Friday 24 March 2017

Everett Hughes on Organisational Risk in Health and Education

My work on organisational risk in healthcare has taken me back to the work of Everett Hughes. Hughes was the leading exponent of the Chicago School of Sociology which focused on an ecological approach to social institutions. It seems quite obvious that the problems in all our institutions is ecological - not in the sense of trees, but in the sense of a 'coordinated diversity'. Indeed, in our educational institutions, diversity is becoming scarce - driven by a technologically-mediated metricisation which eliminates difference.

In Hughes's book of collected papers, "The Sociological Eye" there is a paper on "Mistakes at Work" from 1951 which contains some insights from that time which I think remain relevant (but overlooked) today.

He starts by appealing for a comparative study of work - that we should look across fields of professional activity in order to understand them. He says we should study plumbers to understand doctors, and prostitutes to understand psychiatrists (!). He goes on to say:
One of the themes for human work is that of “routine and emergency”. By this I mean that one man’s routine of work is made up of the emergencies of other people. In this respect, the pairs of occupations named above do perhaps have some rather close similarities. The physician and the plumber practise esoteric techniques for the benefit of people in distress. The psychiatrist and the prostitute must both take care not to become too personally involves with clients who come to them with rather intimate problems.
Routine is of particular interest to him. He points out that one person's chaos and distress becomes another person's routine work.
There are psychological, physical, social and economic risks in learning and doing one's work. And since the theoretical probability of making an error some day is increased by the very frequency of the operations by which on makes one’s living, it becomes natural to build up some rationale to carry one through. It is also to be expected that those who are subject to the same work risks will compose a collective rationale which they whistle to one another to keep up their courage, and that they will build up collective defences against the lay world. These rationales and defences contain a logic that is somewhat like that of insurance, in that they tend to spread the risk psychologically (by saying that it might happen to anyone), morally, and financially. A study of these risk-spreading devices is an essential part of comparative study of occupations. They have a counterpart in the devices which the individual finds for shifting some of the sense of guilt form his own shoulders to those of the larger company of this colleagues. Perhaps this is the basis of the strong identification with colleagues in work in which mistakes are fateful, and in which even long training and a sense of high calling do not prevent errors.
But being the social ecologist, Hughes looks at both sides of the equation in negotiating and managing these risks. He suggests that there is a psychological 'division of risk' between worker and client.
In a certain sense, we actually hire people to make our mistakes for us. The division of labor in society is not merely, as is often suggested, technical. It is also psychological and moral. We delegate certain things to other people, not merely because we cannot do them, but because we do not wish to run the risk of error. The guilt of failure would be too great. 
So the question then is one of fault and blame if something goes wrong.
Now this does not mean that the person who delegates work, and hence risk, will calmly accept the mistakes which are made upon him, his family, or his property. He is quick to accuse; and if people are in this respect as psychiatrists say they are in others, the more determined they are to escape responsibility, the quicker they may be to accuse others for real or supposed mistakes.
What are the defences of the professions to this? Ritual is the key thing, Hughes argues. Of psychotherapists, he says:
A part of their art is the reconstruction of the history of the patients’ illness. This may have some instrumental value, but the value put upon it by the practitioners is of another order. The psychotherapists, perhaps just because the standards of cure are so uncertain, apparently find reassurance in being adept at their art of reconstruction (no doubt accompanied by faith that skill in the art will bring good to patients in the long run).
Education is another example of ritualised practice which is seen to mitigate risk. His comment here resonates with much of what we see standing in for "quality" in education:
In teaching, where ends are very ill-defined – and consequently mistakes are equally so – where the lay world is quick to criticise and blame, correct handling becomes ritual as much as or even more than an art. If a teacher can prove that he has followed the ritual, the blame is shifted from himself to the miserable child or student; the failure can be and is put upon them.

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