed) by rules and routines’
(Ellen J Langer, 2014:11)

When mindful, people are consciously aware of ‘context and content of information’ (Langer, 1992).

The opposite is mindlessness.

‘a state of mind characterized by an over reliance on categories and distinctions drawn in the past’
When mindless, people are ‘oblivious to novel (or simply alternative) aspects of the situation’
(Langer, 1992).

‘When mindless […] people treat information as though it were context-free – true regardless of circumstances’ (Langer 1989: 3)

If we apply the concept to information about medicines, we can ask questions on how clinician read and understand a hospital prescription.

Paracetamol 500mg. It could be just another order for paracetamol. Or it could be paracetamol for this specific patient, who is due to go home today… And does it make a difference if we read this on paper or on screen?

We are all mostly mindless most of the time. It makes us more efficient. But in healthcare work, what is more likely to make us mindless?

  • When we receive highly specific instructions. If the doctor is told to prescribe a pain killer, she may be more likely to question the instruction. If she is told to prescribe paracetamol 500mg, she may be more likely to accept it without thinking.
  • Routines and familiar structures makes us more ‘mentally lazy’ – as if there is no need to pay attention.
  • Most interestingly though, it is also the belief that we can’t deviate from the routine that makes us less able to question it. The same for what we can call ‘limited resources’ – if nurses believe medicines must be given only during drug rounds because there is no time to personalise times of medication, they may be less open to explore alternatives.

The opposite makes us more mindful: if we have greater control we are more likely to be mindful, and being mindful gives us greater control.

In healthcare, with Langerian mindfulness comes awareness of risks and resourcefulness, leading to safety and resilience.

Collective Mindfulness

In the field of organisational studies, Langer’s theory of mindfulness has been extended from individuals to teams, in what is known as collective mindfulness (Weick, Sutcliffe et al. 1999, Sutcliffe and Weick 2013). In the field of reliability and safety, this understanding of mindfulness has been used to explain organisational behaviour in high reliability organisations (HRO) – such as the organisation of fire fighters. In these organisations there is a general awareness of possible danger and that taking anything for granted is risky. Thus, there is constant vigilance, and activities are geared towards anticipating or containing the ‘unexpected’. Five safety organising processes characterise HROs:

  1. preoccupation with failure,
  2. reluctance to simplify,
  3. being aware of interdependencies (being sensitive to operations),
  4. being open to improvise around the routine (when the general rule cannot be applied)
  5. referring problems to the best person, rather than up in the hierarchy.

(We can see how Langer’s mindfulness transpires here: seeking complexity rather than simplification, being aware of context, not being governed by routines).

For example, in a hospital on a Wednesday morning the nurses asked a pharmacist at the end of her shift to order a medicine for a patient they would see on Friday. Being aware of risks of late deliveries, of the interdependencies and the constraints (how long does it take for the aseptic unit to prepare the medicine), this request is interpreted as: ‘urgent for the next half hour’. Of course, whether the patient actually gets the right medicine on time is not only dependent on this individual act of mindfulness. This is why in an organisational context, mindfulness must be collective – of the group, and of individuals acting as if they are a group.

In research of High Reliability Organisations collective mindfulness has been studied in teams, looking at people interaction. In hospital pharmacy, pharmacists work alone, they are professionals, with some capacity to change the routine, and find solutions to problems. Their mindfulness is distributed (along the workflow) and collective as they internalise collective decisions about safety – what is safe, what is risky, for example with new technology. As hospital work of individuals and teams is increasingly organised with and through technology, how is the hospital capability for collective mindfulness affected?

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References and readings

Langer E, Piper A. The prevention of mindlessness. Journal of Personality and Social Psychology. 1987;53(2):280-7

Langer E. Mindfulness: Addison-Wesley; 1989.

Langer EJ. Matters of mind: Mindfulness/mindlessness in perspective. Consciousness and Cognition. 1992;1(3):289-305.

Langer E. The Power of Mindful Learning. Reading, MA: Addison-Wesley; 1997.

Langer EJ. Mindful learning. Current directions in psychological science. 2000;9(6):220-3.

Langer EJ. Mindfulness forward and back. The Wiley Blackwell Handbook of Mindfulness. 2014:7-20.

The Langer Mindfulness Institute: http://langermindfulnessinstitute.com/mindfulness-research/

Weick KE, Roberts KH. Collective mind in organizations: Heedful interrelating on flight decks. Administrative science quarterly. 1993:357-81.

Weick KE. Sensemaking in organizations. London: Sage; 1995.

Weick KE, Sutcliffe KM, Obstfeld D. Organizing for High Reliability: Processes of Collective Mindfulness. Research in Organizational Behavior. 1999(21):81-123.

Weick KE, Sutcliffe KM, Obstfeld D. Organizing and the Process of Sensemaking. Organization Science. 2005;16(4):409-21.

Weick KE, Sutcliffe KM. Mindfulness and the Quality of Organizational Attention. Organization Science. 2006;17(4):514-24.

Weick KE, Sutcliffe KM. Managing the unexpected: Resilience performance in an age of uncertainty. 2nd ed. San Francisco, CA: Jossey-Bass; 2007.

Sutcliffe KM, Weick KE. Mindful Organising and Resilient Healthcare. In: Hollnagel E, Braithwaite J, Wears R, editors. Resilient Health Care. London: Ashgate; 2013. p. 145-56.