PNR Paper

The limits of checklists: paradigmatic versus narrative thinking

Hilligoss, Brian & Moffatt-Bruce, Susan. (2014). The limits of checklists: Handoff and narrative thinking. BMJ quality & safety. 23. . 10.1136/bmjqs-2013–002705.

In 2009, Atul Gawande published The Checklist Manifesto which focused on how well-designed checklists can improve outcomes. Although the book was quite popular, we need to be careful to apply checklists in the right situation, because they have limits and are by no means replacement for critical thinking.

Bottom line: Checklists are successful when they outline step-by-step instructions where the context is immaterial. However, standardized, structured approaches are not appropriate when it involves understanding complex situations and handling ambiguities and unpredictable variation.

Why it matters: Checklists are appropriate for simple or complicated problems, not complex ones. Let’s differentiate between the different kinds of problems:

  • Simple problems require little expertise and can be addressed using highly standardized, formulaic solutions.
  • Complicated problems, which come from multiple causes and parts, can be solved by breaking it down and managing the individual parts.
  • Complex problems involve multiple causes and parts, but the complexity emerges from moving parts, such that it’s impossible to look at individual parts.

Distinguishing between complicated and complex tasks is important because humans rely on different modes of thinking when dealing with different problems.

What they found: When dealing with simple and complicated problems, humans rely on paradigmatic thinking, whereas we rely on narrative thinking when we deal with complex problems. Humans depend on both, which is compared in the table below.

  • The paradigmatic mode tries to apply general conditions to problems. It organizes knowledge into hierarchical categories, the context and circumstances are irrelevant. In the paper, the authors use the example of a sterile insertion in the controlled environment of an intensive care unit to show the paradigmatic mode in action. In such environment, the particular context matters little, as the generalized knowledge base exists to perform a standard procedure. In this case, diverging from standard procedures can even lead to complications and bad outcomes.
  • The narrative mode organizes knowledge into a story, linking specific events into a whole by looking at connections among them. In the paper, the authors use the example of communicating a patient plan of care to show the narrative mode in action. When handing off responsibility at a shift change or transferring the patient to a different unit, caregivers can’t use abstract generalizations, as they need to focus on communicating the complexities and particularities of the patient at hand.

Final words: Storytelling has been an important part of human communication as it helps make sense of complex situations and its ambiguities. As the world becomes increasingly complex, the narrative mode will most likely become more and more important. As such, we need to differentiate between complex tasks that draw that narrative mode and simple and complicated tasks that will draw the pragmatic mode. Differentiating these modes of thoughts will help managers build the right processes given the right context and adapt it as the situations evolve.