Wednesday 20 July 2016

Multiple Description Analysis in Health and Education

I'm doing some work on Patient Safety at the moment (in preparation for an online course). Among the most interesting features of this are the multi-level narrative descriptions which characterise most Patient Safety investigations. There is the account of the doctor/nurse/consultant/surgeon whose action most immediately leads to whatever adverse event is caused (death, removal of the wrong organ, instruments left inside the patient, administration of the wrong drugs, etc, etc). But then there is a chain of other causal factors: the labelling of the syringe, the power dynamics of the hospital, the stress of the environment, failures to communicate, etc. Each carries its own story with different stakeholders.... "the labelling did not feature an explicit warning for fear that it might confuse", or "the senior consultant who instructed the drug administration could not be overruled."

What's clear is that each stakeholder operates within constraints. Some of those constraints are analysable from examining different stories. Emphasis on particular words or themes in an account is a pattern of regularity which must be produced within some kind of constrained context. Accidents happen when constraints line up: the classic description of this in Patient Safety is Reason's "Swiss Cheese model" (see

Constraints are systemically generated: they are often the result of the social dynamics within which individuals participate. The constraints of an individual's practice are, in part, generated by the individual themselves. The way to avoid adverse incidents is for each individual to become more aware of the constraints bearing upon others in the organisation, and each individual's role in reproducing those constraints.

Multiple levels of description pertain to most areas of social life, including education. We do not worry about 'safety' in education because, unlike health (it seems to us) nobody dies. Actually, this isn't necessarily true: people do die from mistakes in education - it's just that it takes a very long time. It's as if the health system were to administer a very slow-acting poison whose action is highly complex. In order to understand the action of this slow poison, we have to be able to draw together the different narratives which relate to an individual's life and their education and the conditions under which the poison was administered.

It doesn't take much to imagine the broad themes of different narratives. We might start with the teacher's narrative: "Johnny was trouble... never interested in learning.", and Johnny's narrative "School was shit - it was obvious they didn't like me... so I found ways of subverting it", or the parents "economic circumstances meant we had no time to care", or social services "we had no resource to deal with this", or government ministers "Johnny should get on his bike and get a job", and so on.

What are the constraints within which each of the narratives emerges? The teacher's constraint which led them to say "Johnny was trouble" was partly the constraint of the formal education system which left no space to deal with Johnny's needs: "Trouble" meant not fitting in with the system. Johnny's constraint was finding ways of dealing with the imprisoned situation he found himself in which gave him no way of exploring his own inner desires, energy or curiosity. Analytically, if we were to measure constraints from the perspective of entropy in statements (the degree of surprisingness in particular statements), we would produce another description. Might this help?

The production of analytical descriptions from narrative descriptions has always been a key ingredient in the psychotherapeutic process. I think if we were to do this, we would find the greatest analytical constraints will bear upon the teachers: they are caught in a rigid system which cannot adapt. The least constraint, by contrast, will bear upon the 'rebel' student. There is no common ground between the constraints of the rebel and the constraints of the system. Such learners can die (eventually) of unmanageable complexity.

The same is true of patients who die in the care of an overly complex health system. Where the complexity of surgeons cannot be managed by junior doctors, or attempts to attenuate behaviour through drug labelling or checklists fail, or professionals in different departments do not communicate, the culprit is always unmanaged complexity: "I couldn't get the surgeon to listen to my concerns", "I worried that the labelling wasn't clear but couldn't talk about it", etc.

Adding analytical descriptions of constraints to the mix can help insofar as each description is an invitation to enter into conversation. When we talk about "organisational learning" what is meant is a communicative dynamic which leads to the identification and codification of new constraints. When common constraints are identified, everyone is changed. Most deeply, this is what education should do - it is what knowledge is really about. But it has real organisational consequences too - learning is always "organisational learning". 

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