11/27 – Shifting from Knowledge Power to Generative Inquiry: Creating the Field for Transformative Learning in Healthcare and Business

Nancy L. Southern, Jorge Taborga, and Mara Zabari

Nancy L. Southern, Jorge Taborga, and Mara Zabari


Jorge Taborga

Jorge Taborga

Nancy Southern

Nancy Southern

Our work in creating opportunities for transformative learning for individuals and organizations has surfaced a pattern that needs attention and consideration.  That pattern is an over reliance on knowledge power that keeps us focused on acquiring more information, often from experts, planning and strategizing based on that information, and taking action assuming that we have the information and knowledge needed. Learning for the most part is used as an adaptive rather than

Mara Zabari

Mara Zabari

transformative process. Two case studies show how organizational leaders can create a field for transformative learning and change in organizations using a generative inquiry approach.

Defining the Shift

One might say that our thirst for information keeps us stuck in a cycle of singe loop learning, a pattern that Argyris and Schon (1978) identified as endemic to organizations. Argyris posited a shift to double loop learning to support improved knowledge generation and decision making. A reflection on action cycle defines the difference between double and single loop learning. After action reviews are a good example of a process intended to support double loop learning. The challenge however is ensuring that what shows up on an after action review is used to inform future action. Often, knowledge that is generated from these types of reflective processes is overlooked in favor of knowledge that is offered from an expert point of view.

To create the conditions for transformative learning and change, we need to shift from a reliance of knowledge power which often resides outside of our collective spaces, to embracing shared understanding that is generated through intentional inquiry that draws forth meaningful, contextual knowledge. Closely related to the concept of triple loop learning, generative inquiry reflects on the underlying assumptions of our actions and the larger systemic context in which they exist. Transformative learning on the individual or organizational level requires the ability to expand our understanding of who we are and what we do within a larger context. Gadamer (1993) referred to this contextual learning as a fusion of horizons or the process of enlarging one’s horizon through a deep understanding and ability to embrace the horizon of another. We see the process of generative inquiry as this type of ontological learning process, a way of being together, as well as an epistemological process of generating knowledge through inquiry, reflecting on it within a context, acting on it, inquiring and reflecting on the learning, and generating new inquiry to continuously support learning and change.

Our paper provides two case examples, one in healthcare and one in the business sector to show how organizations that have been traditionally over reliant on knowledge power can take action to create a container for generative inquiry to support transformative learning and change. You will see in these mini case scenarios, how the work of transformative learning and change requires an understanding that people are working within a cultural context and thus the change being generated is cultural change.

As educators, we need to consider the implications of this shift within our educational institutions. Habermas (1985) noted how the focus on instrumental education was limiting the development of critical thinking and thus negatively affecting civil society.  Democracies and other forms of participative governance require citizens who are able to recognize when power is used over others in a way that suppresses participation.  Participative governance in societies, much like shared leadership in organizations, requires people to constructively engage disagreement and move toward agreement through a critical inquiry process. The skills of critical thinking and dialogue are supported by the art of inquiry and reflection to enable learning and change.

Our challenge is creating learning communities throughout the educational process from K-12 through higher education where generative inquiry drives knowledge acquisition and where students quest for greater understanding of the context in which they participate. Developing the capacity for transformative learning begins at an early age as children learn how to learn and learning how to learn is a capacity we build throughout our lives. Unfortunately education at all levels is becoming more instrumental, focused on acquiring information, often out of context, and irrelevant to learners. We see greater pressure in higher education to create curriculum to help students get jobs. Critical thinking, inquiry, and reflection are replaced with knowledge and skill building that can be accomplished in the shortest period of time and put to use in the workplace. Students quickly learn that education is about acquiring short term knowledge and miss the opportunity for meaningful inquiry and exploration of the unknown.

How do we shift from this focus on knowledge power to generative inquiry in education and in our organizational systems and what difference would it make? Creating curriculum that supports students in experiencing their own transformative learning and leading transformative change can bring purpose to learning. Intentional inquiry can support encounters with the other that challenge beliefs and assumptions. To create the conditions for this type of learning, educational institutions need to recognize the importance of developing learning communities and consider how to engage students and teachers within them in a way that creates space for generative inquiry. These learning communities require teachers to reduce their reliance on knowledge power and become learners alongside their students.

The gap between adaptive and transformative approaches to learning and change is significant. A generative approach is a collaborative process that brings into question what we are doing and why. It creates a space where creativity, systems thinking and design thinking can lead to new ways of being and doing. A generative approach is best accomplished through deliberate conversations, well-orchestrated workshops and open conversations where questions and ideas can emerge.

Participating in this space of transformative learning and shifting from knowledge power to generative inquiry involves the following shift in beliefs and assumptions.

Knowledge based


Reality is objective Reality can be socially constructed
Science is truth Science informs our ability to create truth
Others know better We know ourselves and our situation better than anyone
We need someone else to guide us (and to blame if it fails) – “how will they?” We are accountable for our future – “how can we?”

Generative inquiry creates a space for people to reflect together on their experience and assumptions from which insight, understanding, commitment, and engagement emerges.  When people are invited into a process of generative inquiry they discover how to listen differently, in a way that considers the frame of reference or meaning schemes (Mezirow, 1990) and deeply held assumptions they and others hold. This approach to listening supports an emergence toward shared understanding and constructed knowledge.

The following two case studies provide concrete examples as to how these ideas can be put into practice.

Case Study in Healthcare


The groundbreaking report of the Institute of Medicine (IOM) by Kohn, Corrigan, and Donaldson (2000), “To Err is Human: Building a Better Health System,” revealed that as many as 98,000 people die each year from medical errors.  While significant effort and substantial amounts of money have gone into making improvements in patient safety since the IOM report, recent assessments demonstrate that little progress has been realized, and, according to some accounts, there has even been a decline (U.S. Department of Health and Human Services, Agency for Health and Research Quality, 2008; National Quality Forum, 2009).

A major contributor to the lack of improvement is what is commonly referred to as the culture of medicine described as a tradition of individualism, hierarchical authority structures, and diffuse accountability.  This culture creates significant barriers to teamwork and individual accountability for successful interdependence which is required for safe patient care (Leape, & Berwick, 2005).

In their review of patient cases over a four-year period, leaders at a community hospital’s Family Maternity Center (FMC) determined that occasional poor patient outcomes were a result of that culture. Common themes were: turf issues; existing organizational and professional hierarchical structures leading to difficulties working through disagreement; communication patterns among and between the staff and providers showing gaps in critical information and varying expectations related to needed action; and, the lack of understanding and enforcement of accountability for patient safety.

Issue (s) Being Addressed

Over the prior four-year period traditional methods such as changes in policies and procedures, guideline development, and education, were utilized to address the cultural barriers to providing safe care. These established (or traditional) approaches represent single loop learning and offer only information that fits into existing paradigms. Single loop learning facilitates incremental improvements, which often times is sufficient. However, due to the recurrent nature of the concerns and the potential dire consequences of the outcomes, FMC leadership realized that a new approach was needed.  They desired an approach that would facilitate a reframing of the issues so that fundamental shifts in worldviews, perceptions, and behaviors could bring about collective action for change.

The Approach Taken

An intervention that took place in September of 2011, was titled The FMC Patient Safety Summit. It was a mandatory, all day event, designed to engage the entire FMC care-taker team in exploring the problem of patient safety in a new way.  To reframe the current situation, opportunities for double and triple loop learning were provided to the participants.  Facilitated sessions created space for the group to question the assumptions and mental models that drove past decisions and actions. Further, the group identified values and norms that were at the core of these assumptions and mental models. This level of group reflection fostered a collective awareness and understanding of how the context (culture) influenced individual and collective action.  With this new awareness, possibilities for change were explored.

The FMC Patient Safety Summit was structured in three phases: analyze, decide, and act. Starting with the analyze phase, participants learned about the patterns of errors in healthcare.  Together they watched a film where actors reenacted themes from past FMC cases in which less than optimal patient outcomes were shown to be a result of poor communication, coordination, and teamwork.  These stories were selected by the summit planning team because they included the most common themes affecting teamwork identified through four years of FMC case reviews.

Following the film, using the Organizational Culture Change Pyramid model developed by Nancy Southern (2005) (Figure 1), and adapted from the work of Peter Senge and Edgar Schein, the case themes were deconstructed to identify the events that occurred and their presenting problems.  Working through the model enabled participants to identify the assumptions and beliefs that underlie behaviors and problems and develop new patterns of actions and supporting structures for improved care team coordination.

The decide phase provided a foundation for group decision making and  opened with presentations on specific cases with poor outcomes, the safety practice improvements developed from those cases, and current performance related to those practice improvements.  A round table discussion prompted participants to identify and prioritize safety practices that would lead FMC members towards safer patient care.

The last phase was the act phase.  This session was designed to engage the participants in exploring how to enact new ways toward an improved culture of safety and develop new teamwork commitments to use immediately.  Prior to the summit, participants were asked to suggest, or select from a pre-developed list, a new team behavior they felt would improve patient safety.  At the summit, all of the suggestions were presented and the participants were asked to rank them in order of importance.  The most popular behaviors from the ranking became the new FMC teamwork commitments which they named The Declaration of Interdependence.

Emergent Themes/Insights/Problems

Participants described this all day event as intense, emotional, and uplifting.  Dialogue on areas of conflict and power dynamics that affected the team and patient care led the group to challenge the traditional decision-making structures and processes under which they had been operating.  They developed new structures and processes that reflected their new teamwork commitments along with recognizing human fallibility and valuing the perspectives of all team members.

Several months later, participants were asked to describe the changes they experienced in themselves and their colleagues as a result of the Summit. A common theme expressed was providing more support to others and being more proactive in their roles as team members.  All were embracing past safety practices as well as the new ones and putting more effort into improving communications with one another.  Specifically, employees at the lower level of the organizational hierarchy experienced greater comfort speaking up and asking questions as a result of a general sense of team support. Those at the upper levels of the hierarchy acknowledged the new found assertiveness on the part of the other staff members and were taking steps to be responsive and encourage it. In their reflections on this particular change, while many of them described feelings of pride as they were witnessing the new interactions among the care-taker team, some of them described the difficulties they were experiencing as they were adjusting to this new dynamic. What was apparent was that the generative approach of this Summit created the conditions for transformative change. Effects in patient safety will be measured over time.

Case Study in Business


One in three change initiatives have been deemed successful since the fields of management and leadership studies began researching large transformational changes (Meaney & Pung, 2008). Isern and Pung (2007) characterize large organizational transformation as having “startlingly high ambitions, the integration of different types of change, and a prolonged effort often lasting many months , in some cases, even years (p. 1)”.

This case study documents a large transformational change at a medical devices company in the San Francisco Bay Area. In 2009, Pharma Supply (pseudo name) embarked on a program to retool all of its core processes, implementing a new computer system to operate them, from order processing to manufacturing to financial management.  The initial results of the implementation of this program fell in line with the two thirds of change initiatives that are either challenged or do not succeed. The following sections summarize what Pharma Supply did to overcome its initial challenges and ultimately achieve the goals they envisioned for their change.

Issues Being Addressed

After a year of working on retooling its processes and systems, Pharma Supply decided to go “live” with them.  Within a month of the implementation, it became clear to the leaders of Pharma Supply that the company could not operate the new processes and systems for they were not correct or clear to everyone.  An assessment of the consequences of this situation concluded that the company would likely miss its financial forecast for the quarter and seriously affect customer relationships.

Inherent in the process and systemic problems at Pharma Supply, was the seemingly insurmountable challenge of changing the culture and interactions of the company that led to this potentially disastrous outcome.  The CFO and a small number of leaders of the company viewed the culture and interactions as the most important areas to address.  They believed, if people who worked together in the program could quickly learn how to work differently there was potential of overcoming the difficulties.

The Approach Taken

Schein (1993) submits that dialogue can speed up the process of change within an organization.  Dialogue allows for the identification and solution to a problem by “thinking together.”  This process starts with the suspension of our underlying assumptions followed by deep inquiry into the assumptions of all of the participants.  Dialogue can build a container of trust, a safe place to explore new assumptions, beliefs and actions, similar to what we described in the healthcare case scenario above.

Pharma Supply decided to use a dialogical process to bring its change team together, achieve a high level of coherence and make quick progress towards fixing the process and systems problems.  A leader/moderator was assigned to oversee the process. This individual set up daily meetings, including Fridays, at 4 PM with no end time.  A room was chosen away from everyone’s daily work and physically arranged so that everyone could see one another.  Everyone had to be physically present and could only send a substitute if a personal emergency occurred.  The company decided to pay for any necessary childcare and transportation of family members.  The change team needed to be fully present during the daily meetings.

Little progress toward solutions occurred during the first two weeks. The meetings initially explored where everyone was in reference to the implementation of new processes and systems. The moderator encouraged all participants to share their thoughts and feelings and reassured everyone there would be no judgments or repercussions. The first week, the meetings lasted three to four hours.  The duration eventually decreased to about two hours daily.  Around the third week, the team started to see a way through their conflict. By the end of the fiscal quarter, seven weeks later, the company achieved its revenue goal and most customer commitments were met.  There was still a long journey ahead but the team demonstrated their ability to learn quickly and solve seemingly impossible problems.

The daily dialogues at Pharma Supply took place over a year with a diminishing number of weekly meetings of shorter duration. The format of the meetings remained unchanged: everyone participated, openly shared their perspectives, listened to others, collaborated and made incremental progress.  At the end of the year, the biggest effect everyone realized was how much they learned about themselves and each other.  Strong relationships developed resulting in a high level of mutual trust.  The change team, including new members, implemented future projects faster and more successfully. The generative dialogue process at Pharma Supply resulted in a new capability of working together.

Emergent Themes and Insights

At Pharma Supply, the 4 PM sessions provided the team with the opportunity to engage in double and triple loop learning.  Given the severity of the issues, they could have easily fallen into the trap of single loop learning.  Fortunately they recognized how the team’s thinking and ways of working generated the problems and leaders were willing to create a container for generative inquiry and transformative learning.

Isaacs (1999) makes the connection between dialogue as the process of thinking together and double and triple loop learning.  In his dialogical model, Isaacs describes two stages. The first, reflective dialogue, explores underlying causes, rules, and assumptions to get to deeper questions and framing of problems. As was experienced at Pharma Supply, the second stage, generative dialogue creates the possibility for groups to develop unprecedented new insights and ways of working, resulting in a collective flow and ability to learn how to learn together.

Process for Engaging Participants in Conference Experiential Session

This session creates a forum for presenters and participants to share their perspectives on the challenges and opportunities in the three organizational domains to support a shift from knowledge power to generative inquiry. In small groups focused on the application of the theory to healthcare, business, or education, we will engage the following generative inquiry guiding questions.

  • How might this approach support you in working with a needed change?
  • How would you design a container to generative inquiry?
  • What challenges might you encounter using this approach?
  • How would you address those challenges through new processes and structures?


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About the Authors

Nancy Southern, Ed.D. is Chair of the School of Organizational Leadership and Transformation and of the Organizational Systems PhD program at Saybrook University. Over the last 25 years, she has consulted to organizations and leadership teams striving to create cultures of collaboration to improve their ability to respond to the complex demands of our times. She has worked with senior and mid-management teams to help build their capacity to engage in meaningful conversations using appreciative and critical inquiry to address their challenges and create the desired organizational change. Nancy is a research member of the Society of Organizational Learning and serves on the editorial boards of the Journal of Transformative Education and the Organizational Development Practitioner. Her research interests intersect culture, collaboration, community and innovation using qualitative methodologies including action research, hermeneutics, and other interpretative and transformative approaches.

Jorge Taborga  is the Vice President of Manufacturing, Quality and IT at Omnicell, Inc.  He has an extensive background in change leadership, product development, management consulting, process reengineering and information technology.  His 29 year work experience includes companies like ROLM Systems, IBM, Quantum, Bay Networks, 3Com, and UTStarcom.  Jorge also delivered organizational development and management consulting services to a number of companies in the San Francisco Bay Area and China.  He is currently pursuing a Ph.D. in Organizational Systems at Saybrook University.

Mara Zabari, RN, MPA-HA, is the Director of Integrated Care for the Partnership for Patients program at the Washington State Hospital Association. Funded by the Affordable Care Act, Mara is working with over 100 hospitals in Washington, Oregon and Alaska to make patient care safer.  Mara has worked in the healthcare sector for over 20 years in a variety of leadership positions focusing on strategic planning, program development, and small and large organizational change efforts. She has taught leadership, systems thinking, and organizational change at both Oregon Health Sciences University and The Vermont Oxford Network. Mara is currently a PhD student in Organizational Systems at Saybrook University.


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