n how to manage organisational change, communication and resistance in your palliative care facility

Introduction

The purpose of this report is to brief your organisation and provide recommendations on how to manage organisational change, communication and resistance in your palliative care facility. This report is based on the incident, which happened in your palliative care facility in 2011. This report determines the tension between the two different processes: emotional process between the nurses and patients family and other bureaucratic system of the organisation. Emotional process between nurses and family members means that nurses are generally expected to be polite and more emotionally involved with families because they are mostly the first line contact with the family members of the deceased whereas, management part is more of bureaucratic influenced and involves strict rules and regulation. We will analyse and explore the paradox contained in the model of open disclosure through the medium of culture, talks,voice and discourse which are the pillars of any communication change (Thomas, Sargent & Hardy, 2011; Morgan, 2011; Putnam et all, 1999, p. 139) and will help us to examine the important issues of this incident. At the end this paper will also provide recommendations by using academic and research papers that might be helpful for you in future regarding future investigations and in future incidents.

 

Situation Analysis

This unpleasant event engrosses a young woman who was being treated at your palliative care for her terminal disease. The young lady was kept with her partner at the corner of the ward so they can enjoy privacy. Patient may be delirious and not in her senses because of her serious condition and what happened next was very unfortunate. One night patient left the ward through fire door and didn’t return and very next day she was found fallen on the hospital ground. Furthermore, she died soon after the incident and then a series of internal inquiry was started which included staff meetings and then open disclosure meeting was conducted after the 2 months of the actual incident. There are many questions to rise like why alarm of fire door didn’t ring, why security officers failed to watch patient in security camera. However these are not the issues we wish to raise in this report but other issues such as organisation culture, organisation communication, discourse, power and voice which requires addressing in this incident because these are the issues which are important but often neglected in the process of organisation change and communication (Grant & Michelson 2005, p. 2)

These all concerns will be highlighted in the following report. We will use different academic literatures and we will talk how to react to internal and external voices of organisation, how to analyse discourse within process of change organisation, organisational culture and how to communicate with the employee within organisation.

 

Open disclosure

The result of RCA meeting is to operate a high-level open disclosure. The open disclosure is used to contract with patient’s family and to tell them about investigation. It is also a compulsory procedure for the hospital due to the requirements of the National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care, 2013). The open disclosure implies talk operates in different levels within an organization. Talk permeates all aspect of the organizational reality and represents the values and beliefs of the organisation. Talk refers to the language and sensemaking that influence and construct the organization. It is identified as “the enactment of a sensemaking process”(Thurlow and Mills, 2009). Dervin defines the process of talk as “a programmatic effort to study how people construct sense of their words and, in particular, how they construct information needs and uses for information in the process of sensemaking” (Dervin 1983, cited by Wilson, p.64). The power of talk reflects that it constitutes and constructs organizational reality and identity (Clegg ). Clegg identifies the awareness of talk as the expressive organization (Clegg, 1999). Thus, the content of organizational talk as a part of an expressive organization could influence processes such as strategy making, human resource, marketing and others (Clegg 1999, p.329). In the case, the ways describe the process of the open disclosure reflects the organizational identity and talk in dealings between the organization and individuals. For the internal communication, it is important to consider how employees influence and make decisions about communication. The report shows an initial disclosure with patient’s family was absented in her plan before the official disclosure. The standards of the initial disclosure require “an initial disclosure should “take place face-face and whenever possible within 24 hours of the incident or within 24 hours of the incident being recognized”(Clinical Excellence Commission, 2007). Emotional state has been ignored by the organisation. It is failed to make patients’ family realizing the significance of the open discourse, and to provide the information about patient’s rights they could request. The patient’s mother refused to talk about the incident and attend the disclosure meeting because she was sad and angry in that time. Then, the hospice side decides to give up persuading the patient’s parents to attend the open disclosure, and planned to process a teleconference for transmitting the same information from the open disclosure. Thus, the open discourse could be regarded as asymmetrical communication. Iedema and Allen in their journal article Anatomy of an incident disclosure: the importance of dialogue also defines dialogue is considered as a standard of a successful communication (Australian Commission on Safety and Quality in Health Care, 2013). However, the case shows it does not reach the standard as required. The preliminary issues of the case will be analysed through four main fields: culture, discourse, voice, and resistance.

Culture

 

Culture is often defined simply as a way of life for a certain group of people in a community or an occupation. Organizations have their own cultures, which determine the manner and way in which certain processes and activities will be carried out. The major intent of corporate culture in an organization is to provide the employees and management of the organization with a formula of operations to enable uniformity within the organization. This corporate culture develops over time in terms of attitudes, values, standards and beliefs. This is enhances by having vision, mission and core values that are communicated to every member of the organization. According to Cameron (2010), language is essential in winning hearts and minds. Language is part of culture. It is a way of communication and needed in the organization. It is through language that culture is communicated that bide people in the organization together. Culture plays an important role in determining how an organization conducts itself towards its employees, customers and clients, and any other members affiliated to the organization. While culture creates uniformity and continuity to the organization, it may be inhibitive at times, especially when it is used to deter change and other proactive engagements (Wong, 2010). This leads to the way the patient in the case study is treated and how her death is investigated. As Wong suggest about being a culture to interview employees to check if they fit in the organization culture, the same case happens in the case study. Interview as part of communication takes place to investigate the death of the patient. Communication is also critical in bringing about cultural change. It is through the investigation that the hospital sees the need of an alarm of the fire door.

 

Culture is explicit in the case study above, where the hospice was aware of its responsibility towards its patients as required them in the nursing duty of care and as had been practiced in the hospital in the past. Despite efforts by the patient’s family to pass on blame to the patient’s partner for the events that befell the patient, the hospice was quick to take the blame and do all within its means to ensure that it went over the events and identify any blame on its side. This shows that the hospice knew and understood its responsibilities well and had developed a culture of letting all of the health personnel know that have a primary duty of care to their patients. The hospice also exhibited a strong chain of command and bureaucracy, where all of the health personnel were organized into a structural hierarchy (Thurlow& Mills, 2009). Each of them knew their roles and the timing for these roles, so that every member of the medical team knew where he was supposed to be at every time of the day and night. This is a cultural element and it words effectively to reduce confusion within an organization and enhance orderliness. Bureaucracy helps organize people and work together towards a common goal. In case of anything in the organization, the top management helps organize other members into solving problems. The authors say of organization‘s talk, change and sense making. Sense making can be enactive of sensible environments. This is applied in the health centre whereby the committee see the sense of having a fire door alarm. However, it took the death of a patient to realize such a need. The process is also long due to following bureaucracy. This element can, however, be used to create a negative environment within the organization when it increases bureaucracy within the organization and limits chances of flexibility of change for better procedures. After the incident, the inquiry was able to place nurses at their location during the incident.

 

Culture in an organization is used to give direction to the manner of occurrence of activities and procedures to provide some form of permanency and guidance to protocol (Cameron, 2010). This involves policies that are set and should be followed by the team working in an organization. In regard to this, policies need to be communicated to the team so as to have proper coordination. The policies may be designed by the top management and communicated to the lower level employees.  This serves both negatively and positively in that it can reduce the amount of creativity and innovation into an organization’s procedures by relying on ‘the way things have always been done’ (Cameron, 2010) On the other hand, however, it can reduce ambiguities and vagueness in some procedures. In the case of the hospital, for instance, the requirement that coronial examination is carried out only if the patient dies within 24 hours on an incident limited the options for the hospice to conduct testing to determine if the patient actually died of the events of the incident, especially considering that the 30 minutes was too little to rule out such a possibility. On the other hand, however, this culture at the health facility in the case study, ensured that there was no contention on the need for the coronial examination because of the manner that things had always been. Culture, therefore, should be adopted with caution, ensuring that it is used to preserve the good qualities of a given practice but provide room for innovation to adopt new ways of enhancing performance. Culture is adopted by learning the values, attitudes, and beliefs of an organization and practicing them. This guides employees in the way they run their day to day activities.

 Discourse

When we think or talk about the change intervention in the palliative care facility, discourse analysis may be very useful in identifying that what is happening at both micro and macro level within organisation level. A discursive point of view distinguish the world as assembled through ‘narrative, signs, language and symbolic pattern’ (Grant & Michelson, 2005, p.12)Discourse integrates the two ontological postulation of institution where lexis and verbal communication can be understood and structured as “fixture of reified social system” within the organisation (Putnam et all, 1999, p. 142). At the same time discourse acts as a liquid to bargain through feelings, situation and social construction (Van de Ven& Poole, 2005). It means that we can represent the official, unofficial and sentimental dimensions of the communication and interaction of everyday life at palliative care facility (Idema, 2007, p. 13). Discourse can also stimulatereflexivity about how everythings functionamongst clinicians (Iedema&Carroli, 2010).

Discourse can also be described as little‘d’ and big ‘D’levels. Big ‘D’ represents the bureaucratic and administrative policy forces within an organisation. In contrast, little‘d’ represents the dailyconversation, interaction and documentation at lower level (Kwon, Clarke &Wodak, 2009). ‘Little d’ in the case is represented with phrases such as we understand that staffs were “understandably exhausted” and patient was “understandably very confused and very distressed”. The language shows the nurse unit manger’s empathy which may conflict with other discourse. Whereas,big ‘D’ was represented when the nursing staff manager reports the death as expected and inevitable because of patient’s condition rather than the fall or negligence. Similarly, the delay in finishing the report about incident also shows the effect of macro level discourse in organisation.

 

When we consider this accident in terms of little ‘d’ and big ‘D’, we find out that little ‘d’ is dominating in this case study. We can see that little ‘d’ over powers big ‘D’. We can clearly see that discourse of empathy and emotion was clearly shown in the incident report whereas the investigation procedure following accident was not properly followed. The patient injuries after the fall and reason of death were not fully evaluated with the prejudice that patient was going to die anyhow because of her incurable condition. However, the reason given for not following the proper procedure was to bring further unwanted stress to deceased family but the question to be asked is that would the things be same if the patient was not terminal and in hospice. These prevailing discourses of kindness, empathy and love demonstrate the organisational culture of care and sympathy towards the patients at the end of their life. But the discourse of guiding principle and authority are surpassed by the dominant discourse of little ‘d’which lead to poor execution of principles and values. Furthermore, the little ‘d’ discourse can be seen when information sharing process was involved. It was very obvious from the report that information sharing was only one way from the authority to the patient and most of the time deceased family was informed what the authorities considered to be important enough to tell. It was obvious that information sharing was not transparent and was on hospice term. Another notable feature of the report was the open disclosure meeting which held after two months of the incident and only than the family was notified regarding the findings. Putnam (1999) also described this type of information sharing as “primarily one way, linear, transmission flow”.  In the case, the patient’s family could be seen as receivers who have limited power to speak out. The communication processes of the open disclosure exposes the intersection of ‘Big D’ and ‘little d’. The context of the staff’s words shows it was required from a compliance and legal view, and it could not fully represent what the staff want to say.

 

Voice

Voice intervention tries to enclose the concurrent “expression and suppression of voice” within hierarchichal, hegemonic organisation.(Putnam et all 1999, p. 134). These features of organisation change program will attempt to negotiate the voices and “contending points of view” between Medical staff, family and organisation. (Marshak& Grant, 2008, p. 9) Voice mediations endeavour to embody the concurrent interpretation and concealment of voice inside the progressive association. The research endeavour epitomizes the bending and muting of voices inside the revelation handle on the side of the choices and supposition of administration (Woodman, 2009, pp. 230).

In order to achieve successful change it is important to see organisation as a process rather than a building as(Van de Ven and Scott Poole, 2005) says that a “fundamental issue that influence is how we look at change is weather we view organisation as consisting of things or process”. When we see organisation as a process than every process has voice which can be in favour or against and to implement successful change managers need to listen to both the voices.

Putnam et all 1999in their study shows the importance of managers to listen to different point of view and perception within the institute by using Voice metaphor. Similarly the Voice allows the members within the organisation to raise their concerns and knowledge heard as a crucial part of organisation change.

Allowing family members and staff to raise their voice in open disclosure meeting will allow increase support for grieving families and potentially more successful disclosure. (Iedena& Allen 2014, p.  441). In our point of view the example of voice in this incident is not encouraging as the voices of family were distorted and suppressed by the management of hospice in open disclosure meeting in favour of conjecture and assumption of management. We can clearly see that there was a power imbalance between the staff and the family members. There was only 1 representative from deceased side, although he was asked to bring someone along with him but he decided to come alone, so staff decided themself to conduct meeting with 3 staff members and only 1 representative of family member (Vignette, p.6)

All the investigations were conduct by internal committee and no coroner was involved. And the decision not to involve the coroner was by the organisation members themself. In the report it was assumed that the cause of the death was because of her terminal condition rather than the fall itself but this report was made by the internal committee. We believe that there is equal chances that the death could be because of fall itself and the outcome of the report could have been totally different if coroner or some outside people were involved.

Organizational Change & Communication

Organiational change refers to the changes that take place within an organization as pertaining to the practices of an organization (Thurlow & Mills, 2009). This definition helps understand what organization change is and how it takes place. Communication is the process of conveying messages within an organization to inform the involved parties of the events or requirements in the organization (Michelson & Mouly, 2004). These two tools work hand in hand to reinforce one another as change can only take place through the exchange of information, ideas, or instructions for the involved parties. The processes are tools because they have a purpose to be accomplished. The purpose is to cause change that may have an impact in the organization and the society at large. The advent of the computers and Internet has revolutionized the process of communication, making it simpler, faster, and cheaper and more accessible to a vast and varied number of people for easier and more convenient communication. It is important that organizations maintain the importance of communication in all of their activities and functions (Michelson & Mouly, 2009). Communication should be formal or informal. Formal communication is official and facilitated by the organization. it happens by following the organization’s hierarchy of command. In the case study, there is formal communication whereby management communicates information to nurses and soldier (Michelson &Mouly, 2004). However; there is also informal communication which involves rumor and gossip. Organizations ensure there are proper channels of communication in order to avoid gossip and rumor. The hospital in the case study presents a good case and situation for communication. The one element that was rife and strong within this hospital and among the hospital staff and clients was that of communication. Although the nurse narrating the incident was off duty at the time of the incident, he was well briefed of the events of the incident upon his return to duty and so were all other interested parties within the shortest time possible. The hospice called and informed the patient’s parents as soon as possibly could of the incident to ensure that the informational gap was kept narrow.

 

Organizational change is one of the most common elements in organizations today as each organization seeks a best approach to its processes and activities (Johansson & Heide, 2008). Organizational change works to improve the state of operations within the organizations through innovative and critical thinking and as such, should be informed from the input of all parties to the proposed changes. The hospital was quick to form and start an enquiry into the events leading up to the incident. This enquiry, in the form of a root cause analysis was attended by all of the parties responsible for the incident and was consultative enough to get to the root of the issue. The team agreed on the cause established and went ahead to seek a solution that would ensure that a repeat of the same incident would not occur. This led to some changes being adopted such as the structure of fire doors and the need to put some patients with special needs in isolated wards where they could be safer. What these changes imply is that change is an eminent feature in all organization and that it should not be static, but rather continuous and consultative to ensure that an organization continually adopts better and improved practices and strategies that will improve the overall performance of the organization (Johansson & Heide, 2008). Of great importance is the need to ensure that organizational change is a product of effective communication so that all members of the organization are well informed of the need for the changes and the actual changes and the intention of the changes.

Recommendations

A conflict of the bureaucratic institutions struggling for reifying multifaceted and emotional process is fore grounded in this dichotomy of policy and emotions (Marshack & Grant, 2008). For bridging the gap between incident’s emotional management and meeting the procedural and legal requirements, a comprehensive integral change program is recommended equipped with a verity of effective interventions. Such interventions may include clear communication that helps reduce tension. This should be applied to both employees and the patients in the health facility. There is no need of having a strict chain of command that may slow down the process of action taking. For instance, the nurses may attend to matters such as noticing and correcting problems with fire door alarm. This does not have to wait for executive committee. It would save life rather than waiting for a long time that took to investigate the death of the patient. In this report, the recommendations will portray the concerns of disclosure, culture and voice discovered and is innately associated as an organizational disclosure change will assist organizational change. In addition, this cultural change will permit a greater expression of voice and polyphony for community in the provided case. Polyphony involves many dialogues that occur simultaneously. Each person has a place in the organization. Contribution from each person will lead to an organization talk that contributes to changes (Cameron, 2010). Voice and polyphony will ensure a discourse whereby every party raises his or her views. The views are then consolidated and decision made that lead to change. Voice communication also helps clarify issues. The health facility chose to have an open discussion with the patient’s family. This was done by calling and explaining the incident that took place. This also could help communicate the intervention which involves having an alarm so that when a patient touches the fire door, the alarm will notice the staff on duty.   The change intervention could help the facility to avoid the similar incident happen again.

We suggest the hospice should use culture intervention to minimize the influence of organizational culture to adapt the change regulatory environment. It is important to improving the communication between employees and managements within the organization. It is useful to improve organizational structure and enhancing their professional skills. The hospice has a strong culture of compassion and care giving. The hospice need to think about how it could be better adapt in a change regulatory environment and what it needs to engage differently, as well as the resistance which is another significant issue of change intervention in the organization. Employees may resist the change intervention because they may think it challenge their identities. The organization should abandon the traditional idea of resistance that is extremely negative on change interventions. We advocate the hospice to have a new understanding of resistance that may brings essential information to the organizational change.

 

According to the case study, it shows there is a conflict between macro-level and micro-level of discourses of care and compassion. Indeed, it reflects a phenomenon of power imbalance.  It also explains the failure of the open disclosure. The hospice is necessary to change the discourses in order to balancing the power among organization, employees and patients. We recommend the hospice should clearly identity domain and weak discourse at both micro-level and macro-level through a discourse analysis. It could help the hospice to identify discursive gap in different levels. Thus, the hospice could focus on improving the ways of conversations, narratives, context and other communication can influence organizational behavior and change (Marshak and Grant 2008). Furthermore, we also consider the concept ‘participation’ in the open disclosure to raising voice for the patient’s family and employees. The hospice needs to allow employees and patient’s family to participate in decision making process. It can hold extensive consultations with patient’s family in order to understand the polyphony of voice. In macro-level, the management should face the challenge from the resistance of intervention and to ensure the equality between different parties.

 

Resistance

It is importance to consider the notion of resistance in the change intervention. Resistance is identified as an ‘inevitable and natural reaction’ within the change process (Thomas, Sargent and Hardy, 2011, p35). It predicts the hospice staffs may ‘refuse to implement, repress or even dismantle’ during processing the change intervention  (Agocs 1997, p.918).  In fact, discourses are always related to other pervious discourses that are produced synchronically and subsequently (Marshak and Grant 2008, p S14). The case shows the struggle that the caregiving culture incorporate with the current policy and procedure. The struggles also can be describes as hegemonic power competes within the organisation, or not be in univocal positions (Putnam, Phillips and Chapman 1999, p.139).  It is important to make employees to perform their roles in new ways in a change process, and to admire them leaving ‘the comfort zone’ (Palmer and Dunford, 2008).  We suggest employees should be open to resistance because it may bring new meaning or ideas to that facility the change (Thomas, Sargent and Hardy, 2011). Organizations should allow the “facilitative resistance” to get essential feedback from their customers and employees to help changing their policies and structures (Thomas, Sargent and Hardy, 2011).The idea of ‘ facilitative change’ encourage an open dialogue between employees and employers to increase the acceptance of changes (Hailey and Balogun 2002,p 172)

 

Conclusion

To sum up, the case study report is designed to analysis the real practice of organizational communication in the hospital. It also could be useful for other healthcare facilities that want to improve their services or solve their problems in communication. The open discourse framework provides the standards of processing an open disclosure. It addresses the “ open disclosure” is a symmetric communication that provides an opportunities to exchange facts and experiences between two sides. In the case, the two sides could be generally considered as the patient’s family and the hospital. The processing of an open disclosure is largely relied on the hospital’s understanding of fair communication. The emotional options of the patients’ family that could influence the processing of open disclosure have been ignored in this case. To deeply analysis the boundaries of conducting a dialogue between the two parties, the themes of the article involved with culture, discourse and voice. For the future opportunities, it is important to increase the awareness of organization change that could impact organizations’ existence.