Our NHS People

Decision-making in uncertain times

Decision-making in uncertain times

A reflection on the masterclass

This blog references the first of three masterclasses for senior health and care leaders in England, run on the 19th November 2020 by The King’s Fund as part of the Our NHS People Executive Suite.

This reflective session explored participants’ experiences of how uncertainty has shown up in their organisations in recent months. Participants explored how decisions are made in the context of uncertainty and looked at some alternative approaches that can help to increase the range of options available to decision-makers.

How is uncertainty showing up in organisations?

Thinking about this question in organisations across the health and social care sector and across England, the group noticed that uncertainty showed up in different and sometimes contradictory ways. For example, some participants had experienced being freed up to innovate and take risks in their response to the Covid-19 pandemic – described as generating ‘practice-based evidence’ in the face of a traditional reliance on ‘evidence-based practice’. Conversely, others had intense experiences of the constraints placed on them as they made local decisions based on limited data and insufficient time, while managing competing and rapidly changing national directions. We also heard leaders describe their keenly felt responsibility for communicating clearly and providing direction for others while not being able to know what would happen as a result of their actions.

Some participants also spoke of a shift away from the momentum and camaraderie of the first wave of the pandemic towards more defensive behaviours and an increasing sense of fatigue. This added to the dependence on senior leaders to make significant decisions and increased feelings of pressure and responsibility to ‘get things right’ when it was impossible to know what ‘right’ was. In an echo of what we at The King’s Fund have heard previously about a systemic push towards heroic forms of leadership in the face of the crisis, the group reflected on their ambivalence towards command-and-control styles of leadership – appearing in control was felt to be both needed and disempowering to others who might well be able to contribute.

And if that wasn’t enough, the physical and emotional toll of the ongoing pandemic was compounded further by the reality that the uncertainty was not confined to work, it engulfed all aspects of life and there was little time or space for self-care and recuperation.

Responses to uncertainty – reverting to habits

Together, we considered the ways in which decision-making happens under these extreme circumstances, and the ways in which managing the anxiety associated with uncertainty can reproduce existing patterns of power, inclusion and exclusion in relationships and organisational life. Drawing on the French post-structuralist philosopher Michel Foucault’s concept of disciplinary power (Foucault 1977) and the social defences theory developed by British psychoanalyst, Isabel Menzies-Lyth (1960), we explored how the need to make decisions quickly and to focus on operational performance may have inadvertently crowded out space to think about the emotional impact on the workforce, including on senior leaders.

We considered examples of ‘classification’ as a pattern of power-relating, and wondered what impact the prioritisation of some clinical staff over others for personal protective equipment (PPE) might have had on the morale of the workforce? And what might this mean for teamwork in the future? We thought about how prioritising the hospital sector might set back work on integration, or have diminished the importance of other parts of the sector? And we spent some time considering how social defences, such as increases in reporting, checks, counter-checks, and the splitting up of activities into ritual tasks, might account for the growing sense of fatigue we heard described. In addition to the physical challenges involved in the response to the pandemic, maintaining these defences has an emotional toll of its own.

Some alternatives?

Of course, responses to uncertainty will vary from place to place, team to team, and individual to individual. Our group concluded that there were a few things that could help:

  • creating more spaces to reflect on how people are working together and to engage with uncertainty, and making it safe for people to speak up in those spaces
  • looking for patterns of inclusion and exclusion, and new opportunities to collaborate and communicate in different ways
  • redistributing responsibility for clarifying purpose and co-creating certainty so that it is a joint endeavour rather than pushed or pulled up to the most senior circle.

Making decisions in contexts of uncertainty is a compromised task for any leader, and we can often find ourselves reaching for what is familiar in the way we understand and approach the challenges facing us. But the comfort and certainty these ‘business as usual’ approaches offer us is illusory in the face of complex, novel problems like the pandemic. Time and again we’ve heard that what helps is finding ways to slow down and deepen our thinking, to make sense of the complexity with others, to pay attention to the patterns playing out in the uncertainty, and to hold to purpose. None of this is easy or instinctive in hierarchical systems like the NHS, but as we heard from participants, it can be done.         

References

Foucault M (1977). Discipline and punish: the birth of the prison. Trans. Alan Sheridan. London: Allen Lane.

Menzies I (1960). ‘A case-study in the functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital’. Human Relations, vol 13, no 2, pp 95-121.