In order to develop a more proactive approach to preventing harm and improving the safety of patient care there is a need to understand how people actually work. Steven Shorrock writes eloquently on the subject and describes the different ways people work (Shorrock 2016, Shorrock 2017).
Shorrock proposes that there is a difference or a gap in relation to how people think that work is done and how work is actually done. He suggests that there are four basic varieties that can be considered: work-as-imagined; work-as-prescribed; work-as-disclosed; and work-as-done. These varieties, he says, usually overlap, but not completely, leaving areas of commonality and areas of difference. It is important to know how work is actually done because with only with this knowledge can we start to think about how it can be replicated or improved.
Let us look at this a little more…
Work as imagined
With a complex organisation such as the National Health Service (NHS) it would be virtually impossible for anyone to truly understand how all of the work is actually carried out everywhere. However, if people are responsible for developing guidelines or standards or policies and procedures then relying on what you imagine someone does rather than what they actually do could mean that the policy is either incomplete, unworkable or fundamentally wrong.
Even if you have past experience of that area, the moment you step away from the frontline you start to become removed from it. Change in healthcare happens quickly and people’s memories become distorted. Also even if you go out and about and talk to people who work there you may only be getting a partial story; if the culture is inhibitory then people may say what they think people want to hear not what is actually happening.
Work as prescribed
Sometimes it is important that the work we do is prescribed. Apart from the obvious in terms of medications there is a need for prescribed laws and regulations to ensure care is being provided safely for example in radiotherapy or chemotherapy. These are the ‘islands of reliability’ that Vincent and Amalberti (2016) refer to.
In healthcare we have an abundance of prescribed work; targets, checklists, guidelines, requirements and standards and so on. But do we have ‘work as prescribed’. Similar to work as imagined the work that is prescribed is often done so by those with some distance from the frontline.
The problem as Erik Hollnagel would say is that in healthcare it is usually impossible to prescribe all aspects of what we do, even when that work is well-understood. Healthcare constantly requires people to adjust what they do to match the conditions they work in and the patients they are treating. No two days are the same so there are many ways in which the work can be done.
Work as disclosed
Work as disclosed is how people describe what they do either in writing or when they talk to each other. However this may not always be what is actually done. For many reasons, it may be the partial truth. This may be because explaining every little detail would be too tedious or that because we do things automatically we may forget some of the details. We also often explain things differently depending upon the audience.
Explanations may be too simple because we want to help make it understood or we say what we want people to hear. This could be the case when we are being scrutinised or audited; ‘just tell people what should happen not what does happen’. One fascinating aspect that Dan Ariely (author of The (honest) truth about dishonesty 2012) says is that you may not get the truth because as humans we lie to ourselves and others every 10 minutes.
Work as done
Work-as-done is actual activity – what people do. Shorrock emphasises that work-as-done is the most important and yet most neglected variety of human work. Both he and Hollnagel say that work-as-done is mostly impossible to prescribe precisely. Safety II describes how safer healthcare is achieved by adjustments, variations, and trade-offs. These compromises are necessary to meet the conditions within which we work. These adaptations are based on our day to day experience.
Work-as-done can be observed but like all ethnographic study it is challenging. People may behave differently when they are being observed, (the Hawthorne effect) it may also be really hard to understand just from observation alone.
Shorrock (2017) updates these four activities with his recent posts about seven archetypes (with his own summaries in brackets):
- The Messy Reality (Much work-as-done is not as prescribed (either different to procedures, guidelines, etc., or where there are no procedures), and is usually not known to others who are not at the sharp end of the work. The focus of The Messy Reality is the actual work and the messy details).
- Congruence (Much human work is done ‘by the book’ – at least in general terms if not the fine detail – and is done much in line with how people who are more removed from the actual work imagine. Such work is often even disclosed, since there is no reason not to. However, prescribed work can have unintended consequences. These, of course, were not imagined, at least by those who designed the work.)
- Taboo (This is activity that people don’t want to talk about outside of one or more groups. It is often not in accordance with official policy, procedures, etc., or there is no relevant policy, procedures, or if it is described in procedures, others would find the activity unacceptable. As such, the activity is often not widely known outside of specific groups. The main defining feature is that it is not openly discussed)
- Ignorance and Fantasy (This is what people don’t know about real work and what they imagine happens. The imagination relates to official policy, procedure, standards, guidelines, etc. that people assume are in force, or there may just be a general impression of how things work and should work. The primary focus of Ignorance and Fantasy is the imagination of those removed from the actual work)
- Projection (We are prone to imagine that things will work according to a plan, and prone to wishful thinking, ignoring the potential for problems. The focus of Projection is the imagination of the future, as we think it will be, or would like it to be)
- P.R. and Subterfuge (This is what people say happens or has happened, when this does not reflect the reality of what happens or happened. What is disclosed will often relate to what ‘should’ happen according to policies, procedures, standards, guidelines, or expected norms, or else will shift blame for problems elsewhere. What is disclosed may be based on deliberate deceit (by commission or omission), or on Ignorance and Fantasy, or something in between… The focus of P.R. and Subterfuge is therefore on disclosure, to influence what others think)
- Defunct (Some forms of prescribed work are not enacted, or else drift into disuse, but are still officially in place. Some will imagine that these are in place, while others know or think they are not. However, the existence of the Defunct work may be used to judge actual activity)