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What and how should we measure to support recovery from injury?

25 May 2017

What and how should we measure to support recovery from injury?

           

Not everything that can be counted counts, and not everything that counts can be counted[1]

Albert Einstein (attributed)

Some years ago, tired of my irritating enquiries about the quality of their school day, my teenage sons started to respond to my question - how was your day boys? with a score.  Seven they would say. This response worked well for them because it relieved them of the cognitive effort of recounting their daily activities. The humour, they knew, emerged from the absurdity of responding to something so complex with such an oversimplified rating or score. But how often do we try to reduce complexity, to improve our understanding, by quantifying? Why do we continue to assume we can convert subjectivity into objectivity, by assigning a number?

In injury support we measure return to work rates, duration of injury and cost of rehabilitation. We also measure lost time and injury frequency. Once we have these metrics in front of us, it is impossible not to attribute meaning to them.  And these attributions affect our thinking. One of the most common attributions that I hear expressed are words to the effect that you know, its been x weeks or months now and they still are not better. They should be better by now. The inference is that recovery should follow a linear trajectory. This is then manifest in RTW plans that predict a graduated upgrade over a timeframe that is extracted, sometimes painfully, from treating health professionals. It also manifests as claims costs and premiums, variations of which, drive attribution laden decision making about prevention programs and liability assessments and the latest faddish intervention.

I recently read an article published in Mamamia[2] by journalist Jane Caro, Poor results are a failure of NAPLAN, not teachers.

Caro wrote

human children have an irritating tendency not to behave like inert raw materials. They doggedly refuse to fit simple formulas. They do not and never have continuously improved. This years eight- year -olds need to meet their developmental milestones earlier than last years eight-year-olds ad infinitum, according to Birminghams convoluted logic. 

Indeed, every school can tell you they can have an excellent cohort one year and a much less high achieving one the next; same school, same teachers, same curriculum, just different kids. Damn those human children and their stubborn refusal to respond in the same way to the same stimuli. They do not even do it at home, little bastards. Every parent with more than one child can tell you that what works with one often utterly fails with the other.

Caros characterisation of children easily survives extrapolation to injured workers.

Damn those injured workers and their stubborn refusal to respond in the same way to the same stimuli.

Substitute a schools NAPLAN scores for an annual workers compensation premium and consider the reaction of the same organisation, the same workers, the same approach to injury support in light of an increased or decreased annual premium. To borrow again from Car

Every health professional with more than one patient can tell you that what works with one often utterly fails with the other.

In his book Creative Schools [3], Ken Robinson discusses a teacher, Jo Bower from Alberta, Canada, who concluded that the obsession with measurement was getting in the way of teaching and learning.

Bower says that:

When we try to reduce something that is as magnificently messy as real learning, we always conceal far more than we ever reveal.

If we are to find our way and make learning, not grading, the primary focus of school, then we need to abandon our mania for reducing learning and people to numbers.

Ken Robinson discusses an alternative to standardised testing and grading. He talks about assessment as a learning tool. He describes how students can be encouraged to keep a record of their learning in a way that empowers them to learn about their own learning. He describes a situation where the ultimate goal is assessment as learning.

Injured people are usually intensely interested in measuring. They want to know how long until they will be better, when they will be normal again. They also want to measure the opportunity cost of being injured. They want to measure the effect this will have on their relationships, at work, at home and at play.

My theory that injury support provides an opportunity to strengthen relationships (see previous blog) implies that we might want to measure the strength of relationships.

We do of course measure the strength of our relationships constantly. We measure the utility of time spent in various endeavours. We measure the performance of our children and our children measure us by the amount of quality attention and time we give them, as do our partners and our work colleagues. We have a daily intuitive, and often non-conscious, feeling about how we spent our time. These measurements may not have validity in a strict rationalist/scientific sense, and they defy quantification. In fact, there is something offensive about asking someone to quantify the strength their close personal relationships, despite their importance. We are well served by a fluid, subjective and intuitive sense. When our close relationships are challenged, we discuss them, we apply significant cognitive effort to making sense of them and we act to assess and repair them. Quantification adds little value.

In her book Life on the Screen (1995), Sherry Turkle discusses the concept of bricolage as it applies to problem solving in code projects and workspace productivity. Karl Weick applies this term to organizational learning. Turkle advocates the bricoleur style of programming as a valid and under-examined alternative to what she describes as the conventional structured planner approach. In this style of coding, the programmer works without an exhaustive preliminary specification, opting instead for a step-by-step growth and re-evaluation process. In her essay Epistemological Pluralism, Turkle writes:

The bricoleur resembles the painter who stands back between brushstrokes, looks at the canvas, and only after this contemplation, decides what to do next. [4]

Imagine partnering with an injured worker in a way that encouraged and supported them to engage in bricolage.

When I listen to injured workers I invariably hear them verbalise their sense-making. They usually have an explanation that seems flawed to me at face value. It is often the product of multiple inputs from experts and friends, infused with fear of the unknown around their recovery and their vocation. My instinctive reaction is usually to start strategising over how to correct their errant perspective. This strategising is well intended but poorly informed. It assumes that people can be fixed by doing what I say.  It fails to respect the sense-making they are immersed in and it imposes a pace that a flooded mind can not keep up with. It is anxiety provoking and it trespasses upon their learning. When we impose exercise programs we talk a lot about pacing, but we rarely consider how we pace the information dump, we tend to assume more information is always better.

But what if we took a different approach? What if we recognised that their articulation, as flawed as it may sound, is a by-product of their learning? What if we were to encourage and facilitate self assessment as learning? When we dig a little deeper into an understanding of pedagogy (how people learn) we notice that people are not always ready to hear from us. We notice that a data dump lacks efficacy, regardless of the efficacy of the treatment/intervention we are trying to impose. Providing information and recording the act on file makes us think we have delivered education. My experience is that my educational efforts, previously packaged in the form of a monologue, fall on deaf (or more aptly expressed flooded) ears. I do not know how many conversations i have had with employers and insurers and health professionals about how we have provided information that has not been heeded.  It is easy to conclude that the recipient just is not listening. Once blame has been apportioned it is easy to move on, satisfied that we have all done our job with a, conveniently categorised, difficult person.

I feel like the metrics we have in front of us shape the narrative and subsequent enactment. I wonder whether a greater respect for subjective considerations of the strength of relationships might change the way we think and interact with the people we are trying to support? I wonder if very different narratives would emerge from this approach?

 

[1] Einstein, Albert

[2] http://www.mamamia.com.au/naplan-standardised-tests/

[3] Robinson, Ken and Aronica, Lou (2015). Creative Schools ,Revolutionising education from the ground up. Penguin Publishing, UK.

[4] Turkle, Sherry. Epistemological Pluralism. Papert.org.

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