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.
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.
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.
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.
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.