“Development is always going to destabilize a fragile balance of social forces.”

Via the work of John Adams, I have had some familiarity with the Douglas-Wildavsky Cultural Theory of Risk. Like this reviewer, I find the Douglas/Wildavksy treatment of environmentalism rather crude, while their overall cultural typology of risk stimulating. As the reviewer points out:

Most readers will be struck not by the abstract theory but by its application
to the rise of environmentalism. This emphasis is unfortunate. The
attempt to “explain” environmentalism makes a few good points, but on
the whole this part of the book is crude, shortsighted, and snide.3 On the
other hand, the sections that consider the relationship between risk and
culture on a more fundamental level are sensitive and thoughtful.
Even at its best, Risk and Culture is not entirely successful at explaining
the paradox of risk-the problem of managing the unknown-but
parts of the book deserve to be read seriously by people interested in the
problem of risk, including environmental lawyers.



I am now reading Mary Douglas directly, in currently her Culture and Crises.: Understanding Risk and Resolution  Although she has a prose style that sometimes grates, and I am wary of possibly being unaware of technical anthropological issues that may be taken-for-granted, there is much to enjoy and think about.

Here is a brief quote from one essay – Traditional Culture, Let’s Here No More About It, which follows a passage about the occasional pitting against each other of development and “traditional culture” (usually, under western eyes, to the detriment of traditional culture):

Development is always going to destabilise a fragile balance of social forces. The people are understandably reluctant to do the gruelling hard work and accept the diversion of resources if the resulting prosperity will only line the pockets of outsiders. Furthermore, if it going to erode the community’s accumulated store of trust, and dissolve their traditional readiness to collaborate, the well-being of the community may be worse after development than before. There certainly is inherent ambiguity about the moral case. At least we can say that what stops development is not cultural traditionalism so much as the way it arrives, how it is organised.

This applies – in spades – to the many many “cultural change” / “transformation” etc projects that health services become the subject of. The suspicion that sacrifice and hard work on the part of staff will benefit only a narrow few (the Minister getting good headlines, various outside consultancies, higher management) surely underlies some at least of the cynicism about such projects that is undoubtedly prevalent.



“Happy Organisations and Happy Workers” – blog post by Maria Quinlan

On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan  has a blog post entitled
“Happy Organisations and Happy Workers – a key factor in implementing digital health”

The whole is worth a read. Of course, having a happy organisation made up of happy workers is inherently important of itself, as well as from the point of view of implementing digital health. As Dr Quinlan writes in the first paragraph:

To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions.  If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.

Reading this, I am struck by how important it is to make time in a day with an accumulation of pressing demands for reflection:


What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout [2]. Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key [1].  As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” [3]

Managing what Sigal Barsade, Professor of Management at Wharton calls the ‘emotional’ culture of an organisation is a very important concept – especially in the healthcare environment which expects so much of staff [4]. Healthcare workers face pressures which many of us working in other fields can’t really comprehend, a recent systematic review found that clinicians have higher rates of suicidal ideation than the general population, with a high prevalence of burnout, psychiatric morbidity and depression linked to excessive workload [5].  Attempting to introduce innovative new ways of working within such constrained environments can be challenging to say the least. Exhausted workers, those with little time in their day for reflection, or those who work in organisations which fear failure are less likely to innovate [6].

Much of the rhetoric around healthcare innovation tends to be messianic in tone. A gap between this rhetoric and the messy, pressured reality of healthcare can diminish the credibility of innovators.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

Drawing from their work researching healthcare organisations ability to handle complex transitions in the US, Jaen et al (2010) developed a 23-item scale measure for what they term ‘adaptive reserve’. Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.

Overall, this a fascinating blog post on an issue which is close to my heart. I intend to post some more on this topic over the next while.


Risk and innovation: reflections post #IrishMed tweetchat on Innovation in Health Care:


Last night there was an #Irishmed  tweetchat on Innovation and Healthcare . For those unfamiliar with this format, for an hour (from 10 pm Irish time) there is a co-ordinated tweet chat curated by Dr Liam Farrell and various guest. Every ten minutes or so a new theme/topic is introduced. There’s a little background here to last night’s chat. The themes were:


T1 – What does the term ‘Innovation in healthcare’ mean to you?

T2- What are the main challenges faced by healthcare organisations to be innovative and how do we overcome them?

T3 -What role does IT play in the innovation process?

T4 – How can innovations in health technology empower patients to own manage their own care?

T5 – How can we encourage collaboration to ensure innovation across specialties & care settings?

I’ve blogged before about some of my social media ambivalence, especially discussing complex issue. However I was favourably impressed – again – by the quality of discussion and a willingness to recognise nuance and complexity. The themes which tended to emerge were the importance of prioritising the person at the heart of healthcare, and  that innovation in healthcare should not be for its own sake but for improving outcomes and quality of care.

One aspect I ended up tweeting about myself was the issue of risk. In the innovation world, “risk-averse” is an insult. We can see this in the wider culture, with terms like “disruptive” becoming almost entirely positive, and a change in the public rhetoric around failure (whether this is actually leading to a deeper culture change is another question). In healthcare, for understandable reasons, risk is not something one simply tolerates blithely. It seems to me rather easy to decry this as an organisational failing – would you go to a hospital that wasn’t “risk-averse?” The other side of this is that pretending an organisation is innovative if it has very little risk tolerance is absurd. Innovation involves the unknown and the unknown inherently involves risk and unintended consequences . You can’t have innovation in a rigorously planned, predictable way, in healthcare or anywhere else.

I don’t have time to write about this in much detail, but it does strike me that this issue of risk and risk tolerance is key to this issue. It is easy to talk broadly about “culture” but in the end we are dealing not only with systems, but with individuals within that system with different views and experiences of risk. I have in the past found the writings of John Adams and the Douglas-Wildavsky  model of risk helpful in this regard (disclaimer: I am not endorsing all of the above authors views) and perhaps will return to this topic over the coming weeks. Find below an image of a “risk thermostat”: one of Adams’ ideas is that individuals and systems have a certain level of risk tolerance and reducing risk exposure in one area may lead to more risky behaviour in another (his example is drivers driving carefully by speed traps/black spot signs and more recklessly elsewhere)