Today’s Observer has a lead article with a very scary message. I quote:.
THE TRUE scale of Britain's hospital superbug problems emerged yesterday as a leading hospital trust admitted that a 'hypervirulent' infection had claimed the lives of at least 49 patients – and possibly as many as 78 people – in the space of nine months…..
….. The increase in cases is partly due to dirty wards, but also to a shortage of beds. The bacterium has also become more deadly because it has mutated genetically, becoming resistant to other treatments
This got me thinking about a couple of things. Firstly a paradox, in that we are giving the bugs exposure to danger which we no longer give our children; thus increasing the resilience of one at the expense of the other. Secondly that the inter-connectedness of health systems creates a complex system of great interest and importance. I was working on the chapter in the book which deals with the tractable aspects of intractable systems over the weekend. This was also in preparation for a major experiment in a weeks time, designed to create a method using the concept of attractors that satisfies Verna’s criteria in yesterdays blog. So there follows an attractor type listing and a summary of the differences between human and other complex systems all leading to a thesis of the matron in a hospital as a strange attractor: foolishly abandoned in the late 60’s but now possibly being restored.
I almost missed the article. I had been working all day (bar a lunch meeting) and was up to my neck in epistemological disputes (both from the books and in my head). By way of relief I brought up the on line version of the Observer and went looking for match reports on the Anglo-Welsh Cup in Rugby. I would normally be physically at there, but as a result of the Singapore sabbatical I have to confine myself to explicit rather than experiential knowledge. The poverty of an written rendering of an emotional experience just confirms my view that the tacit cannot be made explicit. The important result was Cardiff Blues 36 London Wasps 20 (Overall Welsh clubs took 3:1 over English in matches, 128-87 in points and 16-9 in tries across the weekend, although results did go with home advantage to be fair), so celebrations all round there.
However I then went to the main section of the paper any elation was suppressed by the depressing front page story from which I quote above. This seemed to come together with my thinking during the day relating to both attractors, but also the question of resilience which I will address first.
There is a paradox around the issue of hygiene. On the one hand there is some evidence that we are more vulnerable (or at least our children are) to infection because we live in a too sterile environment. I read somewhere that increased asthma levels were in part due to lack of exposure to dust particles etc during key phases in childhood development. I know that my generation have a whole host of anti-bodies swirling around in our system as we went through mumps, both types of measles, scarlet fever, chicken pox, some exposure to TB and so on. I also think we are less secure against social issues but that has already had an airing.
Now I am not arguing a case for less hospital hygiene. No question that it is necessary and currently not sufficient. But overall we seem to be giving the bugs the benefits of learning through failure that we are not giving our children. Steam cleaning now has to take over, as chemicals do not work:cost and consequences rise in equal proportions. We can see the same in antibiotics. My father was a Vet, son of a farmer and railed long and hard for as long as I can remember that we were over using antibiotics. He belonged to the generation where a farm accident could lead to blood poisoning followed by amputation and/or death and where pneumonia was a killer. Using them in animal feed, dispensing them to people for flu (where they could make no difference) made him angry. He argued prophetically that the drugs would have less effect as the bugs adapted. He also argued that chemical cleaners and drugs were being used as a cheap substitute for good habits and basic cleanliness. The use of antibiotics in off the shelf cleaners really sent him mad. As he said they will kill of the basic bacterial that do not harm and leave space for the really nasty stuff.
Now that leads me to the question of attractors. If you read the text books there are three types, all trajectories that can be defined by their end points. We have
Point Attractors sometimes illustrated by a pendulum which settles to a single point, or water sloshing around a bowl which will end up at the lowest point.
Limit Cycle Attractors where the system oscillates in respect of position and velocity, repeating periodically.
Strange Attractors which is an evolutionary form of the system itself which permits high degrees of individual behaviour and in which the end point is always different. You will find a lot of fractal mathematics if you search google for this and some very pretty pictures.
Now as many of you know I don’t think we can treat human systems in the same way as chemical reactions and insect behaviour. Human systems are unique in several respects:
Now there are probably others and comments and contributions would be very welcome. But to come back to the main point. We need to rethink the concept of attractors for human systems. Now the experiments in a weeks time will be a part of that. For the moment I have had a notion for some time that human social systems have generated an interesting type of strange attractor which I will call the senior non-commissioned officer role. The Regimental Sergeant Major (Staff Sergeant for US readers), the senior Secretary and the Matron.
If we look at the evolution of the role of the Matron. Its tied up with the development of British Nursing post the Crimean War. In summary a school leaver at 16 would decide to become a nurse. She (and they were mostly female) would then take a very junior role with basic duties including cleaning. The Matron was a terrifying figure around who the hospital largely self-organised. Doctors were theoretically in charge, but defying the matron was not a good idea. All the things that the formal systems did not handle she did. Gradually our trainee nurse would rise through the ranks and one day discovered that she was the Matron and people were now afraid of her. The institution was not formed by diktat of management, it had evolved and the practices and expectations had evolved around it. In other words the Matron was in complexity terms a strange attractor. The activity around her was diverse and varied, but she formed an organising structure. When the Matron was abolished as a role it was done without real depth of inquiry. Its no coincidence that the late 60;s and early 70’s in the UK represent a dismal period in architecture; function was everything. For the consultants and civil servants looking at the health service the Matron was a surplus level of management that could be engineered out of the system. Their questions looked for formal function rather than organising principles and the matrons only knew what they knew when they needed to know it so they could not volunteer information outside the context of its use.
My argument is then simple, and we come full circle to the quoted article. One of the main functions of the Matron was the cleanliness of the hospital which was seen as a part of the total clinical function in practice (it may not have been explicit but it was imbedded into the role). Junior nurses were also engaged in that function along with more traditional nursing duties. Shortly after the Matron was removed, the momentum of engineering and its twin privatisation resulting in cleaning being outsourced to firms who cleaned offices with the cheapest possible labour, mostly falling below any reasonable minimum wage. In those circumstances its not surprising that problems arose, its only surprising that it has taken this long to surface.
The message from this is that its critical to know the attractor (and especially the strange attractor) mechanisms in play before you attempt an major organisational and social change. We already do that to a degree in Cognitive Edge, but its a major focus of work for the next couple of weeks so watch out for more posts on this subject.
Over two years ago I spent the best part of two months in the cancer unit of Ysbyty Gwynedd . My parents died within 10 days of each other and my sister and I more or less were watch on watch off through out the period. I got to know many of the nurses and also got to talk with them and observe their working practices. They were all outstanding by the way and braver than me. They used informal networks to fix problems, focusing on the patients rather than procedure and also used narrative extensively to transfer key knowledge. One of the things that several of them said to me was that they were not happy with the trend to bring in non-nurses to clean patients. It was seen as making Nurses too like Doctors and thus reducing the intimacy of the relationship which had allowed additional diagnostic scanning. Its another example of a complex system working in ways that are difficult to formalise, but very easy to destroy.
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