I could feel the energy in the room rising. Health practitioners, senior managers and research teams exchanged ideas with an intensity I rarely see at conference meetings. I was invited to the meeting to help search for solutions to a perplexing problem – how to get nurses and other front line staff to use the latest techniques when assisting patients.
Staff really care, so you expect them to soak up the information and ideas on offer. But in many situations it was not happening. Despite the memoranda, training sessions, demonstrations and the rest, people would often slip back into their old ways of doing things. Why weren’t the new ways sticking?
I heard how community nurses visiting elderly patients in their homes to apply wound dressings resisted the new techniques and continued in the ways handed down over the years. It was as if a nurse who completed her training in 1969 knew more about wound care than the scientists who spent countless hours researching how we heal. Why were they so resistant to new ideas and methods?
I realised I had run into this problem before, but in a context as different from health care as you could imagine – underground coal mining. Way back in 1994 a mine at Moura in Queensland exploded, killing 11 miners. The immediate cause was a dangerous build up of methane, a natural by-product of coal.
In the old days they used to take canaries underground to detect when the air was not right, but the latest monitoring devices were installed at Moura. Their bright colour screens displayed numbers and graphs and gave out loud signals and alarms when the methane started to build. The monitors did their job, but despite this all the signals were missed. People stared at the monitors and heard the alarms but did not respond as they should have. Why not? After all, the training was comprehensive and everyone had the latest information on what the monitors were telling them.
The Moura tragedy caught my attention at the time and I was hooked. I had to find out more. I flew up to Queensland for talks with the Chief Inspector of Coal Mines, staff representatives and others. The Chief Inspector was adamant that this was about management and human factors, rather than an unavoidable technical problem. I scoured the proceeds of the 40 days of coronial hearings for clues. I found that in the hours, days and weeks before the explosion many mistakes had been made – small errors, miscalculations, erroneous assumptions and miscommunication.
How could this be? I tried to see the world of the miners as they did.
Miners at the coal face work in the unworldly conditions of strange smelling air, unnatural light, and the cracking and groaning of the coal as it shifts in the seam. They are in the belly of the beast and danger is never far away. But management is. Close at hand the miners have their mates, their stories and their ways of getting through the day and home safely. They know that every mine is different, who among their number to rely on for advice, and what all of them have learned from earlier incidents and safety scares.
Sure, management has the latest scientific know-how – it is in the training courses and the manuals. But managers live in a two-dimensional world of formulas, rule books and certainty. The miners do not. They are in a three-dimensional space where information arrives through many channels and it can be ambiguous, unreliable or in conflict. Their responses are clouded by the need to act quickly, without a full understanding of the wider implications. The most critical points can easily be lost in the moment.
The community nurses also have to make sense of the situation as they see it. Every home they enter is different. Their patients have many needs – human, emotional and physical. Wounds and ulcers take a long time to heal regardless of what they do, and they will need to visit often. They make their decisions about how to treat their patients in the here and now. They have learned the best ways from their more experienced colleagues, the stories they share, and of course their training in the newest healing techniques. But providing care means more than just applying the latest scientific findings, it is a far more complex business than that.
Senior managers are rational beings – they expect people to follow the advice of their leaders and apply what they have learned. What I have discovered from observing real, well intentional people at the ‘coal face’ is this. People will not necessarily change their behaviour just because you know a better way. They need your interest, understanding and trust. Then they will listen.