Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff.

Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS.

Work-as-imagined 

This represents our imagination of others’ work and "is a gross simplification, is incomplete, and is also fundamentally incorrect in various ways, depending partly on the differences in work and context between the imaginer and the imagined." In the context of the NHS we could think about how the delivery of frontline clinical services is imagined by those not directly involved in delivering care, for example; senior managers, commissioners, regulators, patients and the public. This inaccurate mental model invariably informs decisions which impact upon frontline services such as decisions regarding how services will be delivered, funded, regulated, overseen and monitored.

Work-as-prescribed

This represent the rules, regulations, policies, procedures, checklists, job descriptions etc. which describe the 'correct' way to work. In the NHS context we could envisage this by way of Care Quality Commission regulations, organisational policies and procedures, clinical guidelines, NICE guidance etc. The fundamental limitation of work-as-prescribed is:

"It is usually impossible to prescribe all aspects of human work, even work that is well-understood, except for extremely simple tasks". Moreover, "Assumed system conditions - staffing levels, competency, equipment, procedures, time - are often somewhat more optimal than those found in practice".

In essence, work is invariably more messy and complex than assumed by rules, regulations and procedures that outline best practice. Anyone who has had experience of developing and implementing standard operating procedures will know that how things are supposed to be done as per the procedure and how they are done in reality often diverge. I think this also helps partly explain why so-called 'Never Events' happen at a regular frequency – the assumption that implementing national guidance based on work-as-prescribed will eliminate the risk of their occurrence is faulty. There are many error provoking conditions in the workplace that cannot easily be eradicated.

Work-as-disclosed

This is an intuitive concept, it represents what those doing the work are prepared to disclose to others about how they do their work. Inevitably this is limited and partially based on "what we want and are prepared to say in light of what is expected and imagined consequences". We can think about this in the context of the NHS as to how staff may relay their activities to senior managers, regulators, commissioners, patient groups etc. The message is tailored to the audience and when it comes to being scrutinised by others we will inevitably say what we think will paint us in the best possible light.

Work-as-done

This represents the reality of how day-to-day work is actually done as compared to all of the above. Inevitably there are shortcuts, variations, deviations based on reality of working conditions, expectations and demands of others. The key insight here is that work-as-done is actually quite hard to understand: even where there is observation this can change behaviour and there may be technical and practical limitations to our understanding when work being done is complex or unsafe to observe. Shorrock includes a very interesting quote from Hollnagel in his article as to how we account for differences between work-as-done and work-as-imagined or work-as-prescribed, we typically do this:

"by inferring that what people actually did was wrong – an error, a failure, a mistake – hence that what we thought they should have done was right. We rarely consider that it is our imagination, or idea about work-as-imagined, that is wrong and that work-as-done in some basic sense is right.”

This is an important consideration to bear in mind when it comes to the investigation of patient safety incidents in the NHS, it is commonplace for fault to be found in the aberrant behaviour of staff who did not adhere to policy or procedure. A more meaningful insight into what has happened would be derived from understanding why this happened and what conditions led this to occur. Were the policies and procedures themselves based on a limited understanding of work-as-done and the real-life working conditions which staff are faced with?

In relation to all of the above, it is important to understand that there can be a disconnect between all of these varieties of human work and that when it comes to decision-making and activities which can impact upon how services are delivered and overseen we need to be humble and recognise the limitations of our knowledge. In practical terms, what might these mean for those who work in roles which are detached from the work-as-done of frontline staff? Some suggested considerations are below:

• Recognise that assurance visits, observation and discussions with staff only give a partial and limited picture: firstly, observation changes behaviour and work-as-disclosed to those outside an organisation may vary considerably from the reality of work-as-done.
• Be aware that any prescriptive requirements regarding how work is to be done may have unintended consequences or create perverse incentives. There needs to be the involvement and engagement of those who are directly involved in delivering frontline services and/or those who can articulate on their behalf when it comes to prescribing how work is to be done. It isn't possible to develop all-encompassing prescriptive requirements of how work is to be done which are realistic and achievable.
• Where a prescriptive top-down approach is taken, based on a ill-informed view of how frontline services are being delivered, the results will not be good so a collaborative approach is needed.
• When it comes to the investigation of patient safety incidents, acknowledge that adherence to policy and protocol is driven by a variety of complex factors. An effective investigation needs to understand why policies and procedures have not been followed from a human factors and systems perspective including consideration that the policies and procedures themselves may be inherently flawed.

In summary, we need to be humble and recognise the limitations of our knowledge and work in partnership with others in a collaborative way rather than trying to instil or enforce change via a limited mental mode of how work is done.

• Student paramedic practice, especially in the placement environment, mirrors human factors seen post registration, but also has its own unique set which require further research.
• The relationship between student and mentoring paramedics is a unique and important human factor in student development.
• Many clinicians may not feel prepared or willing to undertake a mentorship role. More training and support for mentoring paramedics would be of benefit.
• Emotional stresses faced by students when they initially encounter emotive aspects of the placement environment should be recoginised. Institutions and placement providers should encourage students to identify and practise coping mechanisms as well as offer support.
• Placement environments vary nationally and globally, and due to the nature of the job, it is difficult to nurture confident students and clinicians. However, adaptions could be made to reduce stresses on both parties.

We are living in uncertain times, which for most people is stressful and worrying for many different underlying reasons: loss of income, loss of a job, fear of contracting the illness and the lottery of outcomes, living in isolation or living in crowded homes 24/7, reduced opportunity to exercise, concern for children and other family members and friends, fear of what comes next… to name just a few.  As a human factors professional, this comes as no surprise since our job is always to consider the range of human responses and human characteristics in order to identify to what extent it is possible to support this range; and this is indeed happening. 

For those with mobile phones and internet access, the virtual world is rapidly expanding with new and newly found apps to connect extended families and friends, to undertake virtual meetings, online lessons and assessments, access to art and museums, research opportunities, theatre performances, online exercise classes and increased opportunities to shop. For those without this access the difference is stark.  

Let’s turn our attention to these apps; someone first has to have the idea and check that there are people out there who would be interested, then there is the need to design the app, and in such a way that we want to use them and can use them. To do this is dependent upon considering the user, i.e. us humans – this is achieved by integrating user-centred design (UX design) and human factors (ergonomics). Turning our attention back to the health and social care sector, we need to consider human factors when assessing the myriad of health apps out there and the increasing use of apps to support our health and social care – from prompting individuals to take their medication to monitoring our health or providing health advice.  

So what else are we seeing as this pandemic embraces us all? Information is constant, we are truly a connected global society, from daily ministerial briefings to news reports and social media. This provides very public and graphical representations of our human responses – intellectual, emotional, behavioural and physical. For example, we see numbers of confirmed COVID-19 cases and deaths, graphs and charts showing where these are occurring, the age and gender, we see percentages of the population affected BUT to do something about this requires us again to dig deeper. We need to find out the underlying reasons. In the same way, when we respond to patient safety incidents we need to dig deeper and identify the underlying and root causes so that we can truly do something about it.

I'd like to provide some examples of how my work in human factors is influencing COVID-19 research and resources. 

In response to the UK Government asking for businesses to provide thousands of ventilators to help tackle the COVID-19 pandemic, myself and other human factors professionals collaborated with Patient Safety Learning to provide human factors/ergonomics input to support the design effort for these new ventilators. This resulted in a ventilator safety in use driver diagram developed by Patient Safety Learning and a human factors guide from the Chartered Institute of Ergonomics and Human Factors. In addition, in an example of cross-industry collaboration, Yorkshire Water gave me permission to share their human factors engineering specification with designers of ventilators and other critical medical device designers, which quickly took place.

Following this, my attention was turned towards sharing advice on working in high heat and heat stress. Based on the Health & Safety Executive Guidance (HSE (2013) INDG451 ‘Heat Stress in the workplace’), I produced a document and flowchart addressing what happens to us when we experience extreme heat, this has been welcomed and shared by the London midwife managers. 

Next, came questions relating to shift work and fatigue, which led to me creating a summary document based again on a Health Safety Executive website and an ORR document (Office of Rail Regulation [Jan 2012] Managing Rail Staff Fatigue) that emphasises the need for a fatigue management system plus tips for helping ourselves and each other to sleep better when shift working and to recognise and respond to the symptoms of fatigue (www.staffs.ac.uk/clinical-skills).

It has also been interesting to note the range of public and enforcement behaviours shown in the media that relate to our response to the ‘lockdown’ in this and other countries.  Human responses often link to aspects of culture and sub-cultures, power and influence, personal responsibility and risk perception.  All of which are highlighted during our Human Factors for Patient Safety course.

Looking ahead, I can see many learning and research opportunities evolving from this pandemic and the opportunity to add to our human factors knowledge base for the good of society. Within the Staffordshire School of Health and Social Care our mix of staff provides us with a unique opportunity to achieve new research in human factors and patient safety and we look forward to embracing the opportunity to learn together.