In any attempt to understand or intervene in the design and conduct of work, we can consider several kinds of ‘work’. We are not usually considering actual purposeful activity – work-as-done. Rather, we use ‘proxies’ for work-as-done as the basis for understanding and intervention. In this series of short posts, I outline briefly some of these proxies. (See here for a fuller introduction to the series.)
Proxies for Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
Work-as-analysed is the process and product of examination and representation of work.
Function and Purpose:Work-as-analysed involves the use of analysis to understand and represent work, especially in terms of the elements or structure of work. Attempts at synthesis may follow analysis, either in terms of simply combining the elements to form a whole, or representing interactions. Both analysis and synthesis are considered here. Work-as-analysed is always based on one or more of the other proxies (typically, work-as-imagined, work-as-prescribed, work-as-observed, work-as-disclosed). Work-as-analysed is intended to describe how work is done to achieve certain goals (descriptive), or how work should be done (normative). Work-as-analysed may therefore share similarities with – and inform – work-as-prescribed. In fact, it may inform any other proxy, with various purposes concerning work design (e.g., interaction design), artefact design (e.g., interface and sign design, tool design), facility design (e.g., room layout), job design (e.g., job descriptions), competency (e.g., training, performance evaluation), safety and quality (e.g., error analysis, safety assessment, safety investigation, safety improvement), and justice (e.g., investigations and trials).
Form: Work-as-analysed is usually documented, typically as diagrams or tables, or both. The output is produced via a number of methods for activity, task and work analysis (e.g., hierarchical task analysis, link analysis, timeline analysis, cognitive task analysis [various methods]), job analysis (e.g., F-JAS, KSAO), systems analysis (e.g., influence diagrams, AcciMaps, FRAM). These vary in scope and resolution (micro, meso, macro; task, scenario, job, team, system). They also vary in their description or representation of goals, operations, sequence, timing, conditionality, and interactivity. Some industries, such as nuclear, rail, aviation, chemical manufacturing, rely heavy on work-as-analysed for a variety of purposes, especially related to safety and the design of training and artefacts, while others do not, often due to lack of understanding of the need, or a lack of capability.
Agency: Work is often analysed by specialists in professions or functions such as human factors/ergonomics, psychology, design, engineering, training and development, selection, safety, quality, and operational support roles (such as procedure writers).
Variety: Work-as-analysed is limited in its variety, with each task or job typically having one or a small number of representations (perhaps at different levels of granularity), if any at all. The same work, analysed by different analysts even using the same method, will however tend to result in different representations.
Stability: Representations of work-as-analysed may be updated periodically as required, though the effort required can be significant. However, it can quickly become out of date, even when it adequately reflects work-as-done at the time of analysis.
Fidelity: Work-as-analysed is meant to reflect and depict work-as-done. When there are significant gaps between the two, there can be consequences (for safety or usability, for example). However, it is difficult to describe work-as-done fully in the way that it really is done – even work that is well-understood. As with work-as-prescribed, it is just not possible to represent the precise way that much work is really done, except for observable aspects of very simple tasks. This is because of: a) the variable and dynamic nature of work-as-done (between different individuals and by the same individuals over time and in different situations); b) the interdependencies and conditions influencing work-as-done, including the interactions between people, contexts, and tools; c) the dynamic and covert nature of work-in-the-head (e.g., task switching, risk assessment, planning, judgement); d) limitations in terms of methods and the competencies required; e) the holistic nature of work-as-done, which often cannot be represented in a way that seems natural via analysis and synthesis. The atomistic nature of many forms of work-as-analysed loses the richness and subtlety of work-as-done, as well as much of the context. Meanwhile, in our attempts at synthesis (e.g., abstraction hierarchies, influence diagrams) we often “realise that everything connects to everything else” (as noted by Leonardo da Vinci), but representation results in a mass of indecipherable lines and arrows. This is often a sign of unfocused synthesis and is rarely helpful for practical purposes. So it is often impossible to describe work-as-done in a way that will align fully even with observable work, let alone individuals’ thinking and experience. Work-as-analysed – while valuable and even vital for certain purposes – can therefore seem artificial and contrived to those who do the work and have field expertise.
Completeness: Work-as-analysed may form a partial or complete description of overt activity, depending on the boundary of analysis, but at different levels of granularity. As noted above, not all aspects of work-as-done can be analysed and described, and so work-as-analysed will never be ‘complete’. Again, this especially applies to work-in-the-head. Using a variety of methods for work-as-analysed helps to provide different perspectives on the work, and thus forms a more complete representation.
Granularity: Work is analysed at different levels of granularity for different purposes and in different contexts. At a macro level of granularity, there may be systems analyses. At a meso level, there may be team or job analyses. At the micro level, there may be various forms of task, activity and error analyses. Depending on a range of factors (e.g., criticality to quality or safety) certain aspects of work-as-done will be described in greater resolution. In some cases, each task step may be analysed and described in detail, down to cognitive aspects and physical interactions (e.g., monitoring, scanning, detection, identification, recall, recognition, judgement, planning, decision making, physical actions, speech). In other cases, analysis will be at a higher level, focusing more on higher level functions and interactions. Often, the more granular the analysis, the less focus on interactions, since the analysis becomes too unwieldy.
Work-as-Analysed and Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
In any attempt to understand or intervene in the design and conduct of work, we can consider several kinds of ‘work’. We are not usually considering actual purposeful activity – work-as-done. Rather, we use ‘proxies’ for work-as-done as the basis for understanding and intervention. In this series of short posts, I outline briefly some of these proxies. (See here for a fuller introduction to the series.)
Proxies for Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
Work-as-disclosed is the work that people say that they (or others) do or did, either in formal accounts or informal accounts.
Function and Purpose: This is what we say and write about work, and how we talk and write about it. It may be simply how we explain the nitty-gritty or the detail of work, or give a particular view or impression of work (as it is or should be). It serves an intention and need to describe or explain work to others to influence any of the other proxies for work-as-done (e.g., others’ work-as-imagined, work-as-prescribed, work-as-analysed, or work-as-judged).
Form: Work-as-disclosed may be more formal or more informal, in written and verbal forms. It includes what is said or written, and what is not. More formal methods of disclosing aspects of work include interviews, workshops and focus groups, surveys, incident and accident reports, audits, inquiries, press releases, official statements, corporate communications, social media, etc. These may be for organisational, regulatory or scientific purposes. More informal methods include general conversations. Somewhere in-between are handovers, completed checklists and other methods of disclosure on the job. Work-as-disclosed may be in the context of work-as-done (e.g., demonstrating work to a new member of staff; think aloud technique) or remote from work-as-done (e.g., incident report; critical incident technique).
Agency: Work can be is disclosed by anyone, both those who do the work, and those who do not. Some work-as-disclosed is based on (or disclosed with) intimate knowledge of work-as-done and by those who do it. Other work is disclosed by people who know very little about it.
Variety: Work can be disclosed in a wide variety of ways even in the same form, such that the same work is described quite differently by the same or different people. This will depend on various aspects of the context (e.g., the parties to the disclosure, the purpose of the disclosure, the knowledge and recollection of work-as-done, the time and events since work-as-done, and the imagined consequences).
Stability: Work-as-disclosed may change significantly over time (for the same sorts of reasons as noted in ‘Variety’ above). For example, our work-as-imagined of our own work-as-done is a reconstruction, rather than a recording, and this reconstruction will change over time as we try to make sense of the work (or make it seem sensible). We forget details over time and also change what we say to suit particular purposes or respond to imagined consequences (see ‘Fidelity’ below).
Fidelity: The celebrated US Anthropologist Margaret Mead was credited with saying “What people say, what people do, and what they say they do are entirely different things” (there is no written evidence that she every did say this, but it is reflective of aspects of her work). Work-as-disclosed and work-as-done are not necessarily quite so detached, but work-as-disclosed differs in important ways (not just granularity) from work-as-done, and for many reasons.
What we do at work may be different to what we are prepared to say, especially to outsiders or ‘outgroup’ members. What a staff member says to a senior manager or auditor about work may be different to what really happens, for example. There are many reasons not to express how work is really done. But people will tend to modify or limit what they say about work-as-done based on imagined consequences. For instance, staff may fear that resources will be withdrawn, constraints may be put in place, sanctions may be enacted, or necessary margins or buffers will be dispensed. So secrecy around work-as-done may serve to protect one’s own or others’ interests.
This is especially evident when people have to disclose the circumstances of failures or non-compliance with work-as-prescribed. In an environment where there are sanctions for necessary trade-offs, workarounds, and compromises, work-as-disclosed may be more in alignment with work-as-prescribed than is really the case (for instance, in the context of some audits or investigations). This relates to the Tabooarchetype. In some cases, there may be specific activities that people don’t want to reveal relating to unethical behaviour. Such practices will tend to violate prevailing norms (social, procedural, legal, moral or ethical) or expectations, and disclosure would be detrimental to the continuation of the practice. In such cases, work-as-disclosed may reflect the P.R. and Subterfuge archetype. Work-as-done may be described deliberately to influence others’ (especially outgroup members’) work-as-imagined in particular ways. This may extend to large scale cover-ups.
In other cases, work-as-disclosed is more subtly designed to reassure, with goodwill and based on what one imagined is in the best interests of the other (a form of paternalism).
In still other cases, there may not no intentional deceit on behalf of the discloser, but what is disclosed may be fed by subterfuge by others (reflecting the Ignorance and Fantasyarchetype).
If there is a culture that is mutually experienced as fair and trusting, with acceptable levels of psychological safety, then there is a good chance that work-as-disclosed will be reflective of work-as-done. In such cases, the areas of lack of overlap may be limited to inconsequential minutia, or aspects of work that are not easily available to conscious inspection from the inside, bearing in mind that much human work is based on unspoken assumptions and norms, and activity that is not available to awareness.
Completeness: Work-as-disclosed, like work-as-prescribed, rarely forms a complete representation of anything other than very simple work-as-done. Typically, communication (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 for a particular purpose (why it is said/written), and, more or less deliberately, to what is thought to be palatable, expected and understandable to the audience. As noted above, it is often based on what people want and are prepared to say in light of what is expected and imagined consequences.
Granularity: Work is disclosed at many levels of granularity, depending on the purpose of the disclosure. A supervisor might explain to a newcomer ‘how things work around here’ (work-as-done), in a summary form. A surgeon and an anaesthetist/anaesthesiologist, may advise a patient about a surgical procedure at high level. A corporate communications specialist may explain to the news media or via social media the work of staff as a thumbnail synopsis. What is said will reflect what is done, but at a low resolution. In such cases, work-as-disclosed will involve simplifications. In other instances, work-as-disclosed may be at high resolution. An example is a train driver explaining his or her work to a human factors specialist/ergonomist who is undertaking some form of task analysis (for training needs analysis, interface design, or safety assessment). Here, the driver will be thinking about his or her work in detail, and explaining it in great detail.
Work-as-Disclosed and Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
In any attempt to understand or intervene in the design and conduct of work, we can consider several kinds of ‘work’. We are not usually considering actual purposeful activity – work-as-done. Rather, we use ‘proxies’ for work-as-done as the basis for understanding and intervention. In this series of short posts, I outline briefly some of these proxies. (See here for a fuller introduction to the series.)
Proxies for Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
Work-as-prescribed is the formalisation, specification and design of work. It is the work that people ‘should do’, especially according to policies, procedures, rules, and so on.
Function and Purpose: Work-as-prescribed is the formalisation, specification and design of work, based on any of the other proxies (usually a combination). Work-as-prescribed is intended to define and direct how work ought to be done to achieve its objectives, and often why it ought to be done this way. It has many related purposes concerning work and artefact design (e.g., task analysis, standardisation), competency (e.g., training, performance evaluation), safety and quality (e.g., assessment, investigation, audits), and justice (e.g., judicial proceedings).
Form: Work-as-prescribed takes a number of forms, including laws, regulations, rules, procedures, checklists, standards, job descriptions, management systems, user interfaces, as well as normative or prescriptive customs (‘the way we do things around here’). Some of these are more task-oriented (e.g., procedures, checklists) while others are more job-oriented (e.g., job descriptions, regulations). Work-as-prescribed can be embedded in traditional documents, or integrated into interface design, or simply accepted customs and practices.
Agency: Work is often prescribed by more senior members of an organisation (e.g., supervisors and middle managers), or by specialists (e.g., procedure writers), and external organisations, such as standards organisations, regulators (e.g., work time limits) and policy-makers (e.g., performance targets).
Variety: While there is an infinite variety of work-as-imagined, work-as-prescribed is limited in its variety, with each task having one or a small number of prescribed methods (though each job may have many, sometimes amounting to thousands of pages of detailed procedures).
Stability: Work-as-prescribed will tend to change slowly with updates and revisions to policies, procedures, standards, norms, and so on. In written form, it may persist even as the actual work or job in question no longer exists, or has changed substantially (defunct archetype).
Fidelity: Work-as-prescribed is unique in that it is assumed to be the correct (and therefore safe) way to work. As such, work-as-prescribed should form reasonably accurate descriptions of how work ought to be done. It should also reflect how work really is done, since there can be consequences (for safety and justice, for example) when there are significant gaps between the two. Work-as-prescribed is also an arbiter of whether performance is satisfactory. However, it is usually impossible to prescribe work-as-done fully in the way that it really is done – even work that is well-understood. Except for very simple tasks, it is just not possible to articulate – especially in a linear written form – the precise way that much work is done. This is because of the variable nature of work-as-done (between different individuals and by the same individuals over time and in different situations). This is especially true for work-in-the-head (task switching, risk assessment, judgement), which is covert, even if the resulting behaviours are observable. Work-as-done is also inextricably connected to people, contexts, and tools, and the combinations of these are more or less infinite, and so impossible to prescribe in a way that will fully align with reality.
Completeness: Work-as-prescribed may form a more-or-less complete prescription of overt activity, but at different levels of granularity. At a coarse level of granularity, there will be laws, regulations and policies that cover the work. Depending on a range of factors (e.g., criticality to quality or safety) certain aspects of work-as-done will be prescribed in greater resolution. As noted above, not all aspects of work-as-done can be prescribed, and so work-as-prescribed will never be complete. Again, this especially applies to work-in-the-head.
Granularity: Work is prescribed at different levels of granularity from course (e.g., laws, regulations, or general principles of work) to fine (e.g., detailed procedure steps, user interface dialogues). In some cases, there may be relatively little specification, so that work-as-prescribed leaves the details up to the workers. In other cases, each task step may be prescribed in detail – especially for more linear tasks such as can be found in manufacturing. No matter what the level of granularity, procedures, standards, regulations, etc., lack the detail, richness and subtlety of actual work, including the many interdependencies and conditions. The Catch-22 of work-as-prescribed is that the more specified the work is, the more incorrect is it likely to become in messy work situations where everything ‘depends’ (on the situation, primarily).
Work-as-Prescribed and Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
In any attempt to understand or intervene in the design and conduct of work, we can consider several kinds of ‘work’. In practically all attempts at understanding and intervention, however, we are not considering actual purposeful activity – work-as-done. Rather, we use proxies for work-as-done as the basis for understanding and intervention. There are several reasons for this. One is that work itself is so variable, in the short and long term. The same sort of work can often be done in many different ways, in terms of the actual activity performed and its sequence, timing, coordination, and so on. And the way that people work changes over time. Another reason is that much of what we consider ‘work’ is unknowable; it takes place in the head and is not available for observation or even introspection. Even when work is observable by others, or describable by those who do the work, what is observed or described is likely to be partial and even biased – deliberately or not.
In this series of short posts, I outline briefly some of these proxies. The proxies are not necessarily ‘new’ and some have been proposed before (e.g., in The Varieties of Human Work and elsewhere by others, in the same or different terms). Other terms could be used and other proxies may be proposed; they are just constructs to aid reflection and discussion. The proxies serve as a reminder that we don’t fully understand work-as-done, and probably never will. So it pays to accept uncertainty and to remain humble in our attempts at understanding and intervention. The proxies I will explore over the coming posts are as follows.
Proxies for Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
Work-as-imagined is, at a basic level, the work that we imagine takes place. Often, the term is used to describe imagination of the work that others do (now or in the past or future). It may also, however, refer to the work that we imagine that we do (or did, or will do).
Function and Purpose: Work-as-imagined is a basis for all understanding and intervention. It is a basis for work-as-done, and for all of the other proxies for work-as-done, and is influenced by these proxies. It is neither inherently positive (e.g., idealised) nor negative (e.g., demonised). It simply reflects the tendency, capacity or need to use imagination, often for a particular purpose. That purpose may be any aspect of understanding (e.g., safety investigation, research, job assessment) or intervention (e.g., work design, incentivisation, reward, punishment).
Form: Work-as-imagined, as I use the term here, is in the head, and so comprises propositions, images, mental models, and so on. (Others sometimes use the term to reflect any of the other proxies, since it is the basis for them.)
Agency: Work-as-imagined is in the heads of everyone. Everyone has an imagination about their own work, and of the work of many others. Just as a senior manager imagines the work of an operator, an operator imagines the work of a senior manager. Each will have different purposes for their imaginations, if only to try to make sense of another’s decisions and actions.
Variety: Work-as-imagined is potentially infinite in its variety, since everyone’s imagination of work (e.g., the work of an anaesthetist, firefighter, air traffic controller, cleaner, or CEO) will differ depending on their experience.
Stability: Work-as-imagined may change greatly or little over time, largely depending on thoughts and feedback about work-as-done via other proxies.
Fidelity: The correspondence between work-as-imagined and work-as-done will be highly variable. It might seem reasonable to suggest that the closer one is to work-as-done, the closer the correspondence, and vice versa. Broadly speaking, this is probably true, but we may also be surprised at how little we know about how we work, how others experience how we work, and how others work differently (in the head, if not in the world; for instance others’ evaluations of risk), and biased (reflecting the partiality, purpose and attitude of the imaginer, and so on)
Completeness: Work-as-imagined will be more or less partial (reflecting only part of the work, or work performed by certain people, for example).
Granularity: Work-as-imagined may be highly detailed, especially for those who do the work and those who study it in depth. Alternatively, it may be very coarse – just general impressions – especially for those who have no contact with work-as-done. High granularity is no guarantee of fidelity, since one could be wrong in essentially all the details, but right in terms of a general impression.
Work-as-Imagined and Work-as-Done | Steven Shorrock | CC BY-NC-ND 4.0
Many ideas spring up in the world of management and organisational behaviour aimed at ‘treating people better’ – humanely. Very few of these, if any, are really new. Mostly, they stem from basic human values, which might be called humanistic values. Even humanistic values – embodied in the ‘third force’ of psychology known as humanistic psychology – are not new. They can be found in philosophy and religion, in The Golden Rule, for example – the principle of treating others as you want to be treated.
Humanistic psychology is best known for its influence on counselling, psychotherapy and personal development, through early theorists and practitioners such as Abraham Maslow, Carl Rogers, Rollo May and Fritz Perls. But it has also influenced management and organisational theory and practice. Maslow and Rogers were particularly influential early figures. Humanistic psychology in organisations was meant to be underpinned by deep reflection, discussion and personal growth. Instead, it often underwent a bureaucratising and ‘tooling’ process – an efficiency-thoroughness trade-off (and more lately, in a reversal of Maslow’s holism, a reductive obsession with neuroscience).
But as reported by Montuori and Purser (2015), both Maslow and Rogers were concerned with unintended consequences and the trivialisation of humanistic psychology. An example can be found in the concept and practice of ‘active listening’, described by Carl Rogers and Richard Farson (1957).
In the field of organizational development, the literature has shifted toward more utilitarian tools and techniques… (p. 724)
Although Rogers intended active listening to be a transformative vehicle for moving toward greater democracy, participation, and actualization, in actual practice active listening was reduced to yet another management “tool” in the service of maintaining and upholding existing power relations and bureaucratic organizational structures. (p. 727)
Montuori and Purser (2015)
Another more famous example, described by Bridgman, Cummings, and Ballard (2018), can be found in Maslow’s ‘hierarchy of needs’, which was never depicted as a triangle or pyramid by Maslow. Instead, it was depicted by Keith Davis (1957) as a series of steps in ‘Human Relations in Business’, and later as a triangle by Charles McDermid (1960) in his article, ‘How Money Motivates Men’. As Brigman et al explained, “McDermid (1960: 98) advised managers to use Maslow’ s theory of motivation, which ‘can be arranged’ as a pyramid (p. 94) to evaluate the needs of their employees and adjust compensation packages accordingly.” (p. 87).
So, ‘humanistic’ became ‘pseudohumanistic’, then ‘bureauhumanistic’. Ways of thinking underwent a tooling process that often stripped their original depth and meanings. Instead of simultaneously disrupting organisational power structures, adaptations of humanistic psychology were sometimes used actively to reinforce them. This has been a concern of mine while teaching ‘systems thinking’. A rush to acquire and use ‘tools’ can subvert the underlying thinking, which is far more important. Any tool can be used violently.
More recent humanistic concepts relating to organisational functioning include ‘just culture’ and ‘psychological safety’. Neither is a new idea. The ideas of justice and fairness are probably as old as the idea of safety. Even the newer, more humanistic variation of ‘restorative just culture’ is a simple reframing of restorative justice.
The term ‘psychological safety’ is older than many would realise. While recently popularised by Amy Edmonson (2018) in The Fearless Organisation, psychological safety is rooted in family theory and many approaches to counselling and psychotherapy, as well as management. In an organisational context, it appears that the term was coined – albeit in passing – in 1965 by Edgar Schein and Warren Bennis, who mentioned a “culture” and “climate” of psychological safety in their book Personal and Organizational Change. It was later defined as “the ability to show and employ one’s self without fear of negative consequences of self-image, status or career” by Kahn (1990, p. 708).
What is new is the labels. The combination of ‘just’ and ‘culture’, and ‘psychological’ and ‘safety’ makes something (that seems) new, even if it is really just a popularisation of older ideas to a new context or audience, with a different slant, perhaps. And that’s fine. Whole books have since been written about such ideas. This is a good thing. It is necessary to shine a light on values and ideas that are expressions of humanistic values, or even The Golden Rule. Sometimes we forget or neglect the basics of human decency, or goal conflicts mean that we trade aspects of them off against other values.
We sometimes even need to add bureaucratic and technocratic machinations to such concepts. For instance, organisations have adopted just culture decision aids and committees, reflecting a sort of judicial code and jury. This seems to be needed to assist the integrity of deliberations. I’m not completely comfortable with some technocratic developments, but equally my own preference for humanistic approaches involving depth of understanding and empathic discussion is subject to other human tendencies that can act against fairness. Such approaches also carry a heavy burden of personal, group and organisational development, that few organisations appear willing to invest in to the extent necessary for genuine change.
We also know that several dysfunctional aspects of organisations and professions work against depth of reflection, empathy and discussion. Organisational contexts and structures can be hostile to humanistic values and principles. The ‘bureaumorphising’ effects of organisational culture, along with phenomena such as déformation professionnelle and trained incapacity, mean that our organisational and professional upbringing can have a dysfunctional effect on ways of being, as human beings.
And so there is a tension between humanistic ways of thinking and being, and bureaucratised, manualised and commodified tools. There is no perfect way to integrate certain aspects of human decency into an organisational setting since there will always be competing goals and different perspectives on issues. And some individuals and groups with significant power will work against these values.
But we now see humanistic concepts like ‘psychological safety’ transformed into trade-marks, tools, competency levels, certification schemes, belts, and the like. These sometimes look like crass attempts to commodify and commercialise human decency. My heart sinks a little when I see some of these. Who do they benefit? The curricularisation, certification, and call-off contract support for trademarked versions of human decency create revenue streams and external dependency, but do they create care?
We might draw from experience of practices such as ‘active listening’, when structural and cultural issues were not addressed in tandem, or as a prerequisite:
Even many well-meaning efforts to apply active listening were often ineffective when they occurred within an inhospitable organizational context and in conjunction with inconsistent norms and organizational structures that were antithetical to the idea of developing greater individual creativity and responsibility. It should come as no surprise why so many humanistic organizational development initiatives at the microlevel were doomed to failure from the start. … Transformational theories and concepts become trivialized when they are reduced to being merely tools, techniques, or rhetorical slogans, especially when they are used unreflectively within organizational settings.
We might draw further from the writings of those who have described the disabling effects of professionalism in communities, such as Ivan Illich, John McKnight, and Cormac Russell. As McKnight (1995) wrote in The Careless Society:
“Care cannot be produced, provided, managed, organized, administered, or commodified. Care is the only thing the system cannot produce. Every institutional effort to replace the real thing is a counterfeit.”
McKnight (1995)
So we should recognise that institutional efforts to produce, provide, manage, organise, administer, or commodify basic human decency come at great risk. At best, they may help to administer a process of attending to people’s needs. At worst, they are counterfeits that masquerade as the real thing, while ultimately subverting it.
That doesn’t mean that efforts should not be made, and processes put in place, to try to uphold humanistic values and human decency in organisations. But we should do so reflexively and mindfully via humble inquiry into the nature of our problems and opportunities, incorporating contextual conversations about human work and organisations as systems. Reading, reflection and discussion are necessary to help bring to light neglected aspects of human decency. But humanistic values cannot fully be manualised and implemented as a project, only lived and expressed with authenticity and meaning as a way of being.
Afterword
I chose the word ‘decency’ for this post deliberately. I wanted a word that was less obvious, less (over-)used and less limited than ‘care’, less soft than ‘kindness’, and with a nod to dignity, thoughtfulness, fairness, honesty and honour. I was also looking for something more old-fashioned, somehow preceding many of the modern iterations of the sorts of ideas I was referring to. When I was younger, people would say “that’s very decent of you”, meaning “you did the right thing by me/them”.
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.
“Why not the psychology of human high performance?”
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.
