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

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The story of clinical facilities planning

For the past two months I have been working on a project involving clinical facilities planning.  This is still a very novel concept in South Africa. It involves planning the hospital’s flow during the design phase.

As far system strengthening is concerned the physical and spacial relationships within the system and the subsequent influence of each relationship on others impact on the full systems operation and efficiency.  Some of what we attempt when we implement improvement programs is to fix wrongly designed systems, physical structures that are outdated, outgrown and to accommodate new technology within the existing structure.   A way to truly fix a system is to rebuild it…correcting the old model.

It is very hard to simply action the rebuilding of an entire physical structure to resolve system issues.  Therefor physical structure is hardly considered a leverage point when improving a system.  It is only a leverage point if it is designed to suit the system’s needs.  Once built we can only manage constraints and inefficiencies with improvement programs to manage limitations, bottlenecks, matching demand and capacity or even work around system failures.

Hospitals are subject to rapid change and a clear operational concept and accurate scope of services is essential during design.  The ability to forecast trends and change requires clinical insight and not just architectural design capability.

Reading through international literature on clinical facility planning, I was amazed to read a statement that there are more than 600 studies demonstrating the impact of hospital design on outcome measures such as reduction in staff turnover, staff stress and even patient pain level perception.   This obviously implies a link between facility design, perceived quality of care, patient safety and error and nosocomial infection.  Some factors to consider are single versus multiple bed rooms, ability to observe patients, distance between beds, availability of hand wash facilities, slippery floors, and distance from nurse station to patient room.

Clinical oversights in facility design in units where I have worked include a unit where the sluice room had limited space to test urine and no cupboard space to store urine and pregnancy test containers.  The sluice room had only a tiny sink and could accommodate one person at a time.  This resulted in an overflowing messy sluice room during busy times, bottlenecks, running around to obtain pregnancy tests, urine sample bottles etc.  Another example is that it was decided to remove an electronic patient system as it was not effective.  In an independent study conducted afterwards, one of the main reasons given by nursing staff for the ineffectiveness was the location of electronic devices within the facility and its subsequent impact on flow and patient care. And then the steps at an emergency exit at a ward for bedridden patients, the mind boggles.

There is a fine balance in meeting the needs of the clinical facility user (patient) and facility management.   By marrying the financial aspects, clinical intent and the physical infrastructure design, a plan can be developed that appropriately balance the patient journey and operational efficiency.

I’m involved in a facility that is being rebuilt with a structured transition from old to new.  My role is to write the functional narrative, which is the expression of the intent and flow within all functional spaces such as patient rooms, utility rooms, medication rooms, nurse duty stations.   As we are hoping to impact a paradigm shift in culture during the transition the narrative is crucial, it is the story of the new facility after all.

I feel privileged to be part of the change process and I hope that it will result in safer patient care and improve access to care in the new facility.