Too often I get a question from the audience which goes a little like this …
“It’s all very well all this being kind to one another but what can we do about the people who are useless or lazy or unsafe..”
Now I would argue that it is being kind if we help those people deemed ‘incompetent’ or lazy to find something or somewhere that suits their skill set more.
It is also being kind to figure out what may be behind their perceived incompetence.
Crucially it is vital this exploration does not leave us with the view that safety is purely down to ensuring the workers are competent.
What we actually need to study is how ‘work is done’ and what factors influence success and failure. We need to understand the role that the system and the environment plays (i.e. resources, education, infrastructure, staffing, culture, attending to health and wellbeing, supportive behaviours, relationships and so on) in helping people be the very best they can be.
One of the ways we could explore this further is to understand what psychologists refer to as the four stages of competence, or the conscious competence learning model, and how these stages impact on safety.
How we progress from incompetence to competence in our skills in healthcare is a component of safety.
So let’s explore these stages of competence.
First. Unconscious incompetence
The staff member does not understand or know how to do something and does not recognise that they don’t know.
We are all like this when we start out in life or start a new job. We are that novice who may take risky decisions without knowing how risky we are being.
So we don’t know that we don’t know? And not knowing means we could act unsafely without knowing we are acting unsafely.
Second. Conscious incompetence
The staff member does not understand or know how to do something but they recognise this.
The novice that knows they need expertise and experience to become more expert. This means that we can seek the knowledge to help us act safely. Feels a less risky stage to be.
Third. Conscious competence
The staff member understands or knows how to do something but makes a concerted effort to concentrate on the task in order to get it right.
The novice who is becoming an expert but still makes an effort to really think about it when doing the skill. On the road to being an expert but aware they need to continuously learn.
This feels like the conscious mindset to act safely. To have safety at the forefront of the brain when carrying out a procedure or task.
Is this where we should all try to be?
Fourth. Unconscious competence
The staff member has years of experience or has practiced over a significant time to master a skill. The skill has become second nature and can be performed easily. In fact the skill can be performed while doing other tasks at the same time.
The novice has become the expert and so much so that they can become the educators.
While this seems on the face of it optimal it could also be a risky state to be in. What if this leads to complacency or cutting corners inappropriately.
In healthcare there are around 1.3 million employees. All of whom will exhibit all of these stages at one time or another. In fact most of us exhibit all four stages all of the time. We may be both novice in some areas and expert in others. All of which impacts on the ‘work as done’.
It is too simplistic to say that what we should aim for is everyone being in the third stage (if we consider that to be the safest) when we will be constantly moving between the stages. What we need to do is help people who are in all four stages to work as safely as they can.
There feels a link between system competence and individual competence that may shine a light on ‘work as done’.
So how can truly understand how ‘work is done’ in order to help people work safely.
Collecting and studying incidents will tell us how work is done through the lens of failure.
Investigations and inquiries will provide insight into where there are flaws in our systems and processes.
Quality improvement tends to focus on a problem that needs fixing.
But what of the everyday? The everyday that most of us ignore because it simply just went ok. This we know is the majority of the time yet we fail to study this. What are the factors that help our work simply go ok?
How can we study this?
The research methodology that lends itself to this would be to follow people around and watch what they do (ethnographic methods) or to survey or interview people on the ground. However another way may be for those people to simply share their stories of their everyday. Storytelling is really powerful especially written in the first person.
So if you are interested in sharing your everyday stories I am really interested to listen.
Use the hashtag #workasdone and share on twitter your story or if you have too much to say send me a tweet and you may end up being a guest blogger.
Patient Safety Now 