The seven archetypes are:
- The Messy Reality
- Taboo (this archetype)
- Ignorance and Fantasy
- P.R. and Subterfuge
Each archetype includes a number of examples (currently healthcare-related). If you have further examples – from any industry – please provide an example as a comment or get in touch. More examples will be added over time.
Archetype 3: Taboo
Composition: work-as-done but not as-disclosed, nor usually as-prescribed, nor usually as-imagined.
Short description: This is activity that people don’t want to talk about outside of one or more groups. It is often not in accordance with official policy, procedures, etc, or there is no relevant policy, procedures, or if it is described in procedures, others would find the activity unacceptable. As such, the activity is often not widely known outside of specific groups. The main defining feature is that it is not openly discussed.
What is it?
The Taboo archetype represents activity governed by social norms, but which is kept hidden, deliberately not disclosed outside of a defined group, usually for reasons associated with fear. The activity is often informal and not prescribed, but in some cases some prescription may exist but not be widely known. The activity will usually not be known outside of specific groups, though there may well be suspicion among others outside of these groups, though even this is still not widely disclosed. The distinguishing feature of Taboo is that disclosure of the activity is deliberately restricted, more so than will usually be the case with The Messy Reality, which is quite ordinary.
Those familiar with archetype are those who do the work, and those who sanction the practices (explicitly or implicitly), but it may concern work in any part of an organisation, from front-line to senior management. The Taboo archetype may exist in partnership with P.R. and Subterfuge, which may be used to throw out-group members off the scent of Taboo.
Why does it exist?
At the heart of Taboo is one or more conflicts between goals, needs, or values, concerning, cost, financial gain, efficiency, productivity, capacity, safety, security, satisfaction, comfort, sustainability, power, etc., and associated trade-offs and dilemmas. These conflicts may exist within and between groups.
The practices (work-as-done) that are pertinent to Taboo will usually be contrary to a prevailing norm (social, procedural, legal, moral or ethical) or expectation, such that if the activity were widely known, action may be taken that would be detrimental to the continuation of the activity. Hence, disclosure could be damaging to the goals, needs or values of the in-group.
Taboo may simply concern basic human needs, such as the need for rest or sleep, which are not catered for in the design or prescription of work. It is not unusual for sleep to be forbidden on nightshifts, and yet arrangements are made among staff to ensure that they get some sleep. In some cases, the practices might involve personal gain (e.g., remuneration, time off, power or prestige), perhaps associated with practices that might be seen as unfair or unethical, or that might trigger outrage if aired more widely. Taboo may also concern group-level needs (e.g., the need for survival or influence of an occupation). Often, the reasons for Taboo appear personal but are actually systemic, for instance involving perverse incentives, inadequate organisational processes, poor resources and conditions, inappropriate constraints, and goal conflicts. For instance, unhealthy and unsafe levels of overtime may offer financial benefits to individuals (pay) and organisations (fewer staff required), and thus may be form part of a Taboo archetype for both staff and management.
In many instances, there will be an efficiency-thoroughness trade-off (i.e., an emphasis on efficiency over thoroughness) or an acute-chronic trade-off in operation. Increases in demand and pressure, in an environment of inadequate resources, will tend to result in an emphasis on efficiency and short term goals, which will tend to breed practices which cannot be widely disclosed.
The Taboo archetype can, however, in conjunction with P.R. and Subterfuge offer groups protection from unhelpful or detrimental outside influence based on Ignorance and Fantasy of complex issues associated with work-as-done (e.g., safety margins or buffers, the need for resources). This is a complex issue that is difficult to understand without knowledge of the work.
What people can and can’t do and talk about openly sheds light on the shared assumptions, beliefs and values that underlie a group’s culture. Unsustainable, unethical or unacceptably risky practices can remain hidden, leading to ever wider gaps between work-as-imagined and work-as-done and potentially a drift into failure. Those who break the taboo (often referred to as ‘whistleblowers’) and disclose work-as-done may be outcast, from the group, organisation or profession.
The case of Dr Raj Mattu provides an example of Taboo. He was suspended by University Hospitals Coventry and Warwickshire NHS Trust in February 2002 on allegations of bullying, 5 months after he spoke to the BBC about the death of a patient in an over-crowded bay at Walsgrave Hospital, Coventry. A 5th bed was put into 4 bedded bay (so called ‘5 in 4’) in order that the hospital could never be deemed full. I worked as a Neurology SpR at the Walsgrave between January-December 2000 and it was the most stressful period of my career. I too was appalled at the policy of putting a 5th bed into 4 bedded bay (so called ‘5 in 4’) in order that the hospital could never be deemed full. Dr Mattu has faced years of mistreatment and ‘detriment’, and the effective end of his career at a cost for legal expenses alone of around £6 million. His successful employment tribunal was one of the most expensive in NHS history. However the most disturbing aspect of the Mattu case is that those responsible for the ‘5 in 4’ policy have faced no serious public scrutiny. How can we have any confidence that staff concerns such as Dr Mattu’s will be dealt with any differently the next time? The treatment of whistleblowers in the NHS is a reflection of the Taboo archetype: how whistleblowers are treated is often not openly discussed, nor prescribed, and hard to imagine.” (Based on a letter to The BMJ: http://www.bmj.com/content/348/bmj.g2881/rapid-responses.)
Dr David Nicholl, Consultant Neurologist, @djnicholl
When preparing intravenous injections for a patient, guidelines (e.g., NMC medicines management guidelines) and procedures require that the injection must be prepared immediately before it is due to be given, and not prepared in advance of this time. However, under current service pressures, including staff shortages and high acuity, doses may be prepared in advance to save time, or if prepared on time and then for some reason not given, may be stored to one side for later use, instead of being disposed of and re-made at a later time.
Although most people would like to believe that admission to critical care does not depend on the bed status of the unit, this is not the case. If there are many critical care beds available, patients are likely to be admitted who would not be admitted if there was only one bed available.
Taboo describes the attitude of some healthcare workers to uniform policies. For example hospitals have a “bare below the elbow” uniform policy, where people can only wear a plain wedding band on the hands and forearms. Some people choose to ignore this and wear a watch, or a stoned ring. In theatre, this is most often ignored when people wear theatre gowns, as it is often cold in theatre, and no alternative is provided.
Nursing staff on night shifts take turns to have a 2-hour sleep if it is quiet. If it is busy then obviously it is all hands to the pump. This is not described in any job description but is tacitly known about and approved to ensure functioning if required.
With acute prescribing in GP practices, some medicines are kept separate from the repeat prescribing – generally quantities no longer than a month’s supply – with the general idea that these are meds that require a regular review by the GP to determine appropriateness of ongoing supply. Often, these are dealt with as “special requests”; the scripts are not run off by the admin staff with the regular repeat meds, but are passed to the GP (or they are run off by the admin staff but stored separately for the GP to review). The idea is that these meds have greater scrutiny and are not supplied in larger quantities, so there is a sort of a safety net around them becoming inappropriate long term medicines. The reality is these are often not given the greater scrutiny as intended and we see months of antidepressants and analgesics (to name a couple of drugs) issued every month with no proper patient review.