Don Norman wrote the Design of Everyday things in 1988. It is a brilliant book which is underrated in the area of safety. If you do work in safety I would encourage you to read it.
A little taster.
Don was once asked by a computer company to evaluate a new keyboard. He spent the day learning to use it and trying it out on various problems. In this particular keyboard to enter data it was necessary to differentiate between the ‘return key’ and the ‘enter key’. If the wrong key was pressed, the last few minutes work was irrevocably lost (this was the 1980s). He pointed this out to the designer, explaining that he had made the error frequently and that it was likely that others were making the same mistake.
What followed was interesting.
The designer’s initial reaction was to question Don on why he made the error and why he didn’t read the manual. The designer then proceeded to provide Don with a detailed explanation of the different functions of the two keys.
Don explained that he did indeed understand the two keys but that he simply confused them. He told the designer that they had similar functions and were located in similar locations. That a skilled typist would probably, as he had done, hit the ‘return’ automatically without thought. The designer said that no one else had raised this as an issue and the employees had been using the system for months.
Don and the designer then went to talk to a few of them. He asked them if they had ever hit the ‘return key’ instead of the ‘enter key’ which resulted in them losing their work as a result. They said yes and that it happened a lot.
Why didn’t anyone say anything about it?
They had been encouraged to report any problems with the system.
This is an early view on what we now call psychological safety or the ability to disclose ones actions without fear of repercussion.
Don considered that people didn’t report these incidents because they were considered caused by human error. That the employees were happy to report when the system wasn’t working or there was a problem with the technical aspects of the computer but when they themselves pressed the wrong key, they assumed it was all down to them. The employees felt they had simply been erroneous and would do better next time. This as you are aware is a theme that runs through many many incidents.
We know, for many reasons, what people tell us may be only the partial truth. This may be because:
- explaining every little detail would be too tedious
- we do things automatically and we may forget some of the details when we come to explain it
- depending upon who we trust, we may tailor it to the audience and when we come to explain what we do we simply we say what we want people to hear or what we think they want to hear
This is a particular issue for healthcare. In a culture of fear and when we are being scrutinised or investigated, we may ‘just tell people what should or did happen not what does or did happen’.
People often do not report workarounds for example and conceal the actual practices they do in order to keep patients safe because they are not what the policy says they should do. In that respect those designing safety interventions may think that the interventions are working when they are not because no one is disclosing that they are not.
In order to learn from staff about their work-as-done and work-as-disclosed there is a need for both a psychologically safe environment and a restorative just culture because we also have work as judged. [see previous blog referencing Steven Shorrock’s work]
Work as judged relates to the way in which we are watched (work as observed), supervised (work as instructed), appraised, scrutinised and investigated (work as analysed and work as measured). Work as judged relates to the judgement, evaluation, or appraisal of work and may related to performance, competence, safety, and efficiency. Judgements are made based on what the work should be (work as imagined, work as prescribed) and compare it to the work as carried out (observed, measured and analysed and disclosed). This applies to every single person who works in healthcare.
We are judged by others and we judge ourselves.
When we are being judged we may act differently or say things that are different (work as disclosed) from our normal practice (work as done). If we are judged by people who are not from the same profession or people who lack an understanding of our area of work or expertise then there is a risk that we will be judged wrongly.
People try to judge others in healthcare by looking at the standard by which they are supposed to act (work as prescribed) and assess as to how closely our actions were against this. This particularly approach to judgement is predominant in clinical negligence cases. Judgement can also come in a number of ways from opinions of our colleagues, complaints or compliments, incident reports, investigations and the media.
Work may be judged by anyone including the person under scrutiny or judgement. It requires people to agree what is acceptable and what isn’t. This will change over time as society, expectations, knowledge and expertise changes.
Jim Reason says that one of the key lessons he learnt through his career in safety was to dispel his judgement. If we are unable to do this then at least we need to ensure that if we are going to judge others then we need to ensure we know our stuff, that we are up to date, expert and knowledgeable. Above all else we need to be fair, as free as possible from bias, and kind.
PATIENT SAFETY NOW 