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.