Collective sense-making in the Emergency Department. Results from a SenseMaker® study. Sense-making series 3

‘How do people in the ED figure out what’s happening?‘

‘Do doctors and nurses hold the same views when making sense of challenging situations and dealing with flux?‘

‘Do they communicate and share emerging insights and knowledge, or do they withhold it and keep it within their silo?‘

We asked these questions to explore the sense-making capabilities of Emergency Department (ED) teams during operational changes and challenges. The underlying theories guiding the study, originated from Organisational Information Theory and Sense-Making Methodology; these are regarded communication theories that provides insights into the processing and exchange of information and knowledge between people. Even though the quality and quantity of information are important, sense-making perspectives are more concerned what is noticed (or not), and the meaning attached to the information, rather than the intricacies of the communication method.

Sense-making is about making sense of the environment so that one can act in it (David Snowden’s definition). The ED is a dynamic environment with constant changes requiring continuous updating and sense-making. In environments like this, no individual team member can hold all the information or connect all the dots of the incoming information and change. Multiple inputs are needed to complete the partial knowledge held by individuals to see the wider or fuller emerging picture. This implies that collective sense-making is required to make appropriate decisions and act.

Research method

This research study took place in five state ED’s in Cape Town.

We used the following prompt to ask the participants to tell a short descriptive story:

‘Whilst showing a new colleague around in the EC, you are interrupted to assist with a challenging situation. When you touch base with the colleague later, they ask how often these types of challenging situations arise and what they should do. Tell them a story that demonstrates the type of challenges that people in this EC deals with. Refer to the difference between normal and challenging situations and how the team responds.‘

After telling their story, the participants self-interpreted their story within a specialised framework, the results of which provided meta data to explore for patterns of the sense-making dynamics. The specialised framework and survey questions came from ‘Organizing and the process of sensemaking’ described by Weick, Sutcliffe and Obstfeld.

The findings

Using the SenseMaker® tool, we collected 85 short stories including all categories doctors and nurses.

I’ll be zooming in on two data points.

Participants answered the survey question (Figure 1) by moving the blue dot to indicate their preference and beliefs around communication.

Figure 1. Survey question about the best method to communicate during challenging situations.

In Figure 2 we filtered the result with professional role, and it shows that during challenging times, more than half the doctors indicated a preference for informal conversations about what is and should be happening, whereas most nurses preferred reverting to formal channels.

Figure 2. Finding: Professional role and views on communication.

Next, we filtered the data point with the role the participants indicated they played in their story.

Figure 3. Survey question: Role in story.

The findings (Figure 4) suggest muddled communication where different role players use different methods to share their knowledge and information. We deducted that the feedback loops in communication are broken because of disparate beliefs and methods of communication between role players in the ED.

Figure 4. Findings: Role in the story.

Why does this matter?

Based on what we know about knowledge exchange in organisations, operational reliability, and teamwork, it is vital in dynamic situations that collective sense-making occurs. Collective sense-making requires efficacious communication and feedback loops, without which the capacity to effectively convey cues, make sense, and take appropriate action is hindered.

During normal operations, the breakdown in collective sense-making reduces operational reliability that is probably experienced as frustrations, workarounds, and conflict between individuals. In situations requiring optimised sense-making, without it, the risk of operational failure is high, and we should be concerned about the potential of an increased likelihood of clinical failure.

What can be done?

Leaders in Emergency Medicine needs to prioritise building interdependent knowledge exchange methods. Knowledge in organisations is communicated by a variety of social processes – some formal e.g. policy, procedure, written rules and some informal e.g. unwritten rules, conversations, and routines. Currently, in hospitals these processes occur in vertical siloes enforced by the existing organisational structure. The different chains of command and reporting structures creates barriers to interprofessional knowledge transfer, and this creates an opportunity for intervention.

By being intentional about building one ED team that shares clear methods of communication, sense-making, and purpose. The current method of siloed knowledge exchange methods seems non-sensical as doctors and nurses work closely together, looking after the same patients, sharing consumables and other resources. Why not get everyone on one page by combining policies, procedures, and rules for operational processes?

Social cohesion has been identified as an important contributor to optimised team performance. An oblique approach to improve sense-making and operational reliability is fostering social cohesion in formal and informal ways. Formally, cross disciplinary training and capacity building exercises can build horizontal collaboration. Again, this might sound easy, but there are deeply held divides between the professions constrained within organisational structures.

Informally, social cohesion can be improved by creating moments for interaction by sharing notice boards, announcements and perhaps even tea rooms. In the larger study, we found that information flow is constricted during normal operations with no combined formal or informal communication methods, and no shared spaces. Increasing moments for connection between the core ED members can improve collective sense-making.

Healthcare has long favoured individual excellence, yet in dynamic settings with flux, individual competency is less important than collective competency. It is vital that ED leadership build collective competency within the interprofessional teams. I believe that sense-making does not receive the attention it requires, yet improving collective sense-making implies improved operational strategy and efficiencies, and reducing the risk of operational (and clinical) failure.

This blog forms part of my sense-making series, and it would make me very happy if you read the other blogs in the series.