The ED as a social construction, and some personal notes

I’m interested in sense-making and cross-silo collaboration in complex environments. Despite these topics simmering inside of me for about a decade, it took time to articulate these interests into a short coherent sentence. The seeds were planted in 2006, whilst working on an oil platform as a medic, and it kept growing as I continued reading, experiencing and learning e.g. doing an MBA and a BTech Management. Eventually, it culminated into one study a PhD allowing me the opportunity to explore sense-making and operational decision-making in Emergency Centres (EC) as complex environments.

I chose a few public hospital ECs, all situated in Cape Town. The study was divided into two main parts, first a description of the ECs detailing and comparing policy, procedure and daily happenings.  After that, I explored how people make sense of their complex environment e.g. how and when they share of information, level of collaboration, trust, communication and beliefs regarding other disciplines and management.

The social constructionist stance

The research was approached from a social constructionist view; I argued that the EC staff create their own reality and that knowledge is generated and shared via social processes. Thus, social relationships shape how the team or workgroup experience their situation/reality. Management literature describes social networks to be a key determinant of resilience. In turn, resilience is a vital characteristic of high-reliability organisations (HROs).

Linking stories and culture

People interact by swapping stories and sharing their account of events.  Some of these accounts are repeated and in time it is accepted as truth, demonstrating how things happen ‘here’. In a way, it becomes a self-fulfilling prophecy – because people are more likely to see what they are scanning for whilst disregarding some other aspects in the environment. Newcomers are rapidly introduced into how things are done and what to notice and what not i.e. the culture of the workgroup. The culture is reinforced via daily rituals, communication, and anecdotes.

The underlying beliefs (and culture) determine vital interactions e.g. level of engagement, the ‘allowed’ social networks, level of transparency, trust and sharing between peers, other disciplines and those holding positional power (management).

For example, if the prevailing story is that management is ‘out to get people’ or that management cannot be trusted – the operational staff will protect themselves by withholding information and will not report minor mishaps, errors or events. For as long as the prevailing story sticks no progress will be made to introduce a safety culture, create transparency in relationships, etc. The grapevine and informal networks in the workplace are the gatekeepers of the culture.  And as mentioned earlier, these social relationships directly impact on the resilience and reliable functioning of the EC. Studies show that people are more likely to accept organisational stories by face value, favouring plausibility over accuracy.

As Nietzsche wrote:

Madness is rare in individuals – but in groups, parties, nations, and ages it is the rule.

The organisation is socially constructed

The EC is a social construction that is dynamically and collectively shaped by all working in the EC. Those holding positional or personal power have louder voices and are more influential than those with less voice. Those holding personal power may yield their influence to block change e.g. improvement projects that are driven from the top-down or hindering cross-silo communication.

Why it matters

Essentially sense-making is about how abnormality or fluctuation is noticed, whether this information is shared, and what happens next – the subsequent decisions and actions. Gaining insight into how sense-making occurs in the EC provides crucial knowledge about the more obscure factors that determine operational efficiency. It also provides information regarding team dynamics, communication methods, and cross-silo collaboration.

Exposing deeply held assumptions

Tapping into the underlying assumptions that inform sense-making is not straightforward; assumptions are accepted as regularly reinforced truths, and the dynamics are not obvious, not even to insiders.  These deep beliefs are a constraint to sense-making in the EC.  When it acts as an enabling constraint it ensures collective sense-making, effective decision-making, reliable operations, and social cohesion.  Alternatively, when deep beliefs act as limiting constraint, it results in failed collective sense-making, poor decision-making, operational failure, and strong silo mentalities.

Exploring sense-making

To recap: the people in the workplace hold deeply ingrained assumptions, that they are mostly unaware of.  These assumptions directly impact the level of collaboration, situation awareness and their ability to respond to variation in their environment.

So, how do we expose these assumptions? By exploiting the organisational stories told.

Language and stories are essential tools that shape how people understand the world (or workplace). The understanding created is reshared by sharing stories and knowledge, and by using specific words and phrases the storyteller can emphasize certain facts whilst ignoring others.

For part two of my research, we captured the stories that the people in the EC tell about their daily experience, hearing all voices equally. This was done by using the SenseMaker® tool – proprietary to Cognitive Edge to capture the stories.

Capturing stories

Using SenseMaker®, after telling us a story, the participants answered a series of questions based on the theoretical basis from the fields of collective and organisational sense-making, especially those that explored catastrophe, crises, ambiguity and time-critical decision-making.

This allowed for a comprehensive data set via a novel way of combining stories (qualitative data) with self-analysis (quantitative data). The data was then visually displayed allowing easy visualisation of patterns or clusters of responses.

What I liked most about using SenseMaker® is the self-analysis – participants provided information regarding the meaning of their story, distancing the researcher from the initial analysis.

Utilising the stories to effect change

Roughly, the stories can be divided into two extremes: those stories that promote sense-making and collaboration and those that don’t.  By shaping the daily stories in the direction of those that promote sense-making, the underlying beliefs and assumptions can shift, creating a new reality or situation. In time this may lead to a different experience of the workplace, (hopefully) improving relationships, decision-making, and cross-silo collaboration. This can be continuously tracked by using SenseMaker® as a monitoring and evaluation tool.

Personal impact

I plan on journeying more into sense-making, narrative methods, and complexity. I have a special interest in the gaps and overlaps between disciplines and cross-silo work as I deem it the space presenting the greatest potential to disproportionately improve systems and processes. By impacting the level of social cohesion between disciplines, the ability to continue functioning despite major flux or challenge is immediately improved, leading to resilience.

I intend on discussing my PhD learnings and its applications to the health industry, yet the unintended personal consequence is that I realise that I cannot limit myself to working only within Emergency Care or even healthcare. It’s time to spread my wings a bit wider, and in future blogs, the focus will shift a more towards complexity, culture, team, collective sense-making, communication, and management.

I’m in the process of revamping my blog site to be more aligned with these topics, and I hope that you (the reader) will continue supporting the new angle.  I thought it apt to end with the words of Winston Churchill. Even though WW2 only ended in three years later, the battle of Alamein in 1942 marked the turning point in the war and it was after this battle that Churchill spoke these wise words.

Now, this is not the end. It is not even the beginning of the end.  But it is, perhaps, the end of the beginning.

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Making sense…learning about sense-making

Remember the movie ‘Back to the future’ where Marty (Michael J. Fox) travels through time, whilst figuring out what is happening and how to influence the future whilst simultaneously dealing with the current situation?

It reminds me of sense-making. Sense-making is about how we give meaning to a situation. Sense-making is based in our decisions and beliefs and it is influenced by aspects such as power relations, hierarchy, autonomy, linguistics, temporalization (focus on now, the past or the future), justification, culture and traditional society, equality, bargaining power, locus of control, openness to change. Sense-making is done individually or collectively in organizations and communities.  Capturing these underlying nuances in our perceptions allows deeper insights into why an organization or community are angry, failing, succeeding, innovating, etc.

Brenda Dervin, Gary Klein, Karl Weick and David Snowden are a few of the contributors to sense-making. They all describe their own theory about sense-making either as individual or collective activity.  Snowden combined several sense-making theories into one tool.  For my studies I am using his tool to capture community perspectives regarding cost as a barrier to access emergency care. 

Today I’m sharing my understanding of Brenda Dervin’s metaphor for sense-making.  Dervin sees sense-making as the individual activity of information seeking, processing, recreating and application. Information is described as a tool designed by humans whilst making sense of reality.  Methods of communication and the application of information (knowledge) are key aspects of sense-making.

The metaphor 

timespace

It starts in a time-space milieu, implying constant energy and movement. This environment is never static and time-space energy propels us forward or pulls us back, always fluctuating and never stable.

Moving through time-space we have Mr. Squiggly.  Humans are depicted as squiggly because we are caught between certainty and uncertainty.  Thus there is a constant flux within the person (internal) and between the person and the environment (external).  Mr. Squiggly carries an umbrella, symbolizing mind-set, perceived constraints and enablers. (I feel that it should be a backpack – demonstrating our baggage).

Mr Squiggly.png

Whilst moving through time-space, a gap or barrier is encountered. For the purposes of my work, the gap is a life-threatening injury or illness requiring urgent care. The gap can however be any barrier or difficulty in daily life (in an organization it could be new policies, a new boss etc.). The gap forces Mr. Squiggly to stop until a way has been found to ‘bridge’ the gap and reach an outcome.

The outcome depends on how the gap is bridged.  Some potential outcomes are not obvious in the beginning and it may only become apparent retrospectively, influencing future decisions and beliefs.

Moving from situation to outcome requires a bridge. The building blocks used to build the bridge consists of different types of blocks.  One being the individual mind-set, during a life-threatening emergency it would include individual beliefs about health, healthcare, medication, culture. Building blocks also include inputs from others, the stories within the community about a time that something similar happened to someone else, financial hardships suffered, patient outcome etc.  Mr. Squiggly consciously and unconsciously use all the information in the form of building blocks to create the bridge.

Once the bridge is built, Mr. Squiggly can leap across the bridge to the outcome; this is aptly called gap-bridging.  The building blocks of information is now applied, thus knowledge are created. Dervin use the term ‘verbing’ as an important gap-bridging and sense-making tool.  Everyday examples of verbing include the use of words for example emailing, googling or ubering. Verbing thus occurs when a noun is turned into a verb, creating action or experience.  It certainly fits a methodology where knowledge is seen as a context-specific sense-making activity in a specific point in time and space.

 teh gap.png

I’m using sense-making to capture the various roles within a community perceive gaps, bridge gaps and view the outcomes during a life-threatening injury or illness. Perceptions will be captured using a type of narrative enquiry, where the participant is asked to tell a descriptive story.  After telling the story, the storyteller explains the meaning of their own story by indexing it onto a predesigned framework.  This is very different from ‘traditional’ research where the investigator assigns meaning to the stories. Neutral questioning is used to guide the indexing.  Questions are framed in such a way to capture the nuanced aspects of hierarchy, autonomy, equality etc.  After capturing, the data are combined and the software allows for it to be visually displayed, enabling easy identification of patterns and trends.  More details on the software are a story for another day.

This technique has been applied to monitor, evaluate, communicate, and create feedback loops in projects, organizations, communities and even broader society.

I am using sense-making because I’m passionate about the voice of the ‘voiceless’ in organizations and communities.  I feel that tacit knowledge is often overlooked.  Sense-making provides a tool to capture many voices, combine the different perspectives and seek common ground, emerging trends or underlying moods. This is powerful, whether in an organization, community or development project. It prevents the implementation of one perspective, ‘outside’ views or only top-down approaches. Inclusive sustainable implementation requires more than one story, one perspective and more than one type of knowledge.

 As Chimamanda Ngozi Adichie says in her powerful TED talk about the danger of a single story:

The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.”

References

I adapted the pictures from: Facing a gappy situation. Sense-making methodology: communicating communicatively with campaign audience.  Dervin, B. 2003.  In Dervin B, Foreman-Wernet L (Eds). Sense-making methodology reader: selected writings of Brenda Dervin, Cresskill, NJ: Hampton Press 2003.

http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story?language=en

Communication: Semmelweis vs Florence Nightingale

A comparison of two intriguing nineteenth century change agents.

The lady with the lamp: Florence Nightingale, founder of modern nursing, demonstrated the effectiveness of hospital design and administration.

The saviour of mothers: Ignaz Semmelweis, demonstrated statistically that puerperal fever could be reduced by hand washing and implemented hand hygiene at the point of care.

The one was acclaimed during her lifetime; the other died an outcast of medical society in a mental institution at the age of 47.

Similarities

Semmelweis (DOB 1818) and Nightingale (DOB 1820) lived in the same era of health care development.

Both had novel ideas that challenged the existing status quo.

Both used statistics to demonstrate their findings (not commonly used at the time).

They made their world-changing discoveries roughly at the same time (1847 and 1854)

Their discoveries were in the same branch of medicine: spread of disease.

Neither one was completely right.  Semmelweis failed to realize that puerperal fever is an airborne and contact disease.  Nightingale lacked “scientific” insight into the spread of disease.

Brief backgrounds

Nightingale was a lady from the upper class in the Victorian era of British history; women had no legal rights and a Victorian lady’s world was strictly confined to home and family.  Florence’s father held progressive views on the education of women and she was well-educated.  However it remained a radical concept that a privileged lady would want to have a career, especially as a nurse!  Nursing was considered a job for untrained, uneducated women with no other prospects and of poor social standing.

Semmelweis was born in Hungary, the 5th child out of ten in an affluent family from German ascent. He was a physician and worked in a large training hospital in Vienna.  There must’ve been a degree of underlying tension for the Hungarian physician working in Austria due to the European political framework of the time.

How did they communicate their findings?

Florence Nightingale consistently communicated and consulted widely, publishing approximately 200 books and 12 000 letters.   Nightingale was strategic in her allegiances.  She attracted talented and powerful collaborators, connecting with a variety of influential people.  She networked across boundaries, even internationally.  Her collaborative efforts with Sidney Herbert are well-known and demonstrate her ability to influence the right people.  Sidney Herbert carried weight in social circles, he had an influential position and enough access to the Queen to make promise Florence prior to Crimea “unlimited power of drawing on the government for whatever you think requisite for the success of your mission.”

Semmelweis was a reluctant communicator and words used to describe his style includes dogmatic, arrogant and ego-driven.  He displayed a tendency to describe his peers using words such as irresponsible murderers, criminals, adversaries and partners in the massacre.

With the implementation of Semmelweis’s hand washing at point of care idea the mortality rate dropped from 18 – 1%.  For reasons unknown he refused to communicate his reasoning and findings to the learned circles. Only fourteen years after the experiments and after he has left Vienna did he publish a book.  The book was poorly received as it was reportedly poorly written and hard to follow.  Semmelweis responded to the reviews by writing public letters, which did little to win support within the scientific community. He died four years after the publication in a mental institution.  His admission to a mental institution is filled with myth.  He’s reasoning was only accepted 20 years after his death with the further discoveries on the germ theory of disease (Louis Pasteur) and antiseptic techniques (Joseph Lister).

Could Semmelweis have had a greater impact if he could communicate differently? I think yes…

The power to influence

Obtain buy in.  Most of us view ourselves as individuals making independent decisions based on facts, however the behaviour of similar others (our peers) have an influence on our decisions, not to mention our preconceived notions.  When the way that we interpret facts are questioned it threatens our truth and the way we see the world resulting in self-defensive behaviour. The gentlemen doctors in the nineteenth century did not believe that their hands carried germs.  For fourteen years Semmelweis declined to share why he was so forcefully challenging this status quo and insulting his peers.  Semmelweis behaviour made it easier for his peers to shun him than to challenge their own beliefs and buy into his message.

Don’t force your opinion (even if it’s right). Semmelweis felt passionately about his message and his statistics proved that he was “right”.  So he forced his message and when it didn’t work, instead of reviewing and adjusting, he raised the tone, making it more aggressive.  He kept pushing, refusing to consider other’s inputs and views.  It’s not only about the facts; it’s also how we go about communicating and adapting our message that counts.

Use a consistent message in different ways. Nightingale used various ways to communicate the same message.  She wrote letters, books, presented statistics, comparing English and French outcomes and collaborated widely.  She wrote in simple English and innovated difficult statistics into easier visuals ensuring that her message was clearly articulated and understood.

Apply some charm. In addition to our bias, we are more likely to follow the lead of people that we like.  This makes charisma an important leadership and change agent trait. Charismatic people are skilled communicators communicating using just the right amount of emotional appeal to lend credibility to their message.

Nightingale’s background prepared her to be an intuitive and skilful communicator.  She innovated to clarify her message (statistically); she used her influential collaborators and she was persistently persuasive. The power to influence people and get them to work with you or even on your behalf is and advanced form of social interaction. I think Nightingale was a clever strategist and communicated with intent.

Summary

There is a Chinese proverb that states that he who threads softly goes far.

Communicating is a skill. When challenging the status quo we need to be intentional, adapting our personal style yet remaining true to ourselves and our truth.

Footnote:  Semmelweiss was able to make his deductions after comparing a nurse driven clinic (low mortality rates) and a doctor driven clinic (high mortality rates), Nightingale made her deductions from nursing experience.  Both cases illustrate the important role of nurses in improving and advancing health care.