I believe the problem we’re facing in improving the quality and safety of healthcare is about setting new norms rather than the eternal quest to take innovative ideas or set of guidelines and then impose these on the rest of the system. Yes, this “pilot and spread” approach is useful and can be demonstrated to raise standards, though there may be questions about sustainability of results and few organisations review improvement programs three or more years after they were completed to test this.
Obviously new norms can’t be “set” as such. Where does our current norm come from? I think of a norm as the sum of all the behaviours actually at work in a system. A different norm therefore requires a different set of behaviours – not only (if at all) a planning meeting to decide and list these behaviours but an actual change in the behaviour of one, then two, then three, then four and so on people in the way they act and interact with each other.
More about this norm approach in forthcoming posts. In this post I am thinking more about why we end up with the norm we have. For example, what is the norm at work in an organisation where 400 or more patients are harmed or die inappropriately (for a series of reports / investigations on UK health organisations http://www.cqc.org.uk/publications.cfm?widCall1=customDocManager.search_do_2&tcl_id=2&search_string=&top_parent=4513&tax_child=4574 ) or where one nurse is able to harm and kill a number or patients http://www.nytimes.com/2009/04/03/us/03nurse.html?_r=1? No doubt there are many causes involved in each and every event. However, I’ve been asking myself the question “Why is it so difficult to shift the norm?” Allied to this is the question for me of “How can professionals reach the stage where they become part of a norm that seems to go against their stated values, yet do nothing – their behaviour continues “as normal?”
There are procedures for the NHS in England to manage whistleblowing http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4050929 and again, there will be many reasons why people don’t step outside of a norm and take action. So why is this norm “pull” so strong?
One reason I have been dwelling on is the abuse of power. Not so much a conscious step but rather one which is part of our human condition. And when enough people behave in ways where power is being abused, then a norm develops so others, who may not be inclined to do so, end up part of the problem.
How is abuse of power part of our human conditions? We know from a number of experiments that stated values, professional promises and personal beliefs can go out the window if the circumstances are right. For example, the Stanford Prison Experiment in 1971 (http://www.prisonexp.org/ for a slideshow / discussion guide on the whole process) demonstrated in laboratory conditions that when put in a position of power (the guards) about a third of the “guards” showed sadistic tendencies, meting out punishments and inventing ways to humiliate their “prisoners”. The famous Stanley Milgram experiment http://en.wikipedia.org/wiki/Milgram_experiment in 1961 showed how when participants are morally distanced from the consequence of their actions and when they believe in the power of the authority demanding action, they will continue behaviour even when they can see it is physically harming another person. Around two-thirds of participants showed this behaviour. There are many other examples as well, not least of which come from politics and wars.
So what does this mean for raising the standards of healthcare? Imagine working in an organisation where a critical mass of people (clinical professionals as well as managers and administrators) feel distanced from their actions, feel the need to respond to authority figures, are in a stressful context and feel they can act in ways that are driven by their own very personal demons. The sum of the behaviours exhibited become the norm culture.
So when I encounter really good examples of clinical or administrative practice and I am asked to help with spreading this to other places, then one of the key things I am thinking about is the underpinning behavioural dynamic. What is it about the team and the behaviour of the individuals in the team, that contribute to their identified quality / safety improvement performance? What is their norm? To what extent is this about how they manage the power dynamics? And if others are to adopt their work, what will this do to their use and abuse of power within their own systems? How will they break free of their current norm? Whose behaviour will be critical in this shift of norms?
I’ve been through the process of listing, rather objectively, the behaviours required for good practice to be adopted. Maybe this is helpful in working out just what needs to be done to effect the change. What I know now is a list of behaviours is not the same as the behaviour itself. I am also a great deal more aware of the context in which behaviours are played out and I am open as to the impact of power dynamics in a system.
This is messy stuff that doesn’t lend itself to the predominant method of change in healthcare, namely the issuing of a “how-to” guide. I think it requires conversation, dialogue, self-awareness and attentiveness. There’s no quick fix.