Antus Benner psychologica
There is great excitement tonight in the 'Below Ten Thousand' Conceptual Laboratory.
Building on our work with 'Surgery Stat', the game which evolved to help staff visualise resource
boundaries and fatigue inducing factors, we are now proud to announce that we are further
developing the conceptual thinking of operating theatre management by engaging in research on
Yes. After receiving some unanticipated funding, we have acquired the necessary infrastructure to
start an ANT FARM!!!
Stay tuned with barely-contained anticipation for where our laborious research will take us.
So, I have collected my ants and they are currently in the process of adjusting to their new environment.
They should be smart ants, because I collected them from Deakin University.
And maybe I have identified my first mistake.
I collected them from outside the Psychology Department and not the Post-Grad Medical Faculty.
Ants are interesting creatures.
They are a hugely ancient species, and the colony could be considered a self-organised organic system of both biological simplicity and inherent complexity as much as the individual ant is.
A colony of ants is simple, effective, responsive, adaptive, structured, strategic and resilient.
And the individuals pass from being larvae to foragers and patrollers in pretty much the same way as nurses pass from being novices to experts.
To honour their derivation and their usefulness to me in my systems research, I am going to give my ants their own classification: 'Antus Benner psychologica'.
The ants are already tunnelling, so I had better get reading:
'The Dreyfus Model of Skill Acquisition Applied to Nursing';
'Ant Encounters: Interaction Networks and Colony Behaviour'
Am I Smarter than an Ant?
Interestingly, when you think about it, the queen and the workers are mutually dependent on each other.
None will survive without the other.
Therefore the entire organic system is built on trust and collaboration.
And the outcome is that the collective is so much more than simply the sum of its parts.
An ant colony is a value-added community which is much richer in substance than merely the sum of its ants.
The true resilience in an ants nest lies in its built-in redundancy. The number of ants not actually participating in any allocated task is the safety valve that accommodates risk perturbations.
In operating theatre nursing, the only redundancy we rely on is the ability of nurses to be able to multi-task, work overtime and be on-call.
Unfortunately, in many systems, we use on-call to cover 'systems of work', or workloads that we could reasonably expect to expect, leaving us with no contingencies for 'actual' perturbations.
Thus we use our highest risk, fatigue intoxicated performers to be the safety net to undertake our most critical out-of-hours surgery, or to continue a list long past the risk threshold.
Worse, we treat staff like a renewable resource.
It seems like a renewable resource, just like an ant population is renewable so long as the egg production rate equals or surpasses the attrition rate.
So, as clinicians succumb to high risk systems of work, we depend on newer, younger, fresher staff to fill their place.
The mathematics will suffice, so long as you consider the individuals expendable.
So long as you replace Sally with Leland when Sally destroys her back, and so long as you are prepared to accept that Leland does not require any better duty of care, then that is Ok.
But I liked Sally. She was always cheerful, and she always did a great job without complaining.
Interestingly enough, I liked Inge, who was the person who did Sally's job before Sally and before Leland. She was always cheerful, and she always did a great job without complaining.
But she succumbed too.
I like Leland. He is always cheerful, and he always does a great job without complaining.
So if ants accept attrition, should I, then, too?
The question is:
Am I smarter than an ant?
Why does my calculation trend towards neutrality?
No ant colony is viable without a queen.
The queen sows the seeds for the future and sets the cultural tone (or in their case, the 'scent',) for the colony.
It is the skill of the Queen in establishing the first brood that sets the colony on the way to success.
She provides the starting kit for the fungus farm which the ants feed on, and personally nurtures the first brood to start the process of growing capacity in what will eventually become the increasingly sophisticated layers of 'workers'.
The Queen knows from the outset that she is not the 'Controller'.
There is no way that a single ant buried deep within the nest can direct the flow of messages along the communication networks, nor even manage the tasks, recurrent and emergent, necessary for the colony to grow, adapt and respond effectively to changes typical of the dynamic variability inherent
in any naturalistic environment.
However, she depends upon the colony to self-manage with few more than 20-40 pheromone signals, which are not generated by her, but generated by each ant doing nothing more than the execution of its most recent duty or set task, a memory which lasts ten seconds, and a task threshold response function not dissimilar to nerve cell physiology.
Unfortunately, I don't have a queen in my ant farm.
Nor am I interested in raiding a nest to get one, and dooming a whole sophisticated colony to extinction for my own purposes, no matter how noble my purpose may seem to me.
But the foragers I chanced upon will do nicely.
Stay tuned for the next exciting episode where my question may well be:
"Are we smarter than an ant colony??!!"
Can we, should we, build a better, safer cultural construct ?
The subtlety of the ant colony as a super-organism is poetry in motion.
How such an elegant system evolved we will never know, because individuals enter into fossil records, not the system they dwelled within.
In nature, everything tends to entropy, and descends to chaos.
But here we have something that bucks the trend.
With as few as twenty to forty discrete behaviour-producing signals, we have something that not only maintains its structure, efficiency, sustainability and purpose over time, we have something which, in species that have found how to replace the queen when she dies, approaches a singularly phenomenal immortality.
When you stand back and observe, when you look at how an operating theatre suite behaves, it doesn't take long to realise that it often behaves, not as a sustainable system, but as a phoenix system.
It invests every reserve it has at its disposal with increasing intensity over the course of the day, and then crashes in exhaustion to be resurrected the next day.
Increasing complexity in its systems of work, overwhelming workload pressure, lack of negative feedback loops and controls, all serve to make it a runaway system which can only continue a cycle of escalation and crashing into perpetuity.
The question I want to pose is:
Can we create a robust and sustainable simplicity within the systems processes of the operating theatre with which we can then manufacture better performance, better endurance, and less carnage both for patients and staff?
Given that our current system injures good people like Inge and Sally;
Given that 14,000 people in Australia die from preventable clinical errors per year;
Given that the industry steadfastly clings to fatigue as a badge of honour despite the evidence that repeatedly tells us it is a bad idea;
Can we use the methodology of an ant colony to engineer some systems architecture that would see this data re-routed to produce enduringly good outcomes with less given that our bad outcomes cost more than we can reasonably afford?
The ants in the ant farm have created a tunnel big enough for all but one to fit into overnight.
I feel sorry for the one left exposed, and hope she doesn't worry too much.
Though all she really has to fear is my wife with her fly spray.
The tunnel will be bigger tomorrow.
Then everyone can sleep safe
The ant nest works from the inside out.
At the heart lies the queen, producing eggs.
The eggs are tended by the next generation of workers.
Then there are the food preparers and storers and fungus gardeners.
The more mature workers maintain the tunnels and the nest.
And the most mature workers are sent on the most high risk tasks: foraging and patrolling.
In ant colonies, there are thresholds of maturity of any colony where ant behaviour becomes less aggressive and more stable.
In colonies above a certain size, response to perturbations is more measured, less chaotic, and less urgent.
The redundancy existent in larger colonies allows recruitment to nest repairs that affords food collection to continue as if nothing has happened,
In less mature colonies, perturbations cause more chaos.
Two things seem pertinent here.
Structured progression of the maturity and capacity of the individuals;
And structured progression of the maturity and capacity of the colony.
Having worked in operating theatres of all sizes, in country, city and regional centres, it seems that theatre complexes of different sizes resemble colonies of differing maturity.
In each case, I don't think that is is the chronological age that points to behaviour, I presume that it is size that matters.
Country hospitals are small, and need to serve the community they are located in, no matter how diverse the geography and the demographic.
Regional centres have to act as both referral centres for the country hospitals, and serve the community they are located within.
Tertiary centres act as referral centres for everyone, and yet also serve their communities.
The size of each effects the amount of redundancy available, as does proportional investment in infrastructure.
You can see the problem.
Country hospitals behave like fledgling colonies. Everyone is a generalist, and the colony is well aware of the limitations of its resources.
Regional Centres are between thresholds. They have increased capacity, increased production pressure, but not the redundancy requisite to accommodate increases in workload or chaotic perturbations. They behave parochially and aggressively to perturbations.
City hospitals have capacity, redundancy, and concentrations of expertise. They are the specialist centres everyone looks to for hope.
Perturbations are accommodated, dealt with, and things return to business as usual.
What does this analogy deliver us?
Not much, except to realise the challenges and strategic benefits of each; that we can leverage as much as possible the unique functions and capabilities of each, and that we can make the choice to optimise the capacity of each to strategically manage their own perturbations.
The immature temptation is always to do too much with too little.
The mature response is to do enough with enough.
Wisdom is to understand the difference.
Simplicity is the key
Simplicity: Designing the minimum number of steps required to accomplish anything great.
For Apple, this means your final destination being no more than three clicks of the mouse away.
The true measure of design is not when there is nothing left to add
But when there is nothing left to take away
Which is what makes poetry beautiful.
I looked at my ants. Some look like they are gathered in the corner having a meeting.
And the other few not at the meeting are in the tunnel digging like there is no tomorrow.
Of course, everything I say here is inference.
I have no privileged access into an ant's mind.
Which is why I got them from outside the Psychology Department, so that they would know a thing or two about things like Confirmation Bias, the Stockholm Effect, Schrödinger's Cat, and the Stanford University Prison Experiment.
Not that they need to know these things, but they DO need to be able to remind me that these phenomena are as equally applicable to me as they are to anyone else.
So whilst one frame of reference is from Dreyfus and Dreyfus and Benner, taking skill acquisition from novice to advanced beginner to competent to proficient to expert, and from outside the 'group and grid' of Mary Douglas inwards towards the inner sanctum, in my mind, my ants go from larva to
pupa to hatchling to worker to forager to patroller from the inner sanctum out.
Attrition is reversed, because nursing loses its greatest number of aspirants at the beginning through various quantum gates placed in their path, whilst ants lose their greatest number after they have served a long and useful life.
So the next question I ask myself is:
Having a clearer view of what the possible outcome looks like, can we convert the running of an operation theatre complex into a super-colony?
Stay tuned for the next exciting episodes of:
'What Good is an Ant Farm?'!!!!
What good is an ant farm?
Dual Processing Theory of the Brain
So I think where I've gone wrong with my understanding of ant colony hierarchy is not that no-one is in charge, but that EVERYONE is in charge.
Not 'in charge' as we understand it, but in charge of their accountability to the nest.
The redundancy is not a redundancy in retreat, hiding from the dangers inherent in nature, but a redundancy awaiting advance, waiting for exactly the right time to leap into action, whatever task is required of it.
And differing ants have differing roles or expertise, so that the ones who are entrusted to store food....you know where you have to go when you have excess or insufficient food.
It is not always a peaceful environment: you can identify periods when colonies are getting established where there may be several queens who battle it out for dominance, but the forming and storming periods are over fairly quickly.
So in a hospital, we know where the resources lay when inter-personal conflict inevitably arises.
We know who has the expertise in ordering supplies, and who manages our ever-shortening supply lines.
But in the end, no-one is in charge of our engagement or our safety and quality.
We are ALL in charge of our safety and quality, and the more we are energised, effective and engaged, the more advancing redundancy we will be able to engineer to replace the avoidant and retreating redundancy.
In effect, the secret word in here is effectiveness.
We are, after all, a service industry, not a budget industry.
It is the difference between 'Chandelier Jetliners' and 'Bouncealot Air'.
A whole different flying experience.
But both are in the air right now, and surviving into the foreseeable future.
We know a lot about effectiveness, and what makes a human effective. Even from my own limited understanding of high performance teams, I can see where opportunities lie.
No-one in control?
Everyone in control?
It boils down to pretty much the same thing when viewed from the perspective of the superorganism.
Tactical redundancy for the purpose of strategic reinforcement?
Napoleon built a nation on it.
Twenty distinct behaviour-producing pheromone signals?
I can almost smell them now!!!!
Before we get to pheromone signals, lets talk about brain and behaviour.
We think that logicity governs our decision-making behaviour.
But I choose to disagree.
How many of us know, for example, that it would be good to give up smoking, but find it impossible?
We all know that for those who wait for their brains to be ready, it takes a fairly sizeable existential jolt.
For others, they change their behaviour, and eventually their brains catch up.
It is the same for beliefs.
How many of us have fixed beliefs about our beliefs, but act, in reality, in contravention of those beliefs?
My readings of cognitive behavioural advice to people with OCD say pretty much the same thing.
"If we change our behaviour in the face of our fears, our brains will eventually accept the disproportionality of our expectant worst-case imaginings."
The brain can be a powerful and a somewhat illogical governor of our behaviour, if we let it.
The dual processing theory of the brain demonstrates this nicely.
I feel it when I let my son drive me to the Gull Bus so that I can get to the airport.
Even though I believe, know and understand that the greatest discoveries in medicine have been made by accident, and I want to celebrate the victories that diversity offers us, I still feel uncomfortable when his navigation style differs from mine.
My style is dominated by the notion of the least number of turns of the steering wheel.
Haz's style is anywhere, everywhere, quickly.
The physiological benefit for me is that I never have to worry about getting a DVT, because my feet are getting plenty of exercise, reaching for non-existent clutches and brake pedals.
But he gets me there in plenty of time, each and every time.
So in terms of fatigue mitigation in nursing or re-engineering systems processes, the problem is the same:
So, for example, even if you are uncertain about the boundaries of risk around fatigue, if you change your behaviour and start making fatigue-mitigating decisions on behalf of yourself despite your uncertainty, your brain and your body may very well start to find within your newly re-framed methodology, some significant personal benefits.
But if you wait for the existential challenge that will convince the brain to change first, it may well be too late.
For me in the passenger seat?
Distract myself by finding an interesting discussion to descend into, and then listen.
When Haz gets me there, it's: "Hey, Haz. Great trip. Thanks for that. See you when I get home."
Behavioural change? Possible.
Feet instinctively not cramped when I get out of the car?
A new beginning.
Now. For those of you who have been wondering about the delay in publishing further data on my Antus Benner psychologica research, I have to warn you, things have changed.
I'm not sure how much you know about ants (Shot across the bow)
The ants I had were LAZY ants.
They sat all day and all night on a flake of Weetbix, and did bugger-all.
Except consume, elegantly, the fodder I had placed before them at considerable expense.
Frankly, I was getting tired of watching them not work.
Then, yesterday, when I was mowing the lawn, I glanced across at the outdoor table.....
AND THERE WAS A BIG ANT AND A LITTLE ANT, BOTH WITH WINGS, ENGAGED IN ANT INTERCOURSE!!!!!
Fortunately, I had invested considerably in building collaborative trust in my team, and so when it came time to invoke a sudden change in leadership behaviour to one of situational command and control, they complied with startled obedience.
Soon I had at my disposal the very instruments I needed to successfully negotiate the task at hand.
Haz arrived with a glass.
My wife arrived with a piece of paper,
And my daughter arrived with the ant farm.
The glass went over the two copulating specimens.
The paper slipped quietly underneath them.
And with no advanced warning, I sent a shudder through my workers in the form of a corporate restructure, and they were unceremoniously dumped into the garden to make what they could of the wild, wild world.
So now I have a queen, who has been most engaged in her new environment.
She immediately showed her commitment to organisational values by shedding her wings, as queens do, to demonstrate to all and sundry: "I'm in for the long haul, come what may!"
Overnight, a grey splotch has appeared in one of the tunnels.
I'm hoping they are eggs!
Soon, I may have my own fledgling colony thanks to leadership, luck, and my good fortune to have at my disposal the bones of an organisational infrastructure ripe for cultural change.
I hope to have baby photos VERY soon!