Keywords

12.1 Introduction

The future of work is, self-evidently, unknown to us. The future of work has become what is now popularly known as “work-as-imagined” [5]. While this term is often used to describe imagined work now or in the past, it equally applies to work in future. Experience shows that our imagination of the past and present is incomplete and incorrect in fundamental ways. And so, of course, our imagination of the future is even more limited. It is unpredictable, in that it is not possible reliably to characterise with confidence—except in some very broad terms—the details and patterns in the nature of work in the coming decades.

This presents a dilemma for a writer looking to envisage the future of work in a few years, let alone in 2030, and beyond. At the time of writing, the COVID-19 pandemic has changed work dramatically within one year in almost all sectors of industry, and is living demonstration of the limits of imagination applied to the future of work. Research projects and white papers in health care and aviation, for instance, on the future of work have lost some relevance with fundamental changes to the nature of work brought about by COVID-19.

What we can reliably predict about the future of work is that it will change unpredictably and significantly. Changes are likely to involve many “aspects of context”: geopolitical, political, legal, regulatory, judicial, economic, societal, social, cultural, environmental, organisational, technological, and informational, with implications for health, safety, security, productivity, and work in general. The changes will require adaptations at all levels of the system, from front-line staff and service users to regulators and governments. The pandemic has therefore offered an opportunity to look at how work has changed in the light of significant unforeseen events, and how workers and organisations have responded, in the hope of drawing some lessons that may remain valid in the coming decades.

In this chapter, I take a narrative approach to understanding aspects of the future of work, relying not primarily on the predictions and reflections of previous authors, or my own, but the high-context accounts of front-line healthcare workers, whose work has been affected dramatically by the emergence of the pandemic. Using a rapid, micronarrative research approach [7], combining aspects of narrative inquiry and grounded theory [6], I aimed to explore and conceptualise clinicians’ experience in textual form. Via twitter, I asked known healthcare practitioners to answer the following question: What have you learned about work from the COVID-19 pandemic? I requested that answers be limited to around 100 words. The reason for this was to allay expectations of a long, written response (which deter response, especially among busy healthcare professionals) and to encourage respondents to prioritise the most important learning points for them, via reflection-on-action [9].

The data from the 24 participants were subject to thematic analysis and are presented in this chapter with associated learning points, providing insights into front-line experiences of work that may apply to other workers in health care, and beyond.

12.2 Responding to a Rapidly Changing World

In the light of the likelihood of future disruptions (e.g. pandemics, major outages, climate change), the COVID-19 pandemic has illustrated how the future of work will involve responding to volatility and unpredictability, requiring timely adaption. The importance of front-line involvement in such change was emphasised by several clinicians. That “people are the solution” was noted in the context of many healthcare functions. Participant 1 (Intensivist, Australia) stated that the only thing we can reliably predict about the future is the need for change, and that “Frontline workers are the solution to most problems that will inevitably arise. They are the most valuable resource in healthcare, both for delivering the care and for designing how to do it”. His remark mirrors contemporary thinking about safety. As Cook [2] noted,

Human practitioners are the adaptable element of complex systems

and

The system continues to function because it contains so many redundancies and because people can make it function, despite the presence of many flaws.

Dekker [3] (p. vi) sees

people as the source of diversity, insight, creativity, and wisdom about safety, not as sources of risk that undermine an otherwise safe system.

The need for rapid response was mentioned by several clinicians. Some noted the need for interdisciplinary collaboration on a scale never seen previously. A specific example was provided by Participant 2 (Anaesthetist and Health Education England Simulation Lead, England) in the context of the new major “Nightingale” hospital in the UK, where he “witnessed enormous willingness and motivation amongst practitioners and managers to respond to the need for rapid change”. Reflecting on prior inertia in health care, he noted that “This felt like a big contrast from previous ‘norms’ of organisational behaviour in healthcare”. Similarly, in an ambulance context, Participant 3 (Ambulance Service Patient Safety Manager, Scotland) discovered that “some types of ambulance service work systems that would previously have been considered very difficult to change, can actually be reconfigured at pace and new ways of working can be introduced, which lead to significantly different system performance”. Participant 4 (Anaesthetist, Australia) noted also how health care has “a reputation for resistance to change”.

While many workers, especially those in office-based roles, have switched to working from home with extensive use of videoconferencing, a corresponding change in health care has been a switch to telemedicine. Participant 5 (Emergency Physician, USA) described how the job changed rapidly from in-person clinical care: “Our telemedicine urgent care started seeing hundreds of COVID patients a day, a disease and volume that were totally new to us”. This clinician, and her colleagues, learned to adapt rapidly to the new conditions, which presented challenging trade-offs.

Self-organisation and staff-developed standard operating procedures (SOPs) extended to other hospital functions. Participant 6 (Radiologist, England) noted that homeworking was arranged rapidly “after years of dragging feet”. This was helped by having the required IT equipment already available, but not set up, in hospital, as well as adaptive IT support. “Radiologists were split into two groups”, he wrote, “one at home, one in department. Radiographers worked out their own rotas. Radiographers and nursing staff worked on SOPs for imaging COVID positive patients”.

Some indicated, however, that the degree of clinician involvement in change was variable, with a contrast between top-down change done “to” people and change done “with” and “by” people [as discussed by Russell [8], in terms of “modes of change”]. Participant 4 (Anaesthetist, Australia) highlighted especially the “to” mode of change—top-down initiated change, with limited clinician consultation, particularly regarding the rationing of personal protective equipment (PPE). Other organisations, she wrote, have initiated clinician-led processes, “resulting in durable models of care but uncovering ‘wicked problems’”. Participant 4 reflected, “COVID-19 has taught me that engaging clinicians doing the work increases short-term complexity, but doing otherwise risks failure in the long term, losing trust on the way”. This can be seen as an acute-chronic trade-off [4] in responding to change.

Participant 7 (Intensivist, New Zealand) noted the importance of diverse views for solving complex, dynamic problems, such as the rapid reconfiguration of an intensive care unit (ICU). “This required many different teams: ICU clinicians, infection control nurses, biomedical engineers, builders, ventilation engineers and quality improvement specialists”. This clinician highlighted the importance of pre-existing relationships, in this case built up during a prior volcanic burns incident.

Similarly, in a French ICU context, Participant 8 (Anesthesiologist, France) wrote of the need for more ICU beds. “Equipment wasn’t designed for ICU, nor were newly formed teams used to working together in this stressful environment”. He noted the effectiveness of “collective intelligence via inclusive collaboration and open communication” for preventing harm both to patients and to healthcare workers.

An iterative approach to adaptation to keep pace with a rapidly evolving situation, especially in the context of uncertain and volatile information, was the focus of Participant 9 (Intensivist, New Zealand): “By starting to address problems iteratively we could create a network of actions that we could knit together. We rapidly developed a tolerance of failures, using them, with active feedback, to modify our processes and facilities adaptively, alongside the new information that became available”.

The requirement for rapid responses is sometimes confounded by the economic and organisational contexts, including resource constraints, communication channels, and the political context, such as policy and communication. Participant 2 noted his experience of challenges to redesigning clinical services in the context of constraints such as “workforce availability, skill mix and preparedness for redeployment; creating and adapting new clinical environments; accessing critical specialised equipment and supplies quickly and reliably”. Similarly, Participant 10 (Professor of Health care, England) highlighted “the structural and cultural barriers to leveraging talent in surge demand”. Characterising the limitations of blunt-end response to changes in work, she noted that “It’s like a slow-moving major incident without the implementation of a major incident plan”.

12.3 Work-as-Imagined and Work-as-Done

Several respondents highlighted differences between work-as-imagined and work-as-done (WAI-WAD), concepts that have recently gained currency in health care. Participant 11 (Surgeon, Scotland) stated that the pandemic “has shone a light on how we work, and the dichotomy between ‘work-as-imagined and work-as-done’”. Participant 4 reflected that “It is critical that ‘work-as-prescribed’ reflects ‘work-as-done’ to prevent depletion of the workforce through infection and exhaustion”. A specific example mentioned by some respondents was PPE. Participant 12 (Anaesthetist, England) noted that, despite 25 years working in anaesthesia, the COVID-19 pandemic presented his first introduction to PPE and FFP3 masks. Fit testing and training in PPE donning and doffing was, however, not adequate preparation for the daily challenges of working in PPE. “The impact of heat, the need for good hydration, and the communication challenges became stressors—recognised and managed by great team working through adaptations in how we worked”. He remarked further that, “Looking back, local practice is not ‘work-as-prescribed’”.

Participant 13 (Consultant Anaesthetist, England) also commented on unimagined and unintended consequences of PPE: “Working in PPE is hot, tiring and difficult to both hear and see. Staff avoid drinking to reduce bathroom visits, all of which affects their ability to work. Extra time is taken from patient care to put on and take off the PPE”. She noted that measures to reduce the risk of COVID indirectly affected patient safety in other unimagined ways. Participant 14 (Consultant in Emergency and Retrieval Medicine, Scotland) similarly reflected on unforeseen communication difficulties while wearing PPE, especially for aerosol-generating procedures. “Voices are muffled, hearing is compromised and implicit communication through facial expression is lost”. He noted that this is a particular problem for resuscitation teams working under pressure.

Difficulties in compliance with work-as-prescribed [10] were noted by other respondents. Participant 15 (Former Critical Care Outreach Nurse, England) stated that some rules and guidance were developed by people remote from the work and were no longer applicable. “These rules end up being a barrier to do the right thing. For example, filling a 35-page safety booklet about a newly admitted patient takes us away from practical tasks such as personal care or administering medication”.

Participant 15 stated that “Now, no-one knew the best way to do things. There was no evidence base to draw from, and no exemplars to follow”. Participant 2 similarly noted policy-level problems: “multiple channels and frequent shifts in emphasis of central guidance and policy”. This was reiterated by Participant 16 (Critical Care Nurse, South Africa), who cited “information overload, inconsistent messages and departure from plain common sense”.

For Participant 15, the absence of written authority required a collaborative local approach. “Everyone came up with ideas, and many more came from social media”, she wrote. “We openly learned from each other. We were finding solutions from the ground up and the senior leadership team listened”.

The dearth of appropriate procedures and guidance was also noted by Participant 13: “Without timely clear guidance arriving down the traditional lines, the ability of staff to innovate and adapt was remarkable. The constraint of normal change bureaucracy was temporarily suspended and essential new ways of working arrived in a rapid and remarkably effective way, significantly prior to written SOPs”. She stated that front-line staff instead required underlying principles [1] and developed and translated them in appropriate ways for their own local work and working environment. This leveraged the competency and expertise of military nurses who had significant experience with PPE and Ebola.

Team approaches to learning are needed to maximise the impact and ensure the safety of such adaptations, remarked Participant 17 (General Practitioner, Scotland): “In my GP practice, daily ‘huddles’ (short meetings) were used to discuss how we implemented rapidly changing guidance while coping with varying conditions (e.g. demand and capacity) and competing goals (e.g. reducing hospital admissions while maintaining patient safety)”. These huddles encouraged sharing of innovative practice and increased understanding the rationale for decisions, and how decisions affected other parts of the system. They also “supported those making difficult decisions and ensured people did not drift into unsafe practices”. Participant 11 (Surgeon, Scotland) also referred to an approach to team learning in Scotland involving regular reviews of reports by clinicians for the purpose of collective learning, which has helped to bridge this WAI-WAD gap.

Participant 14 (Consultant in Emergency and Retrieval Medicine, Scotland) and colleagues co-designed a checklist to improve communication using PPE called “PRESS”: P—Pre-transmission pause. Think before you speak; R—Read back—close the loop; E—Eye contact—ensure focused attention; S—Say again—repeat critical information; and S—Shared team mental model with a team rally point.

Participant 13 (Consultant Anaesthetist, England) remarked that the WAI-WAD gap also applied to clinicians’ imagination of “patient work”: “Initially we asked our patients to self-isolate for 14 days prior to elective surgery, and (as we knew the reasons) we imagined that they would do that unquestioningly. We ‘prescribed’ that to them, without explanation, and then anyone who proceeded to surgery had to ‘disclose’ that they had completed this. Only the patient ever knew whether they had done so”. She stated that it took time to identify this gap, which is taking longer still to close.

Participant 3 (Ambulance Service Patient Safety Manager, Scotland) noted that the WAI-WAD gap can be minimal for changes up to a certain scale. However, “with larger groups of workforce, it can be very difficult to influence multiple, often subtle, changes in work-as-done to match with the more easily changeable work-as-prescribed (and work-as-imagined)”. He noted that this was particularly evident in the early stages of the response phase when clinical, logistical and PPE criteria were becoming established.

A word of warning was sounded by Participant 18 (Anaesthesiologist, USA), about rapidly created bottom-up methods. “Although this pandemic has brought lots of new concepts and working conditions, it’s imperative that we maintain our usual high standards and not be tempted to try new techniques and alter our usual routine safe practice”. Participant 7 usefully expanded that, in the New Zealand intensive care context “the redesign of clinical work was based on four requirements: to be SAFE, SIMPLE, SUSTAINABLE and ADAPTABLE”. Reflecting more recent focus in safety management on everyday work, he noted that “the ability to anticipate potential challenges required imagination and a deep understanding of the realities of everyday work”.

Participant 19 (Anesthesiologist-Intensivist, France) noted the role of acceptance of uncertainty, and humility: “This whole experience was new for everyone. For many professionals, it has created a touching sense of humility, both among frontline actors and managers. I believe that this humility has facilitated communication and the emergence of a shared governance between caregivers and administrators where I’ve been working”. He noted that, for the first time, work and its goals were shared and the WAI-WAD gap was minimal.

12.4 Human-Centred Design and Systems Thinking and Practice

Adaptive imagination is necessary to respond tactically, or even opportunistically, to rapidly changing circumstances, but there remains a need for more strategic human-centred design and systems thinking in design, and therefore a need for support to integrate appropriate approaches. Traditionally, such approaches are seen as more “blunt end” analysis and support (often over the timescale of months or years), but there is a need for more rapid integration into operations (over the timescale of days or weeks). There is therefore a requirement to balance the need for rapid, user-led change with durable user-centred design.

Emergency care is an aspect of health care characterised by improvisation. Participant 20 (Emergency Physician, Trauma Team Leader and Simulation Educator, Canada) reflected on the nature of emergency care. “Healthcare is a precarious thing, balancing on the backs individual and team resourcefulness and resilience. Emergency medicine, in particular, suffers from ‘ad hoc-itis’. Our ability to improvise solutions in the face of massive systemic limitations and inefficiencies is practically a professional badge of honour”. Participant 20 stated that COVID-19 has highlighted the need for more understanding of complex system design. “We can build systems that make sense. We can use simulation-informed design, prototype testing, multi-source feedback and hazard analysis to help manage complexity rather than compel us to work against it”. He remarked that the pandemic requires a rethink of how health services adapt, beyond front-line tactical or opportunistic adaptations: “and therein lies a massive challenge and unprecedented opportunity: let user-centred and data-driven design lead us in rebuilding”.

Participant 1 (Intensivist, Australia) remarked there has been some success with this. “Locally, we have seen rapid, successful innovation of work practices through the marriage of simulation and human-centred design principles”.

Human-centred design does, however, need to be embedded in systems practice. One of the fundamental activities of systems thinking involves making boundary judgements. Participant 21 (Anaesthetist, Scotland) stated that “Where you draw the system boundary matters. I started chairing a theatre COVID preparedness group in March. We quickly transformed the theatre complex to handle a surge in patients with COVID, while keeping staff safe. We liaised with ED, ICU and the wards which are upstream/downstream of theatres”. The teamwork, dynamism, and psychological safety of the working group, he said, were critical. The system boundary chosen did not include the whole hospital system, since others were focusing on this. However, there were other aspects of the health and social care system that would have benefitted from the group’s input: “Looking back now I wonder about the care homes. They were not within my system and I didn’t give them a second’s thought within my planning. Whose system boundary included care homes? What were their working conditions, demands and constraints?”

12.5 Leadership and Social Capital

In the narratives above, the importance of teamwork has been emphasised. More generally, clinicians remarks concerned leadership, human relations, and social capital. Participant 19 (Anesthesiologist-Intensivist, France) stated that “COVID appears to have acted as a powerful inductor for team building”. He found that “strongly empathetic and benevolent leadership can have a positive impact on patient safety, work organisation, coping and caregivers’ well-being”. Participant 22 (Midwife, England) similarly noted that “The need for sincerity and genuine characteristics is essential. A focus on leadership over management is required. Midwifery managers/consultants need to be able to utilise the clinical skills they started off with to enable support and understanding of their units in today’s world”.

Participant 18 (Anaesthesiologist, USA) noted the need to “foster good relational coordination amongst colleagues particularly during a time of great uncertainty and constant change”. Participant 23 (Anaesthetist, Australia) similarly highlighted the criticality of high-trust relationships to safety. Referring to the importance of bridging social capital, she noted how “The pandemic has required groups to leave their silos and to collaborate rapidly on high-stakes issues”. Some professionals (Participant 19 noted specifically aerodynamic scientists and occupational hygienists) had not previously routinely been included in healthcare teams to keep workers and patients safe. With a nod to the technological context of work, she also mentioned that “many of these experts are accessible on social media, primarily twitter, and have been generously sharing their expertise for the benefit of all”. This rapid, inter-professional adaptation—outside of organisational boundaries—arguably could not have happened without social media.

Participant 15 (Critical Care Outreach Nurse, England) stated that the “flattened hierarchy” does not imply effective leadership, but can be a barrier to effective communication. “For example, everyone is wearing the same outfits, no name badges are shown and no one recognises anyone. So who is the leader? Being involved in a medical emergency with no leadership evident is a scary place to be”. According to Participant 15, the role of a decisive leader has been critical during the pandemic: “[It] has given me comfort and guidance when I have felt as if I was floundering”.

Participant 24 (Orthopaedic Resident, Poland) remarked that “During the pandemic, I learned that no matter how well organised the healthcare system is, you end up counting on good people to do everything they can to overcome and minimise effects of hopefully rare but inevitable system flaws”.

12.6 Lessons for Future Work

From the micronarratives collected, a number of lessons can be drawn for future work, whether in the coming years or decades. While the context will change, many of the lessons that can be identified from these narratives would appear to be relevant. I have drawn the following lessons from the narratives:

  1. 1.

    resistance to change within organisations can ease rapidly in the face of major disruptions to normal work;

  2. 2.

    leveraging the expertise of staff in their own work will be key to responding to change. Involvement of diverse perspectives, especially those of front-line staff, is necessary for short- and long-term adaptation to change;

  3. 3.

    pre-existing relationships and investment in bonding and bridging social capital are required for adaptive response at scale;

  4. 4.

    complicated procedures designed to ensure thoroughness may become a barrier to effectiveness, resulting in abandonment. Procedures and policies should therefore be backed up by principles or a more general philosophy;

  5. 5.

    adapting to change requires sufficient resources (relating to people, equipment, supplies, infrastructure), which must be planned and made available in advance;

  6. 6.

    iterative cycles of understanding and intervention, at micro-, meso-, and macro-system levels, are important for adaptation, and approaches to tactical risk management and improvement should be taught to staff. Human-centred design, and tactical adaptations to work, needs to be embedded in systems thinking and practice, which should be part of general education and development;

  7. 7.

    differences between work-as-imagined and work-as-done exist between all stakeholder groups need to be understood via regular discussions and reviews of everyday work practices and specific events.