Guy Sack, M.A., Management Fellow (2013-2015)
Boston University Questrom School of Business
Department of Organizational Behavior
The study of organizational failures and mistakes has traditionally focused on such high-profile, technologically specialized areas as nuclear power and space travel (Perrow, 1984). However, with yearly estimates approaching 100,000 hospital-blamed deaths per year (Kohn, Corrigan, & Donaldson, 1999), mistakes in the medical field have recently garnered much more substantial attention (Bosk, 2003). The Quality Interagency Coordination Task Force comprised of 10 federal U.S. agencies, labeled the issue a “national problem of epidemic proportions” (2000: 1). In addition to scholarly and government reports, the problem has also received increased exposure in the popular press (Gawande, 2007), bringing the issue home to hundreds of millions of worried potential patients.
In response to the problem, medical policy and regulatory bodies have established systems of evidence-based practice, known as “clinical pathways” or “error prevention pathways” (Furrow, 2003), which act as cook-book-styled checklists for practitioners in the coordination of patient care and prevention of medical mistakes. However, as Furrow notes, these guidelines fail to adequately compensate for what he calls “team deficiencies,” especially in an era where team-based care is increasingly the norm.
At the same time that regulatory bodies are designing macro-level changes in healthcare to address the problem, both medical and organizational researchers have been studying the microprocesses of hospital communication (Moorman, 2007; Gittell, 2000). This has helped us better understand the systematic overreliance on “flawless individual performance” (Moorman, 2007: 173) and regulation-dictated routine in medicine, to the detriment of effective communication.
But why is medical communication so difficult in the first place? Jerome Groopman (2007) discusses the difficult, almost impossible task doctors have of communicating the logic behind the heuristics they use in their decision-making processes. Groopman even goes so far as to specify that only the foundation for these heuristics is actually laid in medical school. It is only through the combination of medical school and the years of experiential learning that take place during internship and residency that young doctors are able to develop these skills. He says that many doctors have four or five working diagnoses, developed through a complicated process of pattern recognition, within seconds of meeting a patient. This kind of cognitive automaticity, while essential for speedy and accurate care, obstructs communication between physicians of different specialties, let alone communication between physicians and non-physicians, such as nurses.
In addition to the medical content knowledge and skills gained through medical education, new doctors, especially surgeons, are trained in a professional culture that highlights the importance of the “iron man” (Kellogg, 2009). Recent changes in federal medical regulations, documented by Kellogg, signal the beginning of the end of this paradigm of individualism and silence in patient care.
Emotion and Relationships in Medical Communication
Jody Gittell (2006) focuses on the lack of mutual respect that often results from status differences in the coordination of teams involved in carrying out interdependent tasks, such as delivering medical care. Displays of mutual respect (or lack there of) in medical communication carry with them an emotional weight that has consequences for the relationships among providers. These relationships are the conduits of information necessary for providing quality care, and relational disturbances can have lasting negative consequences for the organization (Kahn, Barton, & Fellows, 2013), even if they did not result in immediate, observable crisis. This means that a lack of mutual respect can degrade the quality of care without being documented as a “mistake.” As such, it is important to understand the emotional contents and consequences of communicative exchanges in medicine, regardless of whether or not documented mistakes actually occurred.
Unfortunately, medical mistake research on emotions has generally explored the emotional consequences of the mistake, itself, as opposed to the emotional consequences of unhealthy communications (Wu, 2000; Goldberg et al., 2002). In addition to analyzing emotions as consequences of communications, they can also be conceptualized as possible antecedents of future mistakes (or as antecedents to successful prevention of mistakes). Our study will answer questions about this gap in the literature by providing a “thick description” (Geertz, 1973) of the emotional interplay that exists in medical communication. In doing so, we plan to map the variation that exists across communications. We will be looking most closely at emotional expression, especially as it relates to mutual respect. We are also interested in respondent interpretations of the relational consequences of such communications.
Interdependence, Uncertainty, and Space
Gittell (2008) highlights the importance of a relational focus on coordination in circumstances that are highly uncertain and rely on high levels of interdependence among collaborators. Medical care delivery in a maternity services unit meets both of these criteria, as different specialists take over different responsibilities while exchanging information in an unexpectedly changing environment.
Kellogg (2009) explored the importance of shared space, available to organizational reformers and isolated from defenders of the status quo, necessary for the implementation of organizational change. The proposed study will also be exploring space in relation to organizational change. However, there are two striking differences between the proposed study and Kellogg’s: 1) the organizational change under analysis in the maternity services unit will be coming from inside the organization, originating from employee complaints, and 2) the maternity services unit currently lacks the type of physical space (a large lounge) that was necessary for the change observed in the Kellogg study.
Entry and Organizational Diagnosis
The organizational diagnosis was conducted from Spring through Fall in 2013 by two co-collaborators. The presenting problem came from the Vice President of nursing, who complained “the nurses have no voice.”
During the entry process, researchers interviewed numerous staff across all levels and functional units of the organization, and it became clear that the unit lacked a cohesive core around which all of the organizational members could structure their activities. Organizational members failed to display mutual respect, shared practices, or shared beliefs. An overarching issue was the lack of communication coming down from the leadership of the unit, and the absence of coordination among the leadership group was mirrored by a similar lack of coordination on the unit floor.
Specifically, a culture based on individual personal relationships emerged, whereby it became clear that certain employees would only perform certain tasks for the employees they personally liked. In addition, triangulation (talking to one person through another person) displayed a lack of mutual respect and reinforced this culture of personal relationships.
Specialists in the unit include OB/GYNs (surgeons), pediatricians, anesthesiologists, family physicians, certified nurse midwives (CNMs), nurses, physician assistants, and techs. For the purposes of this study, we will focus primarily on the OB/GYNs and the nurses for reasons discussed below. However, clarification of the CNM role is necessary, due to their nuanced training, specialized position within the unit, and potential for becoming an additional focus of the study.
Many people confuse CNMs with doulas, but the differences are vast. CNMs are registered nurses who also undergo specialized training in midwifery. They are able to prescribe medicine in some states. Doulas, by contrast, are classified as “trained lay women” (Rosen, 2004: 25) and lack an official licensing body, which means any person can legally use the title “doula.” They are synonymous with labor coaches and focus on the experience of the birthing process, from prenatal to postpartum, as opposed to medical outcomes. Due to their lack of attention to training around specifically medical issues, they are not interdependent with the medical specialists, making their inclusion in the current study inappropriate, based on our aims of understanding emotion and relationships in communication designed to prevent medical mistakes.
The OB/GYN physicians are the official leaders of the unit; they are legally “on the hook.” However, the head of the OB/GYNs, the Chief Medical Officer (CMO), does not take up a traditional leadership position over the unit as a whole. Instead, he acts as the leader of the OB/GYNs, in a similar fashion to the heads of the other functional groups. These groups lack a single executive to facilitate coordination among each other. The CMO seems like he could fill this role but does not. In addition, the authority of the OB/GYNs is uncertain and can change unexpectedly. For example, family medicine and pediatric patients generally do not require OB/GYN supervision, but if they have complications, those patients become the responsibility of the OB/GYNs. To make matters more complicated, the current CMO is leaving right at the time when implementation of organizational changes (to be described below) will begin. The OB/GYN physicians will be a primary focus of our study, due to their (uncertain) role in leading coordination within the unit.
The nurses are the “boundary spanners” of the group. Their expertise lies in their relationships with patients, putting nurses in a critical information-transferring role, giving doctors and other specialists specific pieces of information needed to make medical judgments about patient care. Gittell (2002) highlights this boundary-spanning role as particularly important in the uncertain and interdependent tasks that characterize maternity services. It is for this reason that nurses will be another initial focus of the study.
As a result of the organizational diagnosis, my co-collaborators recommended that the leaders of each functional unit begin meeting with each other. Currently, the units “bounce off each other,” getting by with little communication, including among unit leaders. In addition, the unit has formed two task forces: one to establish more effective epidural procedures (for example, when should the anesthesiologist be called to give the epidural?) and one to create more useful board rounds. Board rounds are a type of team meeting, which involves members of different functional groups taking time to discuss patient cases with each other as they walk the unit floor.
In addition to boundary spanners, Gittell (2002) has also highlighted team meetings as critical aspects for relational coordination under uncertain conditions. For this reason, we will also be focusing on board rounds in this study, in order to get a detailed perspective on the communication patterns that emerge during these meetings.
Our original objective was to not only study the new board rounds and epidural procedures, but also the discussions within the task forces as well. Unfortunately, the organization has decided not to allow us direct access until the task forces are ready to implement their plans. As a result, we will focus on the implementation of the new epidural procedures, in order to both understand the content of such an interdependent and uncertain type of task and to draw conclusions about the task force, based on organizational members’ interpretations and opinions of the new epidural procedure.
Interviews and Observations
In-depth, open-ended interviews and observations will focus largely on meetings (board rounds) and boundary spanners (nurses), as well as on the new epidural procedure, which will inform our understanding of both uncertain and interdependent tasks, as well as the effectiveness of the meetings used to design those new procedures. However, special attention will still be given to OB/GYNs, due to their formal authority regarding unit coordination. A sample interview protocol is included in Appendix A.
In order to explore the emotional content and consequences of communications made in the unit, I will focus on two dimensions of the communications: whether or not there was disagreement (agreement) and whether or not there was a discussion about a decision (vocality). In this study, we are interested in the actual inner thoughts of agreement or disagreement at the conclusion of an episode (defined here as the point at which a discussion switches from a “planning” discussion, in which input is solicited and explanations are given, to an “implementation” discussion, in which more traditionally authoritative orders are given). Our interest in the actual inner thoughts of organizational members (nurses, in particular) is the reason why in-depth, open-ended interviews, and not only observations, are required.
Several researchers inform our model. Gittell (2000) explains that employees faced with challenges similar to those in a maternity services unit often retreat into silence and over rely on routine decisions. Staw, Sandelands, and Dutton (1981) have characterized this kind of behavior as “threat-rigidity.” They show that threat-rigidity restricts information processing. Regarding another form of routine, Joshua Wakeham (2012) discusses how “surface agreements,” the expression of a false consensus, fail to prevent conflict. Lastly, Carol Heimer’s (2001) work on routinization discusses the ways that routines, when used effectively, structure thinking and focus attention. However, when the routine is too rigid for the task, these routines can have the opposite effect, breaking down structure and distorting attention. All of these literatures will be explored during the iterative process of data collection and analysis.
|Silent||Successful pathway||Lack of mutual respect/threat rigidity|
|Vocal||Positive communication||“Surface agreement” OR power decision/loss of face|
It is our belief that respondents’ emotions regarding their relationships with co-workers will vary depending on vocality and agreement. The box on the upper left (see Table 1) seems as though it will be relatively straightforward. This is a situation in which routine will, in fact, focus attention and lead to positive outcomes for employee relationships. We also predict that communications classified in the box in the lower left will be associated with positive outcomes. However, we will flesh out the variation in this box by discerning how or why agreements tend to be reached. In the right half of the model, we are expecting more negative outcomes. We predict that communications falling into the upper right box will have the worst outcomes because of the egregious lack of respect displayed when disagreement exists but none is vocalized. We believe the lower right box will also be associated with negative outcomes, although not as extremely negative as those characterized by silent disagreement. Some discussion is better than none, even if it results in a “surface agreement,” which Wakeham (2012) points out are essential for many kinds of communications. However, we believe that lower right box communications, in which the parties are honest about their disagreement will have more positive outcomes than these “surface agreements.”
Table 1 Agreement and Vocality in a Maternity Services Unit
Finally, our interviews and observations will take careful notice of the
context in which coordination takes place. One important aspect of the unit context for organizational reformers is the feeling of being “on stage” (Van Maanen, 1973), in front of both patients as well as organizational defenders of the status quo. Will organizational reformers be able to implement the change without the time or space Kellogg (2009) deems necessary? How will emotional reactions vary, depending on who else is in the room?
All field notes from observations of board rounds and epidural procedures will be typed up using Microsoft Word and stored electronically under protection of Boston University “Kerberos” password. These notes will include both what we observe as well as comments and questions about what we observe. Interviews will be transcribed by a person hired to do so and will also be stored electronically under password protection.
- What do you like about working here? What don’t you like?
- Think back to a situation when you felt particularly uncertain of what your role should be. Tell me about it. Where were you? Who was with you? Did you discuss this with other people? How did it end up?
- Think back to a situation in which you disagreed strongly with a co-worker or co-workers. Tell me about it. Did you speak up? Who was it? Where were you?
- Tell me about a situation in which there was total agreement about the course of action? Who was there? Where? Was there a discussion? Was this a surprise?
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