1. Describe the communication process. 2. Understand the importance of feedback in the communication process. 3. Understand various verbal and nonverbal methods of communication. 4. Understand the common barriers to communication. 5. Utilize various methods to overcome communication barriers. Kristina L. Guo is an Assistant Professor of Health Services Administration in the Stempel School of Public Health at Florida International University in Miami, Florida. Professor Guo graduated from Florida International University with a PhD in Public Administration in 1999, and she holds a Masters in Public Health from the University of Miami. Prior to joining the Florida International University faculty, Dr. Guo accumulated extensive experience in the healthcare field. She was the Assistant Director of the University of Miami's intellectual property division, where she conducted market and patent research and analyses. As the manager of several physician practices, she was responsible for formulating and implementing strategies to increase the organization's viability and growth potential. She teaches health services management, organizational behavior, and health policy. Her primary areas of research are healthcare policy and management, where she has developed a managerial roles and skills assessment tool. Her current research focuses on the healthcare needs of elders. Yesenia Sanchez is a contracting specialist for Neighborhood Health Partnership, a five-star health maintenance organization in Florida. Ms. Sanchez holds a Master's in Public Health from Florida International University. She is an adjunct professor for the College of Health & Urban Affairs at Florida International University. She teaches organizational behavior, healthcare policy, and epidemiology. Her primary areas of research are in healthcare policy and organizational behavior. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 77 78 CHAPTER 4 WORKPLACE COMMUNICATION 6. Discuss the elements of effective communication for knowledge management. 7. Describe the various components for effective strategic communication. 8. Understand the flow of intraorganizational communication. 9. Understand the challenges of cross-cultural communication. 10. Understand the flow of communication with external stakeholders and the public sector. OVERVIEW Fundamental and vital to all healthcare managerial functions, communication is a means of transmitting information and making oneself understood by another or others. Communication is a major challenge for managers because they are responsible for providing information, which results in efficient and effective performance in organizations. Communication is the creation or exchange of thoughts, ideas, emotions, and understanding between sender(s) and receiver(s). It is essential to building and maintaining relationships in the workplace. Although managers spend most of their time communicating (e.g., sending or receiving information), one cannot assume that meaningful communication occurs in all exchanges (Dunn, 2002). Once a memorandum, letter, fax, or e-mail has been sent, many are inclined to believe that communication has taken place. However, communication does not occur until information and understanding have passed between sender and the intended receiver. To make oneself understood as intended is an important part of communication. A receiver may hear a sender but still not understand what the sender's message means. Being constantly engaged in encoding and decoding messages does not ensure that a manager is an expert in communication. Understanding is a personal matter between people, and different people may interpret messages differently. If the idea received is not the one intended, communication has not taken place; the sender has merely spoken or written. COMMUNICATION PROCESS Figure 4-1 illustrates the communication process. It shows that the sender is a person, department, or unit of an organization or system who originates the message. A sender uses words and symbols to put forth information into a message for the receiver, the individual(s) receiving the message. Messages are then received and decoded or interpreted by the receiver. Decoding is affected by the receiver's prior experiences and frames of reference. Accurate decoding of the message by the receiver is 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 78 critical to effective communication. The closer the decoded message gets to the intent of the sender, the more effective the communication. However, environmental and personal barriers can hamper the communication process. Details on barriers are described in a later section. To ensure messages are received as intended, feedback is a necessary component of the communication process. The receiver creates feedback to a message and encodes it before transmitting it back to the sender. The sender receives and decodes the feedback. Feedback is the destination's reaction to a message (Certo, 1992). It is an important element of communication since it allows for information to be shared between the receiver and sender in a two-way communication. FEEDBACK Feedback is any information that individuals receive about their behavior. Feedback can be information related to the productivity of groups in an organization, or the performance of a particular individual. For instance, a manager requires feedback to determine staff acceptance of his or her newly set policy whereby staff must phone all patients to confirm their appointments 48 hours in advance of the appointments. Through the feedback process, senders and receivers may adjust their outputs as related to the transmitted information. In the absence of feedback, or in the case where the communication process does not allow for sufficient feedback to develop, or feedback is ignored, a certain amount of feedback will occur spontaneously and tends to take a negative form. In one-way communication, a person sends a one-directional message without interaction. When a physician writes out a prescription and gives it to the nurse to hand to the patient, the physician's order is an example Feedback 79 Image has been redacted. Figure 4-1 The Communication Process Source: McShane, S.L., and Von Glinow, M.A. (2003) Organizational behavior: Emerging realities for the workplace revolution (2nd ed.). Boston: McGraw-Hill, p. 324. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 79 of one-way communication and does not provide the opportunity for the patient to ask questions directly. A negative feedback may occur when the patient expresses frustration or anger through verbal or nonverbal messages when the physician does not directly explain the necessity and functions of the medication. However, the same patient could express satisfaction and appreciation toward the nurse who explains the usefulness of the medication. In this case, the opportunity for feedback results in two-way communication between the patient and the nurse. Two-way communication is more accurate and information-rich when the message is complex, although one-way communication is more efficient, as in the case of the physician's written prescription. To be effective, communication must allow opportunities for feedback. Feedback can take several forms, each with a different intent. Keyton (2002) provides us with three different forms of feedback: descriptive, evaluative, and prescriptive. Descriptive feedback. Feedback that identifies or describes how a person communicates. For instance, Manager A asks Manager B to comment on her behavior at a staff meeting. B indicates that A was specific, clear, and instructive on introducing the staff to the computer database for managing patient accounts. B provides a descriptive feedback of A's behavior at the staff meeting. Evaluative feedback. Feedback that provides an assessment of the person who communicates. In the above case, if Manager B evaluates Manager A's behavior and concludes that she is instructive and helpful, and that causes the staff to feel comfortable when going to A for help or asking questions, then B has provided positive evaluative feedback of A's interaction with the staff. Prescriptive feedback. Feedback that provides advice about how one should behave or communicate. For example, Manager A asks Manager B how she could have made changes to better communicate her message to her staff. B suggests for A to be friendlier and more cooperative by giving the staff specific times that A is available for help with the new computer database. This type of advice is prescriptive feedback. In addition to forms and intent, there are also four levels of feedback. Feedback can focus on a group or an individual working with specific tasks or procedures. It can also provide information about relationships within the group or individual behavior within a group (Keyton, 2002). Task or procedural feedback. Feedback at this level involves issues of effectiveness and appropriateness. Specific issues that relate to task feedback include the quantity or quality of a group's output. For instance, are patients satisfied with the new outpatient clinic? Did the group complete the project on time? Procedural feedback 80 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 80 refers to whether a correct procedure was used appropriately at the time by the group. Relational feedback. Feedback that provides information about interpersonal dynamics within a group. This level of feedback emphasizes how a group gets along while working together. It is effective when it is combined with the descriptive and prescriptive forms of feedback. Individual feedback. Feedback that focuses on a particular individual in a group. For example, is an individual in the group knowledgeable? Does he or she have the skills helpful to this group? What attitudes does he or she have toward the group as they work together to accomplish their tasks? Is the individual able to plan and organize within a schedule that contributes to the group's goal attainment? Group feedback. Feedback that focuses on how well the group is performing. Like the questions raised at the individual feedback level, similar questions are asked for the group. Do team members within the group have adequate knowledge to complete a task? Have they developed a communication network to facilitate their objectives? Feedback can be in the form of questionnaires, surveys, and audio or videotapes of group interaction. It can also occur in activities such as market research, client surveys, accreditation, and employee evaluations (Liebler & McConnell, 2004). Feedback should be used to help a group communicate more effectively by making group members identify with the group and increase its efficacy. Feedback should not be viewed as a negative process. Instead, it should be used as a strategy to enhance goals, awareness, and learning. As a managerial tool, feedback enables managers to anticipate and respond to changes. Structured feedback enhances managerial planning and controlling functions. Because of the value of feedback, managers should encourage feedback and evaluate it systematically. The Johari Window The process of feedback is also illustrated in the Johari Window, a useful model for understanding the communication process, created by Joe Luft and Harry Ingham (hence the name "Johari") (Luft, 1984). The Johari Window model improves an individual's communication skills through identifying one's capabilities and limitations. As shown in Exhibit 4-1, windowpane 1 is the open area in which information about you is known both to you and to others. Tubbs (2001) described this area as the general cocktail party conversation in which an individual willingly shares information with others. For instance, at an office party, you reveal to your coworkers that you do not drink alcohol due to health reasons. Windowpane 2 refers to a blind area in which others know information about you that you are either unaware of or that you do unknowingly. As an example, Feedback 81 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 81 your colleagues know that you are a "close" talker, that you unconsciously stand too close to people while in conversation with them. The third windowpane is the hidden area in which you have likes and dislikes that you are unwilling to share with others. This area includes all of your values, beliefs, fears, and past experiences that you would not wish to reveal. The last windowpane is the unknown. It is also an area of potential growth or self-actualization. It represents all the things that we have never tried, participated in, or experienced. Increasing mutual understanding through feedback and disclosure allows an individual to increase the open area and reduce the blind, hidden, and unknown areas of oneself (McShane & Von Glinow, 2003). In the Johari Window, Luft (1984) argues for increasing the open area so that you and your co-workers are aware of your limitations. This is done by receiving more feedback from others and decreasing one's blind area (windowpane 2), and reducing the hidden area (windowpane 3) through disclosing more about oneself. The combination of feedback and disclosure may also help to produce more information in the unknown area (windowpane 4). The Johari Window can be used for opening the channels of communication. Open communication is important for improving employee morale and increasing worker productivity. Open communication allows supervisors and subordinates to openly discuss organization-related issues such as goals and conflicts. Nevertheless, Luft (1984) is cautious on the use of the Johari Window for all situations. He offers several guidelines for the appropriateness of self-disclosure. He recommends that selfdisclosure is a function of an ongoing relationship. Timing and extent of disclosure are critical. A competent communicator knows when, with whom, and how much to disclose. 82 CHAPTER 4 WORKPLACE COMMUNICATION Source: Based on Luft, J. (1984). Group processes: An introduction to group dynamics (3rd ed.). Palo Alto: Mayfield. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 82 Image has been redacted. Communication Channels 83 COMMUNICATION CHANNELS Another important component of the communication process is selecting the appropriate communication channel. It is the means by which messages are transmitted. There are two types of channels: verbal and nonverbal. The various channels of communication and the amount of information transmitted through each type are illustrated in Figure 4-2. Verbal Communication Verbal communication relies on spoken or written words to share information with others. Dialogue is a form of verbal communication. It is a discussion or conversation between people. It is a process in which participants are exposed to new information. The process involves a series of meetings of organizational members that represent different views on issues of mutual interest. According to Edgley and Robinson (1991), in order for dialogue to be successful, there are several fundamental principles: engage motivated people; use a facilitator and recorder to manage the process; have the group develop procedures and live by them; ensure confidentiality; let the process move at its own pacedon't try to rush it; focus on understanding the issue and not on developing an end product; and allow time to get to know each otherhave dinner before, during, or after a meeting. Successful dialogue between group members in an organization enhances communication. There are different forms of verbal communication, which should be used for different situations. Face-to-face meetings are information-rich, Figure 4-2 Communication Channels Source: Daft, R.L., & Lengel, R.H. (1984). Information richness: A new approach to managerial behavior and organizational design. In Research in Organizational Behavior, B. Staw and L. Cummings (Eds.), vol. 6. Greenwich, CT: JAI Press, Inc., pp. 191-233. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 83 Image has been redacted. since they allow for emotions to be transmitted and immediate feedback to take place. Written communication is more appropriate for describing details, especially of a technical nature as in the example of monitoring a patient's complex medical condition. Although traditional written communication had been considered slow, now with the development of electronic mail and computer-aided communication, written communication through these channels has dramatically improved efficiency (See Case Study 4-1: Are We Getting the Message Across?) Case Study 4-1 Are We Getting the Message Across? James Warick, Director of Physical Plant at Southern Hospital, e-mailed Diane Curtis, Director of Nursing, informing her of a leak in Operating Room 1 that must be shut down for repairs early next morning. Curtis forwarded the message to Joanne Messing, the operating room nurse supervisor on duty for the night shift. Messing, tired from a long night's work, handwrote a message and taped it on the bulletin board to the nurse supervisor in the day shift to switch the 8 a.m. operation from Room 1 to Room 8. David Swanson, the day shift nurse supervisor, arrived at 7:30 a.m. and found Dr. Roberts shouting that his patient was ready for surgery, but no rooms were available because Dr. Jones had already taken Room 8. Discussion Questions 1. What were the channels of communication used by each person? 2. Should a different channel of communication have been used instead? 3. What can be done to resolve the problem? 4. What future policies should be put in place to prevent this from occurring again? Computer-Aided Communication Electronic mail has revolutionized the way we communicate. E-mail allows messages to be rapidly created, changed, saved, and sent to many people at the same time. One can select any part of the message to read and skip to important parts of the message. E-mail is a preferred channel for coordinating work and schedules. Messages can be clearly defined through concrete and specific instructions rather than abstract words or generalization. For example, an e-mail can be sent to all physicians indicating that a meeting starts promptly at 10 a.m. There are several problems and limitations to electronic mail. The most obvious is information overload. E-mail users are overwhelmed by the number of messages received on a daily basis, of which many are unnecessary to the receiver. Moreover, e-mail messages are frequently carrying computer viruses, which have caused major damage to computers and in84 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 84 terruptions in work flow. Another problem with e-mail is its ineffectiveness to communicate emotion. Tones of messages are easily misinterpreted, causing misunderstandings between sender and receiver. Computer experts have even developed icons to represent emotions (emoticons) in e-mail messages. For instance, the symbol :-) or ( ) means happy (Peck, 1997). E-mail also reduces politeness and respect for others. Flaming is the act of sending an emotionally charged message to others, especially before emotions subside. This common problem occurs frequently over e-mail, whereas a traditional letter provides time to cool down and have second thoughts. To reduce these e-mail problems, some have recommended training for communication on the Internet, called netiquette (Extejt, 1998). Netiquette rules include keeping e-mail messages to fewer than 25 lines and not sending sensitive issues through e-mail. Other Computer-Aided Communication In addition to e-mail technology, other forms of technology have infused healthcare organizations and directly enhance and impact the communication process. Coile (2002) describes several such technological advancements that can be used to bridge the communications gap between clinicians and administrators. Computer-aided drug discovery is expected to double the number of new medications. High-speed, high-definition images are created for rapid access via telemedicine. Wireless, handheld digital electronic medical records are capable of voice recognition. Telepresence surgery with minimally invasive, remotely guided instruments extends beyond the precision of humans. Medical applications of artificial intelligence are designed for diagnosis, treatment planning, and continuous monitoring of the chronically ill (Coile, 2002). Nonverbal Communication Nonverbal communication is sharing information without using words to encode messages. There are four basic forms of nonverbal communication: proxemics, kinesics, facial and eye behavior, and paralanguage (Nelson & Quick, 2003). Proxemics is the study of an individual's perception and use of space. Territorial space and seating arrangement are two examples. For instance, to encourage cooperation, co-workers working together on a quality control report should sit next to each other. To facilitate communication, a manager should seat a subordinate at a 90 degree angle in order to discuss resolving staff complaints. Kinesics refers to body language, which is used to convey meanings and messages. Pacing or drumming fingers are signs of nervousness. Wringing of the hands and rubbing temples signal stress. Facial and eye behavior is another example of nonverbal communication. For example, when a healthcare manager interviews a candidate for a position as a clinical care coordinator, the manager attaches meanings to frowns and eye contact. Avoiding eye contact tends to close communication. However, Communication Channels 85 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 85 cultural and individual differences influence appropriate eye contact. Moderate direct eye contact communicates openness, while too much direct eye contact can be intimidating. Paralanguage consists of voice quality, volume, speech rate, and pitch. Rapid and loud speech may be taken as signs of anger or nervousness. The communication process is impeded by negative nonverbal cues. For example, arriving late for an interview with the vice president of finance, talking very fast, avoiding eye contact, getting very close during a conversation or in a seating arrangement for a committee meeting serve as negative factors in the communication process. To determine the most appropriate channel of communication for sending messages, one needs to identify whether verbal or nonverbal communication should be used. At the same time, ideal channels of communications can be selected through an examination of the information richness and symbolic meaning of messages (Daft & Lengel, 1984). Information richness refers to the volume and variety of information that can be transmitted. As shown in Figure 4-2 (page 83), face-to-face meetings have the highest informationcarrying capability, because the sender can use verbal and nonverbal communication channels and the receiver can provide instant feedback. When a wrong channel of communication is used, this creates a waste of time and leads to more misunderstanding. When communication is nonroutine or unclear, information rich channels are required. As an example, a gunshot victim is brought into the trauma center. Coordinating the care of this patient requires face-to-face instructions to quickly coordinate work flow and minimize the risk of confusion among various staff members. However, for routine communications, less information-rich channels can be used. Choosing one communication channel over another lends meaning to the message. That is to say, there is symbolic meaning to the selection of a particular channel of communication beyond the message content. For example, when a manager tells an employee that they must have a faceto-face meeting, this symbolizes the issue is important compared to a brief e-mail message with instructions. In summary, one essential part of the communication process is selecting an ideal channel of communication. The use of different channels leads to differences in the amount and variety of information transmitted. Choosing an appropriate channel of communication involves understanding symbolic meanings and the information richness of messages. BARRIERS TO COMMUNICATION As illustrated in Figure 4-1 (page 79), several forms of barriers can impede the communication process. Longest, Rakich, and Darr (2000) classify these barriers into two categories: environmental and personal. Environmental barriers are characteristic of the organization and its environmental setting. Personal barriers arise from the nature of individu86 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 86 als and their interaction with others. Both barriers can block, filter, or distort the message as it is encoded and sent, as well as when it is decoded and received. Environmental Barriers Examples of environmental barriers include competition for attention and time between senders and receivers. Multiple and simultaneous demands cause messages to be incorrectly decoded. The receiver hears the message, but does not understand it. Due to inadequate attention paid to the message, the receiver is not really "listening." Listening is a process that integrates physical, emotional, and intellectual inputs into the quest for meaning and understanding. Listening is effective only when the receiver understands the sender's messages as intended. Thus, without engaging in active listening, the receiver fails to comprehend the message. Time is another barrier. Lack of time prevents the sender from carefully thinking through and thoroughly structuring the message accordingly, and limits the receiver's ability to decipher the message and determine its meaning. Other environmental barriers include the organization's managerial philosophy, multiple levels of hierarchy, and power or status relationships between senders and receivers. Managerial philosophy can promote or inhibit effective communication. Managers who are not interested in promoting intraorganizational communication upward or disseminating information downward will establish procedural and organizational blockages. By requiring that all communication follow the chain of command, lack of attention and concern toward employees is a sign of a managerial philosophy that restricts communication flows. Furthermore, when subordinates encounter managers who fail to act, they are unwilling to communicate upward in the future, because communications are not taken seriously. Managerial philosophy not only affects communication within the organization, but also impacts the organization's communications with external stakeholders. For instance, when the chief executive officer (CEO) of one hospital becomes aware that patients might have been exposed to a dangerous infection while hospitalized, he immediately decides to cover up the incident and communicates that message down to his managers. However, another hospital CEO deals with this incident in a very different manner. She uses the public media as a channel of communication to encourage patients to come forward and be tested. These various reactions to similar events reflect different managerial philosophies about communication. Multiple levels of hierarchy and complexities such as the size and degree of activity conducted in the organization tend to cause message distortion. As messages are transmitted up or down, they may be interpreted according to an individual's personal frame of reference. When multiple Barriers to Communication 87 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 87 links exist in the communication chain, information could be misinterpreted. As a result, a message sent through many levels is likely to be distorted or even totally blocked. As an example, the CEO asked department administrators to relay his message of sincere congratulations and appreciation for their hard work to obtain their institutional Joint Commission on Accreditation of Healthcare Organizations accreditation status. The message went through several layers of the organization and was received in a more nonchalant manner than originally intended. In another scenario, a report generated by the management information system analyst was given to his supervisor, who went on vacation and left it on his desk without giving it to the vice president who had requested it a week ago. In this case, the message did not reach its destination. Power or status relationships can also effect transmission of a message. An unharmonious supervisor-subordinate relationship can interfere with the flow and content of information. Moreover, a staff member's previous experiences in the workplace may prevent open communication due to fear of negative sanctions as a result. For instance, a poor supervisor- subordinate relationship inhibits the subordinate from reporting that the project is not working as planned. Fear of the power and status of the manager is a common barrier to communication. Another environmental barrier that may lead to miscommunication is the use of specific terminology unfamiliar to the receiver or when messages are especially complex. Managers and clinical staff in healthcare organizations use medical terminology, which may be unfamiliar to external stakeholders. Communication between people who use different terminology can be unproductive simply because people attach different meanings to the same words. Thus, misunderstanding can occur due to unfamiliar terminology. Personal Barriers Personal barriers arise due to an individual's frame of reference or beliefs and values. They are based on one's socioeconomic background and prior experiences and shape how messages are encoded and decoded. One may also consciously or unconsciously engage in selective perception or be influenced by fear or jealously. For example, some cultures believe in "don't speak unless spoken to" or "never question elders" (Longest et al., 2000). These inhibit communication. Others accept all communication at face value without filtering out erroneous information. Still others provide self-promotion information, intentionally transmitting and distorting messages for personal gain. Unless one has had the same experiences as others, it is difficult to completely understand their message. In addition to frame of reference, one's beliefs, values, and prejudices also can alter and block messages. Preconceived opinions and prejudices are formed based on varying personalities and backgrounds. As discussed 88 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 88 in Chapter 3, selective perception is a tendency for retaining positive parts of the message and filtering out negative portions. Two additional personal barriers are status quo and evaluating the sender to determine whether one should retain or filter out messages. For instance, a manager always ignores the complaints from Melissa, the medical receptionist, because Melissa tends to exaggerate issues and events. However, one must be careful to evaluate and distinguish exaggerations from legitimate messages. Status quo is when individuals prefer the present situation. They intentionally filter out information that is unpleasant. For example, a manager refuses to tell staff and patients that their favorite physician, Dr. Ames, has decided to leave the practice. To prevent patients from switching to another physician, the manager postpones the communication to retain status quo. A final personal barrier is lack of empathy, in other words, insensitivity to the emotional states of senders and receivers. In the case where a physician demands that his assistants hurry and clean up the rooms because 50 patients are waiting, the assistants should empathize with the physician and understand that the physician is under stress and pressure to see his patients who are complaining that they have been waiting over three hours. OVERCOMING BARRIERS TO IMPROVE COMMUNICATION Recognizing that environment and personal barriers exist is the first step to effective communication. By becoming cognizant of their existence, one can consciously minimize their impact. However, positive actions are needed to overcome these barriers (see Table 4-1). Longest and coauthors (2000) provide us with several guidelines for overcoming barriers: 1. Environmental barriers are reduced if receivers and senders ensure that attention is given to their messages and that adequate time is devoted to listening to what is being communicated. 2. A management philosophy that encourages the free flow of communication is constructive. 3. Reducing the number of links (levels in the organizational hierarchy or steps between the sender in the healthcare organization and the receiver who is an external stakeholder) reduces opportunities for distortion. 4. The power/status barrier can be removed by consciously tailoring words and symbols so that messages are understandable; reinforcing words with actions significantly improves communication among different power/status levels. 5. Using multiple channels to reinforce complex messages decreases the likelihood of misunderstanding. Overcoming Barriers to Improve Communication 89 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 89 Personal barriers to effective communication are reduced by conscious efforts of senders and receivers to understand each other's values and beliefs. One must recognize that people engage in selective perception and are prone to jealously and fear. Sharing empathy with those to whom messages are directed is the best way to increase effective communication. Communicating effectively among a complex, multi-site healthcare system is challenging. Barriers may be difficult to overcome. Porter (1985) offers several approaches for achieving effective linkages among business units in a diversified corporation and suggests ways in which managers can overcome some of these barriers. 90 CHAPTER 4 WORKPLACE COMMUNICATION Table 4-1 Overcoming Barriers to Communication Barriers to Communication Overcoming Barriers to Communication Environmental Barriers 1. competition for time and attention 1. devote adequate time and attention to listening 2. multiple levels of hierarchy 2. reduce the number of links or levels of hierarchy 3. managerial philosophy 3. change philosophy to encourage the free flow of communication 4. power/status relationships 4. consciously tailor words and symbols and reinforce words with actions so that messages are understandable 5. organizational complexity 5. use multiple channels of community to reinforce complex messages 6. specific terminology 6. consciously define and tailor words and symbols and reinforce words with actions so that messages are understandable Personal Barriers 1. frame of reference 1. consciously engage in efforts to be cogni2. beliefs zant of other's frame of reference and beliefs 3. values 2. recognize that others will engage in selec4. prejudices tive perception, jealousy, fear, prejudices 5. selective perception to help diminish the barriers 6. jealousy 3. engage in empathy 7. fear 8. evaluate the source (sender) 9. status quo 10. lack of empathy Source: Based on Longest, B.B., Rakich, J.S., & Darr, K. (2000). Managing health services organizations (4th ed.). Baltimore, MD: Health Professions Press, Inc., pp. 808-810. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 90 1. Use techniques that extend beyond traditional organizational lines to facilitate communication. For instance, the use of diagonal communication that flows through task forces or committees enhances communication throughout the organization. 2. Use management processes that are cross-organizational rather than confined to functional or department procedures. Implementing management processes in the areas of planning, controlling, and managing information systems facilitate communication. 3. Use human resources policies and procedures (job training and job rotation) to enhance cooperation among members in organizations. 4. Use management processes to resolve conflicts in an equitable manner to produce effective communication. EFFECTIVE COMMUNICATION FOR KNOWLEDGE MANAGEMENT Communication plays an important role in knowledge management. Employees are the organization's brain cells, and communication represents the nervous system that carries information and shared meaning to vital parts of the organizational body. Effective communication brings knowledge into the organization and disseminates it to employees who require that information. Effective communication minimizes the "silos of knowledge" problem that undermines an organization's potential and, in turn, allows employees to make more informed decisions about corporate actions. Effective communication is one of the most critical goals of organizations (Spillan, Mino, & Rowles, 2002). Recent research evidence suggests that an effective manager is one who spends considerable time on staffing, motivating, and reinforcing activities (Luthans, Welsh, & Taylor, 1988). Shortell (1991) identified multiple key elements to effective communication in a model developed for physicians and hospital administration to improve their communication abilities to disseminate knowledge within the organization. The following summarizes these key elements: An effective communicator must have a desire to communicate, which is influenced both by one's personal values and the expectation that the communication will be received in a meaningful way. An effective communicator must have an understanding of how others learn, which includes consideration of differences in how others perceive and process information (e.g., analytic vs. intuitive, abstract vs. concrete, verbal vs. written). The receiver of the message should be cued as to the purpose of the message, that is, whether the message is to provide information, elicit a response or reaction, or arrive at a decision. Effective Communication for Knowledge Management 91 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 91 The content, importance, and complexity of the message should be considered in determining the manner in which the message is communicated. The credibility of the sender affects how the message will be received. The time frame associated with the content of the message (long vs. short) needs to be considered in choosing the manner in which the message is communicated. More precise cues are needed with shorter time frames (see Figure 4-3). A formula to evaluate an individual's effectiveness in communicating to others can be calculated as shown in Exhibit 4-2. The index of communication effectiveness is a percentage of the reaction to the intended message over the total number of messages sent. If managers find that their index of communication effectiveness is low over time, they should evaluate their communication processes to identify ways to make improvements (Certo, 1992). Research suggests that 92 CHAPTER 4 WORKPLACE COMMUNICATION Effective Communication Understand how others learn Purpose Content Sender Credibility Time Frame Desire to communicate Feedback Effective Communication Figure 4-3 Interrelationships of Effective Knowledge Management Communication Source: Based on Shortell, S.M. (1991). Effective Hospital-Physician Relationship. Ann Arbor, MI: Health Administration Press, p. 87. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 92 Image has been redacted. to improve healthcare organizational communication and cohesion, exchanges between employees and leaders should involve leaders' direct support and encouragement of employees' constructive expressions of dissatisfaction and innovative ideas (Sobo & Sadler, 2002). (See Case Study 4-2: What Should We Do Now?) Case Study 4-2 What Should We Do Now? Jenny Taylor, Receptionist at Caring Physicians Clinic, was responsible for calling patients to remind them of their appointments. Dr. Ann Ryan, Medical Director of the Clinic, found Jenny to be hardworking and pleasant to the patients. One morning, Dr. Ryan arrived and found Jenny crying in the supplies room, and when she questioned Jenny, Jenny sobbed that she had forgotten to order supplies for the past three months. Jenny had been borrowing supplies from the pediatrics office next door. Now, they were unwilling to lend her more. Jenny confessed that she had called once to the supply center and faxed a list of supplies over but had not followed through. This morning, Jenny called the supply center again and found out that they were out of business. Jenny told her immediate supervisor, Barbara Lakes, Patient Care Coordinator for the Clinic. Lakes fired Jenny for incompetence. In the meantime, patients were waiting and there were no clean sheets, gloves or gowns. Discussion Questions 1. When was the beginning of the problem? 2. What should Jenny have done? 3. Using the elements of effective communication, discuss what should Dr. Ryan and Barbara Lakes do now? STRATEGIC COMMUNICATION Strategic communication is an intentional process of presenting ideas in a clear, concise, and persuasive way. A manager must make an intentional effort to master communication skills and use them strategically, that is, consistently with the organization's values, mission, and strategy. To plan strategic communication, managers must develop a methodology for thinking through and effectively communicating with superiors, staff, and peers. Sperry and Whiteman (2003) provide us with a strategic communication plan, which consists of five components. 1. Outcome. The specific result that an individual wants to achieve. 2. Context. The organizational importance of the communication. 3. Messages. The key information that staff need to know. Strategic Communication 93 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 93 4. Tactical reinforcement. Tactics or methods used to reinforce the message. 5. Feedback. The way the message is received and its impact on the individual, team, unit, or organization. Strategic communication requires forethought about the purpose and outcome of the message. Managers must be able to link the needs of the staff to the organization's mission and deadlines. FLOWS OF INTRAORGANIZATIONAL COMMUNICATION Communication can flow upward, downward, horizontally, and diagonally within organizations. Upward communication occurs between supervisors and subordinates. Downward communication primarily involves passing on information from supervisors to subordinates. Horizontal flow is from manager to manager or from co-worker to co-worker. Diagonal flow occurs between different levels of different departments. Longest et al. (2000) provides us with several forms of intraorganizational communication for healthcare organizations. Upward Flow The purposes of upward communication flow are to provide managers with information to make decisions, identify problem areas, collect data for performance assessments, determine staff morale, and reveal employee thoughts and feelings about the organization. Upward flow becomes especially important with increased organizational complexity. Therefore, managers must rely on effective upward communication and encourage it as integral parts of the organizational culture. Upward communication flow helps employees meet their personal needs, by allowing those in positions of lesser authority to express opinions and perceptions to those with higher authority. As a result, they make contributions to the organization, and participate in the decision making process. The hierarchical structure (chain of command) is the main channel for upward communications in healthcare organizations. To increase the effectiveness of upward communication, Luthans (1984) recommends the use of grievance procedures, open door policies, counseling, employee questionnaires, exit interviews, participative decision-making techniques, and the use of an ombudsperson. Grievance procedure. This allows employees to make an appeal upward beyond their immediate supervisor. It protects the individual from arbitrary action by their direct supervisor and encourages communication about complaints. Open door policy. The supervisor's door is always open to subordinates. It is an invitation for subordinates to come in and talk to the superior about things that trouble them. 94 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 94 Counseling, questionnaires, and exit interviews. The department of human resources in a healthcare organization can facilitate subordinate-initiated communication by conducting confidential counseling, administering attitude questionnaires, and holding exit interviews for those leaving the organization. Information gained from these forms of communication can be used to make improvements. Participative decision-making techniques. Through the use of informal involvement of subordinates or formal participation programs such as quality improvement teams, union-management committees, and suggestion boxes, participative techniques can improve employee performance and satisfaction. Since employees can participate in the decision-making process, they feel that they can make valuable contributions to the organization. Ombudsperson. The use of an ombudsperson provides an outlet for persons who feel they have been treated unfairly. In upward communication, subordinates can provide two types of information to supervisors: (1) personal information about ideas, attitudes, and performance and (2) technical information to provide feedback. Managers who encourage feedback enhance upward flow of communication. Downward Flow Downward communication involves passing information from supervisors to subordinates. This includes verbal and nonverbal communication, such as instructions for completing tasks, as well as communications on a one-to-one basis. Downward communications include meeting with employees, written memos, newsletters, bulletin boards, procedural manuals, and clinical and administration information systems. Horizontal Flow Upward and downward communications are inadequate for effective organizational performance. In complex healthcare organizations, horizontal flow or lateral communication must also occur. The purpose of lateral communication is the sharing of information among peers at similar levels to keep organizational staff informed of all current practices, policies, and procedures (Spillan et al., 2002). For example, coordinating the continuum of patient care requires communication among multiple units. Furthermore, committees, task forces, and cross-functional project teams are all useful forms of horizontal communication. Diagonal Flow The least used channel of communication in healthcare organizations is diagonal flow. Diagonal flows are growing in importance. While diagonal Flows of Intraorganizational Communication 95 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 95 flow does not follow the typical hierarchical chain of command, diagonal flow is especially useful in health care for efficient communication and coordination of patient care. For example, diagonal communication occurs when the director of nursing asks the data analyst in the medical records department to generate a medical records report for the month on all patients in the intensive care unit. (See Case Study 4-3: Communication Flows.) Case Study 4-3 Communication Flows Sara Lang is a charge nurse at Sunny Nursing Home and has worked under the same president, Lisa Davis, for five years. In fact, the two have become good friends. They frequently socialize after hours. Rick Walters, Director of Nursing, is a capable person who has been working there for three years. Four nurses (Anna, Barbara, Charles, and Dan) report directly to Sara. Anna, one of the nurses, was having personal difficulties. She asked Sara if she could change her work schedule from the usual 8-hour shift of 4 days with 3 consecutive days off to 16-hour shifts for two days and 5 consecutive days off. Sara thought that was not a problem and told Anna that she would enter that information into the computerized scheduling system, and that she would tell Lisa Davis of the change, since they were getting together for a drink after work. Barbara overheard the conversation between Sara and Anna, and she immediately went to see Rick Walters and complained that Anna was getting preferential treatment and she wanted the same schedule. Rick, who always wanted to make sure that the nursing staff were happy and got along, approved Barbara's change in schedule. He made this change through the computerized schedule and did not tell anyone else. Barbara, who is good friends with Charles, told him of her new schedule. Charles, who works closely with Chief of Staff, Dr. Goodman, told Dr. Goodman of the change in Barbara's schedule and asked Dr. Goodman to change his. Dr. Goodman thought it was a good idea and e-mailed Charles' new schedule to his assistant, Susan Stevens, to enter it into the scheduling system. On the next Monday morning, changes were implemented to Anna's, Barbara's, and Charles' schedules. Yet, no one had discussed these changes with anyone else. When the schedule was printed out and posted, it showed that Anna, Barbara, and Charles were all off for 5 days that week from Monday to Friday and all three began work on Saturday. In the meantime, the only nurse left working was Dan. Discussion Questions 1. What are the different forms of communication flow taking place? 2. What changes should have been implemented? 3. What should be done now? 96 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 96 COMMUNICATION NETWORKS Flows of communication can be combined into patterns called communication networks. These networks are interconnected by communication channels. A communication network is the interaction pattern between and among group members. A network creates structure for the group because it controls who can and should talk to whom (Keyton, 2002). Groups generally develop two types of communication networks: centralized and decentralized (Figure 4-4). Decentralized networks allow each group member to talk to every other group member without restrictions. An open, all-channel or decentralized network is best used for group discussions, decision making, and problem solving. The all-channel network tends to be fast and accurate compared with the centralized network such as the chain or Y-pattern networks (Longest et al., 2000). Nevertheless, a decentralized network can create communication overload, in which too much information or too complex communication may occur (Keyton, 2002). When a communication overload is produced, messages may conflict with each other and result in confusion or disagreement. To reduce communication overload, a facilitator should be used to monitor group discussions. A centralized network restricts the number of people in the communication chain. In a group setting where a dominant leader takes over group discussions by controlling the number of messages and amount of information being passed, group members do not interact except through the leader. Such a network can create communication underload, in which too few or simple messages are transmitted. In this type of network, group members feel isolated from group discussions and generally feel dissatisfied. In the chain network, communication occurs upward and downward and follows line authority relationships. An example is a staff nurse who reports to the charge nurse, who reports to the director of nursing, who reports to the vice president for clinical services, and who finally reports to the CEO of a large hospital. This network delineates the chain of command and shows clear lines of authority. Other types of centralized networks include the Y-pattern, the wheel, and the circle network. The Y-pattern is similar to the chain network, with its hierarchical structure, except it shows two employees at the same level who then follow the chain. An example is of two medical assistants in the division of transplant who report to the clinical administrator for the division, who reports to the clinical administrator for the department of surgery, who reports to the vice president of clinical services, who finally reports to the CEO of the hospital. The wheel pattern shows four subordinates reporting to one supervisor. Subordinates do not interact, and all communications are channeled through the manager at the center of the wheel. This pattern is rare in healthcare organizations and systems, although elements of it can be found in the exCommunication Networks 97 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 97 98 CHAPTER 4 WORKPLACE COMMUNICATION Figure 4-4 Two Types of Communication NetworksCentralized and Decentralized Source: Longest, B.B., Rackich, J.S., & Darr, K. (2000). Managing health services organizations (4th ed.). Baltimore, MD: Health Professionals Press, Inc., p. 813. ample where four vicepresidents report to a president if the vice presidents have little interaction. Even though this network pattern is not routinely used,it may be used whenurgency or secrecy is required. For example, the president with an organizational emergency might communicate with the vice presidents in a wheel pattern because time does not permit using other modes. Similarly, if secrecy is important, such as when investigating pos47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 98 Image has been redacted. sible embezzlement, then the president may require that all relevant communication with the vice presidents be confidential. The wheel pattern works well when there is pressure for time, secrecy, and accuracy. The circle pattern allows communicators in the network to communicate directly only with two others. Since each communicates with another in the network, there is no central authority or leader. The circle network works well when there are open channels of communication among all parties; however, it can also slow down the communication process to enable everyone access to information. Although there are different communication networks, there is not one that works for all situations. Different forms can be applied under varying circumstances. To be effective, healthcare managers must be able to select appropriate flows of communication for specific situations. Identifying an ideal communication network is critical to successful communication. Since health problems range from simple to complex, simple problems can be easily resolved using simple networks. As an example, scheduling patient appointments for Dr. Davis can be easily accomplished through the superior-subordinate chain network. However, complex problems require many levels of decision making. For instance, whether Horizons Hospital should merge with its major competitor to gain more market share at the risk of making a major capital investment can be accomplished through the all-channel network, which is more useful and effective for tackling complex problems. Hellriegel and Slocum (2004) compared the five communication networks using four assessment criteria. Figure 4-5 shows the specific criteria when making a selection among the different types of networks. 1. Degree of centralization. This is the extent to which team members have access to more communication than others. In the case of the wheel network, because communication flows from and to only one member, this is the most centralized network. However, the allchannel network provides everyone in the network with the same opportunity for communication; thus, it is the least centralized network. 2. Leadership predictability. This is the ability to anticipate which member of the communication network is likely to emerge as the leader. In the case of the Y and wheel, the most centrally positioned individual is the most likely person. 3. Average group satisfaction. This reflects the level of satisfaction of members in the communication network. In the wheel network, average member satisfaction is the lowest compared to other networks, since the most centrally positioned person plays the most crucial roles and leaves small decision-making roles for those around the wheel. 4. Range of individual member satisfaction. The range of an individual's satisfaction within the communication network shows an inverse relationship with the average group satisfaction. Again, in the wheel, Communication Networks 99 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 99 although average member satisfaction is low, the range of individual member satisfaction is high, because they are highly dependent on the individual in the middle. In the case of the all-channel, average group satisfaction is high since there is greater participation by all members of the communication network; yet, individual satisfaction is very low. INFORMAL COMMUNICATION In addition to formal communication flows and networks within healthcare organizations, there are informal communication flows, which have their own networks. Employees have always relied on the oldest communication channelthe corporate grapevine. The grapevine is an unstructured and informal network founded on social relationships rather than organizational charts or job descriptions. According to some estimates, 75 percent of employees typically receive news from the grapevine before they hear about it through formal channels (McShane & Von Glinow, 2003). Early research identified several unique features of the grapevine. It transmits information very rapidly in all directions (Newstrom & Davis, 1993). Figure 4-6 illustrates four common patterns that the grapevine can take. The typical pattern is a cluster chain, whereby a few people actively transmit rumors to many others. The grapevine works through informal social networks, so it is more active where employees have similar backgrounds and are able to communicate easily. Many rumors seem to have at least a little bit of truth, possibly because rumors are transmitted through information-rich communication channels, and employees are 100 CHAPTER 4 WORKPLACE COMMUNICATION Figure 4-5 Effects of Five Communication Networks Source: Hellriegel, D., & Slocum, J.W. (2004). Organizational behavior (10th ed.). Mason, OH: South-Western, p. 301. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 100 Image has been redacted. motivated to communicate effectively. Nevertheless, the grapevine distorts information by deleting fine details and exaggerating key points of the message. In this era of information technology, e-mail and instant messaging have replaced the traditional water cooler site of grapevine gossip. Instead, networks have expanded as employees communicate with each other inside and outside of the organization instantly through computer-aided communication. Furthermore, public websites have become virtual water coolers for posting anonymous comments about specific companies for all to view. This technology extends gossip to anyone, not just employees connected to the social networks. A manager's responsibility is to utilize the informal network selectively to benefit the organization's goals. (See Case Study 4-4: Did You Hear the Latest?) Case Study 4-4 Did You Hear the Latest? Sally Reeds, a medical secretary for the department of neurology at Western Heights Hospital in Colorado, turned on her computer and found an e-mail from her friend and co-worker, Justin Zeels, a social worker in the same hospital. Justin wrote that Dr. Sites, Medical Director Informal Communication 101 Figure 4-6 Grapevine Networks Source: Newstrom, J.W., & Davis, K. (1983). Organizational behavior: Human behavior at work (9th ed.). New York: McGraw-Hill, p. 445. 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 101 Image has been redacted. of Neurology, was found under a bench outside the ER. The hospital security allegedly reported that Dr. Sites was completely intoxicated, and he was rushed home. Sally spiced up the tale and immediately e-mailed 10 of her friends. This morning, Sally looked up and saw Dr. Sites seeing his patients as if nothing had happened. She confronted him and asked him how he could possibly face everyone after what happened last night. Dr. Sites looked confused until a copy of Zeels' e-mail was thrust into Dr. Sites' hands by another staff member. After reading it, Dr. Sites became livid and fired Justin for spreading such a malicious rumor. Meanwhile, Maria Hummingshire, another medical secretary, who saw the entire incident, ran to her computer to e-mail the latest to her friends. Discussion Questions 1. What did Sally do wrong? 2. What should Justin have done? 3. What should the organization do to prevent the spread of gossip through the grapevine? CROSS-CULTURAL COMMUNICATION Increasing information technology, globalization, and cultural diversity present a number of communication opportunities and challenges for organizations. Organizational personnel must be sensitive and competent in cross-cultural communication. While ethnic and racial diversity enriches the environment, it can also cause communication barriers and impede efficient and effective service delivery. Communication difficulties arise from differences in cultural values, languages, and points of view. For instance, in the healthcare industry, one major barrier is language, because as many as 20 languages may be encountered among staff and patients. In the United States, more than 25 percent of the population is foreign-born, and 15 percent speak a language at home other than English (Thiederman, 1996). Since language is the most obvious cross-cultural barrier, words can be easily misunderstood in verbal communication (Dutton, 1998). Although the English language is relied on as the common business language, English words may have different meanings in different cultures. Voice intonation varies by country. For instance, in Japan, communicating softly is an expression of politeness, whereas in the Middle East, the opposite holds true, for the louder the voice, the more one is believed to be sincere (Mead, 1993). To achieve effective communication, healthcare professionals can apply several strategies to reduce communication barriers. Thiederman (1996) provides us with several verbal and nonverbal techniques to improve cross-cultural communication. Write down in simple English the issues that have been agreed upon in order to obtain feedback on accuracy. 102 CHAPTER 4 WORKPLACE COMMUNICATION 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 102 Repeat a message when there is doubt. Watch for nonverbal signs of a lack of understanding. Listen carefully to an entire message, especially when there is a foreign accent involved in the communication. Create a relaxed atmosphere so that tension is reduced to increase the flow of communication. Phrase questions in a different way to allow the sender the opportunity to respond, utilizing different words that may be easier for the receiver to understand. COMMUNICATING WITH EXTERNAL STAKEHOLDERS In healthcare organizations, managers must be competent communicators, because they spend most of their time and energy communicating with large numbers of external stakeholders, individuals, groups, and organizations that are interested in the healthcare organization's actions and decisions. A competent communicator is an individual who has the ability to identify appropriate communication patterns in a given situation and to achieve goals by applying that knowledge. Competent communicators quickly learn the meaning that listeners take from certain words and symbols, and they know which communication channel is preferred in a particular situation. Moreover, competent communicators use this knowledge to communicate in ways to achieve personal, team, and organizational objectives. A manager with high communication competence would be better than others at determining whether an e-mail, telephone call, or personal visit would be the best approach to convey a message to an employee. To competently communicate with external stakeholders, organizations and their managers are responsible for assessing the environment to gain information in order to make strategic decisions. Managers must utilize their roles as liaisons and monitors to scan the environment for opportunities and minimize threats. Furthermore, managers must utilize their strategist role to formulate and implement public policies that are consistent with their organization's strategic goals and plans (Guo, 2003). Exhibit 4-3 shows steps for analyzing stakeholders to increase the acquisition of useful information. First, scanning the macro- and microenvironments results in information about stakeholders. In the case of one state's Department of Health, shown in Figure 4-7, the diversity of stakeholders is illustrated (Ginter, Swayne, & Duncan, 1998). The relationships and communications between the organization and its external stakeholders are complex since the organization is a dynamic, open system operating in a complex and turbulent external environment. Communicating with External Stakeholders 103 47688_CH04_077_110.qxd 3/9/05 4:51 PM Page 103 The size and variety of external stakeholders make communication complex, especially since stakeholders attempt to influence the decision making of organizations. Fottler, Blair, Whitehead, Laus, and Savage (1989) examined communication between a large hospital and its stakeholders and found different relationships. Wh