Evaluating organizational response to a cognitive problem: A human factors approach

Evaluating Organizational Response to a Cognitive Problem: A Human Factors Approach by Elizabeth May Serig The commission of error is often perceived as the result of such internal attributes as negligence, laziness, carelessness, and inattention. In organizational settings, such a perception often leads to the administration of punitive actions against the responsible individual. Recent research on error, however, has moved thinking from a “conventional wisdom” perspective of human error to a systems perspective. According to this systems perspective, humans are remarkably reliable “stand-alone” systems, and errors tend to arise primarily when humans interact with technological systems. Errors can be triggered by technology and its environment, as a result of the way these factors interact and challenge human limitations. Byrne and Bovair (1997) found that the commission of a particular type of error, postcompletion error, is related to a high working memory load imposed by external forces or task complexity. Two experiments were designed to assess the effects of typical organizational responses to error on the commission of postcompletion errors over time. Because organizations tend to assume that errors are under the control of the individual, methods such as reprimands and re-instruction are often administered to “motivate” individuals to not commit errors. Similarly, praise is often administered to encourage the continuation of appropriate behavior. A systems perspective, however, would argue that a troublesome task should be redesigned to accommodate the limitations of the human cognitive system under certain circumstances. The results of the experiments reported here indicated that, over time, simple tasks were learned so well that people made few errors, and therefore, responses to error appeared to have little effect on the commission of error. It was found, however, that when a task was redesigned, participants were much quicker at executing a critical redesigned task step than participants who were reprimanded, received re-instruction, or were praised for their performance. This indicates that the cost of low-error performance for these participants came at the cost of increased time to complete the critical step, further indicating that these participants had to consciously expend effort to not commit the error. ACKNOWLEDGMENTS For sharing their time and expertise, I would like to express my appreciation to the members of the committee: Dr. Kenneth R. Laughery, Sr., Dr. Michael D. Byrne, Dr. James R. Pomerantz, and Dr. H. Albert Napier. Their comments, constructive criticisms, and support have proven invaluable throughout this process. In particular, I would like to thank Dr. Byrne for developing the software application for the Bridge Officer Qualification Tasks. Additionally, I would like to thank those others without whom this research never would have been completed: Brian Webster for helping with the software application development, Bryan Blauvelt and Peter Centgraf for running participants, Monica Freedman for developing the reverse digit-span task, all the guys in the CHIL lab for pitching in when I needed it, the Office of Performance Improvement at The University of Texas M. D. Anderson Cancer Center for giving me a chance and letting me abuse office supplies, and finally, Ashley Sides for being moral support and for helping me with that most important but frustrating of all tasks pinning down the details of experimental design. I would like to dedicate my dissertation to my family (and yes, that means you too, Bob); the best darn “autistic” committee around. Your input, support, patience in the face of incessant babbling, data mangling, and most importantly, kicks in the butt have made all the difference. Finally, where would I be without my “boys” Jake, Tucker and Tyler who let me know when it was time to work, time to take a break, and time to break out the Friskies. TABLE OF CONTENTS INTRODUCTION AND OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 HUMAN ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 WHAT ARE ERRORS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 TWO PERSPECTIVES ON ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 SYSTEMS THEORIES OF ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 POSTCOMPLETION ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 GENERAL THEORY OF POSTCOMPLETION ERROR . . . . . . . . . . . 13 COMPUTATIONAL MODEL OF POSTCOMPLETION ERROR . . . . 15 ORGANIZATIONAL RESPONSES TO ERROR . . . . . . . . . . . . . . . . . . . . . . . 17 MODEL OF ORGANIZATIONAL DISCIPLINE . . . . . . . . . . . . . . . . . 18 ORGANIZATIONAL DISCIPLINE IN HEALTHCARE . . . . . . . . . . . . 23 THE UNDERLYING ASSUMPTION OF ORGANIZATIONAL RESPONSES TO ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 EXPERIMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 EXPERIMENT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 EXPERIMENT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 MATERIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 PROCEDURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 vi TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 OVERALL TASK PERFORMANCE . . . . . . . . . . . . . . . 78 PERFORMANCE AT “TURN OFF TRACKING” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PERFORMANCE AT “POWER CONNECTED 1" AND “SCANNER ON” . . . . . . . . . . . . . . . . . . . . . . . . . . 88 PERFORMANCE AT “POWER CONNECTED 2" AND “SCANNER OFF” . . . . . . . . . . . . . . . . . . . . . . . . . 93 LETTER RECALL TASK . . . . . . . . . . . . . . . . . . . . . . . . 96 WORKING MEMORY CAPACITY . . . . . . . . . . . . . . . 98 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 GENERAL DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 GENERAL MODEL OF TASK PERFORMANCE OVER TIME . . . . . . . . . . 106 COGNITIVE COMPONENTS OF TASK PERFORMANCE . . . . . . . 106 SKILL ACQUISITION IN LEARNING . . . . . . . . . . . . . . . . . . 106 WORKING MEMORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 INTEGRATED MODEL OF OVERALL TASK PERFORMANCE OVER TIME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 APPENDIX A OPERATIONS OFFICER QUALIFYING EXAMS: CADET MANUAL . . . . . . . . . . 126 APPENDIX B TACTICAL TASK TRAINING MANUAL: POSTCOMPLETION VERSION . . . . . 129 APPENDIX C TACTICAL TASK TRAINING MANUAL: CONTROL VERSION . . . . . . . . . . . . . . 142 APPENDIX D TRANSPORTER TASK TRAINING MANUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 APPENDIX E CONN TASK TRAINING MANUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 vii APPENDIX F OPERATIONS TASK TRAINING MANUAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 APPENDIX G EXIT QUESTIONNAIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 APPENDIX G-1 EXIT QUESTIONNAIRE FOR CONTROL AND POSTCOMPLETION CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 APPENDIX G-2 EXIT QUESTIONNAIRE FOR REPRIMAND CONDITION . . . . . . . . . . . . . 185 APPENDIX G-3 EXIT QUESTIONNAIRE FOR RE-INSTRUCTION CONDITION . . . . . . . . 189 APPENDIX G-4 EXIT QUESTIONNAIRE FOR PRAISE CONDITION . . . . . . . . . . . . . . . . . . 193 APPENDIX G-5 EXIT QUESTIONNAIRE FOR REDESIGN CONDITION . . . . . . . . . . . . . . . 197 LIST OF TABLES TABLE 1. CORRECTIVE ACTIONS TAKEN BY NRC LICENSEES IN RESPONSE TO RADIOPHARMACEUTICAL MISADMINISTRATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 TABLE 2. EXPERIMENT 2: INTERVENTION TEXT FOR THE REPRIMAN