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Work as imagined versus work as done

In human factors there is a set of terminology that is used to describe our work. The terms used are work-as-imagined, work-as-done, work-as-prescribed and work-as-disclosed.

Work-as-done is the work that takes place every day.  What we actually do.

Work-as-imagined is the work people think we should be doing or imagine we are doing.

Work-as-prescribed is the work as set out in rules, policies, procedures, standards and guidelines.

Work-as-disclosed is the way people work if they are prepared to share, if they feel safe to share with you what they actually do.

To improve safety and apply safety-II [insert link to safety-II section in toolkit] what we need to do in healthcare is take a close look at the work as it and in all the different situations.  Not the work that people think should be done, not the work that people will tell you about, but the actual way in which people work. 

In any normal day – a work-as-done day - people:

  • Adapt and adjust to actually demand and change their performance accordingly
  • Deal with unintended consequences and unexpected situations
  • Interpret policies and procedures and apply them to match the conditions and patients
  • Detect and correct when something is about to go wrong and intervene to prevent it from happening

However, conventionally we assume that people will work as they are supposed to.  This is the gap between work-as-imagined and work-as-done.  The term work-as-imagined can often refer to as the work of policymakers, standard writers, regulators and inspectors.  That they imagine what the work is like and set policy or design interventions for frontline staff to implement.  However, there may be a considerable difference between what people are assumed or expected to do and what they actually do. If people who are responsible for developing guidelines or standards or policies and procedures are relying on what they imagine someone does rather than what the frontline workers actually do then the policy could turn out to be unworkable, incomplete or fundamentally wrong.

It can also be a gap between work-as-prescribed and work-as-done.  There are some specialties such as radiotherapy, chemotherapy, medication administration when the gap between work-as-prescribed and work-as-done needs to be as narrow as it possibly could be. This is where it is vital that the prescribed practice matches reality and is constantly reviewed to ensure that it remains so.  However, most work-as-done is carried out in areas of healthcare that are constantly adapting (ultra-adaptive) and consequently impossible to prescribe exactly.  Work-as-done in these areas is a combination of experience, expertise, clinical judgement and know-how. Not everything we do in ultra-adaptive environments can be written down in detail. In this case, the prescribed guidance is more likely to work if it is written in general terms rather than the fine detail. It is important to ensure that the guidance is constantly reviewed to ensure that it is up to date and workable.

In respect of safety solutions, if the safety experts don’t understand, consult and engage the frontline then they can develop the wrong solutions that won’t work. If they think they have come up with something that ‘will solve the problems at the frontline’ and those who are at the frontline are left with the feeling that ‘this doesn’t solve our problems’, it feels clumsy. The incongruence makes it hard for frontline staff to implement things they are being told to do, resulting in frustration and workarounds. The unintended consequence of this is that it triggers a degree of fatigue in relation to initiatives that seem misaligned with the goals of their day-to-day work (work-as-done) creating a chasm between the leadership and frontline of organisations. When we fix the wrong thing for the wrong reason, the same problems continue to surface. It is costly and demoralising.

Finally, work-as-disclosed is how people describe what they do, either in writing or when they talk to each other. However, this may not always be what is actually done. For many reasons, it may be the partial truth. This may be because:

  • explaining every little detail would be too tedious
  • we do things automatically and we may forget some of the details when we come to explain it
  • depending upon who we trust, we may tailor it to the audience and when we come to explain what we do we simply we say what we want people to hear or what we think they want to hear

Work-as-disclosed is a particular issue for healthcare. In a culture of fear and when we are being scrutinised or investigated, we may ‘just tell people what should or did happen not what does or did happen’.  People often do not report workarounds and conceal the actual practices they do in order to keep patients safe because they are not what the policy says they should do. In that respect those designing safety interventions may think that the interventions are working when they are not because no one is disclosing that they are not. In order to learn from staff about their work-as-done and work-as-disclosed there is a need for both a psychologically safe environment and a restorative just culture.