In a previous post on four ‘varieties of human work‘, I introduced the concept of ‘work-as-disclosed’. Work-as-disclosed is what we say or write about work, and how we talk or write about it, either casually or more formally. Work is disclosed by many people, both those who do the work, and those who do not, based on more or less knowledge of work-as-done.
It may be simply how we explain the nitty-gritty or the detail of work, or espouse or promote a particular view or impression of work (as it is or should be) in official statements, etc. Work-as-disclosed is typically based on a partial version of one or more of the other varieties of human work: Work-as-imagined, work-as-prescribed, and work-as-done. But the message (i.e., what is said/written, how it is said/written, when it is said/written, where it is said/written, and who says/writes it) is tailored to the purpose or objective of the message (why it is said/written), and, more or less deliberately, to what is thought to be palatable, expected and understandable to the audience. It is often based on what we want and are prepared to say in light of what is expected and imagined consequences.
As I explain in the post, work-as-disclosed will tend to be different to work-as-done in several ways and for several reasons, including lack of knowledge about the work, difficulties in communicating about the work (e.g., the technical details), or fear about the consequences of disclosure.
This brings us to three spaces for work-as-disclosed that are relevant to trying to reduce the gap between work-as-disclosed and work-as-done, or at least to understand why such a gap exists.
The public space for disclosure is the context (combining social and cultural, organisational and institutional, legal and regulatory, and personal contexts) that warrants and permits public disclosure about one’s understanding of work-as-done. The public space will tend to involve reduced fear of unwanted consequences of disclosure, and therefore higher perceived levels of psychological safety and associated fairness or justice.
The public space will tend to involve disclosure about work-as-done that is congruent with work-as-prescribed, or at least with the work-as-imagined of others who are seen as significant (e.g., management, regulatory bodies, judiciary, staff [especially colleagues], and public/citizens). Finding means to expand safely the public space is a way to increase the shared reality about work-as-done, including its context.
This is a difficult task since there are different demands and expectations on those who do the work, from different stakeholders (public/citizens, government, regulatory bodies, judiciary, associations senior management, middle management, staff, and service users). There are therefore conflicts that create barriers to disclosure.
There are various regulatory and organisational attempts to expand the public space. One example is the UK Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20. This requires that registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. Another example is the open publication of safety investigation reports, which are normally kept internal to an organisation. For instance, LVNL – the Dutch air navigation service provider – “pro-actively publishes the reports of potentially serious occurrences and the results of the occurrence investigations. In this way, we give the local community more insight into aviation safety. The investigation results for each occurrence can be read here, and we indicate which measures LVNL has taken to prevent occurrences.” In the UK, freedom of information requests can also be submitted to expand the public space.
Institutional measures do not always work, however, and require measures to ensure people feel safe to disclose, or at least not unjustly treated following disclosure. This reminds us that the concept of just culture – as well as psychological safety – remains important, in both a corporate and judicial context.
The Private Space
The private space is the context in which much or most disclosure about work occurs, since disclosure is limited and still on a ‘need-to-know’ (or useful-to-know) basis, as is the case for the public space. In the private space, we see most communication about work as done, in general or in terms of the nitty gritty of human work. Between colleagues and immediate managers, for instance, there is a high need to know about what has been done (and what is left to do), at least at some level of detail. As one moves further away from the context of work (physically, temporally, or socially, for example), there is less need to know about the details. However, events that trigger work from others (such as unwanted events, major achievements or simply part of the ordinary workflow between individuals and teams) will tend to require wider disclosure.
The private space requires good relationships and understanding about work-as-done. It is a space for reducing the gap-between work-as-imagined and work-as-done. Poor relationships may constrict the private space, however, and there is little point in disclosing the details of work-as-done that is not relevant or understandable to others.
The private space is therefore similar to much of the disclosure space within a couple or a family. What is private does not need to be made public. But equally, it is not secret.
The Secret Space
The secret space is the context in which work-as-disclosed is limited or distorted deliberately, based largely on fear of the potential consequences of disclosure.
Staff may fear that resources will be withdrawn, constraints may be put in place, sanctions may be enacted, or safety margins or buffers will be dispensed. Hence, secrecy around work-as-done can be a self-protective measure against the drive to improve efficiency at the expense of other goals (such as safety and well-being). … In an environment where people are punished for trade-offs, workarounds, and compromises, which the staff believe to be necessary to meet demand, then the overlap between work-as-disclosed and work-as-done may be deliberately reduced.
In this space, deliberate efforts are made to keep hidden or to distort aspects of ‘Taboo‘ work-as-done, in line with the ‘P.R. and Subterfuge‘ archetype, where work-as-disclosed (and often as-prescribed) is not as-done. These two archetypes of human work are therefore intimately connected to the secret space. (And so I’ll not repeat these posts here.)
Stigma and shame around unwanted outcomes associated with ‘work-as-judged’ (even when these outcomes are mostly accounted for by the context of work, such as demand, resources and constraints) will of course tend to restrict the public and private spaces, and expand the secret space. The secret space can become a burden to those who have to maintain it, which may be one, several or many people. Deliberate or accidental disclosure may present various risks, and these risks may be present for a long period of time. Meanwhile, others are denied the possibility to act on information that is pertinent to them, and their needs and rights may be denied.
There is an overlap between the private and secret spaces, but not all privacy is secrecy. In many or most cases, there is no special need to keep secret the nature or details of work-as-done. So work-as-disclosed will tend to be in the private space voluntarily, with there being no justifiable need for disclosure in the public space. Work-as-disclosed in the secret space, however, is often there because bringing it into the private space is not seen as a viable option. The potential consequences are simply too great (e.g., shaming, loss of job, prosecution). However, there is sometimes a desire to bring work-as-disclosed into the private space from the secret space. The burden of secrecy may be too great, or ethical concerns (concerning safety or justice, for example) may trigger a need for disclosure (or confession). When such attempts are frustrated, perhaps by colleagues or management, then work-as-disclosed is sometimes moved purposefully into the public space, via so-called ‘whistleblowing’. Here, the consequences of disclosure are even greater for the discloser, but seen as somehow preferable to the consequences of secrecy.
The lesson, then, must be to act ethically and to create conditions to help expand the private space, and even the public space (where this does not result in a flood of unnecessary or meaningless information), and reduce the secret space as much as possible. This is the responsibility of all of us.
All human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily).
An approach that I have found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. This should done with those who have relevant field expertise, in an interview or workshop setting, virtually or in-person, supported by secondary sources (e.g., research publications, policy and regulatory documents). In doing this, the various contextual aspects of a given activity, problem or opportunity become clearer.
Understanding the system boundary
Before embarking on this activity, it is important first to consider, and define, the system boundary of interest. This is not a hard or objective boundary, but one that we choose for our own reasons, which might be pragmatic (relating to our sphere of influence with regards to intervention) or opportunistic (access to participants and information), for instance. A system boundary is therefore a deliberate choice, but one that should be made clear, along with the reasoning for this choice. It could be anything at the micro, meso or macro scales. It could be a workstation, a room, a centre, an organisation, a sector of industrial activity, etc. The system boundary of interest may change over time for the same sorts of reasons as it was chosen in the first place, and so is not necessarily fixed, and can be expanded, contracted or shifted as required..
Understanding the problems and opportunities of interest
Once the system boundary has initially been delineated, it is important to discuss perspectives on the problems or opportunities of interest. These will differ depending on the person or group (though each person or group may not be fully aware of this). So it can be useful to try to get multiple perspectives from the points of view of different people in the system, for instance at the levels of:
Public/citizens
Government
Regulatory bodies
Judiciary
Associations
Senior management
Middle management
Staff
Service users
The task here is to understand how each stakeholder frames and conceives of the problems or opportunities of interest. (Each stakeholder may conceive of several, more or less interconnected, but in any case there will always be several, and even the same basic problem will be framed differently.)
Understanding the context
For each problem or opportunity, context can be considered in many different ways, but here are 10 aspects of context relevant to problems and opportunities in organisations. Each can usefully be the topic of a conversion.
Societal
Political
Legal and regulatory
Organisational and institutional
Social and cultural
Personal
Physical and environmental
Temporal
Informational
Technological
Each of these will be more or less relevant to a given problem or opportunity. Some could be combined and others could be added, but these are ones that I have found useful. I’ll not attempt to define each of them. I prefer for people to use the keywords to trigger their own meanings, but some expansion of terms may be useful. For instance, ‘social’ may refer to family, friendships, communities, associations, and social networks. ‘Physical and environmental’ may refer to the designed and natural environment. ‘Personal’ may refer to one’s unique personal context, including values, beliefs, habits, health, and so on.
The point is to spend some time thinking and talking about each chosen aspect of context in relation to the problem or opportunity of interest. The bi-directional nature of influence means that at least the following questions might be considered:
a) How does/did/could this aspect of context affect the problem or opportunity?
b) How does/did/could this problem or opportunity affect this aspect of context?
By spending some time talking about each pertinent aspect of context, we can gain a better understanding before going on to think about intervention. The conversations act as a buffer and a bridge between our detection of a perceived problem (or opportunity), and our urge to resolve (or realise) it.
The conversations about context could end there, having resulted in valuable insights on a problem or opportunity. To take understanding a step further, one might want to look at interactions. The question here might be:
How do aspects of context interact to affect the problem or opportunity?
This essentially involves drawing influence diagrams for contextual influences, but these need not be giant spaghetti diagrams. Rather, we might look at aspects of context of interest from the previous exercise, and see if any of them influence or are influenced by other aspects of context. For example, aspects of context at the political level (e.g., performance targets) will usually not exert direct influence, but rather via other aspects of context. Similarly, organisational aspects of context may exert influence via physical aspects (e.g., workplace design), informational aspects (e.g., feedback), temporal aspects (e.g., production pressure), etc.
Understanding leverage points for intervention
When it comes to intervention, we can use the same aspects of context to have more conversations by seeing each as a leverage point, in conjunction with approaches from relevant disciplines (e.g., systems engineering, human factors and ergonomics, resilience engineering, improvement science). The question then might be:
How might we intervene to help address the problem situation or manage the opportunity in a way that improves the situation?
The exercise as a is not a precise method, but does help to uncover aspects of context that have previously not been considered thoroughly, or at all, and can be combined with methods to inform analysis of human work, and associated problems and opportunities.
Everyday work in aviation COVID-19 pandemic has been affected almost beyond recognition, and with it how many feel about work and the future. So what might we learn about work from the perspectives of two front-line professions: air traffic controllers and professional pilots? I asked for some short answers – whatever came to mind.
Some of the entries will be included in the next issue of HindSight magazine. Thanks to those who kindly responded. If you are willing to contribute, as any aviation professional, please scroll to the bottom of this post to add your comment.
“The current situation presents a ‘skills fade’ challenge for all controllers”
Without regular application, the high level of aerobic fitness achieved by athletes can evaporate in a fraction of the time that it took to attain. The same can be said of ATC competency. Those of us working in procedural and technical roles are acutely aware of the challenge of maintaining competency despite periods away from the operation. The current situation presents a ‘skills fade’ challenge for all controllers. When traffic levels increase, we must ensure that we avoid the ‘frog in the pan’ scenario, and we are working with our training, technical and competency teams to ensure we have robust strategies to get back to full ATC fitness.
Ady Dolan, ATM Procedures & Development Controller (Heathrow), UK
“The importance of building relationships and trust in good times”
I’ve learned that no matter how confident you are about the path you’re on, and how resilient you think you are, managing your resilience over time is quite challenging, especially if you are in a situation that has no clear outcome over time. As a leader, it has shown me the importance of empathy and compassionate leadership in navigating a team through an already challenging environment and on the importance of balancing emotional needs with mission objective within a team. Finally it has shown me the importance of building relationships and trust in good times that will sustain the team in bad times.
Paul Reuter, Captain (Boeing 737NG), Luxembourg
“ATCOs were affected by isolation, loneliness and uncertainty”
During the COVID period, besides the disease anxiety, ATCOs were affected by isolation, loneliness and uncertainty. Isolated in our control centre, we barely had news or contact with anybody for days. We felt useless: no aim nor any working perspective during our duty. Used to being ‘in control’ and to anticipate, we experienced motivation loss, weaker commitment and passive behaviour, including disengagement on changes integration and on documents updating efforts. This wellbeing and safety drift may create new holes in the James Reason Swiss cheese model.
Sebastien Follet, ATCO (TWR/APP), France
‘The sense of community has been heart-warming”
Prior to the pandemic, simple interactions at work were taken for granted. As humans we (mostly) thrive and depend on face to face contact. Needed for our mental health and well-being, it is this aspect which has impacted the way I view work in the current situation. With no clear idea of what the short-medium term future holds for the industry, I’ve found myself cherishing every opportunity to work and try to really interact with everyone I come into contact with during the course of my duties. The sense of community has been heart-warming in these difficult times. The professionalism demonstrated with an ever-present threat of redundancy has been nothing short of inspiring.
Pilot, Captain (A350), UK
“People are willing and capable to adapt and adjust their work”
The pandemic changed everything in a way I have never experienced during almost 40 years as an ATCO. During these last months, I have learned that even when conditions change dramatically and outside of the system’s normal boundaries, people are willing and capable to adapt and adjust their work so that production can continue, and the work gets done while maintaining safety. And this was done without too much action from management.
Anders Ellerstrand, ATC Centre Watch Supervisor, Sweden
“Returning to flying after many months off was a daunting prospect”
Returning to flying after many months off was a daunting prospect. Would I remember everything I needed to? What elements of my skill set would return easily? It became apparent that motor skills – the actual flying of the aircraft returned very quickly – it was like I had never left. However, cognitive processes took a little more time. In fact, it was a few flights in that small things were forgotten. I suppose I began to relax more. However, mitigations included keeping things ‘SOP’, taking things slowly, and ensuring the operation was kept as simple as possible.
Ben, Captain (A320), UK
“An extra dose of care and attention…has been necessary”
The COVID-19 pandemic has faced us with an unprecedented scenario. Some issues have come up strongly. 1) The importance of the team. It has become clear that it does not depend on an individual performance. An extra dose of care and attention to each other and to the operation has been necessary, and a strong stress reliever. 2) The uselessness of ‘the super controller’. Today, the super controller is the one who knows his or her limits, accepts help, and asks for help. 3) This crisis has highlighted the enormous interference posed by ‘the ego’, and how it underlies many of the main operational problems.
David Garcia Hermosilla, ATCO (ACC), Spain
“My ex-colleagues showed little or no degradation in pure piloting skills”
Planning license revalidations for my ex-colleagues after the bankruptcy of our previous employer, I was little nervous the evening before the first check. What to do, if your colleagues perform insufficiently? The worst would be if you have to fail them. Surprisingly my ex-colleagues showed little or no degradation in pure piloting skills. It perhaps took a minute longer to get used to to the aircraft again after half a year on the ground but flying skills seem to be quiet resilient. What definitely showed degradation was scanning skills and overview in general. These are the skills required in complex and unexpected multiple failure scenarios.
Wolfgang Starke, Dash8-Q400 Captain, Germany
“We have to take care of our mental wellbeing”
The lack of certainty and the scarcity of tasks let the mind run, while equilibrium is essential. I had never felt anxiety but there were different and opposite reactions (from panic to refusal). Although measures to protect airport workers from infection were taken immediately, the emotional impact caused by the pandemic was not taken in equal consideration. One morning during a break, I was walking in the airport and the only sound was ambulance sirens and bells announcing deaths. I have noted the immediate resilience (mental and logistic) of most of my colleagues. But this exceptional situation has confirmed that if we look for high performance at work, we have to take care of our mental wellbeing, as well as physical.
Marcello Scala, ATCO, Italy
“I learned about adaptive capacity”
Resilience is nothing new in the world of safety science. However, I learned the importance of extrapolating the concept to business strategy and operations. In fact, it can even be reduced to the level of household or individual resilience. While some organizations like Amazon had business models that were already aligned for success during COVID, I learned more about adaptive capacity watching my airline transform their passenger aircraft into freighters by utilizing cargo netting, seats, and existing anchor points in a novel way. Innovation like this is driven by front-line field experts collaborating with managers, engineers, and regulators to drive change.
Brian Legge, Training Captain (Boeing 777), Hong Kong
“Problem-solving took place again during lockdowns”
As one of the key factors to manage air traffic is problem-solving, and even when traffic decreased dramatically, controllers have to face new challenges. Problem-solving took place again during lockdowns to keep teams working together, despite all limitations. It was incredible how the system worked because of the definition of the system itself: ‘a group of interacting or interrelated entities that form a unified whole’. COVID-19 posed new way of interacting, but problem solving made it work again.
Oliviero Barsanti, ATCO, Italy
“COVID-19 has changed our lives as pilots utterly”
COVID-19 has changed our lives as pilots utterly, mainly for worse, although in other ways for better – sleeping in my own bed instead of spending two or three nights per week in hotel rooms. After the initial five weeks without flying, I’ve since flown almost weekly, enjoying quiet airports and airspace. In 20 years of flying into Heathrow, I had never before been given “Direct centre-fix and high speed approved. Let us know when you’re slowing down!” from 80 miles out. Then back out early (what’s a slot?) with push-back to airborne in four minutes. (Pity about the paycut though.)
Niall Downey, Airbus A320 Captain, Ireland
“I wasn’t aware of how important wellbeing is”
Up until the beginning of the pandemic, I wasn’t aware of how important wellbeing is to personal happiness and to those around me. Everyday work and family life unfurled in a routine way. Then air traffic stopped. Wellbeing is not something we think of every day, however through anxiety over competency through lack of traffic, for the first time worry over job security and potential economic measures, it is something that has become important – much more than I could have imagined. It is omnipresent, something that we take home, even if we pretend that these things shouldn’t affect us.
Jules, ATCO (Geneva TWR/APP), Switzerland
“Our job as air traffic controllers is much more akin to that of athletes”
The current pandemic has reminded me and my colleagues how our job as air traffic controllers is much more akin to that of athletes and sports people than to that of office workers. Every day, we have to perform to the best of our ability, applying the skills acquired during our training and perfected through experience. The drastic reduction in air traffic has brought the problem of skill fading to the fore, whose effects we must minimise in preparation for when air traffic returns. In the same way that athletes practise competition scenarios during their training, it will be important for air traffic controllers to have access to simulators so they can hone their controller skills back to their peak level.
Luis Barbero, ATCO (Heathrow Approach), United Kingdom
“ANSPs could study the system to be ready when the traffic resumes”
In the European ATM system of a few months ago, the only problem that seemed to exist was the lack of capacity and the lack of controllers. Then the black swan, COVID-19! Traffic suddenly dropped from one day to the next by 90%. So how does the ATM system react? ANSPs could study the system to be ready when the traffic resumes, or could dedicate this time to select new staff and train them to be available in a couple of years (the time it takes to train a controller). Unless we do this, when traffic starts to grow, we will ask ourselves how to deal with the lack of controllers and the lack of capacity of the European ATM system, again.
Marcello Di Giulio, ATCO (ACS-RAD, Milano), Italy
What have you learned about work during the COVID-19 pandemic as an aviation professional? Please add your answer, preferably in 100 words or fewer, via the comment function at the bottom of this page, and I will integrate these also into the text (please also add your name, role, and country).
N.B. Collecting these insights was partly to inform an article for a forthcoming HindSight magazine, reflecting on lessons on work from the COVID-19 pandemic in healthcare and aviation. At the time of posting, only two aviation roles were reflected. The aim was not a comprehensive survey. While many people have dual roles in front-line work and safety, CRM/TRM, simulation, human factors,, etc., I have simplified all of this down to name, primary aviation role, and country.
The COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? I asked a variety of practitioners to give a short answer – whatever came to mind. Many have kindly responded so far, and more are expected (scroll the the bottom of this post, where new entries are dated).
What might we draw from the learnings below? You will draw your own insights, no doubt. For me, the themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisatonal hierarchy, problem solving and innovation, and – generally – change. In fact, many of the themes of recent issues of HindSight magazine are reflected.
Thanks to those who kindly responded and to those to who plan to, despite high workloads. If you are willing to contribute as a healthcare practitioner, or as a patient or family member, please scroll to the bottom of this post.
Before we move to the learnings, here is a word from someone who has spent many years helping to understand and improve patient safety:
We understand a great deal about the impact of stress, long hours, tiredness and fatigue on our performance. We just ignore this in healthcare! What we don’t really understand is the impact of long periods of time away from work. Time away from work is not uncommon, for example when a professional has a lengthy sickness absence. Yet some people bounce back with minimal assistance, whilst others struggle to “get back in the saddle”. Achieving peak performance for sports people is a whole scientific discipline. Why not the psychology of human high performance in safety critical industries?
Martin Bromiley OBE, Founder Clinical Human Factors Group
“Frontline workers are the solution to most problems“
During COVID19 I learned that the need for change is the only thing we can reliably predict about the future. Fortunately, frontline workers are the solution to most problems that will inevitably arise. They are the most valuable resource in healthcare, both for delivering the care and for designing how to do it. Locally, we have seen rapid, successful innovation of work practices through the marriage of simulation and human-centred design principles. Sadly, though the safety of our workforce is paramount, it has been threatened worldwide. We still haven’t learned how to put humans at the centre of healthcare.
“The pandemic has required groups to leave their silos“
High trust relationships are critical to safety. Strong bonds within groups develop organically over time. This social capital has many advantages particularly during a crisis, but can have the unintended consequence of excluding others. The pandemic has required groups to leave their silos and to collaborate rapidly on high-stakes issues. I have learned that we need to call on those who have not previously routinely been included in healthcare teams – such as aerodynamic scientists and occupational hygienists – to keep workers and patients safe. Many of these experts are accessible on social media, primarily twitter, and have been generously sharing their expertise for the benefit of all.
Individual adaptations are necessary to cope with goal conflicts, but team learning is needed to maximise the impact and ensure the safety of such adaptations. In my GP practice, daily ‘huddles’ (short meetings) were used to discuss how we implemented rapidly changing guidance while coping with varying conditions (e.g., demand and capacity) and competing goals (e.g., reducing hospital admissions while maintaining patient safety). Huddles encouraged sharing of innovative practice and increased understanding of why decisions were made and how decisions affected other parts of the system. It also supported those making difficult decisions and ensured people did not drift into unsafe practices.
Duncan McNab, General Practitioner, Scotland @Duncansmcnab
“It is essential to foster good relational coordination”
I have learnt the importance of emotional contagion. It is essential to foster good relational coordination amongst colleagues particularly during a time of great uncertainty and constant change. Although this pandemic has brought lots of new concepts and working conditions, it’s imperative that we maintain our usual high standards and not be tempted to try new techniques and alter our usual routine safe practice.
The potential impacts of COVID-19 required a rapid reconfiguration of the intensive care unit. This required many different teams: ICU clinicians, infection control nurses, biomedical engineers, builders, ventilation engineers and quality improvement specialists. These diverse views were brought together for the complex, dynamic problems we faced. This work leaned heavily on the pre-existing relationships built up during a recent volcanic burns disaster. Additionally, the redesign of clinical work was based on four requirements: to be SAFE, SIMPLE, SUSTAINABLE and ADAPTABLE. The ability to anticipate potential challenges required imagination and a deep understanding of the realities of everyday work.
Carl Horsley, Intensivist, New Zealand @HorsleyCarl
“Systemic inequity has become apparent”
New Zealand was fortunate to have very few cases of COVID. Preparation involved a high level of adaptability and dizzying pace of change where everything seemed possible. As the situation calmed, the true cost of these adaptations has become apparent. Major systemic inequity has become apparent for those whose care was compromised by prioritisation on others. Important perspectives came to light, which had not been heard in the rush to respond based on traditional institutional hierarchies and values. The lesson for us has been the need to consider unintended consequences by truly listening to those who have different perspectives and to focus on flattening hierarchies. Addressing inequity is now a major target of our health response.
Fiona Miles, Paediatric Intensivist, New Zealand @fionam_miles
“I witnessed enormous willingness and motivation”
The pandemic provided me with an opportunity to work locally in my hospital and elsewhere at a major new hospital, ‘Nightingale’. I witnessed enormous willingness and motivation amongst practitioners and managers to respond to the need for rapid change. This felt like a big contrast from previous ‘norms’ of organisational behaviour in healthcare. I also observed and experienced significant challenges to redesigning clinical services when facing considerable resource constraints such as workforce availability, skill mix and preparedness for redeployment; creating and adapting new clinical environments; accessing critical specialised equipment and supplies quickly and reliably. This was confounded by multiple channels and frequent shifts in emphasis of central guidance and policy, that did not always seem to match scientific evidence or the wider public narrative.
Bryn Baxendale, Anaesthetist & Health Education England Simulation Lead, England @gasmanbax
“Working in PPE is hot, tiring and difficult to both hear and see”
With the arrival of PPE – the sort you see on television – came the notion that it alone ensured staff and patient safety. Thus the assumption evolved that the more PPE, the more safety, without considering the downsides. Working in PPE is hot, tiring and difficult to both hear and see. Staff avoid drinking to reduce bathroom visits, all of which affects their ability to work. Extra time is taken from patient care to put on and take off the PPE. Thus the measures to reduce a single source of danger – Covid – indirectly affected patient safety in many other ways.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“Pay attention to human and organisational factors”
The COVID19 outbreak has been thunder on a sunny day. Surprise, ignorance, fear for our relatives. The need for more ICU beds required us to work outside our comfort zone. Equipment wasn’t designed for ICU, nor were newly formed teams used to working together in this stressful environment. So, what could we do? The only answer that came to my mind was to pay attention to human and organisational factors. Those were the skills needed to tackle this disease. The use of collective intelligence via inclusive collaboration and open communication was very effective in preventing harmful events for both patients and healthcare workers.
Frédéric Martin, Anesthesiologist, France @drmartinfred
“It is critical that ‘work-as-prescribed’ reflects ‘work-as-done’”
Healthcare has a reputation for resistance to change, particularly top-down initiated change, with limited consultation with clinicians. During the pandemic, many frontline clinicians experienced change done ‘to’ them, instituted by administrators, particularly rationing personal protective equipment. Other organisations have initiated clinician-lead processes, resulting in durable models of care but uncovering ‘wicked problems’. COVID-19 has taught me that engaging clinicians doing the work increases short-term complexity, but doing otherwise risks failure in the long term, losing trust on the way. It is critical that ‘work-as-prescribed’ reflects ‘work-as-done’ to prevent depletion of the workforce through infection and exhaustion.
“What differs from country to country is dependent on leadership”
It’s confronting, working in an industry that conditions staff to risk their own lives unnecessarily instead of speaking up with sufficient impact to deliver the safety initiatives we need. COVID19 has bared the healthcare issue for all to see. Dreadful administration in top down hierarchical frameworks is registering in different countries as a death rate. What differs from country to country is dependent on leadership. Those countries with great leadership – overcoming siloed thinking behaviours, overcoming ‘airborne deniers’ and responding appropriately with early hard lockdowns, mandatory mask wearing and adequate Personal Protective Equipment – have fared so much better.
The COVID-19 pandemic has been an acid test of the quality of health care, standard of governance and social capital across countries. The pandemic certainly has exposed the limitations in healthcare systems and existing health inequities. It has shone a light on how we work, and the dichotomy between ‘work-as-imagined and work-as-done’. Well-resourced and supported teams that perform regular reviews using a ‘systems approach’ for the purpose of collective learning has been critical in bridging this gap and achieving good outcomes. Teams were able to confidently balance efficiency and thoroughness safely when faced with the challenge of multiple uncertainties.
“For the first time, work and its goals were shared”
“I know what I’m doing, I don’t need to be told how to do it” … these are words I haven’t heard during these months of COVID19. This whole experience was new for everyone. For many professionals, it has created a touching sense of humility, both among frontline actors and managers. I believe that this humility has facilitated communication and the emergence of a shared governance between caregivers and administrators where I’ve been working. For the first time, work and its goals were shared and the gap between work-as-imagined and work-as-done was almost zero.
François Jaulin, Anesthesiologist-Intensivist, France @Francois_JAULIN
“Looking back, local practice is not ‘work-as-prescribed’”
Despite 25 years in the specialty, the COVID19 pandemic was my first introduction to Personal Protective Equipment (PPE) and a FFP3 mask. Fit testing achieved and training in PPE donning and doffing undertaken was great preparation to prevent catching a deadly viral disease. However, this was no preparation for the daily challenges of working in PPE exacerbated by concerns around PPE availability and changes in doffing station practice. The impact of heat, the need for good hydration, and the communication challenges became stressors – recognised and managed by great team working through adaptations in how we worked. Looking back, local practice is not ‘work-as-prescribed’.
I have learned that some types of ambulance service work systems that would previously have been considered very difficult to change, can actually be reconfigured at pace and new ways of working can be introduced, which lead to significantly different system performance. Work-as-done can be close to work-as-imagined with changes up to a certain size. With larger groups of workforce, it can be very difficult to influence multiple, often subtle, changes in work-as-done to match with the more easily changeable work-as-prescribed (and work-as-imagined). This was particularly evident in the early stages of the response phase when clinical, logistical and PPE criteria were becoming established.
Gary Rutherford, Ambulance Service Patient Safety Manager, Scotland @garyrutherford2
“A completely flattened hierarchy is also a barrier to effective communication”
We often hear about ‘flattened hierarchy’ and how hierarchy can be a barrier to effective communication. I found that a completely flattened hierarchy is also a barrier to effective communication. For example, everyone is wearing the same outfits, no name badges are shown and no one recognises anyone. So who is the leader? Being involved in a medical emergency with no leadership evident is a scary place to be. The role of a leader in any critical situation is required. The role of a decisive leader has also been critical during the pandemic. Being led by a leader that is decisive has given me comfort and guidance when I have felt as if I was floundering.
Claire Cox, Critical Care Outreach Nurse, England @safetynurse999
“Let user-centred and data-driven design lead us in rebuilding”
COVID-19 has shone a light on our lack of insight into complex system design. Healthcare is a precarious thing, balancing on the backs individual and team resourcefulness and resilience. Emergency medicine, in particular, suffers from ‘ad hoc-itis’. Our ability to improvise solutions in the face of massive systemic limitations and inefficiencies is practically a professional badge of honour. But it doesn’t have to be this way. We can build systems that make sense. We can use simulation-informed design, prototype testing, multi-source feedback and hazard analysis to help manage complexity rather than compel us to work against it. The pandemic has compelled us to tear down and begin again, and therein lies a massive challenge and unprecedented opportunity: let user-centred and data-driven design lead us in rebuilding.
Christopher Hicks, Emergency Physician, Trauma Team Leader, and Simulation Educator, Canada @HumanFact0rz
“Work-as-imagined and work-as-done might well apply to how patients ‘work'”
Hollnagel’s descriptions of work-as-imagined (WAI) and work-as-done (WAD) might well apply to how patients ‘work’ as well as staff. Initially we asked our patients to self-isolate for 14 days prior to elective surgery, and (as we knew the reasons), we imagined that they would do that unquestioningly. We ‘prescribed’ that to them, without explanation, and then anyone who proceeded to surgery had to ‘disclose’ that they had completed this. Only the patient ever knew whether they had done so. It took a period of time to identify the gap between WAI / WAD and is taking longer yet to close this gap.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“By starting to address problems iteratively we could create a network of actions”
The biggest problem we faced at the start was the uncertainty and a stream of unfiltered information. We had tentative ideas of what needed to be done and what might happen. What we learned subsequently was that by starting to address problems iteratively we could create a network of actions that we could knit together. We rapidly developed a tolerance of failures, using them, with active feedback, to modify our processes and facilities adaptively, alongside the new information that became available. This made it much easier to try and keep pace with a rapidly evolving situation.
“A significant issue…has been effective communication”
A significant issue for health professionals during the coronavirus pandemic has been effective communication while wearing PPE, especially for aerosol generating procedures. Voices are muffled, hearing is compromised and implicit communication through facial expression is lost. This is especially a problem for resuscitation teams working under pressure. We provided our staff with 5 tools (PRESS) to improve communication using PPE:
P – Pre-transmission pause. Think before you speak
R – Read back – close the loop
E – Eye contact – ensure focussed attention
S – Say again – repeat critical information.
S – Shared team mental model with a team rally point
Stephen Hearns, Consultant in Emergency and Retrieval Medicine @StephenHearns1
“Simulation is a great tool for training”
I learned three things in particular: 1. Simulation is a great tool for training; but it is much more effective to establish a shared mental model (understanding) and then simulate it, than use a simulation to establish a shared mental model. 2. Complex teamwork tasks with sequential critical actions are easier to develop in medical subcultures which have already established the role of expert team-leader as being separate from expert technical operator. 3. Maintaining buy-in to a different way of working is difficult when in a prolonged high-vigilance, low-activity state (such as here in NSW).
Tom Evens, Emergency Physician, Australia @DocTomEvens
“We were finding solutions from the ground up”
During the start of the pandemic, the rules and guidance we had normally been following were gone. Sometimes, rules set out by people that don’t ‘do the work’ are not the way that the work happens. These rules end up being a barrier to do the right thing. For example, filling a 35-page safety booklet about a newly admitted patient takes us away from practical tasks such as personal care or administering medication. Now, no-one knew the best way to do things. There was no evidence base to draw from, and no exemplars to follow. This led to a more collaborative approach. Everyone came up with ideas, and many more came from social media. We openly learned from each other. We were finding solutions from the ground up and the senior leadership team listened.
Claire Cox, Former Critical Care Outreach Nurse, England @safetynurse999
“COVID appears to have acted as a powerful inductor for team building”
I’ve discovered through the different cases reported on the Patient Safety Database how strongly empathetic and benevolent leadership can have a positive impact on patient safety, work organisation, coping and caregivers’ well-being. COVID appears to have acted as a powerful inductor for team building. On the other hand, where human and organisational factors did not seem to be considered, it reinforced the cleavages, created tragic situations for both patients and caregivers and increased workers’ ‘ill-being’. Empathy and benevolence were overused words that we no longer knew the meaning of. I believe it is now much clearer.
François Jaulin, Anesthesiologist-Intensivist, France @Francois_JAULIN
“The ability of staff to innovate and adapt was remarkable”
Without timely clear guidance arriving down the traditional lines, the ability of staff to innovate and adapt was remarkable. The constraint of normal change bureaucracy was temporarily suspended and essential new ways of working arrived in a rapid and remarkably effective way, significantly prior to written SOPs. Front-line staff absorbed the principles and developed them in appropriate ways for their own local work, often utilising the skillset of their staff, e.g., military nurses who had significant experience with PPE and Ebola. Staff needed guidance in underlying principles, but then excelled at translating them into their own working environment.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“You end up counting on good people to do everything they can”
During the pandemic, I learned that no matter how well organised the healthcare system is, you end up counting on good people to do everything they can to overcome and minimise effects of hopefully rare but inevitable system flaws.
“My colleagues and I could adapt rapidly to these new conditions”
Overnight, my job changed from in-person clinical care to online telemedicine. Our telemedicine urgent care started seeing hundreds of COVID patients a day, a disease and volume that were totally new to us. I learned that my colleagues and I could adapt rapidly to these new conditions. The tradeoffs between in person care and online care were challenging for everyone, as patients feared contracting COVID at the hospital. Communicating clearly with one another and with our patients about uncertainty and risk were essential, as conditions changed rapidly.
Shannon McNamara, Emergency Physician, USA @ShannonOMac
“Design and processes affect the normal functioning of a team”
Preparing a new ‘COVID operating theatre’ has highlighted the importance of how design and processes affect the normal functioning of a team. To minimise risk, the negative air pressure of a dedicated COVID theatre needs maintaining and non-essential equipment and personnel removed from the ‘hot-zone’. Limiting opening of doors and wearing of masks and face shields results in markedly difficult communication – even when that communication is critical. Cameras, microphones, patching of monitors and hand signals are valuable but inadequate. There is certainly greater appreciation for shared mental models and planning for complications with pre-operative briefings than before the pandemic.
“I’ve learned about ethnography and how contextual narratives can yield a theme”
I’m part of a research team looking at organizational responses to COVID-19. Using special federal funding, the team we’ve assembled includes Ethnographers, Human Factors (HF) experts and Infection Prevention & Control (IPC) specialists. For one major project, three team members visit and review COVID-19 in-patient units, looking at HF aspects of Personal Protective Equipment (PPE). We conduct observations from all three perspectives, weighing what is done against what should and what could be done. We present suggestions and thus help co-design workable solutions. I’ve learned about ethnography and how contextual narratives can yield a theme that helps illuminate a problem.
Jan Davies, Anesthesiologist (clinically-retired), Canada @JanMDavies
“Lessons from Europe don’t necessarily translate well in LMIC’s”
As a country the pandemic reached us later than Europe, and we were able to learn from them. Strong decisive measures from government limited the impact on the healthcare system initially. However it soon descended into information overload, inconsistent messages and departure from plain common sense. It reiterated the inequalities of access and availability to healthcare. One unanticipated factor was the effect of fear and stigma of the illness in the community and in healthcare workers, and the negative impact it has had on patient care. Lessons from Europe don’t necessarily translate well in LMIC’s where the cultural context is different.
Ellen, Critical Care Nurse, South Africa (added 18/09/20)
“A focus on leadership over management is required”
The need for sincerity and genuine characteristics is essential. A focus on leadership over management is required. Midwifery managers/consultants need to be able to utilise their clinical skills they started off with to enable support and understanding of their units in today’s world. Point scoring is no good in a pandemic, any holes will just grow bigger. Never underestimate what a major stress relief it is to begin a shift without busy traffic and being able to park close to your work.
Suzanne, Midwife, England (added 18/09/20)
“Let departments organise themselves”
Let departments organise themselves. Radiologists were split into two groups – one at home, one in department. Radiographers worked out their own rotas. Radiographers and nursing staff worked on SOPs for imaging COVID positive patients. No top down orders. Homeworking was sorted in short time after years of dragging feet (helped by already having screens and laptops in hospital, but not set up). We found that if IT sorted this out we could be appreciative and positive people, rather than grumpy and negative about IT (we even nominated the IT staff who sorted this out for a ‘GREATix’ excellence report).
James, Radiologist, England (added 18/09/20)
“Where you draw the system boundary matters”
Where you draw the system boundary matters. I started chairing a theatre COVID preparedness group in March. We quickly transformed the theatre complex to handle a surge in patients with COVID, while keeping staff safe. We liaised with ED, ICU and the wards which are upstream/downstream of theatres. The teamwork, dynamism and psychological safety of the working group were excellent. There were times on the fringes of this system when we found other systems which benefitted from our input. Our system boundary did not include the whole hospital system and that was appropriate, other people were focusing on this. Looking back now I wonder about the care homes. They were not within my system and I didn’t give them a second’s thought within my planning. Whose system boundary included care homes? What were their working conditions, demands and constraints? How could we do better next time?
Michael Moneypenny, Anaesthetist, Scotland (added 17/09/20)
“It’s like a slow moving major incident”
Mass redeployment, degrading staff by giving one set of technical skills primacy and devaluing primary work which still needs doing causes distress. I have also learnt a lot about the structural and cultural barriers to leveraging talent in surge demand. It’s like a slow moving major incident without the implementation of the major incident plan.
Alison Leary, Professor of Healthcare, U.K. (added 28/09/20)
Please feel free to add or adjust if you’re happy for me to add!
What have you learned about work during the COVID-19 pandemic as a front-line healthcare professional, patient or family member? Please add your answer, preferably in 100 words or fewer, via the comment function at the bottom of this page, and I will integrate these also into the text (please also add your name, role, and country).
N.B. Collecting these insights was partly to inform an article for a forthcoming HindSight magazine, reflecting on lessons on work from the COVID-19 pandemic in healthcare and aviation. Not all healthcare roles are well eflected – of course – and I’m still waiting for some reponses. The aim was not a comprehensive survey, and I was asking people at a time of very high workload. However, as there were more healthcare responses than I expected – and more than is possible to print in a magazine article – I thought most benefit would be gained by publishing them all here. As is quite typical of healthcare staff, many have dual roles in front-line work and education, simulation, quality, improvement human factors, safety, etc. And of course healthcare staff tend to have many post-nominals. I have simplified all of this down to name, primary clinical role, and country. For more information, check out their twitter profile.
The text in this post is from the HindSight magazine, Issue 30, on Wellbeing, published in April 2020, at SKYbrary here.
Most of us will experience post-traumatic stress at some point in our lives, associated with critical incidents at work or events in our personal lives. For some, this progresses to a more severe disorder. In this article, Steven Shorrock reports on an interview with Captain Richard Champion de Crespigny, on his experiences post-QF32.
“Pan, Pan, Pan, Qantas 32, engine failure, number two engine, maintaining 7,400 feet, maintaining current heading. Stand by for instructions.”
While such transmissions will usually be followed by a temporary increase in stress for both pilots and air traffic controllers, they are trained to deal with such emergencies. But the engine failure of QF32 on 4th of November 2010 was on a scale that very few front-line professionals ever have to deal with. In fact, 21 out of 22 aircraft systems on the Qantas A380 were compromised, and the crew had 120 ECAM checklists to deal with (compared to four or five checklists in a typical simulator session). The crew brought the aircraft to a safe landing at Singapore.
But the stress of critical incidents doesn’t end with a safe outcome. The end of a critical incident may be the beginning of another kind of stress, which can last for weeks, months, years or even decades: post-traumatic stress (PTS) and post-traumatic stress disorder (PTSD).
For the rest of the article, I’ll refer to ‘PTS(D)’ to cover both PTS and PTSD. Post-traumatic stress (PTS) is a normal and generally adaptive response to experiencing a traumatic or stressful event, such as an accident or assault. PTS is very common and normal condition that most people will experience multiple times during their lifetime. If symptoms persist for months or years, they may fit the diagnosis of post-traumatic stress disorder (PTSD), a clinically-diagnosed condition listed in the Diagnostic and Statistical Manual of Mental Disorders (fifth revision, May 2013). According to the National Institute of Mental Health, PTSD will affect 6.8% of U.S. adults in their lifetime. The difference between PTS and PTSD depends on a set of diagnostic criteria and a diagnosis, but PTSD often remains undiagnosed.
Having spoken to Richard for a few hours, I discovered we had a few things in common. We both grew up in family businesses. Both of our mothers died while we were in our late teens. And we had both experienced, and studied in some depth, PTS(D) (my account can be read at http://bit.ly/PTSDandme). So, I was naturally interested in Richard’s experience, post-QF32, having read his accounts of it in his books QF32 and FLY!
In FLY!, Richard noted that he knew nothing about PTS(D) when he stepped off his A380 at Singapore, but “what happened that day affected me badly for many months”, he wrote. After dealing with the immediate briefings and checking on the wellbeing of passengers and crew, he attempted to return home as a passenger with the other pilots to Sydney. That B747 flight was forced to return to Singapore after another engine failure. He finally arrived home after another day of delay. The following morning, he woke feeling wretched, and was soon in the bathroom, physically unwell.
Engine number 3. Copyright Richard Champion de Crespigny (used with permission)
I asked Richard when he first become aware of the signs of PTS.“It was five days afterwards when I attended an interview at the Australian Transport Safety Bureau. They said, ‘Tell us what happened when you left the hotel and for the rest of the flight.’” The ATSB had allocated about 20 minutes to hear Richard explain what happened. It took four hours.
Richard got to the point in the story 12 minutes after the engine failure when he decided to climb to 10,000 feet and remain inside 30 miles to mitigate for an all-engine out approach to Singapore – what he calls an ‘Armstrong Spiral’. He decided on this action after being overloaded by all the failures that affected QF32. Complexity overwhelmed his senses and thinking. He was unable to maintain his mental model for the aircraft, its many failures and the knock-on effects that created additional failures.
That was a point of maximum stress. “I was trying to describe the failures to the ATSB,” said Richard, “but recalling my memories put me back into the cockpit reexperiencing this avalanche of stresses. My emotions became overloaded and at that point I broke down and cried.” Five days after the crisis, the act of recalling the original situation triggered the PTS. “That was the first time I realised I was in trouble”. He wrote in FLY!, “It was the first time I had lost my composure since my mother had died 37 years earlier, when I was 17 years old.”
For the next two weeks, every time Richard recalled that point in the flight where he had to prepare for an ‘Armstrong spiral’, he would start to cry. He then realised that he needed professional help.
Symptoms
Richard experienced typical symptoms of PTS, including flashbacks – perhaps the most well-known symptoms of PTS(D) in popular culture. Traumatic events are re-experienced from memory, as if you are back in the scene, triggering the emotions and often physical sensations that were present at the time. Flashbacks can involve several senses, or just one.
Richard remarked that “These stressful memories stay dormant, ready to be re-enacted when a certain sensory pattern of events arrives at the brain. It could be a sound, a smell, a taste. These memories remain strong, replay often and put the sufferer back into the crisis.”
While flashbacks are temporary, a more general background rumination is also familiar to those who have experienced PTS(D).Richard’s mind was stuck in a four-hour loop, starting with engine explosions, through two hours in the air, then two hours on the ground. The loops were incessant and exhausting, while awake and in his dreams. A related problem is counterfactual thinking – mental simulation of ‘what ifs’. “During the day when I was suffering PTS, my conscious mind was full and distracted. I had no free mental space. I couldn’t stop thinking about the event. I was thinking about ‘what-ifs’. There was no room for anything else.” This can bring feelings of ‘survivor guilt’ and shame, even if others would see no justification for these feelings. Such rumination is common among people with PTS(D). While it seems counter-intuitive, it is actually a form of ‘avoidance’ since it avoids actively processing the traumatic event itself.
Another symptom is hyperarousal or hypervigilance, where the mind and body are on red alert to perceived threats. Of all the symptoms of PTS(D), hypervigilance, heightened startle reactions and associated ‘fight-flight-freeze’ states can be the most physically and mentally exhausting and debilitating. Everyday things and situations can become potential threats, and reactions tend to be neither proportionate nor predictable. Because of this, focusing can be a problem. “If I read a sentence, I’d immediately forget it. I was looking at the words, but I wasn’t reading or absorbing them. My mind was totally preoccupied and distracted.”
Sleep was also a problem.Sleep is shorter, lighter and more disturbed with PTS(D), and disturbed sleep exacerbates the condition. Sleep disturbances such as insomnia, fragmented rapid eye movement sleep, and nightmares predict later development of PTSD symptoms, and go on to maintain and exacerbate PTSD. Research findings show that sleep affects emotional regulation and so-called memory extinction, a process of new learning that inhibits older memories. “One side of my brain seemed to be awake. And even when I was dreaming, I would have lucid dreams about the event and all the ‘what-ifs’, so I would wake up even more stressed and exhausted. The bad dreams reinforced my bad memories. They didn’t weaken with the processes of sleep.” Memories of QF32 were persisting and being reinforced. Newer, more pleasant memories were not getting laid down. To many, nightmares can be one of the most acutely distressing symptoms of PTS(D). As they reoccur, and you come to expect them, sleep can become further affected, with severe consequences for mental and physical health – a vicious circle.
When talking to Richard, his enthusiasm for the inner workings of things is impossible to miss, whether referring to an A380 or the brain. “Well, I’m fairly mechanical, so I always have to start at the core.” He is naturally analytical and understanding the brain and mind was, for him, an essential part of recovery. The first chapter in FLY! is about neuroscience. When talking to him, he often refers to the brain’s core – the limbic system, which serves several functions necessary for preservation, as an individual, group, and species. “The amygdala, the thalamus, and the hippocampus form the old subconscious lizard brain. It’s fast and responds to threats. And we have the cortex, which is a slow but very powerful part of the sentient mind, providing thought, awareness, consciousness, reasoning, prediction, so on.”
Richard found it useful to understand why, with PTS, people think, feel and react the way they do. “If you can just be aware that the amygdala – the emotional centre – is responding to threats very quickly. It’s situated below the cortex but it’s disconnected from the higher conscious functions of logical analysis, reasoning and language. This helps to explain our gut feelings and fears that we cannot explain in words. With the fear response of fight, flight or freeze, the amygdala causes levels of cortisol and adrenaline to spike. That increases our heart and breathing rates, tightens our muscles, and turns off part of our immune system.” For people with PTS(D), it means that they may be angry, touchy, emotional, nervous or even unresponsive.
For Richard, understanding brain function helped him explain his experience, normalise his feelings and remove shame.
He also noted that with PTS(D), the amygdala and cortex can become cross-coupled in a situation of positive feedback that leads to overload and panic, from which recovery is difficult. Passengers with a chronic fear of flying know this state well. This is the feeling that causes some to stand up and try to open the aircraft door. This also helps to explain people’s fights for toilet paper during the coronavirus crisis.
Symptoms of PTS(D) will depend on the person, but it is not just a mental condition. It is profoundly physical.Research indicates a variety of biological changes. The amygdala helps control emotion, memories, and behaviour, and the right hemisphere, which controls fear and aversion to unpleasant stimuli, can change in volume. The hippocampus, which helps to consolidate the transfer of information from short-term memory to long-term memory, can become significantly smaller.
Brain signals are affected, as are hormone levels. Noradrenaline (or norepinephrine) helps to mobilise the brain and body for action, and levels tend to be raised with PTSD. Cortisol, meanwhile, helps the body to respond to stress, and baseline levels are often lower in people with PTSD compared to people without PTSD. Research shows that cortisol helps to reduce the levels of high adrenaline that are released during a ‘fight or flight’ response. Adrenaline (and noradrenaline, or norepinephrine) is also involved in memory formation. But the picture is complex, and there may be a greater cortisol response to trauma-related memories, especially in men. On a more relatable level of physical experience, PTS(D) feels like it is stored in the body – in the head, muscles, and skin.
Many with PTS(D) also experience physical illnesses, often associated with detrimental changes to the immune system. In Richard’s case, he was sick for two months after QF32 with pneumonia. “The sickest I’ve ever been”, he said. Some research evidence indicates that PTSD is associated with several conditions, including viral infections, cancer, Alzheimer’s and obesity.
Opening Up: Acknowledging PTS(D)
Traumatic experiences are so common that you or someone close to you is likely to experience them at some point in your lives, and many of you will experience PTS, which for some will progress to PTSD. It is so ubiquitous that we rarely acknowledge it or talk about it. PTS(D) symptoms can remain hidden for months or years after a triggering event. Many will never come to understand or accept their experiences. This can create severe complications. Richard said, “PTS is a normal reaction to stress. But if we don’t manage the PTS then it can become a more physiological condition, which is PTSD. And that’s when you can suffer greatly.”
Richard noticed something interesting after giving presentations about PTS. Sometimes, women would ask him to sign a book for their husband. He was curious about why this was. “I’d say, ‘Sure, why doesn’t he come and talk to me?’ And they’d say, ‘Well, he can’t. He’s outside crying!’ That happens regularly.” Many who have experienced PTS(D) will recognise this. For some, discussing or accessing memories of the original traumatic events is too much to bear, while others can but struggle to discuss the symptoms of PTS(D) without crying. Richard noted that, “Women tend to express what they’re feeling and that’s part of the grieving process. Men tend to hide their emotions, particularly military veterans.” There is a large body of research on this. But one finding is consistent: women cry significantly more than men. And research also suggests that crying has several benefits for wellbeing.
On writing and talking about PTS(D), Richard found that many of those he had written about were suffering in silence. “About half the people I wrote about in QF32 contacted me afterwards and said, ‘Thank you for writing about the PTS that you had, because I had a traumatic experience, and have suffered PTS and nightmares ever since. And that’s the first I’ve ever heard of it.’”
This may explain the interest in PTS and QF32. It will surprise many to learn that the second most-asked question Richard is asked about QF32, is about PTS. (The first was about why he didn’t pass the route check on the day.)
Richard wrote in FLY! that he thinks every one of the 26 QF32 crew members, and many passengers, suffered PTS to some degree.
Copyright Richard Champion de Crespigny (used with permission)
PTS(D) and Just Culture
Our conversation moved on to another dimension: just culture as a critical part of PTS recovery. “QF32 turned out well. It had a happy ending. But what if I’d made a mistake and it didn’t turn out well? What is someone had died?Then I’d have intense guilt and shame. And if you don’t have a just culture, and in an environment where people might be criminalised for their honest mistakes, the PTS gets a lot worse.” Accidents happen sometimes, he noted, particularly where decisions must be made quickly under uncertainty. “We need to really be on the lookout for people who have, through an honest mistake, had an incident, because they will most likely be suffering severe post-traumatic stress.”
He emphasised how this attitude is necessary not only for senior management, but everyone, including colleagues.“Everyone has strengths and limitations, but failure is part of the human condition. I embrace failures as opportunities to learn and adjust. And I don’t mind that errors happen in the cockpit. What’s important is that we detect and fix them so they don’t escalate.”
Time Out
Once Richard realised that he was experiencing PTS, he knew that he had to recover before returning to work.
He recalled the actions of Major General John Cantwell, now a retired senior Australian Army officer. Cantwell opened up about suffering from PTS as a result of military service that included leadership roles in the Gulf War (1990-1991), in Bagdad (2006), and as the Commander of the Australian Forces, Middle East & Afghanistan in 2010. John wrote about his PTS(D) in his book Exit Wounds, published in 2012. “You must get yourself out of leadership positions if you are suffering PTSD,” said Richard. “You must take yourself off-line. You’re not in a fit state to make good decisions and lead others. It is critical that you take yourself out of positions of responsibility, especially concerning safety.”
Specifically, air traffic controllers, pilots and others in positions of leadership and responsibility should not go to work if they are suffering PTS(D), until it is treated. In Richard’s case, it took four months. “After QF32, one of the managers said, ‘Richard, you’ve had a bad week. I want you take a week off.’ And I said, ‘You know what? I think I need a couple of months.’”
Soon after returning to Sydney, Richard was meant to take delivery of a new A380 from Toulouse and fly it to Australia. This was a great privilege, and a reward for handling a 24-hour delay on an earlier flight. But he knew he wasn’t ready. “I rang the A380 fleet manager, and I said, ‘Look, I’m not sure I’m able to evaluate my fitness to fly, so to be safe, you should take me off that delivery flight. You need to allocate it to someone else.’ And he said, ‘Thank you, Richard. Thank you for saying that.’” Following this, Richard sought psychological counselling.
It seems that many of us, and especially men, deny or hide our experiences or else try to fight them alone. For traumatic experiences, this denial prolongs a struggle that is already too much for any of us individually. This is understood among those who work professionally with trauma. Dr Peter A. Levine, author of the book Waking the Tiger: Healing Trauma, wrote, “Because the symptoms and emotions associated with trauma can be extreme, most of us (and those close to us) will recoil and attempt to repress these intense reactions. Unfortunately, this mutual denial can prevent us from healing. In our culture there is a lack of tolerance for the emotional vulnerability that traumatized people experience. Little time is allotted for the working through of emotional events. We are routinely pressured into adjusting too quickly in the aftermath of an overwhelming situation.”
Richard recalled a pilot colleague who turned up to a briefing one morning before a seven-day trip. Richard noticed that the man looked tense, his fists closed tight. Richard asked the pilot “What’s the matter?” The pilot replied, “Nothing”. Richard persisted until the pilot revealed that his mother had a heart attack the night before, and was in hospital. “I said, ‘Why are you here?’ He said, ‘I’ve got to do the trip.’ I said, ‘No, you don’t.’ I rang up the chief pilot and we got him a taxi to see his mother in hospital. If you look for the signs, you can detect stress in other people. As a leader, you have a duty of care.”
Referring pilots, air traffic controllers, and others in positions of responsibility, Richard talked about the need to be humble and vulnerable about one’s mental state. “In the same way that we feel no shame to tell others about broken bones and other physical injuries, we should not feel reticent to admit fractures in our mental health. We need to say, look, ‘I’m not well and I need to seek help.’ Faced with the stresses that we have today, the people that will cope are the people who will detect that something is wrong, tell others and seek help.”
As noted by Amy Edmondson in her book, The Fearless Organization, this is helped by an environmental where it is psychologically safe to be vulnerable. “And that that is the critical thing we need,” said Richard. “If we want to care for and make the most out of the people in our organisations and around us, then we need a culture of psychological safety where people feel safe to step up, voice their problems and ask for help.”
But many with PTS(D) do not understand or communicate their experience. Richard said, “You never know the state of people when they turn up to work. You never know what’s happening in the background. So you can only look for the signs.” In some cases, people may mention that they’re suffering PTS. In these cases, “We should be empathetic and compassionate and believe them because it takes courage to talk about this. We should help them to seek professional help.”
Recovery and Growth
In FLY!, Richard wrote that “PTSD wears you down physically, mentally and emotionally, damaging health, happiness and relationships.” No one who has experienced it would disagree. But the truth is that there can be recovery and even growth from trauma. People recover from PTS(D) in different ways. Efforts to recover may need to address the physical, mental, interpersonal and spiritual dimensions. People find benefits in exercise, psychotherapy, walking in nature, meditation, writing, poetry, and – crucially – sufficient, good quality sleep. For Richard, it initially involved a few sessions with a psychologist. “You need trained professionals to build trust with the person and work out a way to recovery.” For Richard, this involved replacing unwanted memories with good memories, an approach known in the literature as ‘memory reconsolidation’. However, there are various ways to work clinically with PTS(D), with psychologists, psychotherapists and psychiatrists. An early sign of Richard’s recovery was when he became interested in aviation again. Three months after QF32, he started looking up again at aircraft in the sky.
But even after initial recovery, people’s PTS(D) can still be triggered many years or even decades later by reminders of the events or the symptoms, or both. Richard overcame this by reading and writing to understand PTS(D) as thoroughly as possible. “I’m a logical person. I didn’t quite understand. I just wrote two pages about post-traumatic stress in QF32, but then I studied a lot more about PTS and PTSD for FLY! I found it cathartic to write and talk about it.” Since then, he has spoken about QF32 so many times that it does not trigger an emotional reaction. “There is nothing in the QF32 story that drags me to tears.”
In FLY!, Richard talks about the analogy of PTS(D) and a broken vase. Once it’s broken, it may not be possible to remake a vase, but you can make something new – a mosaic. “Well, when you come out of PTS(D), when you start to heal and grow, you’re not going to be the same person any more.” Research on ‘post-traumatic growth’ shows that there can be growth from trauma, and people can come out of post-traumatic stress stronger, albeit different.
Richard still flies the A380 (currently grounded by the coronavirus crisis), has written two books and delivers presentations to many governments and industries worldwide. He is involved in clinical safety with many organisations and is the Ambassador for Health, Safety and Quality at St Vincent’s Hospital in Australia. “There were many opportunities that presented after the QF32 crisis. I accepted the challenge to take up some of these opportunities. After a crisis, some of us are given a platform to take what they’ve learned and put it to great use to help others.”
Often forgotten in literature about PTS(D) are the partners and other loved ones who experience the person’s symptoms or may be traumatised by the event itself, who may suffer from secondary trauma. Partners and families of people with PTS(D) also find the symptoms difficult to live with. These may include anger, irritability, moodiness, emotional and physical distance, and unpredictable crying. Richard said, “It was at a party three months after the QF32 event when the first person approached Coral and said, ‘You know, Richard’s had a bad time after this flight. How do you feel?’ Coral burst into tears. No one had ever asked her that question.” More recently, Richard was surprised to learn that, even after several years, certain memories of QF32 still upset his wife.
During the process of recovery, Richard kept his pilot’s licence current in the simulator and went back flying once he was well enough. After four months off, fully recovered, he got back into a plane. “I was fine because I’d taken all that time off to satisfy the investigators, company, media and to get my emotional health back. And I’ve never looked back because I resolved my PTS. I’ve flown out of Singapore in Nancy-Bird Walton [the A380] many times and while those southerly departures sometimes trigger memories of QF32, these memories are calm and factual, not fearful emotional memories, so I don’t suffer a fear response.”
QF32 and You
You are highly unlikely to experience an event that is even remotely similar to QF32. But during your life, you or someone close to you will probably experience PTS, and here the symptoms are similar. Your understanding and response to them will determine whether your recovery is swift or long. Understanding the symptoms and underlying causes, and finding or offering support – from friends, family, colleagues, and professionals – may be the crucial difference. And by taking positive steps, you are more likely to grow from the experience.
‘FLY! Life Lessons from the Cockpit of QF32’ was published by Penguin Random House in 2018 (Fly- TheBook.com). ‘QF32’ was published by Pan Macmillan in 2012 (QF32.com).
Dr Steven Shorrock is Editor-in-Chief of HindSight. He works in the EUROCONTROL Network Manager Safety Unit, where he leads the development and promotion of systems thinking, Safety-II and safety culture. He is a Chartered Psychologist and Chartered Ergonomist & Human Factors Specialist with experience in various safety-critical industries working with the front line up to CEO level. He co-edited the book Human Factors & Ergonomics in Practice and blogs at http://www.humanisticsystems.com.
RICHARD CHAMPION DE CRESPIGNY AM
Richard Champion de Crespigny is an Airbus A380 Captain with Qantas Airlines with over 20,000 flying hours. He was born and educated in Melbourne, Australia. He decided on a flying career at 14-years old when his father organised a tour of the Royal Australian Air Force (RAAF) Academy at Point Cook in Victoria. Three years later, he joined the RAAF Academy in 1975 and began flying a year later. By 1979, he had successfully completed a BSc in Physics and Maths, and a Graduate Diploma in Military Aviation. He continued in the RAAF until 1986, when he joined Qantas, where he converted to Boeing 747s. In 2004, he converted to Airbus A330 and in 2008 converted to Airbus A380 as one of Qantas’ most senior captains.
Following QF32 in 2011, Captain Richard Champion de Crespigny was appointed as ‘Member in the General Division of the Order of Australia’ (AM) “for significant service to the aviation industry both nationally and internationally, particularly for flight safety, and to the community”. He has won a number of awards including Flight Safety Foundation Professionalism Award in Flight Safety and the Guild of Air Pilots and Air Navigators Hugh Gordon–Burge Memorial Award for Outstanding Contribution to Air Safety (both in 2011). In 2014, he was awarded Doctor of the University (honoris causa) at Charles Sturt University. He has written two books: the best-selling QF32 and recently-published FLY! Life Lessons from the Cockpit of QF32.
HindSightIssue 30 on Wellbeing is now online at SKYbrary. You can download the full issue, and individual articles. HindSight magazine is free and published twice a year, reaching tens of thousands of readers in aviation and other sectors worldwide. You will find an introduction to this Issue below, along with links to the magazine and the individual articles.
Welcome
Welcome to Issue 30 of HindSight magazine – the EUROCONTROL magazine on the safety of air traffic management. The theme of this Issue is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about.
This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
With HindSight, we hope to help support conversations about wellbeing, not only now during the coronavirus pandemic, but after coronavirus. Please let your operational and non-operational colleagues know about this Issue of HindSight.
The next Issue is on ‘Learning from Everyday Work’. What have you, your peers and your organisation learned by paying attention to what goes on in everyday work, whether things go well or not so well? Let us know, in a few words or more, for Issue 31 of HindSight magazine. See inside back cover for details.
Jim White (sports broadcaster): What baffled me – and I don’t know if you’ll just give me a couple of sentences on it – you’re a good-looking man, you played at the highest level, you were a good player, you’re a good husband, a good football administrator, you’re an intelligent fella. So why?
Clarke Carlisle (professional footballer): Well, here is part of the problem, Jim. Because all of that is an irrelevance. It’s an illness. So that’d be like applying that and saying, why have you got diabetes? It’s all an irrelevance. That circumstantial stuff is irrelevant. When you’ve got an illness, and it takes hold, and it’s not diagnosed or it’s not treated correctly, it will get to that disaster stage. Now that’s why we’re here today. Fellas, we talk to each other. We do talk to each other, but we can be very blasé or flippant. “What’s going on?” “Aw, you know, she’s doing my head in, or he’s doing my head in, they’re doing my head in.” Then we’re like, “Oh OK, let’s pop off.” Do you know what? Ask again. “What can I do for you? Can I help you?” You know, it’s not for me to fix your problems, but what it is for me to do is listen to you, Jim. Because sometimes, as a guy, all you need is to be is listened to and acknowledged. You feel dismissed in this generation, in this 24/7. Everyone wants a piece of you. Just listen to me for once. When guys are going through tough times, there’s often that thought that no-one wants to listen. Nobody’s going to help me. You’ve got to ask yourself, have you given someone the opportunity to help you? You know, in the first ten years of my suffering, I didn’t let anyone help me because I thought I had to deal with it.
A good player in deep distress
This is a video-recorded conversation between Jim White, a well-known Scottish sports broadcaster, and Clarke Carlisle, an English former professional footballer and former Chairman of the Professional Football Association. Carlisle made over 500 appearances during his 17-year career, playing for nine clubs across all four English divisions. At 1.91 m (6 ft 3 in), he was an imposing centre-back and also known to be a highly intelligent footballer (and with a clean sweep of A grades at the end of high school).
In December 2014, Clarke stepped out in front of a lorry in North Yorkshire. He survived physically relatively unscathed, but his mental health deteriorated and he disappeared in 2017, again considering taking his own life. A year later, in the video, he described himself as “very, very content today”.
A 2015 study by FIFPRO (Fédération Internationale des Associations de Footballeurs Professionnels), the worldwide representative organisation for 65,000 professional footballers, found 38% of 607 active professional players and 35% of 219 former players reported suffering from symptoms of depression or anxiety, or both. In a typical 25-person squad, this equates to nine members of the team. Sleep disturbance affected one in four, overall. How much do we talk about mental health, especially in professions where a large majority of staff are male?
Two lessons seem to be learned by many males growing up in this world, perhaps even by most of us. One lesson, learned from a young age through parenting and early socialisation, is “Boys don’t cry”. The second, learned and reinforced in social groups and via the media, is “Men don’t talk about feelings”. These phrases don’t need to be said, as such. Observing and interacting with others is powerful enough to embed these rules in our psyches. Yet these are perhaps two of the worst lessons in human development, and contribute significantly to many problems of mental wellbeing throughout life.
My paternal grandfather died in 2001 at 92 years of age. A few years before he died, he disclosed to my father some hitherto unknown family history: in World War II, my grandfather served as a sniper in the British army. Most families know about a relative’s history in military service, but we never did. My father asked his father, “Why did you never tell me?” My grandfather said, “Son, if you saw what I saw, you’d never want to talk about it.” His remark perhaps betrays a common male attitude to disclosure. That day, he did disclose some of his experiences of life as a sniper, but not many. What was clear is that he experienced post-traumatic stress (PTS) as a young man, and he didn’t talk about it.
I was not in the armed forces, but throughout my late teens and in my mid-20s I experienced what might be referred to flippantly as ‘a series of unfortunate events’. Many of the events centred around death and near-death experiences. This is not the place to describe them, but they were the sort that many people experience once in their life – loss of a parent at a young age, a high-speed car crash, violence (real and threatened), and vicarious experience of life-threatening health problems, among other events, some which are described in poetry here. I just happened to experience a series of such events in rapid succession over a few years at a young age. Some of the traumatic events occurred against a backdrop of a generally stressful day-to-day environment, growing up in a family business.
On leaving home to study psychology, I had already experienced post-traumatic stress symptoms but further events were to occur during and after university studies, which led to reactivation and new symptoms. Some of these stuck for years. I’d heard of ‘post-traumatic stress disorder’ (PTSD), but associated that with soldiers like my grandfather, and didn’t consider it further. Ironically, that is how I felt, like a soldier under persistent attack. The symptoms as a cluster lasted around 12 years overall. Some lay dormant thereafter and re-emerged occasionally.
Throughout the whole experience, I was high-achieving in education and subsequently in employment, and was known to have a very high capacity for hard work. I probably channelled much of my energy into this as a distraction from what I was feeling, while also trying other means to avoid certain thoughts and feelings, because when I opened the door to all of this, it was very difficult to close. And you can’t simply close the door on PTS and PTSD. If you try, it will get in through the windows.
For the rest of the article, I’ll refer to PTS(D) to cover both PTS and PTSD. The difference in practice is a set of diagnostic criteria and a diagnosis, but PTSD often remains undiagnosed. Post-traumatic stress (PTS) is a normal and generally adaptive response to experiencing a traumatic or stressful event, such as an accident or assault. PTS is very common and most people will experience it and experience some of the signs. If symptoms persist for months or years, they may fit the diagnosis of post-traumatic stress disorder (PTSD), a clinically diagnosed condition listed in the Diagnostic and Statistical Manual of Mental Disorders (fifth revision, May 2013). According to the National Institute of Mental Health, PTSD will affect 6.8% of U.S. adults in their lifetime.
My primary experience of PTS(D) was in my teens and 20s. But in later adulthood, pre-empting a major life change, I experienced another episode of PTS(D), after a very long hiatus. In this case, the thoughts and feelings mostly did not relate to memories of the original events (which no longer triggered the same responses), but rather the memories of the PTS(D) symptoms from my younger days.
Symptoms of PTS(D) will depend on the person, but below are some characteristic symptoms which I experienced over many years. Each has psychobiological explanations. For instance, there are physical changes to brain structures. The amygdala helps control emotion, memories, and behaviour, and the right hemisphere, which controls fear and aversion to unpleasant stimuli, can become enlarged. The hippocampus, which helps to consolidate the transfer of information from short-term memory to long-term memory, can become smaller. Brain signals are affected, as are hormone levels, with higher noradrenaline/norepinephrine levels and (counterintuitively) lower cortisol levels. There are also psychological, socio-interpersonal, and cultural explanations. Each kind of explanation may be of more or less help to different people. But I’ll not go into those further here. Rather, I’ll describe the symptoms from an experiential point of view, along with some general information.
Flashbacks
Flashbacks are perhaps the most well-known symptoms of PTS(D) in popular culture. Traumatic events are reexperienced from memory, as if you are back in the scene, with the emotions and often physical sensations that were present at the time. The flashbacks can take the form of all of the senses, or just one. They can also include feelings of guilt and shame, even if others would see no justification for them. Flashbacks are the first thing that I remember about PTS(D) and were linked to a few traumatic events. Avoiding a trigger or waiting for the scene to play out was often the only thing I could do, but it required a great effort not to get sucked in the vortex of reexperiencing. Flashbacks dissipated over the years, but this took a very long time because I didn’t get proper help at the time, either from friends or professionals. Ultimately, psychotherapy did help but I waited far too long to get it.
Nightmares and night sweats
Imagine waking up in the middle of the night, night after night, experiencing the death of a loved one – someone different each night – until almost everyone you love has died. They’ve not all died in reality, but rather in your dreams. It hardly bears thinking about, and I didn’t consciously think about it. My unconscious mind did that for me. I would also wake full of sweat – the bed sheets soaking – and this could happen with or without any nightmare. Nightmares can be one of the most acutely distressing symptoms of PTS(D). As they reoccur, and you come to expect them, sleep can become further affected. This occurred over a number of weeks, several years into the experience, until I sought help from a clinical hypnotherapist. Only two or three sessions of clinical hypnotherapy later, and the nightmares stopped. They returned many years later, but only temporarily, as a sign that all was not well.
Fight, flight and freeze
So-called hypervigilance and heightened startle reactions are well known symptoms of PTS(D). For me, they were the most tiring and debilitating. Everyday things and situations can become potential threats. I became hypersensitive to noise and situations where people were gathered together, especially if I sensed trouble. In some senses, this could be useful: I became an expert at spotting potential disorder or violence. But in most ways, it wasn’t useful. A dropped object, slightly raised voices, unexpected claps, or a demonstration elicited the fight, flight or freeze response. Flight was the usual action – escaping the situation, such as a crowd. Occasionally the fight response prevailed – the body and mind ready to fight (usually a non-existent threat). But sometimes, freeze – the most debilitating of the three – would take over instead. With the freeze response, the body literally becomes immobile, stuck like glue. Fight, flight, and freeze is also characteristic of anxiety more generally, even without PTS(D), and can be visible to others, even though observers probably won’t understand what’s going on for the person.
Dissociation: depersonalisation and derealisation
With PTS(D), the person can begin to experience dissociation, including depersonalisation (feeling as if the self is not real) and derealisation (feeling as if the world is not real). Disassociation is a common and normal response to trauma. Like fight, flight and freeze, it stems from a survival instinct. But if PTS(D) is left to its own devices, it can become more persistent and problematic, when survival is no longer the issue. It is more common among those who have experienced repeated traumas. I experienced derealisation. It is, for me, the hardest symptom to explain, partly because it is hard to explain something that feels so unreal. It is like seeing the world as an observer through a frosted glass window, or as a dream. The episodes – somewhat like flashbacks but without the imagery of past experiences – didn’t seem to last long. The most common sign to others may be an appearance of being spaced out or frozen, or both. Memory loss is also common.
Physical manifestations and illnesses
In my teens, in the context of trauma, I experienced tics (involuntary body movements) for the first time. I had no idea what they were, though later came to learn that tics and Tourette syndrome runs in my family. I learned to suppress them by what I thought of as keeping a ‘clean internal environment’ – a sort-of mindfulness mixed with avoiding known emotional triggers. In my experience of PTS(D) in later life, the tics returned, but this time I was unable to prevent or suppress them. Having forgotten that I ever had them as a teen, I had to adjust to a totally new self-concept – an adult with tics. This was intensely upsetting to me, even though few probably even noticed them, and certainly were not bothered by them. Depending on circumstances, they still come and go, to the extent that I can maintain this internal environment. Deliberate suppression is possible at a price due to the energy required, and when this energy is depleted, it is not possible at all – like trying to resist a sneeze.
Many who experience PTS(D) also experience physical illnesses, often associated with changes to the immune system. I developed shingles (herpes zoster) during my second experience of PTS(D) in adulthood. (As if the emotional pain of PTS(D) symptoms were not enough, shingles is like A Greatest Hits of Physical Pain!).
Depression and low mood
It is not surprising that depression and PTS(D) often co-occur. The day-to-day toll of PTS(D) is enormous. The flashbacks, the nightmares, the sleep disruption, the fight/flight/freeze state, the physical manifestations and illnesses. Any of these alone can be enough to trigger depression. And yet none of these is even necessary. The event(s) that triggered PTS(D) can be enough. But in combination, the symptoms can be overwhelming. While it is different for everyone, for me it resulted in a combination of numbness, being less interested in doing things I used to enjoy (I could no longer paint or draw, for example), and trouble feeling positive emotions. It was a sort of death of part of my emotional life. There were also bouts of crying, which were often unexpected, and returned later in life as a sort of PTS(D) about PTS(D). Perhaps the most distressing aspect of depression, though, was a loss of sense of self, a kind of detachment from the world, and an inability to envision a positive future. Depression is a very common condition. Each year, 25% of the European population suffer from depression or anxiety (WHO, 2020). Unfortunately, about 50% of major depressions are untreated (WHO, 2020). Thankfully, as I found, help and hope can be found in counselling and psychotherapy, nature, exercise, mindfulness, hobbies, friendship, community and personal development.
It is not for me to give any advice on recovering from PTS(D). This is the job of an experienced doctor, psychologist or psychotherapist trained in PTS(D), not a psychologist who has experienced it. Still, it feels appropriate to share some things that did help me and that seem like fairly low risk things to suggest. What I want to emphasise first though is that PTS(D) is not just a ‘mental’ condition. PTS(D) is profoundly physical. It feels like it is stored in the body and seems to live in you like a virus. Research also indicates a variety of biological changes.
Any effort to recover may need as much focus on the physical as the mental, as well as the interpersonal and the spiritual. For me this included exercise, tai chi, yoga, walking in nature, meditation, and plenty of sleep.
Taking to trusted friends who are able to listen without interruption, judgement or advice is essential. Seeing a professional is especially important if symptoms last for a long period of time – more than a few days or weeks. (For a person to be diagnosed with PTSD, symptoms last for more than a month but often persist for months and sometimes years, as was the case for me.). A general practitioner doctor may be a good place to start, but contact with psychologist or psychotherapist with experience of traumatic stress may well be a necessary step.
And then there are the spiritual aspects of PTS(D) and recovery. In my late 20s, I explored these via recovery groups, Buddhist meditation, and Quakerism. Most surprisingly for me, in later life, when I reexperienced PTS(D), I found myself writing poetry. Having never written a poem since high school, and previously having no interest in it whatsoever, I wrote dozens of poems within weeks, and published some at https://ptsdays.home.blog/poems/. There is something about writing poetry that is very different to talking or writing prose. I still can’t explain it, but it seemed to help process and wrap up certain events. Perhaps, for me, poetry is most connected to the spiritual aspects of PTSD and recovery.
“Son, if you saw what I saw, you’d never want to talk about it”
I thought for a long time before writing this article, and throughout writing it, I have wondered whether I should publish it. The sentiment expressed by my grandfather lives within me. Indeed, this article is very different to every other article that I have ever written. Many of my articles concern risk, but there is no risk to me in writing them. This one does concern me and feels very risky, even if that there is – in reality – very little risk.
But I’m writing this article for a few reasons. The first is for me. Writing is the way that I make sense of the world and in this case, my experience. PTS(D) is the bull in the china shop, and it’s hard to make sense of what’s going on from within the china shop. Writing prose or poetry is like watching a film of the bull from outside of the window. Getting out of the china shop in order to take this perspective is difficult, and writing does not come naturally for everyone. I never imagined writing poetry either. Letting go of perfectionism and just writing from experience seems to be the gentle way. There are other ways out of the china shop, such as via art, talking, and therapy.
The second reason is that, while I can write about PTS(D), and can now talk about the events, I cannot yet talk about the symptoms and experience of PTS(D), except one-to-one in a safe environment with people I trust. I have given talks in front of over 1000 people, but could not (yet) talk about PTS(D) even in a small group. It may be something to do with a profound lingering sadness at being affected for so long in my young years. So I guess this is the talk I cannot give.
The third reason is to help normalise PTS(D). Any one of the symptoms of PTS(D) can feel stigmatising to some. While an understanding of the cluster of symptoms that constitute the diagnosis of ‘PTSD’ may well have encouraged me to seek help in my teens, one word would probably have discouraged me: ‘disorder’. As retired U.S. Army General Peter Chiarelli said, “no 19-year-old kid wants to be told he’s got a disorder.” (There is now pressure from outside of the psychiatric profession to ‘drop the disorder’ from such labels.) I didn’t want to think of myself as having a ‘disorder’. It seemed stigmatising. It also didn’t fit my self-concept of being in control; PTS(D) actually heightened a need for control, which dissipated significantly during recovery. But it should be understood that post-traumatic stress is a normal response to traumatic experiences. Most people will experience trauma, and people will have different perspectives on what constitutes trauma for them. If you try to manage it alone, the cluster of symptoms known as PTSD is more likely.
The fourth reason is to encourage others to do what I didn’t do enough – give someone the opportunity to help you. Coupled with this is a hope that those who know someone with the signs and symptoms of PTS(D) might ask twice when the person says they are “fine”. You are not there to cure the person, but can give time, a safe space, and a non-judgemental listening ear, perhaps along with gentle encouragement to seek professional help.
The fifth reason is to give hope. From post-traumatic stress can come post-traumatic growth. I could not have imagined what I have been able to do in the years after PTS(D), including moving around the world and getting through some of the most stressful as well as joyful life events. While the bull does occasionally return to the china shop, it has mostly been relaxed or asleep in the field, which is where it ought to be.
Traumatic experiences are so common that you or someone close to you are likely to experience them at some point in your life, and many of you will experience PTS, which for some will progress to PTSD. It is so ubiquitous that we don’t acknowledge it or talk about it. PTS(D) symptoms can remain hidden for months or years after a triggering event, and many will never come to understand or accept that their cluster of experiences really do amount to PTS(D).
Going back to Clarke Carlisle’s observation, Dr Peter A. Levine, author of of the book Waking the Tiger: Healing Trauma, wrote that “Because the symptoms and emotions associated with trauma can be extreme, most of us (and those close to us) will recoil and attempt to repress these intense reactions. Unfortunately, this mutual denial can prevent us from healing. In our culture there is a lack of tolerance for the emotional vulnerability that traumatized people experience. Little time is allotted for the working through of emotional events. We are routinely pressured into adjusting too quickly in the aftermath of an overwhelming situation. Denial is so common in our culture that it has become a cliché.”
It seems that many of us, and especially men, deny our experiences or else try to fight them alone. This prolongs a struggle that is already too much for any of us individually. If you think you may be experiencing PTS(D), or depression, anxiety, or indeed any mental health problem or experience of distress, ask yourself, have you given someone the opportunity to help you?
Getting Help
The following are some English-language resources.
PTSD UK. PTSD UK is currently the only charity in the UK dedicated to raising awareness of post-traumatic stress disorder – no matter the trauma that caused it.
Helpguide. HelpGuide is a nonprofit mental health and wellness website. Our mission is to provide empowering, evidence-based information that you can use to help yourself and your loved ones.
Black Dog Institute. The Black Dog Institute is dedicated to understanding, preventing and treating mental illness.
PTSD Association of Canada.A non-profit organization dedicated to those who suffer from post-traumatic stress disorder (PTSD) those at risk for PTSD, and those who care for traumatized individuals.
Some books that may be helpful:
Haig, M. 92015). Reasons to stay alive. Canongate Books Ltd.
Levine, P. A. (1997). Waking the tiger: Healing trauma. North Atlantic Books.
van der Kolk, B. (2015). The body keeps the score: Mind, brain and body in the transformation of trauma. Penguin.
Sincere thanks to the friends who read this article prior to publishing.
Several fields of study and spheres of professional activity aim to improve system performance or human wellbeing. Some focus on both objectives (e.g., human factors and ergonomics, organisational psychology), while others focus significantly on one or the other. Disciplines and professions operating in these areas have a focus on both understanding and intervention. For each discipline, the focus of understanding and method of intervention will differ. For instance, for human factors and ergonomics, understanding is focused on system interactions, while intervention is via design. Understanding alone, when intervention is required, may be interesting, but not terribly useful. Intervening without understanding may have unintended consequences (and indeed it often does). With appropriate understanding and intervention, both system performance and human wellbeing have a chance of being improved.
Understanding and intervention for system performance and human wellbeing is rooted – to some extent – in four kinds of thinking. In this short series, I outline these.
Unless we engage in the right kinds of thinking, it is likely that our understanding will be too flawed, partial, or skewed. In this case, intervention will be ineffective or even counterproductive. Integrating all four kinds of thinking involves compromises and trade-offs, as the kinds of thinking can conflict, presenting dilemmas that we must resolve.
“In systems thinking, increases in understanding are believed to be obtainable by expanding the systems to be understood, not by reducing them to their elements.”
Russell L. Ackoff, in “Creating the corporate future“, in Understanding Business: Environments edited by Michael Lucas and Vivek Suneja
Why?
It should be self-evident that thinking about systems, or thinking in systems, is important to improving system performance and human wellbeing. Systems cannot be understood, let alone improved, without thinking. These ‘systems’, however, are social constructs, defined for a particular purpose with respect to a boundary of interest. This explains Ackoff’s quote about ‘expanding’ the systems to be understood. He, and others (e.g., Checkland, Meadows), are referring to expanding our perspective on the system boundary that we define (zooming out). And when it comes to wellbeing, the broader system in which people work and live has the lion’s share of influence on wellbeing: social conditions, working hours, pressure, opportunities to rest, exposure to hazardous substances and conditions, nutrition, housing, and so on.
Systems thinking is an alternative to analytical thinking – taking things apart, conceptually or physically, and trying to infer the behaviour of the whole from the behaviour of the parts (reductionism). This approach takes us down a never-ending path that, often in business, leads to the individual, even their brains (or other organs), down to microscopic units of analysis. This strips out the context that is so vital to understanding and intervention. Ignorance of systems leads to interventions based on poor understanding, and hence are ineffective (e.g., unsustainable), have unintended consequences, and are often counterproductive.
The best (e.g,, most efficient, safest) parts, designed and managed separately, will not result in the best system. It may well result in a system that works very badly, or not at all. Similarly, an organisation broken down into parts (departments, measures), without significant attention to how it functions as a whole, will not function effectively. Frequently, the result is separate silos and activities that run at cross purposes and are in competition.
Systems thinking is also an alternative to linear cause-effect thinking – considering one thing to be the cause of another, if it is necessary and sufficient to produce the behaviour (determinism). Neither reductionism nor determinism have a practical stopping point; it is always possible to go further (though the stopping point is, in practice, often defined by disciplinary boundaries). Neither also allow for the humanistic principles of choice and intentionality.
What?
When asking ‘what is systems thinking?’, it is helpful to ask ‘what is a system?’ In her book Thinking in Systems, Donella Meadows described a system as “a set of elements or parts that is coherently organized and interconnected in a pattern or structure that produces a characteristic set of behaviours, often classified as its ‘function’ or ‘purpose'”. Russell Ackoff, meanwhile, defined a system as two or more elements that satisfies the following conditions: 1. The behaviour of each element has an affect on the behaviour of the whole; 2. The behaviour of the elements and their effects on the whole are interdependent; 3. However subgroups of elements are formed, each has an effect on the behaviour of the whole and none has an independent effect on it.
Therefore, a system cannot be understood via reductionism and determinism – our dominant modes of thinking. Systems thinking offers a complementary approach that works with the following axioms, among others:
A ‘system’ is a social construct. Systems are not out there waiting to be found, but in us waiting to be identified.
System boundaries are not fixed and are often permeable. Systems exist alongside and within other systems. Boundaries are social constructions.
Systems have a purpose, which can be seen in what the system does. Some systems have purposes of their own, and their parts have purposes of their own. Other systems have purposes that we ascribe to them, or purposes that belong to a bigger system. Purposes at different system levels interact, and often conflict.
A system does something that none of its parts can do, so the essential properties of any system cannot be inferred from its parts (holism). The performance of a system depends more on how its parts interact than how they function independently.
Influence is more important to systems thinking than cause-effect (determinism). Patterns of system behaviour allow us to observe influence. Where cause-effect relations can be ascertained in complex systems, they are often non-linear; small changes can produce disproportionately large (and unpredictable) effects. Effects usually have multiple causes, however. These causes may not be traceable and are socially constructed.
Complex systems have a history and have evolved irreversibly over time with the environment. Apparent order and tractability is often an artefact of hindsight.
There will be different assumptions about the ‘system’ under consideration. Systems-as-imagined rarely correspond fully to entities in the world.
Synthesis and analysis are critical to systems thinking, but synthesis distinguishes systems thinking from reductionist thinking.
Understanding can only ever be partial, and can only be approached via interdisciplinary efforts. No single discipline is sufficient and understanding is multi-layered.
There are multiple perspectives on a system from different stakeholders. These multiple perspectives are not a weakness; they are necessary for understanding.
How?
Ackoff explains that systems thinking reverses the three steps of the ‘machine age’. We move from reductionist thinking to systems thinking. The three steps are therefore:
Identify a containing whole (system) of which the think to be explained is a part;
Explain the behaviour or properties of the containing whole.
Then explain the behaviour or properties of the thing to be explained in terms of its role(s) or function(s) within its containing whole.
The process of synthesis therefore involves zooming out, while analysis involves zooming in. For instance, I work predominantly in aviation, and in particular in air traffic management. I work with air traffic controllers and pilots, and most other professions involved in air traffic management. But in understanding the behaviour of air traffic controllers, I do not go first down to the cognitive and the neuropsychological and the biological. I go up – in the case of air traffic controllers – to the working position, the sector, the control unit, the airspace, the organisation, the regulatory environment, transport system, the government, the judiciary, and the press, for example. Where I choose to draw the system boundary will depend on my purpose, my understanding, and in perhaps my scope for intervention.
So let’s say we seek to understand and intervene with respect to something so local as occurrence reporting. Analysis may allow us to describe certain phenomena, such as low rates of reporting and perhaps self-protective reporting behaviour (e.g., basic description of an outcome). That does not give us understanding. For that, we need to go up and out, to the organisation and perhaps to the judicial system, for both will influence reporting behaviour. Effectively, we are zooming out before zooming in, in order to understand why things work in the way that they work. Now, we can approach an understanding, but never attain one. We therefore remain humble and anchored by uncertainty – a friend of intervention. Now we find that our ability to influence the judicial system is severely limited by hard constraints (e.g., penal codes), but with some room for manoeuvre (e.g., interpretation). So we have some possibilities (e.g., education of judiciary), but otherwise must now go down and in. With more understanding of the whole, we may be able to intervene where this will do some good (and more good than harm).
There are a number of methods and tools that can help us along the way, such as stakeholder maps, system maps, influence diagrams, multiple cause diagrams, rich pictures, stock and flow diagrams, system archetypes, and so on. But the insights, understandings and perspectives that emerge along the way (e.g., via conversation) are always more important than the outputs.
This kind of thinking might prompt questions such as:
What is the purpose of the system, evident from system behaviour?
What goal conflicts does the system produce?
What is the system boundary?
What are the elements of the system?
How do these elements interact, and what kinds of patterns emerge?
Who dos the people that contribute to, influence, and are affected by the system?
What is the mental model that affects systems structure and patterns of system behaviour?
What kind of outcomes emerge from system behaviour?
What patterns or archetypes may help explain the system behaviour that we are seeing?
How might a proposed intervention influence system behaviour?
What perspectives might we take?
Shadow side
The shadow sides of systems thinking are less about systems thinking than the way in which we typically think, especially in a business context. But this kind of thinking is arguably the most difficult of the four. We are trained to think analytically from schooling (where subjects are studies, which are further reduced to topics), and throughout work life. We also, as Ackoff remarked, think analytically quite intuitively – taking things apart in order to understand how they work. We therefore tend to think in terms of parts and linear cause-effect thinking, within a restricted system boundary. This kind of thinking is more suited to simple or obvious systems than the complex world in which we now live. Systems thinking is difficult, tiring, and we are not trained to do it.
Systems thinking also often frustrates our objectives. The problem here is not systems thinking, though, but our objectives. For instance, we may wish to introduce a performance target, league table, or new incentive. Systems thinking may well suggest unintended consequences, as these interventions sub-optimise the system, perhaps introducing internal competition and unwanted adaptive behaviours. Even the edition of three words in radio-telephone communication phraseology for clearances to pilots or seemingly small changes to communication with respect to drivers crossing a runway may have significant unwanted consequences, not predicted by analytical methods. Systems thinking exposes problems with our understanding and intervention. Sometimes, scientific evidence is demanded for these objections, even though the same was not provided for the intervention itself (and the underlying understanding), or else the evidence was so constrained by a reductionism and determinism as to be meaningless in messy, real world settings.
Additionally, the tools that are routinely in use tend to be reductive, rather than synthetic, aimed at analysing components, not understanding interactions. Where interactions are modelled, they are typically assumed to be fixed (unchanging) and linear (lacking feedback loops), assuming direct cause-effect relationships, with no consideration of emergence. Such tools may also focus only on certain outcomes (e.g., failures), thus giving a partial view of system performance. There is an important distinction between thinking systemically (thinking in an ordered or structured way) and systems thinking (thinking about systems). The former may reinforce doing the wrong thing right (e.g., consistently), making our efforts ever more problematic.
Systems thinking, like scientific thinking, can be depersonalising. The person can seem to be an anonymous system component, less interesting than system interaction. To counter this, systems thinking must be combined with humanistic thinking.
Finally, this kind of thinking can make issues of responsibility and accountability difficult to ascertain. Responsibility for system outcomes now appears to be distributed among complex system interactions, which change over time and space. Outcomes in complex sociotechnical systems are increasingly seen as emergent, arising from the nature of complex non-linear interactions across scale. But when something goes wrong, we as people, and our laws, demand that accountability be located. The nature of accountability often means that this must be held by one person or body. People at all levels – minister, regulator, CEO, manager, supervisor, front line operator – have choice. With that choice comes responsibility and accountability, but choices are also made in a context, including conflicts between goals, production pressure, and degraded resources, including restricted or contradictory information. While it is simplest to ignore aspects of systems that influence decisions and behaviour, it is also unfair, as well as counterproductive in our efforts to improve systems performance and human wellbeing.
Several fields of study and spheres of professional activity aim to improve system performance or human wellbeing. Some focus on both objectives (e.g., human factors and ergonomics, organisational psychology), while others focus significantly on one or the other. Disciplines and professions operating in these areas have a focus on both understanding and intervention. For each discipline, the focus of understanding and method of intervention will differ. For instance, for human factors and ergonomics, understanding is focused on system interactions, while intervention is via design. Understanding alone, when intervention is required, may be interesting, but not terribly useful. Intervening without understanding may have unintended consequences (and indeed it often does). With appropriate understanding and intervention, both system performance and human wellbeing have a chance of being improved.
Understanding and intervention for system performance and human wellbeing is rooted – to some extent – in four kinds of thinking. In this short series, I outline these.
Unless we engage in the right kinds of thinking, it is likely that our understanding will be too flawed, partial, or skewed. In this case, intervention will be ineffective or even counterproductive. Integrating all four kinds of thinking involves compromises and trade-offs, as the kinds of thinking can conflict, presenting dilemmas that we must resolve.
“It is not enough that you should understand about applied science in order that your work may increase man’s blessings. Concern for the man himself and his fate must always form the chief interest of all technical endeavors; concern for the great unsolved problems of the organization of labor and the distribution of goods in order that the creations of our mind shall be a blessing and not a curse to mankind. Never forget this in the midst of your diagrams and equations.”
Albert Einstein, from a speech to students at the California Institute of Technology (in “Einstein Sees Lack in Applying Science“, The New York Times, 16 February 1931)
Why?
There are several reasons why humanistic thinking is important to (sociotechnical) system performance and human wellbeing. One reason relates to human wellbeing as something more than an absence of disease, illness or injury, encompassing the body, mind and spirit (or whatever term one wishes to use), individually and collectively. Having worked in psychopathology, Abraham Maslow, the father of humanistic psychology, found that the concepts, language, tools and methods did not serve the needs of the mass of relatively healthy and well-functioning people. According to Maslow, psychology was being viewed from the wrong end of the lens (pathology). The same might still be said of health, and of safety – akin to psychiatry when it comes to organisational functioning. Humanistic thinking encourages us to think more from the perspective of: what we want than what we don’t want; what works than what doesn’t; assets and human potential than deficits and constraints. Human wellbeing is ultimately linked to human flourishing, individually and collectively, or the idea of ‘actualisation’ in humanistic psychology.
A second reason for the need for humanistic thinking relates to holism. A reductionist focus (typical of science and engineering, including HF/E) tends to mask the person and their unique context. This is exacerbated by the industrial context, characterised by reductionism in the design, analysis, measurement and evaluation of work. The humanistic perspective provides another way of thinking about human beings and human work.
Another reason for the importance of humanistic thinking concerns the relationships through which our work flows. Any practitioner will be aware of the constraining or facilitating influence of relationships, regardless of the technical nature of the work. HF/E, for instance, is officially seen as a “scientific discipline” by the International Ergonomics Association but is more properly described as a blend of elements of science (to explain and predict), engineering (to design for improved performance), and craft (to implement and evaluate) (Wilson, 2000). Humanistic thinking helps to avoid scientism and hard engineering thinking. It also steers us away from ‘technical rationality’ (Schön, 1983) and its assumptions about ‘research application’, recognising that strong theories and inflexible methods can break down in messy situations, requiring reflection-in-action. Humanistic thinking orients our practice so that craft – including reflective practice – is properly valued.
What?
While typically associated with counsellors and psychotherapists, humanistic practitioners (or practitioners of anything, working humanistically) may work in fields such as medicine, education, and social work. Humanistic theory has also been applied to human work and organisational functioning. But what does it mean, exactly? The Association for Humanistic Psychology in Britain usefully summarise five basic postulates, which focus on a view of human beings rather than a discipline or profession.
Human beings, as human, supersede the sum of their parts. They cannot be reduced to components.
Human beings have their existence in a uniquely human context, as well as in a cosmic ecology.
Human beings are aware and aware of being aware – i.e., they are conscious. Human consciousness always includes an awareness of oneself in the context of other people.
Human beings have some choice and, with that, responsibility.
Human beings are intentional, aim at goals, are aware that they cause future events, and seek meaning, value and creativity
There has been relatively little direct cross-pollination of humanistic psychology into many disciplines associated with human wellbeing. But humanistic thinking is ultimately concerned with people, relationships and contexts, and it has this in common with several disciplines (especially HF/E).
How?
Integrating humanistic thinking means going beyond the ‘tools and methods’ that can be found in so many textbooks (including those of HF/E). One of the essential approaches of humanistic psychology is otherwise known as ‘listening’, hanging out with people, relating to them, trying to empathise with them and their unique situation and perspective.
Empathy is a rich and complex concept, it may be viewed as a trait or state of a person, a process and a skill. Empathy is colloquially seen as ‘walking in another’s shoes’. In this sense, empathy can be thought of as ‘perspective taking’; the ability to perceive accurately the frame of reference of another person while maintaining a sense of separateness – the ‘as if’ quality.
Humanistic thinking in the context of improving system performance and human wellbeing, may involve empathising emotionally, cognitively, physically, and socially. But effective empathy is not as intuitive as we may think. Bohart et al suggests that we can distinguish between three different modes of empathy, these are:
Empathic rapport: using empathy to build rapport and support the person.
Process empathy: a moment-by moment empathy for the person’s experience, cognitively, emotionally, and physically.
Person empathy: this is known as ‘experiencing near understanding of the person’s world’ or ‘background empathy’.
Time spent training in fundamental counselling skills is particularly helpful. Also helpful is time spend understanding and practising ethnographic approaches, which are likely to be of more value to humanistic thinking than reductionist scientific and engineering methods. Combined, these can give an insight into the person that analytical methods, even systems thinking methods, cannot.
This kind of thinking might prompt questions such as:
What is this person’s story?
What does this (situation, job, etc) mean to this person, within the broader context of her or his life?
To what degree does the work context respect the person’s autonomy?
What tensions exist between freedom and constraint, and how does the person and other people address these?
What does a good job look like to this person?
How do people perceive their self and their situation, and how might this differ from their ideals?
How can work create space for greater flexibility and creativity?
How might work contribute to growth, and also to suffering?
Shadow side
Methods that come more from the biological, psychological, and engineering sciences tend to focus on reliability and validity. Humanistic approaches may seem to lack the same rigour, meaning that there are different perspectives on people and situations that cannot be controlled by method. While reductionism makes measurement and diagnosis easier, but also less meaningful, holism questions the idea of measurement and diagnosis, at least as it is often applied (e.g., as can be seen in person centred counselling vs psychiatry). Still, humanistic thinking may be accused of lacking ‘validity’ when viewed from a traditional scientific frame of reference.
Empathy is core to humanistic thinking, but the term has – especially recently – been misunderstood and misused in some quarters. In UX, quick and dirty ’empathy’ has sometimes become a proxy for research (and even a proxy for people, in some persona development). Another problem in practice is the line between empathy and sympathy. Sympathy involves losing a sense of separateness and impartiality or losing the ‘as if’ quality. Sympathy can block the capacity for empathy and so can be counterproductive, blurring the boundaries between ‘me’ and ‘you’, and associated issues (e.g., choice and responsibility).
Another shadow side consideration is that humanistic thinking, when considered on an individual level, may seem to result in unsustainable solutions, from a systems thinking perspective. In many cases, however, this conflict arises not from humanistic thinking per se (the five basic postulates above), but from from sympathy and charity.
Safety-II, its cousin Resilience Engineering (and offshoots such as resilient healthcare), as well as predecessor concepts and theories, have attracted great interest among organisations and their staff. People, especially front-line staff, understand the need to understand all outcomes – wanted and unwanted – and the systems and associated patterns of system behaviour that generate these outcomes. The trouble is, people are not sure where to start with ‘doing Safety-II’. Some methods and seemingly complicated words and ideas might seem off-putting. They don’t need to be. In this post, I will provide some initial ideas and inspiration for getting started. The ideas are in plain language without reference to any specific techniques.
Safety-II and Resilience Engineering are not solo efforts. You can do little of practical benefit alone. In fact, going alone will almost guarantee a miserable work life. You will start to see the reality of how patterns, system structures and mental models are connected to produce events, both wanted and unwanted. But you will have to stand back and watch how this complexity is boiled down to mechanistic thinking and methods that don’t describe how safety is created, or even how unsafe events really occur. You will also have to observe foes of intervention in action, which almost guarantee unintended consequences. For the sake of sanity, it is almost better not to know how complex systems fail, let alone how they work on a day-to-day basis. Finding a small number of open-minded people who are willing to expand their thinking and listen to ideas and experiences without prejudgement, and not hamstrung by personal barriers, is a good place to start. A diverse group that traverses organisational silos is helpful.
Idea 2: Read
If you want to do Safety-II, you have to read. At least a bit. You might find that you don’t have enough time to read technical books. You don’t have to, though you may well want to, at some point. Start by reading some short articles on Safety-II, and associated concepts, by authors with a pedigree in this area. You might want to expand your search terms to ‘systems thinking‘, ‘resilience engineering‘, ‘systems ergonomics and human factors‘. From here you might start to explore methods from social science (e.g., action research, practice theory, ethnography). See where the search takes you, from blog posts (search this blog for a few, as a start), through to White Papers, articles (email the author if you can’t access them), and books. A couple of short articles a week and you’ll be on your way to understanding the key ideas. Be mindful that some of what is written may be way off the mark (what Safety-II isn’t), as Safety-II, like anything else, is subject to the bandwagon effect.
Idea 3: Think
It might seen strange to suggest thinking as a way to do Safety-II or Resilience Engineering. But in many lines of work, we somehow manage to avoid taking a step back to think more holistically about outcomes, work, systems, and the mental models that give rise to all of this. I teach a systems thinking course which is about…thinking. At the end of the most recent course, one participant said that it was the first course that they had participated in where they actually had to think, and not just learn content or follow a process. The course doesn’t provide a process, but rather a space to think and challenge one’s own assumptions. The thinking required involves going up and out to the system as a whole, switching perspectives (stakeholders and situations), and generally questioning how things go. Thinking through situated examples is especially useful, so long as there are links to theory.
Idea 4: Listen and Talk
From the above, and the below, prepare some topics or questions on concepts, methods and everyday work for discussion. Find a room, get some drinks and snacks, and arrange some chairs in a circle. Try to get rid of tables and anything else that gets between you. The questions may emerge from your reading or from your experience…preferably both. E.g. If you had to explain to a neighbour why your organisation operated safely, what would you say? What do we do well? What dilemmas do we face? What surprises do we experience? How do we handle them? What unintended consequences have we experienced from interventions? What factors are at play when things go right and wrong? What is the role of designed artefacts and processes versus adaptive performance in creating safety? A good discussion will harvest new insights, including multiple perspectives and thick descriptions.
Idea 5: Write and Draw
Write about your experiences of work in the frame of Safety-II or Resilience Engineering. Think deeply about your own work and the situations you encounter and write in a way that you would explain it to a neighbour. Start to think about patterns of interactions inside and outside of your organisation – micro, meso, and macro. But keep it concrete. How do things influence each other at technical, individual, team, organisational, regulatory, governmental, media, and economic levels, to create patterns and associated wanted and unwanted outcomes? Put the concepts that you read about into the context of your practice and experience of the systems that you are a part of, or interact with. The concepts you encounter will make sense not only from the points of view of what you observe in others’ work, but in what you experience in your own. Keep it short and snappy. Think short vignettes, not a treatise. Sketch out the images that come to mind (e.g., rich pictures) and start to map out some influences that you come across. Remember, thinking is more important than method, and should always precede it.
Idea 6: Observe
Arrange to observe ordinary work. It is best to observe work that you are not intimately involved with, but that you can understand well enough to know what’s going on. This might be another hospital or ward, or another air traffic control room or sector, for instance. It is essential is that you have the right attitude – apprentice, not master. It is also essential that the people you are observing consent, and understand the purpose of the observation. If you have another role that may conflict with learning how things work (e.g., competency assessor) then you have some work to do to deconflict these roles and the mindsets and perceptions that may be associated. Don’t go with a checklist. Just hang out. Notice how people resolve the dilemmas created by goal conflicts, what trade-offs and compromises are necessary, how people work around a degraded environment (staffing and competency gaps, equipment problems, procedural complexity, etc), and how – despite the context – things work reasonably well most of the time.
Idea 7: Design
At this point, you may well have ideas about improving the system structure and patterns of system behaviour (including work), to help create the conditions for success to emerge. This effort will always start with understanding the system. You’ll need to understand interactions between people, their activities, their tools, and the contexts of work (micro, meso and macro). It is advisable to avoid major initiatives and ‘campaigns’. Small designed interventions are a good way forward. You may wish, for instance to: a) make small changes to work-as-done that help balance multiple goals; b) review procedures to remove or reconcile those that are problematic (e.g., conflicting, defunct, over-specified); c) help managers and support staff to become familiar with how the work works; d) adjust buffers or margins for performance; e) review onerous analyses of events could be better directed at patterns (e.g., onerous safety analysis of multiple events outside of one’s control); f) create a means of getting regular outside perspectives on your work (perhaps an observer swap arrangement); g) create a means to simulate unusual circumstances and allow experimental performance (not a competency check). The interventions may aim at reducing unhelpful gaps between the varieties of human work (e.g., the ignorance and fantasy, taboo, PR and subterfuge, defunct archetypes). After designing, iterate to the previous ideas.
