Judgmental feedback from managers to field experts is one of the topics that penalise reporting the most: they do not want to hand them the stick to beat them with. This expression comes up often when talking about reporting. Field experts have the feeling that they are judged like children who are given approval or disapproval by external people who do not know their work. Nonetheless, it all depends on how analysts approach feedback: “before, it was like we were put on trial, so reporting stopped, then, when X arrived, it started to increase again”. Analyst selection and training on benevolent listening and constructive criticism therefore shows much room for improvement.
Anonymity is somehow relative, whether the feedback comes from peers, or from management, whether it is implicit or explicit. In this organisation, anonymity is a feature of
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the system, but analysts need to contact the field experts affected to analyse safety events better. If needed, after they are studied by managers, events are analysed during a local safety committee, with managers from different services, the controllers affected, and their representatives. And, if necessary, the event is analysed on a national level, with a representative of the local analysts. Along this process, anonymity is relatively respected, but, locally, peers witness the event, and rumours are the same wherever you work.
Judgmental feedback can have different causes, for instance culture. Analysts are nearly always former controllers who passed very selective and competitive exams, and are used their performance’s being judged harshly, sometimes very harshly. Initial training can leave marks on them: unreasonable performance demands, or a belief that perfect performance is possible. The tendency is then to judge others in the same way they have been judged by authority (family authority, school teachers, instructors, and then managers). The cultural differences between organisations or countries are then particularly relevant: hierarchy distance has been thoroughly studied (Hofstede, 2010).
The analyst position is indeed highly sensitive. It requires some delicate diplomacy, in listening, debriefing, pulling back into line when needed, at risk of counter-productive actions that trigger defence mechanisms from the field experts. It is indeed essential to both supports, understand and provide constructive criticism, set limits, in order to foster a genuine just culture within the safety culture. This delicate position, as many jobs based on human relationships, requires debriefings between peers affected by similar issues. Actually, when professionals from other sectors encounter interpersonal risks that can affect their work, they receive practise analysis, debriefings, supervision, to get hindsight and insight into their work, to analyse it better and in greater depth, and to adjust the way they work to people, situations and issues. In some sectors, this kind of specific training is even mandatory.
Additionally, in this organisation, analyst training focuses exclusively on technical skills, and not at all on non-technical skills or knowledge. The safety events analysis therefore lacks this knowledge. Understanding elements of the operational constraints like cognitive trade-offs that happen in real life are rarely taken into account in the analysis. As they are not known by analysts, they are hardly conceptualised, and mostly put aside, to the benefit of the technical elements of the analysis and of an old conception of the individual “human error”. Analysis misses’ elements about work organisation and systemic vision, which would permit a shift away from an antiquated vision of safety centred on the “human error” of the first line operator.
Another point about this incomplete analysis is the level analysed. It is only the first line level, the field expert level, not the intermediary or high levels of the organisation that are analysed on their decision-making process. This is resented as unfair by the field experts: because they have to find solutions to all problems that have not been anticipated and managed by the hierarchy, this system shows some disequilibrium between decision-making process on the field and on the high spheres, that they have to endure and compensate for. It also ends up with putting all the weight of safety on their shoulders: if they are the only ones who provoke safety events, are they the only ones responsible for safety? In this case, going a little further in the reasoning: what is management worth? And still a little bit further, what are the rules, norms, and regulations enacted by management worth?
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- Training aimed at analysts and focusing on Organisational and Human Factors, such as cognitive operating in the real world, cognitive trade-offs, better understanding and managing of violations,
- training about non-judgment, active listening, and benevolent listening, non-violent communication, would improve analysis, as well as constructive criticism and assertive communication, taking into account the person, his-her operating modes, and reactions. They have to “connect before correct”. Analysts would benefit from a better understanding of resistance and protection mechanisms when they question field experts, mechanisms that play a role during analysis and interviews: denial, passive aggressiveness, sidesteps, evasion, banalisation, aggressive projecting, lies…
- Debriefings or practise analysis may help analysts to analyse their own practise, and to lighten the burden of evaluating the work of their colleagues, to give recommendations, without assuming an omnipotent position over the others, which can sometimes be counter-productive in reporting. Helping field experts to reflect on their practise instead of judging it can bring more individual and collective intelligence.
- Analyst recruiting could be improved by taking into account these soft skills.
- In-depth training on safety culture and on Organisational and Human Factors could also improve analysis by taking into account systemic and contextual factors. Field experts would then understand that the safety committee is not there to judge them, but to judge safety events. In addition, safety actions would therefore be more relevant.
To help field experts who are nonetheless the second victims of safety events, as stated in health systems, it would be interested to know what they would prefer when bad events happen. When there is an unwanted event, peers and managers do not know how to behave with the field experts affected. Should they talk about it, should they talk about other common subjects, should they say nothing? Or just ask them how they feel? Or what do they prefer? In these very sensitive times for all those affected, it is important to favor collective intelligence.
Of course, offering specific support to them when bad things happen is essential, for the safety as well as the efficiency of the system. The Critical Incident Stress Management is an important tool to implement in units, to enable field experts to recover with no after-effect for them and for their work.