The Archetypes of Human Work: 7. Defunct

This is the seventh and last in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence
  3. Taboo
  4. Ignorance and Fantasy
  5. Projection
  6. P.R. and Subterfuge
  7. Defunct (this Archetype)

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 7: Defunct

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Archetype 7: Defunct

Composition: work-as-prescribed but not as-done. May or may not be as-imagined or as-disclosed.

Short description: Some forms of prescribed work are not enacted, or else drift into disuse, but are still officially in place. Some will imagine that these are in place, while others know or think they are not. However, the existence of the Defunct work may be used to judge actual activity.

What is it? 

Much human work exists in prescribed form, such as regulations, management systems, policies, procedures, guidelines, checklists, good practice, user interface dialogues, etc. Sometimes, this work-as-prescribed does not reflect the reality of work-as-done, which might be characterised as The Messy Reality. The prescribed work still exists, but in a form which is Defunct. Sometimes, this is just a temporary matter, where work-as-prescribed for some reason does not apply. Other times, work-as-prescribed may be permanently Defunct. Work-as-prescribed may even seem quite irrelevant; few would even think about it or discuss it, let alone follow it, especially at the front line of work, or even throughout an organisation or industry sector.

Why does it exist? 

It is often the case that Defunct designed work has been prescribed without adequate attention to the the design process, often an efficiency-thoroughness trade-off at the blunt end. A thorough approach to design (of interfaces, procedures, checklists, etc) would require that: 1) the stakeholders (especially the users), system, activities and context are understood; 2) stakeholder needs are investigated and design requirements specified; 3) prototypes are developed; and then 4) prototypes are tested. The testing would reveal any flaws in the implementation of this process, and thus there would be iterative loops back to each stage. If the prototype (e.g., checklist) meets the users’ and other stakeholders’ needs, then we have a final step: 5) implementation. The whole process would be planned with appropriate resources allocated (expertise, time, etc). This is a thorough approach, known as human-centred design (or ergonomics).

The ‘efficient’ approach, which is more common, is to go straight to step 5 (implementation), perhaps with some perfunctory consideration of step 1. Commercial-off-the-shelf/pre-designed systems and artefacts are often purchased, which is understandable and often completely necessary. The problem is, neither the developer nor the purchaser may have completed the previous 4 steps. Even if the developer has used some kind of human-centred design process, the new context and stakeholders (and therefore the stakeholders’ and users’ needs and design requirements) may well be very different. Since there is no testing, feedback is gathered in real operations, by which time it is too late. Local adaptation of the artifact (e.g., checklist, user interface dialogue) to the users’ needs may be impossible, prohibitively expensive or impractical.

People at the sharp end are now faced with a Catch-22. Either they comply with work-as-prescribed (Congruence) or they find another unprescribed solution (The Messy Reality) and the work-as-prescribed is Defunct. In either case, work-as-done may have unintended and unforeseen consequences.

Even with human-centred design, work-as-prescribed may fall into disuse. Such cases are often a mystery to those at the blunt end and even many at the sharp end. This tends to happen when the work-as-prescribed is not understood, either the details or the purpose. In such cases, continuous monitoring and discussion of work-as-done is likely to be helpful, with appropriate adjustment and education where necessary.

There may also be cases where work-as-prescribed is simply not annulled or abolished when it should be. Many organisations and governments have numerious policies, procedures, regulations, laws and so on that remain officially in place, but that no-one imagines are in use. (British law is replete with such laws. For instance, Section 54 of the Metropolitan Police Act 1839 makes it an offence to carry a plank of wood on a pavement.)

Shadow side

Many of the problems associated with the Defunct archetype concern the nature of work-as-done and work-as-imagined, and so are associated with other archetypes, especially The Messy Reality and Ignorance and Fantasy.

In some cases, work-as-prescribed is Defunct only in particular circumstances. This was the case with the QF32 engine failure. The Airbus A380 ECAM checklists could not be followed as prescribed. In such cases, the people in control are deep into The Messy Reality and have to use their judgement and experience to find alternative solutions to the problems that they face. If appropriate training is not provided to help deal with such exceptional events, then the assumption that work-as-prescribed is universally safe becomes a particular liability.

In other cases, work-as-prescribed is more or less permanently Defunct. This presents some different problems, again mostly associated with other archetypes. A particular problem concerns the consequences of not working to rule. Gaps between work-as-prescribed and work-as-done may be the basis for disciplinary and regulatory/legal action against individuals and organisations. In some cases, such action may be unfair and vindictive, for instance when Defunct rules are used for used as a tool for workplace bullying.

Finally, an obvious problem with this archetype is that the Defunct work might actually represent good practice with benefits for safety, health, or other goals. In this case we need to try to understand why the work-as-prescribed failed to make it over the line of reality.

Examples (Healthcare)


Of the 2184 policies, procedures and guidelines (PPGs) in my organisation, 28% are currently out of date and may therefore not reflect current practice. More interesting still, are the nearly 19% of PPGs that have been opened less than 5 times in total, including by their authors. These documents are often written to meet the requirements of external agencies with the idea that not having a policy leaves the organisation vulnerable to criticism. These documents remain unopened, unused and unrelated to daily work but may be used after incidents as a form of organisational protection: “yes, we had a policy for that”.

Carl Horsley, Intensivist, @horsleycarl


In operating theatres that use lasers, certain precautions, rules and safety precautions have to be in place. Part of this is to have a risk assessment and standard written laser protection policy. This risk assessment is normally carried out by a laser protection supervisor from a distant site who has no knowledge of local practice. In addition this tends to be written when a new laser is purchased and then is never updated. While work-as-imagined would be following the policy to the letter, if the policy is impractical for the local use of the laser, the local team will tend to develop workarounds (The Messy Reality). When there is a site visit by the laser protection supervisor however, work-as-disclosed will follow work-as-imagined – as they are reassured that everyone follows all the rules to the letter (P.R. and Subterfuge). If a laser protection incident does however occur, the local team would all be held to account by the Defunct laser protection rules.

Craig McIlhenny, Consultant Urological Surgeon, @CMcIlhenny


When the surgical team book a patient for theatre, they are supposed to discuss this with the anaesthetic team, to explain the indication for surgery, the degree of urgency and any medical conditions the patient has. The anaesthetic team should therefore be a central point who are aware of all the patients waiting for theatre to help with appropriate prioritisation. In reality this only happens if they happen to see an anaesthetist when they book the case. More often than not, cases are “booked” with no discussion with the anaesthetist and often the cases are not ready for theatre (may need scans first for example) or may not even need an operation. This only becomes obvious when the anaesthetist goes to review the patient, or perhaps even later. Despite many organisations having guidelines about this, it still seems to happen.

Emma Plunkett, Anaesthetist, @emmaplunkett


 

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The Archetypes of Human Work: 6. P.R. and Subterfuge

This is the sixth in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence
  3. Taboo
  4. Ignorance and Fantasy
  5. Projection
  6. P.R. and Subterfuge (this Archetype)
  7. Defunct

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 6: P.R. and Subterfuge

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Archetype 6: P.R. and Subterfuge

Composition: work-as-disclosed and often as-prescribed, but not as-done. May or may not be as-imagined by the discloser. 

Short description: This is what people say happens or has happened, when this does not reflect the reality of what happens or happened. What is disclosed will often relate to what ‘should’ happen according to policies, procedures, standards, guidelines, or expected norms, or else will shift blame for problems elsewhere. What is disclosed may be based on deliberate deceit (by commission or omission), or on Ignorance and Fantasy, or something in between… The focus of P.R. and Subterfuge is therefore on disclosure, to influence what others think.

What is it?

Work-as-disclosed is what people say (in verbal or written form) about work-as-done by themselves or others, and is the dominant variety of human work in the P.R. and Subterfuge archetype. ‘P.R.’, in this context, could stand for ‘Public Relations’ or ‘Press Release’, which focus on disclosure but not necessarily reality. P.R. could also mean ‘Pre-Reality’ (disclosing that something is real before it really is real) or ‘Post-Reality’ (where “words don’t matter nearly as much as the intent, the emotion, the subtext…”, Seth’s Blog). It might also be seen as what is now called ‘alternative facts’ and fake news. P.R. and Subterfuge is commonly associated with politicians, spin doctors, lawyers, lobbyists, reporters, public relations specialists, sales people, and advertisers, but will be familiar to most, to some degree.

P.R. and Subterfuge tends to concern what in-group members say about work-as-done to out-group members. It is especially evident when people have to disclose the circumstances of failures or compliance with regulations, management systems, policies, procedures, guidelines, checklists, good practice, etc. to internal specialists (e.g., auditors, investigators, competency assessors, doctors, HR, senior managers) or outside agencies, organisations or individuals (e.g., regulators, supervisory bodies, professional associations, judiciary, journalists, citizens, interfacing organisations). It includes what is said or written, and what is not, in audits, investigations, inquiries, press releases, interviews, freedom of information requests, corporate communications, social media, etc.

P.R. and Subterfuge may involve varying levels of deception. Generally, where the consequences of disclosure are pertinent, unless the other party is trusted, people will tend to describe the work that they do in a way that accords with work-as-prescribed or (what is thought to be) work-as-imagined by other party. In some cases, the difference between work-as-disclosed and work-as-done with P.R. and Subterfuge is very much deliberate, from minor omission to large scale cover-ups. In such cases, a partner archetype will often to be found in Taboo; the aspects of work-as-done that cannot be discussed openly will be omitted from P.R. and Subterfuge. In other cases, there may not no intentional deceit on behalf of the discloser, but what is disclosed may be fed by subterfuge by others.

Why does it exist?

There is often a need to describe or explain performance, both internally within organisations and outside of organisations. What is said (work-as-disclosed) will clearly influence the work-as-imagined of these others, and this is the primary purpose of P.R. and Subterfuge. Because work-as-disclosed does not align with work-as-done, P.R. and Subterfuge will tend to feed the archetype Ignorance and Fantasy in others, inadvertently or deliberately.

The reasons for P.R. and Subterfuge are varied but many of these can be grouped into two major categories: ignorance and fear. Often, those who are distant from work-as-done talk about it based on Ignorance and Fantasy. Such individuals are reliant on their work-as-imagined, knowledge of work-as-prescribed, and work-as-disclosed by others. For instance, a corporate communications specialist, press officer, or a senior manager, will tend to know little about the specifics of how front-line workers actually work, and will rely on others for this information.

P.R. and Subterfuge can also be motivated by fear of possible consequences should the reality of work-as-done be revealed. These consequences for individuals and organisations may relate to legal action, bad publicity, journalistic inquiry, regulatory investigation or sanctions, fines, cut backs to funding or resources (e.g., staff, training), loss of reputation or status (individual or organisational), loss of profession, operating/professional licence or livelihood, and in extreme cases, loss of liberty. The perceived risk of such consequences will tend to shape what is disclosed, what is not, and what else is said.

It may seem like P.R. and Subterfuge is the product of dishonest organisations and individuals, but a number of systemic features of organisations and industries can  cultivate the archetype. Examples include aspects of regulatory practice, management control measures, procedural constraints, measures, information flows, performance targets, incentive systems, punishments, and goals (especially goal conflicts). In the face of conditions or interventions that get in the way of the work (and potentially make it unsafe or otherwise ineffective), individuals and groups may justify P.R. and Subterfuge via a perceived higher purpose or goal. An illusion of Congruence may be created for out-groups, perhaps in response to the Defunct archetype, or to try to see off damaging interventions based on a superficial and inaccurate perception of work-as-done, such as cutbacks to resources (e.g., cutbacks to staff based on observation of a quiet period) or inappropriate constraints (e.g., procedural diktats based on one incident). P.R. and Subterfuge may therefore offer perceived benefits by protecting people from unwanted and potentially damaging outside influence or intervention which does not recognise the reality of work.

Shadow side

P.R. and Subterfuge, especially in its more deceptive form, involves a variety of ethical problems and dilemmas. More generally, it increases further the distance between work-as-imagined and work-as-done. Work-as-prescribed may become increasingly detached from reality, perhaps Defunct, thus invalidating many organisational and regulatory control measures, which are tied to  work-as-prescribed. Work-as-done (and associated risks) remains unknown to most stakeholder groups. This creates problems of safety, accountability and liability.

In many industries, organisations have been known to cover up work-as-done (especially The Messy Reality) when things have gone wrong (see this reported decades-long cover-up by Dupont, which has long promoted itself as a “world class safety leader”). In explaining failure, the activity of an organisation may be Taboo, and what is disclosed may differ markedly from what is found by an independent inquiry. In 2016, four Dupont workers died in a toxic gas leak four workers died in a toxic gas leak (see here). The U.S. Chemical Safety Board inspectors said the reasons for the accident related to the corporate safety culture nationwide, citing design flaws in DuPont’s complex pesticide production unit, inadequate gas detectors, outdated alarms and broken ventilation fans. DuPont, the company originating from the founder of the ‘zero injury’ philosophy (chemist and industrialist Éleuthère Irénée du Pont de Nemours, 1771-1834), attributed the cause of the disaster to actions by rank-and-file employees. The tendency of organisations to point the finger at sharp end workers is an example of P.R. and Subterfuge which perpetuates P.R. and Subterfuge among rank-and-file employees, in order to protect themselves from blame; a spiral of subterfuge.

Examples (Healthcare)


Commissioners often use CQUINs (Commissioning for Quality and Innovation payments framework) to drive innovation and quality improvement in the NHS. In theory, the metrics relating to individual CQUINs are agreed between commisioners and clinicians. In practice, some CQUINs focus on meaningless metrics. A hypothetical example: a CQUIN target for treating all patients with a certain diagnosis within an hour of diagnosis is flawed due to a failure of existing coding systems to identify relevant patients. Clinicians inform the commissioners of this major limitation and offer suggested improvements to the metrics. These suggested improvements are not deemed appropriate by the commissioning team because they deviate significantly from previously agreed definitions for the CQUIN. The clinicians are demotivated by the process of collecting meaningless data and are tempted to use gaming solutions to report best performance. This situation is exacerbated by pressure from the management team within the NHS Trust who recognise that failure to demonstrate adherence to the CQUIN key performance indicators is associated with a financial penalty. The management team listen to the clinicians and understand that the data collection is clinically meaningless, but insist that the clinical team collect the data anyway. The motivational driver to improve performance has moved from a desire to improve clinical outcomes to a desire to reduce financial penalties. The additional burden is carried by the clinical team who are expected to collect meaningless data without any additional administrative or job plan support. 

Anonymous, NHS paediatrician


It is one thing when you find out that your local hospital has suffered serious failures of care resulting in numerous preventable deaths, it is another when you find that hospital is involved, if not in blatant cover-up, in obscuring the extent of the problems. But when you find the organisations responsible for regulating hospitals have not only failed to maintain standards but are complicit in their own cover-ups then you can begin to despair whether you will ever get to the bottom of just how and why these tragedies occurred. [Extract from Joshua’s Story, by James Titcombe – used with permission.]

James Titcombe, Father of Joshua Titcombe, who died nine days after his birth at Furness General Hospital in Barrow in October 2008, @JamesTitcombe.


Healthcare staff often have to complete mandatory online modules, e.g. in fire safety, manual handling, blood transfusion. The modules have a pass rate (e.g. 80%) and sometimes a maximum number of attempts before the healthcare worker is locked out and has to discuss their poor performance with their line manager. Healthcare workers may then sit down in groups to share the correct answers and therefore pass the module.

Anonymous


The use of checklists for the prevention of Central Line Associated Bacteraemia (CLAB) is well described and has been taken up widely in the healthcare system. The purported benefits of the checklist include ensuring all steps are followed as well as opening up communication between team members. After introducing the CLAB bundle into our Intensive Care Unit, we saw very high levels of reported checklist compliance followed by the expected drop in our rates of infection, confirming the previously reported benefits. However, when we observed our staff it became apparent that they were actually filling in the checklist retrospectively without watching the procedure, as they were busy with other tasks.The fall in the CLAB rate could therefore not have been due to the use of a checklist and instead appears to be due to the use of “CLAB packs”. These put all required items for central line insertion into a single pack thereby making it easier for staff to perform the procedure correctly.

Carl Horsley, Intensivist, @horsleycarl.


 

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The Archetypes of Human Work: 5. Projection

This is the fifth in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence
  3. Taboo
  4. Ignorance and Fantasy
  5. Projection  (this Archetype)
  6. P.R. and Subterfuge
  7. Defunct

Each archetype includes a number of examples (currently clinical). 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 5: Projection

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Archetype 5: Projection

Composition: work-as-imagined, often as-prescribed and perhaps as-disclosed. May or may not be as-done.

Short description: We are prone to imagine that things will work according to a plan, and prone to wishful thinking, ignoring the potential for problems. The focus of Projection is the imagination of the future, as we think it will be, or would like it to be.

What is it?

When we need to design or plan human work, we project our imagination into the future. Informally, we plan our or others’ work, at some level, over the coming minutes, hours, days, months or years. Projection may involve planning a task about to be performed, via  mental preparation, or the use of specific tools. Or it might involve planning a new system to be implemented some time in the future. This formal Projection might involve new or major changes to major infrastructure or facilities (such as hospitals, airports or railways), changes to equipment, changes to staffing and competency, changes to artefacts of management (such as performance targets or league tables) or changes to procedures. For changes to the design of work, there will be some kind of prescription of how we think things should happen, and this may be communicated to others, in designs, plans, procedures, etc. We might also try to project what we don’t want to happen, perhaps via hazard identification or risk assessment.

Why does it exist?

Projection serves our need to reduce fear and uncertainty about the future, and have some confidence that our future needs will be met.

Shadow side

In our attempts to bring future work-as-done into the present, Projection will often be far from the mark, and will usually be inaccurate in some way or other. Even when you are familiar with work-as-done now, Projection of future work-as-done, and related resources (including time), can be very unreliable. We tend to overestimate the degree to which future work-as-done will follow our designs and plans (due to overconfidence, lack of imagination, wishful thinking, variability in demand and resources, etc.). We also tend not to foresee unwanted side-effects or long-term consequences of our designs and plans. Even small changes can have disproportionately large effects/

It is difficult to project with accuracy even seemingly straightforward activities, but as work becomes more complex, emergence becomes the thorn in the side of Projection. We try to overcome this with the application of formal methods, but most of these involve decomposing future tasks and related systems into parts, considering these parts, and using these parts to project performance. Because of interactions between activities and the environment, adaptation, and the effects of multiple changes over time, future work-as-done cannot always be projected in this way, and so is often not as expected. The mismatch between what we expect and what happens will tend to increase with complexity.

At the blunt end, those involved in the design of future work may engage in Projection on a basis of Ignorance and Fantasy, especially if they are distanced from The Messy Reality of work-as-done even today. Close proximity to work-as-done is no guarantee of success in predicting the future, but increasing distance – which is common – stretches the feedback loop back to imagination and design.

As work-as-done comes into fruition, other archetypes emerge. The Messy Reality will tend to rise to the surface, of course alternating with Congruence, and instances of Taboo may also emerge as certain aspects of work – at the blunt end or sharp end – cannot be discussed openly, perhaps replaced with P.R. and Subterfuge. Unwanted effects are covered up by day-to-day adaptations at the sharp end, perpetuating Ignorance and Fantasy at the blunt end. The Defunct archetype will also tend to unfold over time, as policies, procedures and plans remain docked in the work-as-imagined of days gone by…

Examples (Healthcare)


The computerised estimation of the time it will take to perform a case in theatre can be an example of Projection. Theatre scheduling uses the average time that similar cases have taken in the past to predict how long a case will take in the future. Individual patient, surgical and anaesthetic factors are not considered. Sometimes this is accurate, but other times it is not. It is therefore a crude system, although it is the best that we have at present. The problem comes when staff feel they have failed when cases take longer than the projection and theatre over runs. This is inevitable given the nature of the system.

Emma Plunkett, Anaesthetist, @emmaplunkett.


Installation of computerised medical systems can display this trait. For instance with the installation of a fully computerised system for ordering all sorts of tests (radiology requests, lab requests, etc.) work-as-imagined (and -as prescribed) was that this would make work more efficient and safer, with less chance of results going missing or being delayed. Prior to the installation there was much chat  (work-as-disclosed) with widespread talk of how effective and efficient this would be. After installation it became apparent that the system did not fulfill the design brief and while it could order tests it could not collate and distribute the results. So work-as-done then reverted back to the system that was in place before where secretaries still had to print results on bits of paper and hand them to consultants to action.

Craig McIlhenny, Consultant Urological Surgeon, @CMcIlhenny.


There are a lot of discussions about how electronic solutions will solve all the problems! Medicines reconciliation still remains a challenge, on admission and discharge, and there is great faith put into how electronic solutions will solve these. They are seen as reducing risks but often just introduce other different risks. Fundamentally we still need competent practitioners to be able to use good clinical judgement and clear decision making for them to be effective.

Anonymous, Pharmacist.


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The Archetypes of Human Work: 4. Ignorance and Fantasy

This is the fourth in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence
  3. Taboo
  4. Ignorance and Fantasy (this Archetype)
  5. Projection
  6. P.R. and Subterfuge
  7. Defunct

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 4. Ignorance and Fantasy

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Composition: work-as-imagined, often as-prescribed but not as-done (may or may not be as-disclosed).

Short description: This is what people don’t know about real work and what they imagine happens. The imagination relate to official policy, procedure, standards, guidelines, etc that people assume are in force, or there may just be a general impression of how things work and should work. The primary focus of Ignorance and Fantasy is the imagination of those removed from the actual work.

What is it?

The Ignorance and Fantasy archetype concerns work-as-imagined, usually in the minds of those who are more distant from the work, who often lack knowledge about how things work, perhaps imagining that work is a reflection of what is actually prescribed. Ignorance and Fantasy may be harmless, but if it is disclosed inappropriately in verbal or written form (e.g., to those who can invalidate it or hold people to account for it), or if it is the basis of decisions about the actual work (e.g., demand, resources, constraints), then it may be harmful. As it applies to current work, Ignorance and Fantasy will tend to apply more to some policy makers, journalists, senior managers, other  professions (who do not do the work), and the public. Ignorance and Fantasy may occasionally apply to those who actually do the work, when those people have an imagination about how they work (or would have worked) which is not how it is really done – a fantasy. We may genuinely think and declare that we do work one way but actually do it another way. Ignorance and Fantasy inhabits a different zone to The Messy Reality, and if the two ever come into contact there can be surprise, bewilderment, even outrage…and more mess.

Why does it exist?

Most of those who exhibit the Ignorance and Fantasy archetype are far removed from work-as-done and those who do the work, or lack understanding of it, or both. Lack of knowledge and understanding is therefore a primary reason for the existence of archetype. A group who knows little about the real work may reinforce shared beliefs about the work: false consensus.

There may be several perceived benefits to Ignorance and Fantasy. A false narrative about the work may reduce the perceived need to really understand The Messy Reality, which is often difficult to understand. It can also reduce uncertainty, confusion and anxiety about how we think others work. There can be significant cost savings, because Ignorance and Fantasy can negate the perceived need to spend resources to properly understand or improve work-as-done (including the system conditions under which work is done). For journalists and the public, Ignorance and Fantasy offers an easy to understand narrative which helps to reduce uncertainty and gives a simple explanation for events that mask context, complexity and causation (e.g., ‘human error‘ or hero/villain narrative).

Shadow side

As mentioned above, Ignorance and Fantasy can be harmless. Most people do not need to know much, or even anything at all, about various types of work-as-done. We may not, however, want to know about the details of work-as-done (when we really ought to know) in light of the consequences of this knowledge for us. As said by Iris Murdoch (Irish-British novelist and philosopher): “We live in a fantasy world. A world of illusion. The great task is to find reality. But given the state of the world, is it wise?”.

But Ignorance and Fantasy, whether through simple lack of knowledge or not wanting to know, can also be extremely harmful, and lead to problematic decisions, or inaction. At a management or regulatory level, this may concern, for instance, staffing, training, and equipment, and constraints such as rules and regulations or goals such as performance targets. There can be problems of risk control, accountability and liability. Various means of organisational monitoring, assessment and control – including risk assessments and resulting risk controls – may be relied up yet rendered impotent, essentially Defunct. At a journalistic level, Ignorance and Fantasy may feed simplistic or inaccurate narratives. Among citizens it may affect purchasing and shareholding/service user decisions and other civic participation

Examples (Healthcare)


The WHO Surgical Safety checklist was introduced into the National Health Service following the release of Patient Safety Alert Release 0861 from the National Patient Safety Agency on 29 January 2009. Organisations were expected to implement the recommendations by February 2010 including that ‘the checklist is completed for every patient undergoing a surgical procedure (including local anaesthesia)’. All organisations have implemented this Patient Safety Alert and the WHO Surgical Safety checklist is an integral part of the process for every patient undergoing a surgical procedure. Whilst the checklist appears to be used in every patient, there is clear evidence that there is variability in how the checklist is used both within an organisation and between organisations. Within an organisation, this variability can occur between teams with differences in the assumed value of using the checklist  and within a team between individuals or professional groups. Its value can degrade to a token compliance process to ‘tick the box’. The assumption within an organisation at ‘the blunt end’ is that it is done on every patient.

Alastair Williamson, Consultant Anaesthetist, @TIVA_doc


Senior management often believe that all healthcare staff have received basic or intermediate life support training, as these staff work in the acute setting and would, of course, have received this training. In reality, life support competence is merely recommended and not mandated by bodies such as the Resuscitation Council (UK). This means that competence in life support is dependent on the number of resuscitation officers, whether staff have been released from work to go to training, etc.

Anonymous, Anaesthetist.


I think the simplest example of this is hand hygiene. Work-as-imagined (and indeed as prescribed) in this situation is that all healthcare staff follow the WHO Five Moments for hand hygiene. Multiple audits do of course reveal that our compliance (work-as-done) with hand hygiene is abysmal (especially amongst medical staff) with compliance rates of around 30%. Work-as-disclosed in regards to hand hygiene depends on who is asking – but again generally does not reflect work-as-done. Our patients however are mostly ignorant of our very poor levels of compliance in this regard.

Craig McIlhenny, Consultant Urological Surgeon, @CMcIlhenny


In 2005 my wife was admitted to hospital for a routine elective procedure. It took just over 20 minutes for people and a system that didn’t do human factors to leave my wife brain dead. It would be another 13 days before she really was dead. As clinicians the world over have reviewed my late wife’s case, in a quiet break room perhaps, they have all, with very few exceptions stated clearly: “I wouldn’t have done what they did”. Yet place those same people in a simulated scenario with the same real world disorder, which deteriorates into the same challenging moment, most actually do. This gap illustrates the difference between human performance as imagined and human performance in the real world. (Adapted from the Foreword of Human Factors and Ergonomics in Practice [CRC Press].)

Martin Bromiley OBE, Pilot and Chair of Clinical Human Factors Group, @MartinBromiley


There are high levels of burnout. A target-driven culture is exacerbating this problem. A typical example was when the government seemingly became convinced by poor quality data which suggested that dementia was under diagnosed So it decided to offer GPs £55 per new diagnosis of dementia. Targets were set for screening to take place – despite the UK National Screening Committee having said for years that screening for dementia was ineffective, causing misdiagnosis. And when better data on how many people had dementia was published – which revised the figures down – it was clear that the targets GPs were told to meet were highly error-prone. The cash carrot was accompanied with beating stick, with the results – naming and shaming supposedly poorly diagnosing practices – published online. Setting doctors harmful tasks, leading them almost to “process” patients, fails to respect patient or professional dignity, let alone the principle of “do no harm”. [Extract from article The answer to the NHS crisis is treating its staff better, New Statesman]

Margaret McCartney, General Practitioner, @mgtmccartney


This archetype is at the heart of the clinician-manager divide to the extent that it exists. (I understand that many clinicians get on well with many managers. And many wear both hats.) Senior managers (blunt end) may be ignorant of what clinicians (sharp end) do. They may have a fantastical view informed by preconceptions, unconscious bias, the views of intermediaries etc. The genesis of such a view may be consciously or unconsciously purposeful. Humankind cannot bear too much reality. It would be unfair not to say that in another sense clinicians (blunt end) may be just as ignorant of what senior managers do at their own equally sharp end. In the interest of the primary objective of the activities of both groups, high quality, safe patient care, a sympathetic mutual understanding is essential. No to ignorance. No to fantasy.

On the cusp of a major hospital change programme in 2009 I found myself at the centre of a situation that in the interest of patients required total cooperation between clinicians and managers. Unfortunately the way it was handled resulted in all out conflict.

On the one hand we had the board represented by the CEO. On the other the consultant body led by me. I had until recently been clinical director and understood the department, its workings and its history better than anyone. In between the two we had the three service managers, a midwife, an obstetrician and a recently arrived non-clinician who had not managed a clinical department before.

The CEO introduced a major  change programme under the slogan “More for Less”. After this there was no direct contact with the consultants. The managers were her main conduit for the top down communication. The consultants were unable to stand fully together to either co-operate with positive changes or challenge initiatives which would jeopardise care. You may sense Reason’s cheese slices sliding into position here.

A RCPCH review later criticised senior management for the failed change programme being all about cuts and not service improvement, and for naively thinking that the soon to be commissioned PFI hospital would resolve deep relational issues (people are more important than buildings!). The middle managers were criticised for their aggressive managerial style. All nursing staff for example were put on notice of possible redundancy in a circular, without any face-to-face meeting. The wiser ones quickly jumped ship to adjacent Trusts. Two managers were accused of bullying by nursing staff, shouting, swearing, threatening job security etc. The consultants were unable to speak with a common voice. On the whole the clinicians had only one real interest – seeing patients. With the odd exception they were very good at that.

At this time I had become familiar with the ideas of Gerry Robinson, a management “guru” who had achieved a certain media profile. One of his central ideas on NHS management was expressed thus:

“I understand how this culture of multiple managers develops. I think Chief Executives get to a point where it is easier to manage other managers than it is to deal with medical and nursing staff, especially consultants, who can be resistant to being told what to do by those with no medical background. Instead, Chief Executives surround themselves with a safe set of managers who tell them what they want to hear, and perhaps they look to hire more – for business development or finance or new initiatives. Increasingly, the man or woman at the top of the tree is distanced from the reality of leading doctors, nurses and other staff, and delivering care to patients.”

I still believe there is a lot of truth in this. It is an arrangement that strengthens hierarchy and pits different groups against each other. (The remedy is fairly obvious by the way.) In our case we became locked in a triangle of mistrust. To different extents we all became the prisoners of our own fantastical views of each other with little or no desire to understand the other’s perspective. This fed the conditions that militate against co-operative working for high quality and safe patient care.

Older and wiser now I have at least come to understand in terms of organisational psychology why many of the actors in this tragedy behaved as they did. Where understanding falls short of a full explanation only agnosticism serves any purpose. A benevolent agnosticism.

I have one piece of evidence for the ignorant and fantastical view the CEO developed of me. The denouement was my own dismissal for, amongst other things, insubordination. Any CEO who views a senior consultant who has led his department for many years as a subordinate (as in some kind of military hierarchy) can only do so out of ignorance. It is essential that clinical/managerial teams are coalitions of equals who come to understand and respect each other. Only insecure leadership could believe otherwise.

In fairness to anyone I have criticised here there is nothing personal intended. In any case although I have put a fresh gloss on this the story has now been in the public domain for some years without those individuals making public comment.

David Drew, Consultant Paediatrician in a former life, @NHSwhistleblowr


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The Archetypes of Human Work: 3. Taboo


This is the third in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence
  3. Taboo (this archetype)
  4. Ignorance and Fantasy
  5. Projection
  6. P.R. and Subterfuge
  7. Defunct

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

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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.

Shadow side

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.

Examples (Healthcare)


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.

Anonymous, Pharmacist.


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.

Anonymous, Anaesthetist.


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.

Anonymous.


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.

Anonymous. 


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.

Anonymous, Pharmacist.


Posted in Culture, Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , , , | 6 Comments

The Archetypes of Human Work: 2. Congruence

This is the second in a series of posts on The Archetypes of Human Work, which are based on the interactions or relationships between The Varieties of Human Work. For an introduction, see here.

The seven archetypes are:

  1. The Messy Reality
  2. Congruence (this Archetype)
  3. Taboo
  4. Ignorance and Fantasy
  5. Projection
  6. P.R. and Subterfuge
  7. Defunct

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 2: Congruence

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Archetype 2: Congruence

Composition: work-as-done and as-prescribed and usually as-imagined (and often as-disclosed).

Short description: Much human work is done ‘by the book’ – at least in general terms if not the fine detail – and is done much in line with how people who are more removed from the actual work imagine. Such work is often even disclosed, since there is no reason not to. However, prescribed work can have unintended consequences. These, of course, were not imagined, at least by those who designed the work.  

What is it?

Congruence comprises activity that largely conforms with prescribed work, and is known to other relevant stakeholders. Congruence might apply to specific activities and where prescription is limited to general goals or principles, essentially giving discretionary space to practitioners. In such cases, work can be said to align with these principles, even though there may be variation in how these are achieved or adhered to. Since work-as-done accords fairly well with procedures and is known to others, it may well be discussed both inside and outside the practitioner group; there is no reason not to, and no reason for P.R. and Subterfuge. Work-as-done in these cases is therefore more or less known and understood further from the sharp end, though this is unlikely to extend far. Congruence will normally reflect quite specific activities, but may resemble much of the work in some environments, e.g., call centres. Much work is likely to shift frequently between Congruence and The Messy Reality.

Why does it exist?

Some work, usually specific activities, can be prescribed such that work-as-done is an accurate reflection of work-as-prescribed. This applies especially where work has a defined process (e.g., simple sequences, loops, or conditional structures [if then <action/s>), where the pre-conditions and conditions of work are more or less known, exceptions are well understood, and variation in system conditions and human performance is restricted and known to relevant stakeholders. In such cases, prescription might be simple or complicated, in the form of procedures, checklists, or forcing functions built into interface dialogues, requiring varying degrees of competence.

In some cases, Congruence may reflect well-designed work, inasmuch as the imagination of how it will and should be done matches how it is and should be done in order to optimise system performance and human well-being. There is typically a high level of field expert involvement in the design of this kind of work (including resources and constraints), for instance via a human-centred design processes. In other cases, how work is done informs how work is prescribed and imagined, i.e., procedures are written to reflect the real work. Here it may be the case that there is a low authority gradient or power-distance, and management is well connected to the front-line work.

A technological forcing function (also known as a poka-yoke), such as a hard interlock on a chemical processing plant or a required field on a web form, may ensure that work is done in the way that it is prescribed, with no or few opportunities for variation. This is likely to reflect specific activities rather than the general work. In other cases, organisational monitoring and control systems (e.g., audits, competency checks, behaviour-based safety), and associated sanctions, may ensure that work is done in the way that it is prescribed. In such cases, the way that people talk about the work is also likely to conform with how it is done at that time, leaving those further removed from the sharp end with a perception of Congruence, which may be persist only for a time…

Shadow side

Work-as-prescribed may be badly designed, such that it is inefficient or even hazardous, e.g., conflicting air traffic control arrival and departure routes designed by someone with no experience of working the airspace. In such cases, work may be done in the way that it is supposed to be done, and this may be known, but the hazards may not be known, especially beyond the front-line. In some such cases, prescribed work may not account for exceptional ‘black swan’ events that are beyond the imagination of those who prescribed the work. An example of this is the checklists in QF32 (2010). In this case, multiple aircraft system failures resulted in dozens of electronic centralised aircraft monitor (ECAM) alerts, which could not be processed by the crew in the prescribed way, forcing them deep into The Messy Reality, which was never imagined (i.e., never projected). In this case, and in the better known Hudson River landing (2009), the crew had very high levels of competence. In other cases, lack of competence or experience may leave practitioners unaware of how to anticipate, detect, and handle such trip hazards. On a social level, group processes may be at play. Prescribed work may be hazardous, inefficient or otherwise ineffective, but people may become desensitised to this by the need for group cohesion and harmony, fear of speaking up or rocking the boat, or may have attempted before, but given up.

Where work-as-done is monitored and controlled, especially where work is not well designed, and in a climate of low trust, Congruence may emerge only temporarily. Typically, this cannot be sustained for long due to the variable and degraded nature of real (as opposed to imagined) system conditions (goals, demands, pressure, resources, constraints, incentives, punishments, climate, etc.), which force a return to the The Messy Reality when monitoring and control allows. Those observing work-as-done, however, may leave with the impression that Congruence is the norm.

Examples (Healthcare)


Congruence can happen in the medical workplace, but is usually not the norm. An example would be the use of debriefing after a day’s operating list. A debrief should take place at the end of every team’s operating list, and has been mandated in Scotland for a number of years. In my operating theatre we do have a debrief at the end of every list. Work is therefore ‘congruent’ – our work-as-done is identical to work-as-prescribed (mandated by the Scottish patient safety programme) and we perform a robust, checklist-prompted debrief looking at both task and team performance, so our work-as-done is also congruent with work-as-imagined (in some teams a very superficial debrief occurs – so work-as-done technically is congruent with work-as-prescribed; a debrief does take place – but is certainly far removed from work-as-imagined). As a result we also have a positive attitude to work-as-disclosed – as we are very happy to talk about implementing a process that we feel quite proud of. We are however, a positive outlier in this respect – and finding Congruence in this domain is the exception rather than the norm.

Craig McIlhenny, Consultant Urological Surgeon, @CMcIlhenny.


One of the priority areas for the Scottish Patient Safety Programme in Primary Care (SPSP-PC) was the accurate reconciliation of changes to patients’ medication regime following discharge from hospital. The use of a care bundle audit was promoted to measure compliance with a number of process measures, including completing the reconciliation within a set time frame and discussing significant changes with patients or carers. This has many potential benefits especially as patients are vulnerable to medication-related harm (due to inappropriately prescribed or omitted medication) after discharge. In my practice, systems were altered to ensure compliance with the bundle audit and 100% compliance was quickly achieved. This may seem like success but a few problems arose. Staff prioritised contacting patients to discuss medication changes whereas previously they knew which patients were confused about their medication and would contact the pharmacy (rather than the patient) to make sure changes were implemented. This resulted in delay in implementing changes, increased confusion for patients and more work for staff. Secondly, the information in the immediate discharge letter (IDL) is often inaccurate. With the focus on accurate reconciliation, any discrepancy between the immediate discharge letter (IDL) and the patient’s pre-hospital medication list had to be resolved. This meant changing the patient’s usual medication list if the information on the IDL seemed reasonable. However, if there was no obvious justification for discrepancies, clarification would be sought from secondary care. This would delay the process of completing medicines reconciliation and increase work for staff in both primary and secondary care. Previously GPs would often make changes to the patient’s usual medication list based on their knowledge of the patient, their condition and the information from secondary care.

Duncan McNab, GP, @Duncansmcnab.


A Do Not Attempt Resuscitation (DNAR) form is put into place when caregivers feel that resuscitation from cardiac arrest would not be in the patient’s best interests. These forms have received a significant amount of bad press, primarily because caregivers were not informing the patient and/or their families that these were being placed. Another problem with DNAR forms is that some clinicians feel that they are being treated as “Do Not Treat” orders, leading (they feel) to patients with DNAR forms in place receiving sub-standard care. This means that some patients who would not benefit from resuscitation are not receiving DNAR forms. As a result when these patients have a cardiac arrest they are subjected to aggressive, yet ultimately futile, resuscitation measures which may include multiple broken ribs, needle punctures in the arms, wrists and groin, and electric shocks. It is not unusual to hope that these patients are not receiving enough oxygen to their brains to be aware during these last moments of their lives.

Anonymous, Anaesthetist.


Most hospital pharmacy departments in the UK now use dispensing robots for a large chunk of their medication dispensing. Robotic dispensing reduces the risk of picking errors (manually picking the wrong item from the shelf), as well as theoretically speeding up the dispensing process. Though the overall process may vary depending on whether other systems are electronic or manual (e.g. paper prescription charts or an electronic prescribing system), the work-as-imagined/as-prescribed is along the lines of: operator enters prescription details into pharmacy computer system, indicating the required item; computer system communicates with robot; robot picks correct item from shelf and outputs it to the operator for labelling and checks. For much of the time this process accurately reflects the work-as-done (by human and robot), and the process works very well. However, there are occasions when things can go wrong. An example: a request is received for an antibiotic injection (clindamycin); it is showing up as out of stock on the pharmacy stock control system, but the robot inventory indicates the item is there. In order to supply the item, the operator uses the stock control system to create a label for the clindamycin injection (which is still as-prescribed), and then walks round to the back of the robot to perform a manual output of the item. However, they may manually output a different antibiotic injection (clarithromycin) inadvertently, and dispense this in error, with the clindamycin label. The automated robotic picking system has been bypassed, removing that safety net.

Anonymous, Pharmacist.

Pharmacists and technicians provide support to care homes to carry out medication reviews and support repeat ordering. One piece of documentation we use to support this is the Medicines Administration Record (MAR). These are generated by the community pharmacy, which supplies the medication. This in itself is not deemed a care home confidential document until such a time as the care home starts to use them to note administration of medications. At this point, access to it by anyone but care home staff requires consent. We do obtain patient/welfare/proxy consent to undertake our work, but technically, as the MAR sheets are issued monthly and can be different on a monthly basis, we should be getting monthly consent. This would make it unworkable and unmanageable.

Anonymous, Pharmacist.

As I walked into the six bedded bay the patient in the first bed on the right was in distress and breathing heavily. He looked very frail. I was on my ward round with a long list of patients to see with our team of doctors. We went to the middle bed on the right, drew the curtains around and attended to our patient. During the consultation there was a commotion from the next bed and a Cardiac Arrest call was put out. The patient was put on the floor, chest compressions and ventilation started (Cadio-pulmonary resuscitation, CPR) whilst we waited for the Resuscitation Trolley to arrive along with the full Cardiac Arrest team. The nurse read out the patient’s notes and we immediately stopped the CPR attempt, and the patient was pronounced dead. The patient had been in frail health with advanced chronic obstructive pulmonary disease (COPD), heart failure, kidney impairment and had been chair bound at home. Overnight the admitting Doctor had written “Discuss DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) with the Consultant in the morning”. Instead of dying with symptoms of breathlessness controlled by morphine and oxygen and having a Health Care Assistant sit with him as be died, he was left with distressing breathlessness. Then we did chest compressions and ventilation as he died. We did not get as far as using the defibrillator. I am sure that the chest compressions would have been forceful enough to break some ribs. In this scenario it is possible that the patient had some consciousness, and that his last memories would have been fear and pain. The other patients in the bay were, of course, terrified by these events and no one in the healthcare team felt good about the turn of events. Looking back I feel guilty that I did not turn to that patient, and take steps to ensure he had a calmer end of life. 

What is sad is that this is not an unusual story. Unless a person dying in Hospital or a Nursing Home has a DNACPR then CPR will be usually be done. CPR may even be done when a person in frail health dies at home without a DNACPR, because the paramedics may be instructed to do CPR ”Just in case it was a cardio-pulmonary arrest”. Nurses and paramedics work in such fear of not doing CPR when there is no DNACPR that they may override their own professional judgement and do CPR when it is clearly inappropriate. Recently a nurse was reprimanded by the Nursing and Midwifery Council for not trying CPR on a nursing home resident who, in my opinion, was clearly already dead. I know of a case in our Hospital in which CPR was started on a person whose body was already in rigor mortis.  

How did we get to this point in the United Kingdom that to ensure a person experiences a calm end of life, a DNACPR form must have been completed, and be available in a prominent place? Unless the DNACPR is readily available to the compassionate nurse, instead of comforting the dying person with her presence, her touch, words of kindness and symptoms relieving medicine, instead she must start basic life support and call for a Cardiac Arrest Team?   

Dr Gordon Caldwell, Consultant Physician, @doctorcaldwell

Posted in Human Factors/Ergonomics, Humanistic Psychology, Safety, systems thinking | Tagged , , , , , , , | 6 Comments

The Archetypes of Human Work: 1. The Messy Reality

In my last post, I outlined some thoughts on four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. As with most things, what is most interesting about these varieties concerns their relationships and interactions. Considering the various zones of the figure below – where the varieties overlap or don’t overlap – it is possible to recognise a number of archetypes, patterns or forms concerning the relationship between the varieties of human work, which will be familiar to many once seen.

In this post, I outline seven such ‘archetypes of human work’. This is not to say these are the only archetypes, and the archetypes do not necessarily characterise the zones that they inhabit. But they have shown themselves repeatedly in my experience of research and practice in organisations, and may well be recognisable to you. To sensecheck and exemplify the archetypes, a number of healthcare clinicians have kindly provided examples. These clinicians have helped to refine the archetypes themselves. 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.

The seven archetypes that will be outlined are:

  1. The Messy Reality (this Archetype)
  2. Congruence
  3. Taboo
  4. Ignorance and Fantasy
  5. Projection
  6. P.R. and Subterfuge
  7. Defunct

These archetypes will be outlined in this and subsequent posts.

Archetype 1: The Messy Reality

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Archetype 1: The Messy Reality

Composition: work-as-done but not as-prescribed and usually not as-imagined (may or may not be as-disclosed).

Short description: Much work-as-done is not as prescribed (either different to procedures, guidelines, etc, or where there are no procedures), and is usually not known to others who are not at the sharp end of the work. The focus of The Messy Reality is the actual work and the messy details.

What is it?

The Messy Reality is characterised by the kinds of adjustments, adaptations, variations, trade-offs, compromises, and workarounds that are hard to prescribe and hard to see from afar, but can become accepted and unremarkable from the inside. Mostly, such variability is deliberate, but sometimes is unintended. As such, this archetype will be familiar to almost everyone.

The work-as-done that is characteristic of this archetype may or may not be disclosed by those who do the work. It is not necessarily secret (as is more characteristic of Taboo). The key point is more that work-as-done is not as prescribed, and probably not as-imagined or known by others. This archetype is common and applies to much specialist activity in most sectors, e.g., healthcare, banking, WebOps, shipping, and agriculture.

Why does it exist?

The archetype exists for a few reasons, associated with the nature of work-as-prescribed, work-as-done and work-as-imagined. Much work-as-done is not prescribed to any significant degree, especially where the work is so simple that it does not need to be prescribed, or so complex that it cannot be prescribed, even if attempts are or were once made. It is not necessary, possible nor desirable to prescribe all human work. Even if some major steps in a process are prescribed, much of the underlying or related activity is not. It can’t be.

This archetype provides important discretionary space in which practitioners can operate, since the various adjustments, adaptations, trade-offs, compromises, and workarounds that characterise work-as-done are necessary to meet demand under (often normal) system conditions involving degraded resources, inappropriate constraints, perverse incentives, goal conflicts, and production pressure. More generally work evolves over time, and prescribed work proves too inflexible or too fragile to cope with real conditions. Over the longer term, these adaptations may result in a drift from prescribed policy, procedure, standards or guidelines, assuming any such prescription is in place.

This archetype is reinforced by a lack of contact between those who do the work, and those who design, make decisions about, or influence the work (e.g., senior managers, purchasers, HR, regulators and policy makers), who may operate in the Ignorance and Fantasy archetype. Much work-as-done is taken for granted, neither observed nor discussed meaningfully outside of the immediate working environment, and so the messy details remain known only to those who do the actual work. The Messy Reality is therefore ignored or denied (perhaps glossed over with P.R. and Subterfuge). Even where there is an imagination of work-as-done (and associated system conditions), decision makers may turn a blind eye or encourage The Messy Reality, either because stuff gets done or because the costs of fixing sources of mess are seen as too great.

Shadow side

Work-as-done but not as-imagined by others is mostly unproblematic. The Messy Reality does provide important discretionary space for practitioners to meet demand. But The Messy Reality masks a multitude of degraded system conditions involving demand, pressure, capacity, staffing, competence, equipment, procedures, supplies, time, etc. To create flow, more adjustments, adaptations, trade-offs, compromises, and workarounds are required. Performance variability (short term fluctuations or longer term biases and trends), while necessary, may become problematic.

An underlying problem with The Messy Reality is its coexistence with the archetype Ignorance and Fantasy. When work-as-done is not understood by decision makers, problems and drift toward danger may well be invisible, both to the worker in-group (e.g., due to habituation) and to various out-groups (due to ignorance). For some time, a drift into failure may be invisible – masked by inadequate measurement, safety margins, or deliberate P.R. and Subterfuge, but practitioners will tend to feel – as a minimum – uncomfortable. Their concerns may be initially disclosed (formally via reporting systems or letters, or informally), but this disclosure is often discontinued if no timely and appropriate action is taken in response. This decline in disclosure convinces those at the blunt end that the problem no longer exists or was never really a problem, thus feeding the Ignorance and Fantasy archetype and associated blunt-end decisions that create systems of problems – messes.

When things go wrong in The Messy Reality, outcomes are often attributed to the choices that practitioners make, especially when these are different to the work-as-prescribed. Often, such attributions take insufficient account of context, and instead take the form of simplistic labels (‘violation’, ‘non-compliance’, ‘rule breaking’, etc), while choices made at the blunt-end of design, management, and regulation, which may influence, shape or encourage such sharp-end decisions, are rarely labeled the same. This dynamic exists even in the absence of detailed prescription of work. For instance, if an organisation does not have a policy on a potentially problematic issue, such as the use of mobile devices in environments such as air traffic control, then practitioners could be blamed for their choices in case of an incident or accident, even when practices are known or imagined. Ultimately, The Messy Reality, can become a liability in terms of regulation and law, both to the organisation and to individual practitioners.

Examples (Healthcare)


Certain clinical situations are volatile, uncertain, complex, ambiguous (VUCA) and time critical and they can highlight different aspects of ‘The Messy Reality’.  For example, a patient with a ruptured abdominal aortic aneurysm, if they reach hospital alive, will require immediate transfer to theatre for the life threatening bleeding to be stopped and a new vessel to be grafted into place.  The complex and dynamic nature of the case deems that it cannot be prescribed and so the practitioner has to operate within the discretionary space. This allows the practitioner the necessary freedom to treat the changes as they arise and potentially to deviate from ‘standard operating procedures’ (SOPs). These SOPs are ordinarily designed for non-emergency work and have a number of ‘safety steps’ inherent within them. There are important steps such as identifying the patient, procedure and allergies and form part of the wider WHO ‘five steps to safety’ but also other points less critical but important, especially in the non-emergency setting. It is commonplace for the practitioner to deviate from the SOPs and to perform an ad-hoc, yet necessary, streamlining of this process in order to proceed at the appropriate pace and to treat physiological changes as they present themselves.  This can give rise to a number of issues. Firstly, I have known this deviation to create friction amongst the team at this critical time that is generally not helpful in both proceeding with the work and maintaining team harmony. Secondly, if the outcome for the patient is poor and the case is investigated, I have known for practitioners to be admonished for their deviation from the SOPs, although they nominally relate to the non-emergency setting. This is in stark contrast to if there is a good patient outcome as the deviation is often not even noted, or highlighted as potentially being intrinsic to the positive outcome. Lastly there is often a corporate response that seeks to prescribe the work that is by definition VUCA and cannot be prescribed. Ultimately, I believe that on balance practitioners benefit from The Messy Reality as it is when the work is at its most complicated and cannot be prescribed that autonomy and professional judgment can be exercised most readily for the benefit of the patient. 

Dr Alistair Hellewell, Anaesthetist, @AlHellewell


The ‘normalised’ unsafe practice of hyperventilation during cardiac arrest management provides a comprehensive example of The Messy Reality archetype. It has become evident, from analysing retrospective observational data, that during the procedure of cardiopulmonary resuscitation (CPR), medical practitioners (usually anaesthetists) almost always deliver too much pressurised oxygen/air to the lungs of patients (both adults and children). Traditional Safety-I concepts may regard this as a ‘violation’, in that that this practice continues to occur despite a succession of recommendations in international guidelines to the contrary, supported by the established and widespread provision of systematic, organised education and training. However, when directly questioned, anaesthetists demonstrate a clear, functional knowledge that such practice is detrimental to patient outcome. When contemplating this behaviour we must consider the following. Firstly, there is no intention for airway management practitioners to deliberately hyperventilate a patient. Secondly, these clinicians do not know that they are hyperventilating patients during the period that it is actually happening. Thirdly, there is not ordinarily any recognition or acknowledgement that they may have hyperventilated the patient after the clinical intervention has been discontinued. Despite the fact that this issue is widely known to anaesthetists, others (particularly at the blunt end) would generally be ignorant of the issue. 

Ken Spearpoint, Emeritus Consultant Nurse, @k_g_spearpoint


Radiology request forms are meant to be completed and signed by the person requesting the procedure. In the operating theatre, the surgeon is usually scrubbed and sterile, therefore the anaesthetist often fills out and signs the form despite this being “against the rules”. Managers in radiology refused to believe that the radiographers carrying out the procedures in theatre were “allowing” this deviation from the rules.

Anonymous.


The use of clinical early warning scores is well established in secondary care. More recently, the use of the National Early Warning Score in primary care has been promoted as a way to aid the identification and appropriate management of sepsis. A score is calculated based on the value of each of the following physiological parameters: temperature, pulse rate, blood pressure, oxygen saturations, respiratory rate and level of consciousness. When interviewed, most general practitioners (GPs) stated that, although they do not calculate the overall NEWS score, they always record the relevant observations when they are concerned about sepsis. On analysis of referral letters of adults admitted with an infective cause from out-of-hours primary care to secondary care, all physiological parameters necessary for the NEWS score were recorded in 50% of patients but when the admission diagnosis was given as sepsis or possible sepsis, the values were only complete in 30% of cases. When this is explored with GPs using specific cases it becomes clear that often the decision for rapid admission is made on temperature, pulse and often the ‘look’ of the patient. Rather than measuring other parameters (such as respiratory rate) the GP decides to start arranging admission as further evidence is not needed to guide their next action. This is a more efficient if less thorough approach. (Early findings of work – unpublished at present.)

Duncan McNab, General Practitioner, @Duncansmcnab.


Hospital policy is that free samples of drugs may not be accepted from pharmaceutical companies, and that all supplies of drugs should be ordered and received via the pharmacy department. However, drug company representatives have been known to bypass this by directly offering/sending free drug samples directly to consultants.

Anonymous, Pharmacist.


Pharmacists and technicians provide support to care homes to carry out medication reviews and support repeat ordering. One piece of documentation we use to support this is the Medicines Administration Record (MAR). These are generated by the community pharmacy, which supplies the medication. This in itself is not deemed a care home confidential document until such a time as the care home starts to use them to note administration of medications. At this point, access to it by anyone but care home staff requires consent. We do obtain patient/welfare/proxy consent to undertake our work, but technically, as the MAR sheets are issued monthly and can be different on a monthly basis, we should be getting monthly consent. This would make it unworkable and unmanageable.

Anonymous, Pharmacist.


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