The Race to the Top of the Mountain

Remember the old joke about the two men who were racing to the top of the mountain and when they got there, a third man asked them what took them so long? The guy at the top has been a rabbi, a priest, a woman, and a host of other things, depending on the point the comedian was trying to make.

I feel like that joke just became real after reading this article. Nurses, doctors, and health care researchers clamoring to the top of the mountain as they discuss how to interpret data from interventions in health care settings, and realizing that the organizational scientists have been there for some time.

I couldn’t agree more with the conclusions drawn in the article. Randomization is a great tool, but it loses power in quasi-experimental settings. Field studies trade realism for control, and while the ecological validity of a field study is very valuable, extraneous variance due to internal validity violations is always problematic.

Organizational scientists are in a unique position to help those involved in RCTs with the identification and modeling of these variance sources, both in terms of measurement AND with respect to the meaning that they provide. For example, the article states that “changes in the skill and confidence of practitioners” was observed (Results section, first paragraph). Of course, this is not surprising from a human performance perspective, but it also constitutes a history effect, which is an internal validity concern. How are these concerns being addressed? Psychologists have many ways to do so, but how well have we applied these ideas to health care practice?

I encourage health care practitioners to seek out partnerships with organizational science. We can help each other make patient experiences in care of even higher quality.

Safety News – April 10

Interesting article regarding the FAA’s scolding of UAL/Continental linked here. It is a good example of how one set of activities that are normal to business in so many ways (i.e., retirement, new hiring, etc.) can be easily scapegoated when regulations are violated. How much of the “problematic behavior” highlighted by the FAA might be due to power struggles between the union and the company? This is a potential side effect of bureaucratic safety – regulatory oversight forces some bad behaviors out while decreasing corporate adaptability and providing opportunities for employees to use safety as a means to achieve other ends. Solution? More training and oversight. There is much we don’t know, obviously, but this smells like good old Newtonian “broken parts” mentality.

Meanwhile, in another industry, we get the distinct scent of “system drift,” the gradual acceptance of abnormality as normal. PG&E will pay $1.6B in damages for the San Bruno gas explosion in 2010. The article targets “safety failings by the utility and lax oversight by state regulators,” suggesting inter-organizational drift that was likely fueled by years of drifting toward a riskier mode of operation and rooted in factors that had nothing to do with safety – motivation, costs, staffing, etc.

Punishing the “bad guys” still plays well in the papers, though. I wonder how much UAL and PG&E will actually learn? Or will they just be motivated to find sneakier ways to do what they want?

 

Bullies

In my discipline (organizational psychology), we have studied for some time the issue of “counterproductive work behaviors.” These are activities that employees generate for the purposes of harming the organization in some way. Typical examples might include theft, sabotage or abuse of breaks and lunch hours, but in other forms of the phenomenon another employee might be the target of the counterproductive behavior. Organizations often act as breeding grounds for individuals to use social power against one another in order to enhance or preserve their own statuses, and those who do not enjoy structural power in the organization may find themselves suffering at the hands of those that do.

The attached article addresses what the authors call “bullying”, which appears to be a new organizing label attached to behaviors that have been discussed in patient safety for some time. Nurses have long reported that doctors treat them poorly, pharmacists have long complained of marginalization, and administrators have long been vulnerable to perceptions among employees of mistrust, aloofness, and arbitrariness in punishments. Remedies are suggested, such as improving communication skills, decision making, and advocating for collaboration. Leadership and staffing are also identified as factors that contribute to “bullying.”

However, there are many nuances to how power differentials play out in organizations that are not addressed. For example, “bullies” in organizations are often not out to harm anyone, but to preserve  their own position and self-perception. Have hospitals considered what structural and cultural norms are in place to encourage those with power to be so hesitant and fearful about sharing it? Teaching the appropriate skills is a wonderful idea, but skills are just tools that one has to be motivated to use.

Hope you enjoy the article, and comments are welcome.