Work as imagined and more

Work as imagined is what we imagine work is like or what we imagine the work could look like.  The ‘we’ is often policy makers, standard settings, guideline developers, regulators and commissioners.  It also includes us. The term work as imagined can also apply to policies themselves. When we first set out the intention of a policy we are in fact setting out how we imagine what a policy will achieve. Does it mean that happens?

For example with the surgical checklist, the intention of the policy was to reduce harm associated with surgery. We imagined that by using the checklist this would happen.

Another example is the intention behind the patient safety response framework. The intention of the policy is to shift the focus towards understanding the system factors that can lead to incidents and to understand how the individuals involved are impacted by those factors. The intention is also to focus organisations so that they investigate less incidents, the assumption being a few high quality investigations will lead to a better understanding that a lot of potentially superficial investigations. There is also the intention to create a just and learning culture to support the response to when things did not go as planned.

However, there may be a considerable difference between what people are assumed or expected to do and what they actually do. If people who are responsible for developing guidelines or standards or policies and procedures are relying on what they imagine someone does rather than what the frontline workers actually do then the policy could turn out to be unworkable, incomplete or fundamentally wrong.  If the designers think they have come up with something that ‘will solve the problems at the frontline’ and those who are at the frontline are left with the feeling that ‘this doesn’t solve our problems’, it feels clumsy.

The incongruence makes it hard for frontline staff to implement things they are being told to do, resulting in frustration and workarounds. The unintended consequence of this is that it triggers a degree of fatigue in relation to initiatives that seem misaligned with the goals of their day-to-day work (work-as-done) creating a chasm between the leadership and frontline of organisations. When we fix the wrong thing for the wrong reason, the same problems continue to surface. It is costly and demoralising. 

The creation of the gap between work as imagined and work as done is not intentional.  There are many people who develop policies or safety solutions who do their very best to try to understand what is really happening on the frontline.  They speak to staff and where possible observe the work in real time.  It is also not all bad.  Imagining things can mean a new way of doing the work that others have yet to think of, it can challenge the status quo and describe an ideal people may want to aspire to.  However, imagining work on its own, in isolation of context, lived experience, ‘work as one’, can be risky and in some cases simply wrong. 

Steven Shorrock (https://humanisticsystems.com/author/stevenshorrock/) has taken this further and describes human work from multiple perspectives.  He describes, work as prescribed, instructed, observed, measured, analysed, simulated and disclosed.

Work as prescribed is usually the output of work as imagined.  The written rules, standards, guidelines, protocols detailing how people should work.  This can come from the Department of Health and Social Care, individual policy makers, The Care Quality Commission, professional regulators, royal colleges, other professional bodies, unions and other national organisations such as the National Institute for Clinical Excellence, or NHS Resolution or the Health and Safety Executive.  These form the way people are expected to work and are used to judge whether the work has been carried out in accordance with what they prescribe. There are some specialties such as radiotherapy, chemotherapy, medication administration when the gap between work-as-prescribed and work-as-done needs to be as narrow as it possibly could be. This is where it is vital that the prescribed practice matches reality and is constantly reviewed to ensure that it remains so.  However, we are falsely led to believe that we can describe all care in detail.  If we did, we would be stifled by the constraints, we would not be able to adapt where necessary and everything would take far too long.

Work as instructed is the way in which work is explained in order to support someone to carry out a task or procedure.  It can be through work as prescribed (standards, checklists etc.) but mainly relates to training or on the job instructions.  Healthcare workers are more often instructed on the job rather than in the classroom.  They are instructed by those more senior or more experienced than them to carry out a particular task or procedure, sometimes with supervision, sometimes not.  In certain cultures, the instructions are not questioned even if people don’t understand them or don’t think they are correct or safe.  Sometimes this can lead to harm both for staff and patients.  Work as instructed needs to be supported by a culture that encourages people to question and challenge.

Work as observed is the attempt to monitor and observe what people do at work.  It may be both formal and informal.  It forms the input into work as analysed.  Work as observed is often used by regulators or professional auditors and is linked to work as measured and work as analysed.  In a complex adaptive system such as healthcare it is not possible to observe all aspects of the work.  This is because of dynamic nature of the work, the variation of the work, the situations and circumstances the work is being undertaken and the interdependencies that influence what is done. With regard to research work as observed may take the form of ethnographic study.  These types of research are now being used to study work as done, in order to understand how practices are done well to support the safety-II approach.  However, ethnography can be subjective depending upon the way the observer interprets what they see.  In order to make the data collection and interpretation transparent, researchers attempt to be reflexive. This is the video reflexivity methodology.  Reflexivity refers to the researcher’s (observer) aim to explore the ways in which the researcher’s involvement with a particular study could influence the research. Reflexivity also refers to the act of self-reference; the examination of an action or practice.  A low level of reflexivity would result in individuals shaped largely by their environment.  A high level of social reflexivity would be defined by individuals shaping their own environment. 

Work as measured is the data that comes from work as observed which is then fed into work as analysed.  In healthcare we are overwhelmed by the number of measures we are expected to capture and monitor.  

Shorrock sums it up for me in the following:

In practice, work-as-measured is often to assumed to have more validity than it really does. It often does not measure what it claims to measure. Measures for aspects of work-as-done are also often overgeneralised, not evaluated properly in situ, or are affected by biases, especially when there are perceived or real adverse consequences for poor measures (work-as-judged). Many aspects of work-as-done (especially work in the head, coordination, social behaviour) cannot be measured with high levels of fidelity. Quantitative measures can – via precision bias and false precision – appear to be more valid than they really are. Finally, work-as-measured can be affected by perceived and actual consequences, such as those associated with incentives and punishments, sometimes associated with performance targets, and limits. These may affect the selection, collection, analysis, interpretation, and evaluation of measures and associated data. A practical example is the four hour target in UK hospitals, where accident and emergency (A&E) departments in the UK must admit, transfer or discharge patents within four hours. This has been associated with reductions in recorded waiting times, but also peaks just before the four-hour limit, and occasionally data falsification, without sustained improvements in patient care.

Work as analysed is the output of work as observed and analysed.  It is the output of any review, inquiry and audit.  It is part of the examination of work as done; the scrutiny of what people do, by describing what people do from the facts and figures gathered.  It is usually the work of expert analysts.   Similar to work as observed, it is difficult to describe the nuances of everything we do in healthcare.  It is constantly changing, there are multiple unseen interactions and unseen behaviours and pressures.  For this reason, analysis can lose the depth of what we do and provides us simply with a surface view of what we do.

Work as simulated is usually conducted in simulation training where there is an attempt to understand how work is done but also to recreate aspects of care to try to see how it was done at a certain time or can be used to test out ways of working for the future.  It is often used to support team training or to support a particular skill that needs to be practiced in a safe way.  It can be with work colleagues or even with actors.  There has been an increase in the use of simulation training across healthcare and it provides a really useful way of gaining experiential learning without the fear of doing something stupid, or doing something wrong. 

Work as simulated can inform work as imagined but will still be different from work as done.  In the same way as we all change when we are being watched or filmed, we also change or act or behave differently within the simulation space.

Work as disclosed is the work we say we do or if we don’t feel we can do that is could be described as work as undisclosed.  Work as disclosed is how people describe what they do, either in writing or when they talk to each other.  This may not be the actual work they do but the work they expect people to want to hear, the work as it should be and not how it actually is.  If there is a culture of psychological safety where people feel safe to share, then work as disclosed might be close to what people actually do.  

As Shorrock says:

What we do at work may be different to what we are prepared to say, especially to outsiders or ‘outgroup’ members. What a staff member says to a senior manager or auditor about work may be different to what really happens, for example. There are many reasons not to express how work is really done. But people will tend to modify or limit what they say about work-as-done based on imagined consequences. For instance, staff may fear that resources will be withdrawn, constraints may be put in place, sanctions may be enacted, or necessary margins or buffers will be dispensed. So, secrecy around work-as-done may serve to protect one’s own or others’ interests.

Anyone who works in safety and beyond needs to understand these different ‘works’ in order to understand how to influence change more effectively.