**4. The challenge of habits: The art of learning and unlearning**

A culture of safety represents a complex system of behaviors and hardwired procedures, designed to synergistically create a safe, reliable and efficient, high-quality clinical environment [51, 52]. The creation of such a sophisticated institutional cultural milieu requires all stakeholders to commit to unprecedented amounts of commitment and flexibility [51–53]. In many cases, the organizational transition process can span years and require the replacement of "bad habits" with positive behaviors—a difficult undertaking given the inherent human tendency to resist change when having to "unlearn things" [54]. So how do we change bad habits, motivate people to "do the right thing", and sustainably instill safe and productive behaviors? To motivate individuals, we must first recognize why and how people are influenced. In his book *Drive: The Surprising Truth About What Motivates Us*, Daniel Pink points out that historically our good behavior has been incentivized with rewards and our bad behaviors reprimanded [55]. This carries the unintended consequence of undermining an individual's motivation. He suggests humans have a strong inner-drive to be autonomous, self-determined, and connected. We all seek the trifecta of attaining autonomy, mastery, and purpose in both our work and our lives. Upon achieving these elements, people will take on greater responsibility, believing they are effecting positive change. With this sense of autonomy and purpose comes increased self-esteem, confidence, and motivation to go beyond what is merely required. The pursuit of mastery naturally follows [55].
