Communication in a shared governance hospital: Managing emergent paradoxes
Carroll, Lee Ann
Shared Governance (SG) is a model of employee participation that is increasingly being implemented in hospitals. This paper examines communication processes that occur in SG by providing a case study of a Nursing Department at Western Hospital. A review of literature related to SG in professional nursing provides a background for introducing a chronology of implementation in Western Hospital. Data was collected in long interviews conducted with 15 bedside/staff nurses. Nurse accounts revealed paradoxes that paralyze the SG process. Forms of paradox are discussed and examples of paradox are identified. Leaders must determine priorities in managing on-site paradox and suggestions are offered for working within paradoxes to enhance organizational functioning.
Professional nurses experience increasing workplace demands from inside and outside the hospital. The internal pressures of patient care and a traditional organizational hierarchy are coupled with external factors such as medical reimbursement guidelines and competition from other healthcare providers. In an effort to ease organizational pressure, a shared governance (SG) system of management is being introduced in many hospitals.
Each year, the American Hospital Association’s (AHA) Committee on Governance identifies key health care issues to address as strategic initiatives. Five issues were identified for 2001: patient safety, creating the future, political advocacy, trustee education, and health care policy. AHA’s “creating the future” initiative is directed to provide “insights on ways to strengthen hospital governance, especially in entities structured through relationships rather than through ownership organizations” (Kope, 2001, p. 4). This initiative situates a study of SG within the current health communication literature (Kar, Alcalay, & Alex, 2001; Kreps, 2000). The SG model (Porter-O’Grady, 1986, 1990, 1992, 1994; Porter-O’Grady & Finnigan, 1984; Porter-O’Grady, Park, & Hawkins, 1997; Porter-O’Grady & Wilson, 1995; Wilson & Porter-O’Grady, 1999) offers one of the most popular forms of employee participation in health care settings.
This research examines the implementation of SG in the Department of Nursing at Western Hospital.1 We begin by reviewing literature that grounds this decentralized management style. We introduce the history of SG at Western Hospital and share information from nurses about communication in that process. When examining nurses’ accounts of the SG experience, we recognized that paradoxes were foregrounded in the communication process. We discuss these paradoxes and offer suggestions for working within paradoxes to enhance organizational participation.
SHARED GOVERNANCE IN PROFESSIONAL NURSING
Most hospitals operate using a classical management structure (Weber, 1947) which does not lend itself to open communication: the physician is responsible for directing the care of the patients and nurses are expected to carry out the healthcare protocol identified by the doctor. However, nurses have valuable information that can aid in patient care. The SG model provides one way for nurses to communicate that information. In this section, we review the hospital environment in which nurses function and discuss principles that underlie SG.
Hospitals are somewhat atypical organizations in that they have numerous stakeholders and confront many formalized accreditation sources. In order to enhance public trust, external organizations such as the American Medical Association (AMA), the American Hospital Association (AHA), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and other accrediting agencies for specialized services provide a means to legitimate the organization. Internal participants “also make legitimacy evaluations that can affect their own levels of involvement and motivation” (Ruef & Scott, 1998, p. 880). One or another assessment may be most salient at a specific time and in certain areas of the organization. Different sources of legitimacy may conflict with one another.
Current hospital pressures frequently mandate cost cutting, which may result in a decrease in the number of nursing staff and rushed treatment for patients (Arkin, 1990). Nurses are responsible for most of the daily front-line, face-to-face interaction with hospital clients. Inherent in this front-line position is nurse responsibility and accountability for care given to patients. Nurses are responsible for patient care 24 hours a day, yet they are not legally allowed to give a patient food or water without first checking with a physician. If the patient is harmed while a nurse is following a doctor’s orders, the court system holds the nurse accountable. Nurses are increasingly dissatisfied with this position of high responsibility and little real authority. This lack of power afforded nurses in traditional healthcare models can cause stress. The lack of autonomy, limited opportunities to use their talents, and exclusion from decision making processes can lead to burnout if experienced over a long period of time (Anderson, 1996; Ellis & Miller, 1993; Miller, Ellis, Zook, & Lyles, 1990).
Kritek (1988) noted “most nurses are not dissatisfied with nursing, they are dissatisfied with the institutions in which they do their nursing” (p. xvii). Nurses are interested in having a healthier and stronger relationship between their profession and the workplace (Pinkerton & Schroeder, 1988). Recognizing the importance of nurses to a medical institution’s profitability, administrations strive to “create a work environment that is more satisfactory to professional nurses and thus decreases turnover” (Daly, Phelps, & Rudy, 1991, p. 33). Nurses seek empowerment to establish “standards of professional practice,” to “monitor quality and professional development,” and “to broaden their understanding of the scope of professional responsibility and organizational dynamics” (Perly & Raab, 1994, p. 12).
Nursing is traditionally practiced in an institutional setting that is hierarchical, bureaucratic, and autocratic. Porter-O’Grady (1986, 1990; Porter-O’Grady & Finnigan, 1984) initiated the use of SG in healthcare settings to enable nurses to engage in a form of participative management-giving them a voice in decisions that affect their work. SG is a philosophy that allows change from a traditional management structure to one that authorizes more staff involvement (Bell, 2000; Leftridge et al., 1999; Smolensky, Zuzak, Adams, & Mackaly, 1999). The focus on decentralization and autonomy is directed toward enabling trust to emerge and information to flow more freely within the organization (Leftridge et al., 1999). Volden (1989) observed:
Sharing wisdom . . . means going from a parliamentary-like format (where meetings and business often are controlled by the leader and designed to get business done efficiently and effectively) to an empowering of each member to share knowledge and feel valued by others, (p. 9)
Within SG, clinical nurses are given the opportunity to contribute to the formulation, implementation, and evaluation of change efforts in the hospital. The result is high participatory involvement by staff nurses utilizing lateral communication in all areas of clinical practice.
This “organizational model reflects the relationship of the players to each other rather than the status of the players (hierarchical) in the organizational system” (Nielsen, 1993, p. 27). This design empowers staff nurses by “involving them in patient care decision-making and providing accountability and responsibility in practice” (Jones, Stasiowski, Simons, Boyd, & Lucas, 1993, p. 208). The most basic guiding principle of the SG model is that it allows for increased communication, accountability via empowerment, and participation. This combination increases professionalism in nursing practice (McDonaugh, 1990).
First, nursing professionalism is enhanced in SG through communication. Communication between professionals in the field of nursing affects everyone associated with health care. SG provides a systemic framework for nurses to consider problems of caregiving as they relate to the entire hospital. Partnerships may involve any person or group that can contribute to the solution. Considering the organization-wide implications of decisions is new for nurses accustomed to functioning in individual nursing units. Trust develops as groups learn to work together in an environment of openness, self-disclosure, and honesty. This environment clarifies communication and reduces uncertainty by giving direct access to information and to people who can clarify that information. Consensus decision making is advocated in SG. Working with other staff nurses who have diverse goals, expertise, and experience, teaches the professional nurse to value and celebrate diversity.
Second, nursing professionalism is enhanced in SG through empowerment. Porter-O’Grady (1998) defined empowerment as:
Recognizing the power that already exists in a role and allowing or expecting a person to express it. This definition emphasizes recognizing the power in a role, not generating or giving power from somewhere outside a role. . . . Empowerment, then, is the expression of trust between two partners who are equally committed to a process. It’s a partnership between the individual and the workplace. (p. 5)
Communication is central to the empowerment process.
In its truest form, SG empowers leadership from the bedside nurse by validating her or his experience and knowledge. SG reverses many nurses’ attitudes of feeling unimportant, uninformed, and without professional unity. The more effective the nursing profession becomes, the more it can become a major part of the solution to timely, cost-effective health care. Success of the SG model directly empowers nurses to positively impact health care delivery and improve their own work environment. SG supports nursing involvement in the daily decision-making processes and may lead to increased job satisfaction because it empowers these front-line workers (see Zelauskas & Howes, 1992).
Employee participation processes are designed to empower employees (Kanter, 1977). Stohl and Cheney (2001) defined employee participation from a theoretical and operational perspective: “worker participation comprises organizational structures and processes designed to empower and enable employees to identify with organizational goals and to collaborate as control agents in activities that exceed minimum coordination efforts normally expected at work” (p. 357). Merely participating in workplace decisions does not mean workers are empowered (Cheney, 1995; Stohl, 1995). Empowerment is both a perception and a process. Empowerment “is the symbolic construction of one’s personal state as characterized by competence, or the skill and ability to act effectively, and control, or the opportunity and authority to act. Empowerment is also the process of creating this state” (Chiles & Zorn, 1995, p. 2). Empowerment is the perception that an employee “can influence people and events in an organization to achieve desired ends” (Papa, Auwal, & Singhal, 1997, p. 221), and is brought about by creating working conditions that encourage people to work toward their full potential (Allen & Kraft, 1984).
Third, nursing professionalism is enhanced in SG through participation. Involvement is accomplished by moving nurses from subservient roles to autonomous roles by giving them authority over practice decisions (Blegan & Mueller, 1987; Vanderslice, Rice, & Julian, 1987). Implementation of empowerment processes generally demand a change in working conditions-which requires innovation (Peters & Waterman, 1984). For innovation to occur, the environment must be safe enough to allow the staff to take risks. Risk-taking emerges in an environment of trust. Mistakes and failures, traditionally perceived as highly shameful, must be acknowledged as positive learning experiences. When positive change results, staff develop the courage to participate by asking questions and proposing solutions. Each success and failure can then be viewed as an opportunity for learning and growth. When learning is the desired outcome, risk taking will be encouraged because creative solutions are sought (Stayer, 1990).
Healthcare is in a state of active change. Nurses are in a position to help ease organizational tensions related to patient care (Crowell, 1996) and workforce issues (Izzo & Klein, 1998; Kupperschmidt, 1998, 2000). SG is a lateral organizational structure designed to enhance communication and empower nurses through participation in decision-making processes. However, implementation of SG can be problematic.
Organizational communication challenges exist in the practical implementation of SG. “Unfortunately, most shared governance efforts are seen by staff as chiefly structural with staff nurses on councils and committees but without the authority to have significant control over professional practice, thus leading to cynicism” (Laschinger & Wong, 1999, p. 308). In a recent study, Smolensky et al. (1999) reported that SG was implemented and subsequently disbanded in the nursing department of one hospital (not Western Hospital). Although positive outcomes related to the SG process emerged,
the inpatient nursing department became somewhat disillusioned with the model and began to re-examine the whole concept. Most carefully scrutinized was the need for multiple councils and the time commitment these councils required, which many nurses saw as time taken away from patient care. (Smolensky et al., 1999, p. 174)
The choice to disband SG in that hospital may lead to a chilling effect on implementing participatory processes in other healthcare organizations. Yet, the challenges in health care organizations that propelled a need for SG have not changed-and have only increased over time. This case study considers the SG experience of nurses at Western Hospital in an effort to seek ways to manage the implementation process so SG is not abandoned as a productive structure for employee participation.
IMPLEMENTING SHARED GOVERNANCE AT WESTERN HOSPITAL
The focus of this case study is the Department of Nursing in Western Hospital, a city-owned hospital in a western state. The hospital is a regional medical center that employs approximately 2000 people. Within the hospital are nursing areas designed for patients needing services in one or more of the following specialties: medical, surgical, obstetrics, maternal child, pediatrics, critical care, cardiac, emergency, orthopedics, and neurology. Additional healthcare services are also provided by the hospital.
The mission of Western Hospital is to provide patients and their families with “the best and most sensitive professional care and service.” Western Hospital’s nursing philosophy states: “The nurse has a responsibility to work in partnership with the patient, the physician, and the entire patient care team to accomplish the care of the patient. . . . Our intent is to provide quality leadership and to remove the barriers that prevent employees their right to pride in workmanship.” In an effort to improve working conditions, the Nursing Department explored the use of participatory management. The rest of the hospital continues to function using a traditional management style.
Nursing administration took the first step toward participatory management by terminating house supervisors in 1985. Each unit was then assigned a charge nurse, whose primary responsibility is to assure the efficient and effective running of her or his unit. The charge nurses network with one another to complete all tasks once undertaken by house supervisors. In 1988, hospital administration acknowledged a lack of interdepartmental communication-resulting in a loss of information that could potentially benefit patients. In 1989, nursing volunteers were involved in a committee to investigate processes that would enhance communication. The six nursing directors investigated various management styles with the goal to isolate the one that seemed to best fit the nursing situation at Western Hospital. They considered McGregor’s (1967) work on theory X and theory Y management styles, Hersey’s (1984) situational leadership model, Kaoru’s (1985) total quality management, the Deming management method (Walton, 1986), quality circles (Fitzgerald & Murphy, 1982), and shared governance (Porter-O’Grady & Finnigan, 1984). The result of their search was the selection of SG.
Porter-O’Grady identifies several formats for SG in his work, and all are based upon interactive meetings. He encourages administrations to adapt, rather than simply adopt, his concepts. This administration viewed SG as creating an environment in which employees can best accomplish their work, and incorporated the added advantages of quality circles and total quality management incorporated into the SG process. A chronology of implementation and explanation of SG processes in the Nursing Department at Western Hospital follows.
Drawing on Porter-O’Grady and Finnigan’s (1984) work, bylaws were created to form the conceptual framework of SG in Western Hospital. A proposal was then sent to the administrative board of the hospital, who supported the proposal and included money in the budget to initiate SG activities.
One nursing unit was selected to serve as a one-year pilot group, first implementing SG in 1992. During this time, nursing administration learned the assumptions and practices that were constructive as well as counterproductive to the use of SG at Western Hospital. Utilizing the knowledge gained from the pilot project, half of the nursing units implemented SG in 1993. During initial implementation, nursing administration intended to have one or two units “go live” with SG at a time, followed by a period of several months before any other units implemented SG. Staff nurses, excited and positive about SG, were upset at the slowness of this original plan. In 1994, the implementation process was escalated and all remaining nursing units instituted this new communication process.
Western Hospital’s SG model consists of committees and councils that provide opportunities for nurses to participate in the functioning of their work unit (see Figure 1). The basic nursing committee is the Unit Practice Committee (UPC). Each floor or unit has a UPC comprised of bedside nurses from that unit. Members of each unit’s UPC attend various council meetings to represent their unit’s issues and make suggestions to those councils. The UPC representative also reports back to her or his floor regarding the minutes from council meetings. This enables the bedside nurses to be aware of what is happening in the councils and units throughout the Nursing Department.
Western Hospital’s SG model involves several councils. (1) The Coordinating Council comprises Nursing Administrators and Nursing Directors. In addition, two nurses from each of the other councils is included. (2) The Nursing Management Council is made up of Nursing Directors and Clinical Managers. (3) The Clinical Practice Council consists of representatives from all UPCs, a nurse educator, a Clinical Manager, the Nursing Quality Manager, and the Director of Nursing. (4) The Quality Assessment and Improvement/Research Council includes representatives from all UPCs, the Nursing Quality Manager, and a nurse educator. (5) The Professional Development Council is made up of representatives from all UPCs, the Director of Nursing Support Services, a nurse educator, the Discharge planner, the Nursing Quality Manager, and representatives of all unit secretaries and office managers.
At least one member of the nursing administration regularly attends one or more of these council meetings. Nursing proposals, suggestions, and complaints raised in the various council meetings still must go through the “regular hierarchy” for approval, questions/clarification, or disapproval. The SG process is a communication structure that overlays the functional organizational chart. SG adds a line of communication between nursing administration and the bedside nurses through the use of councils. SG “flattens the hierarchy”-not by altering the organizational chart, but by adding a unit level to it. The goal is to bring nurses voices up the hierarchy to empower nurses through greater participation in hospital governance processes.
The following process would be used by nurses to introduce a change into their unit/floor. First, a nurse sets a change in motion during a UPC meeting. Second, the UPC representative will present the unit information in the council that is designated for the type of change desired. If needed, that Council will convene a committee within the council to gather information related to the suggested change. Third, representatives from the Council will introduce the UPC request to the administrative councils (i.e., Nursing Management Council, Coordinating Council). The Council representative gets information from administrative councils and takes this feedback to their meeting. Fourth, the UPC representative will receive feedback in the Council meeting regarding their unit’s request. Finally, the representative takes the information back to their UPC and this information is used to set staff meeting agendas.
SG was adopted to allow clinical nurses more input into their daily work life and is designed to open channels of information flow for nursing staff. This promise of open, lateral communication is a drastic shift from the traditional top-down flow of information in hospitals. Critical to the success of shared governance are staff nurses who can make sense of these new expectations and incorporate appropriate communication skills to maximize their performance.
This case study considers the SG process at Western Hospital from introduction, through early implementation, and into routine use. Our goal is to understand nurses’ perceptions of the communication culture created by SG. We are interested in the impact of SG upon the daily worklife of nurses who perform the routines of patient care.
The quality of communication in SG is a subjective experience determined by people involved in the organizational process.
Reality is a dynamic process with layers that nest within and complement one another. Each layer provides a different view of reality; none of which can be considered more ‘true’ than the other. Layers cannot be understood alone but interrelate to form a pattern of ‘truth.’ It is these patterns of multiple realities that qualitative research searches out for understanding. (Lincoln & Guba, 1985, p. 270)
Reporting “truth” requires understanding the world as it is interpreted by individuals. Qualitative methodology allows the researcher to obtain first-hand knowledge of the empirical world that grounds participants’ experience.
This qualitative project collected nurses’ accounts of the SG process through long interviews. “The long interview is the method of choice when cultural categories, assumptions, and themes are objects of investigation” (McCracken, 1988, p. 5). The long interview format allows for gathering much more in-depth information than shorter interviews. Individual face-to-face interviews were conducted utilizing a semi-structured interview guide to ensure that all participants had a similar opportunity to share their experiences with the SG process.
The premise behind SG is that the front line worker understands the problems and the solutions best-they are the experts to access for solutions. Two criteria for participant selection were identified: a working knowledge of SG and a minimum of two years experience with SG in the workplace. A call for participants was distributed, and all volunteers who met the criteria for participant selection were interviewed. Only female nurses were employed in the nursing units at the time data was collected. Seventeen nurses volunteered to be interviewed; however, two nurses were unable to meet due to their schedules. A total of 15 nurses from the six nursing units that comprised the Medical/Surgical Division of the Department of Nursing were interviewed for this study. The women had diverse employment backgrounds and ranged in age from early 20s to mid 50s. All nurses were bedside/staff nurses. Many of the staff nurses rotated as charge nurse of their unit as well as attending to their bedside/staff nurse responsibilities. Participants included nurses who had originated SG, nurses who currently were participating fully on committees/councils, and nurses who chose not to participate on committees/councils.
Interviews were not conducted at the hospital and participant anonymity was assured. Participants had the option to not respond to particular questions and/or terminate the interview at any time. The average interview length was 2 hours 20 minutes. All volunteers were interviewed, even after data saturation was reached. Information was recorded by both audio-recording and note-taking during interviews. Transcripts of the taped interviews were generated. Respondents were given the opportunity to “line-out” information on the transcript at their request. The interviews enabled us to gain a thorough understanding of the meanings that comprise nurses’ accounts of SG.
We initially sought to analyze the data by utilizing account analysis (Austin, 1961; Backman, 1976; Blatz, 1972; Blumstein, 1974; Buttny, 1985; Geist & Chandler, 1984; Geist & Dreyer, 1993; Geist Martin & Dreyer, 2001). Account analysis centers on “language as the appropriate vehicle for the analysis of human behavior. Accounts are considered to be reflexive commentary which explains action” (Geist & Chandler, 1984, p. 70). Accounts disclose how individuals interpret both their own and others’ communications in context. They “reveal how individuals situate self and others in relation to the social order of a particular context” (Geist Martin & Dreyer, 2001, p. 123). Once data was gathered, the nurses’ accounts revealed a paradoxical picture of social action present in the SG process at Western Hospital.
Organizational scholars are increasingly aware of “the presence of simultaneous opposites or contradictions” in organizations (Cameron & Quinn, 1988, p. 1; See also Handy, 1995; Lewis, 2000; Molinsky, 1999; Putnam, 1985; Quinn & Cameron, 1988; Smith & Berg, 1987; Stohl & Cheney, 2001; Westenholz, 1993). Paradox results when, “in the pursuit of one goal, the pursuit of another competing goal enters the situation (often without intention) so as to undermine the first pursuit” (Stohl & Cheney, 2001, p. 354). Recognizing the presence of paradoxes, we used communication literature to guide our textual analysis.
Two studies of paradox most closely relate to Porter-O’Grady’s (1990) conception of using communication, empowerment, and participation to enhance nurse professionalism. Smith and Berg (1987) identified paradoxes of speaking, engaging, and belonging in group functioning. The SG process is centered around group processes (see Figure 1). Stohl and Cheney’s (2001) work focuses on paradoxes of employee participation and workplace democracy. They identified four main categories of participatory paradox: paradoxes of power, structure, agency, and identity. The SG process is conceived as a form of participative management for enhancing nurse professionalism.
Our analytic process used categories identified in Smith and Berg (1987) and Stohl and Cheney (2001) to examine both manifest (semantic) and latent (inferred) content in the nurses’ comments (Wilson, 1989). Each category of paradox encompasses several types of paradox. The categories overlap and are interdependent, however practically and ethically all paradoxes are not the same (Stohl & Cheney, 2001). Our goal was to capture the contextual character of comments which reveal “taken-for-granted knowledge brought to the experience and displayed in the talk” of nurses (Manning & Cullum-Swan, 1994, p. 464). We examined transcripts for instances of paradox that moved to the foreground with the implementation of a SG structure.
PARADOX IN A SHARED GOVERNANCE DEPARTMENT
Nurses were asked how SG, designed to provide a space for communication, empowers their participation in the governance process. Paradoxical tensions remained latent at Western Hospital-held in place by external and internal legitimizing forces-until n participatory system was added to the organization. The bureaucratic norm in a hospital setting hides these organizational dynamics by suppressing the dialectic of paradox. Within a classical management system (Weber, 1947), a complementary relationship (scalar chain) exists between administrators and workers. Administrative responsibilities (authority and responsibility) are to design and control the organization (unity of command) while the workers are to cooperate (line and staff, initiative) and attend to identified responsibilities (discipline, division of work, equity). With the introduction of nurses’ voice in governance (and expansion of their role), this organizing dynamic was altered and paradoxes emerged. Interview transcripts revealed interrelated parodoxes regarding nurses’ participation in the management process. Theoretically, SG “looks wonderful and should work,” however, nurses stressed the challenges that accompany participation in the SG process.
The data revealed that all forms of paradox are interwoven throughout the nursing units. Heeding Stohl and Cheney’s (2001) caution that these categories should not be employed in a “cookie-cutter fashion” (p. 390), we wish to show that identifying central paradoxes in SG can assist leaders in understanding the situation and provide them with a place to enter the conversation to address nurses’ “frustration” with the process. Paradoxes overlap and are interdependent with one another, and more than one paradox may be found in a single statement, as indicated below in parentheses. The next section addresses paradoxes that emerged in the interview transcripts, incorporating quotations from nurse accounts of their SG experiences.
Paradoxes of Speaking
Paradoxes of speaking are associated with “how members and the group as a whole find a voice to give expression to what is going on” (Smith & Berg, 1987, p. 131). Paradoxes of speaking include paradoxes of authority, dependency, creativity, and courage. Authority paradoxes recognize “the paradoxical nature of resistance to authority, one’s own and that of other group members. . . . [and describe] the way in which resistance is also acceptance and acceptance involves resistance” (Smith & Berg, 1987, p. 132).
“But it’s like CM’s [Clinical Managers] have to control everything; everything has to be the way that she wants it to be. I’ve heard managers say they are so committed to SG; then they proceed to be a huge block to the committees. That’s not the way SG is supposed to be. My CM has THE POWER GRIP. She is emphatic-you have to go to this meeting; you have to go that meeting; you have to bring this back. She will not allow us to make decisions because it will take control from her delegated authority.” (Authority, Control)
Dependence paradoxes “explore the proposition that to be independent in a group, one must fully accept one’s dependence” (Smith & Berg, 1987, p. 133).
“You have to participate. Even if you don’t, that’s participation by omission. If you don’t like something but you choose not to participate, then your accountability is not to gripe and complain about what’s happening because your choice was to not give input.” (Dependence, Courage, Intimacy, Self-Disclosure)
Creativity paradoxes are “born of the link between creation and destruction. . . . In order to create new patterns, patterns must exist and must be changed or destroyed” (Smith & Berg, 1987, p. 133).
“After you sit through endless meetings you can’t remember what you were supposed to be doing or wanted to know.” (Creativity, Authority, Control)
Courage paradoxes note the inherent tension that “courageous action, the willingness to speak one’s mind and to act in accordance with it, is courageous only when it is undertaken in the presence of doubt and uncertainty” (Smith & Berg, 1987, p. 133).
“In fact, one of our main leaders that we really look up to, is in constant trouble because she just won’t go along with everything. I think a lot of people are reluctant to bring up issues for fear of repercussions.” (Courage, Dependence, Homogeneity)
Paradoxes of speaking are interrelated with paradoxes of engaging.
Paradoxes of Engaging
Paradoxes of engaging “arise when members begin to ask how much of themselves they are willing and able to contribute to the group and how much is required of them for the group to be effective” (Smith & Berg, 1987, p. 109). Paradoxes of engaging include paradoxes of self-disclosure, trust, intimacy, and regression. Self-disclosure paradoxes address “how and whether we allow ourselves to known in groups. . . . [,] concerns about acceptance and rejection common among members of groups[,] and the paradoxical relationship between rejection and disclosure” (Smith & Berg, 1987, p. 110)
“People don’t tell their reps, or if they do they don’t feel like it’s taken or that they didn’t get feedback on it. I think participation does lead to empowerment. But . . . it has evolved that the participation only counts if you are a seated member of a council.” (Self-disclosure, Trust, Punctuation)
Trust paradoxes recognize tensions in developing trust. “How does trust ever develop if, in order for it to develop, there needs to be trust? . . . How safety is created out of fear is the question at the heart of the paradox of trust” (Smith & Berg, 1987, p. 110).
“It tends to set up some suspicious attitudes because things do seem to be decided behind closed doors. It’s horrendous when you don’t know just exactly what’s happening, where it’s coming from, or why.” (Trust, Intimacy)
Intimacy paradoxes explore “the apparent contradiction that to know others we must know ourselves and that to know ourselves means knowing others” (Smith & Berg, 1987, p. 110).
“We all need to share our ideas and all the ideas should be met with, ‘OK, this is obviously a concern.'” (Intimacy, Trust, Self-disclosure)
Regression paradoxes enter “the past to unlock the present. Regression allows progression, and progression requires regression” (Smith & Berg, 1987, p. 111)
“But it comes back to the CM [Clinical Manager], too. You have a CM who supports you in your role. And, if you’re new at it, the CM needs to help you by saying you have a meeting, or even something as simplistic as making sure you’re always off on that day.” (Regression, Trust, Cooperation)
Organizational structure reflects and is determined by organizational membership.
Paradoxes of Belonging
Paradoxes of belonging refer to tensions associated with organizational membership. Paradoxes of belonging include paradoxes of identity, involvement, individuality, and boundary. Involvement paradoxes explore “the contradictions and the connections in the coexistence of involvement and withdrawal” (Smith & Berg, 1987, p. 90).
“We don’t get enough participation. People feel like they don’t have a say. UPC does what management tells us to do, then reps get the buck from the ranks because they think we’re telling them what to do.” (Involvement, Design, Punctuation, Cooperation, Trust)
Individualisation paradoxes consider how “individuals are able to express their individuality, their differences, so that connections can be found. . . . [Individualization paradoxes] search for what links the individual to the collective” (Smith & Berg, 1987, p. 90).
“I always tell people you have to determine if this is just your own little quirk or personality issue, or is this something that is really vitally important to our practice on this unit.” (Individualization, Representation, Cooperation, Formalization, Agency)
Boundary paradoxes address “belonging to and not belonging” to a group (Smith & Berg, 1987, p. 90).
“SG is a committee setup to give the staff the power to make decisions about their unit, specifically the running of their unit. No one had ever asked us before what we wanted to do. . . . But that only means that I know it. It doesn’t change what I can do about it.” (Boundary, Design, Commitment, Control)
Identity paradoxes examine “the link between individual identity and group identity” (Smith & Berg, 1987, p. 89).
“And then everyone else is like, ‘Well, ‘they’ make all the decisions.” Then it’s, ‘Well, if you would participate or tell you ideas to your rep . . .’ They won’t do it. Typically, as nursing they want a scapegoat. Because, we all feel like we can’t every make a mistake, and I don’t know how we can get around that.” (Identity, Trust, Self-Disclosure, Regression)
Belonging paradoxes contribute to paradoxes of power.
Paradoxes of Power
Paradoxes of power concern “the locus, nature, and specific exercise of power in the organization” (Stohl & Cheney, 2001, p. 360). Paradoxes of power include paradoxes of control, leadership, and homogeneity. Control paradoxes explore “encountering less, not more, freedom within team-based structures, at the group level or at the system-wide (organizational) level” (Stohl & Cheney, 2001, p. 360).
“So in a way it’s like they encourage us to have a voice. But in a way, if it’s something they don’t want to change, or doesn’t meet management’s criteria, or it’s not on their list of changes, it doesn’t matter how strongly you feel about it, it ain’t gonna change.” (Control, Trust, Self-disclosure)
Leadership paradoxes examine contradictions around “waiting for a charismatic leader to inspire, create, and maintain democracy” (Stohl & Cheney, 2001, p. 360).
“And sometimes I wondered if administration even knew what they wanted until somebody finally made a decision. Well, I think that’s wrong; this is her problem. She needs to figure out what’s wrong and how to fix it. There is some point where you take the things as, ‘I am the manager.’ Someone has to be the manager around here.” (Leadership, Punctuation)
Homogeneity paradoxes address “failing to see the value of resistance or oppositional voices, excessive valuing of agreement, cooperation, and consensus, while preaching diversity of opinion” (Stohl & Cheney, 2001, p. 360).
“They could probably have 100% [participation] if they weren’t afraid. Afraid of what will happen, of the administration, the CM [Clinical Manager] and her buddies. Because a lot of people will gripe, but they will never say anything during meetings.” (Homogeneity, Courage, Trust)
Paradoxes of power shape and reflect paradoxes of structure.
Paradoxes of Structure
Paradoxes of structure consider “rules, regulations, resources, guidelines, and procedures” (Stohl & Cheney, 2001, p. 359). Structural paradoxes include paradoxes of design, adaptation, punctuation, and formalization. Design paradoxes concern “imposing or mandating grassroots participation from the top” (Stohl & Cheney, 2001, p. 360).
“SG’s even part of your yearly eval now. If you choose not participate, then you may not get your raise.” (Design, Courage, Dependence, Adaptation, Responsibility, Commitment)
Adaptation paradoxes consider “while trying to preserve the organization’s essential qualities, adapting so much to outside forces or expectations that the organization’s soul is lost” (Stohl & Cheney, 2001, p. 360)
“In SG we have so many committees scattered all over that the right hand doesn’t know what the left hand is doing.” (Adaptation, Design, Agency)
Punctuation paradoxes address “short-cutting the democratic process in practice (because the process costs time) in such a way that, over time, the vitality of the system is lost” (Stohl & Cheney, 2001, p. 360).
“It’s a general attitude. . . . So people that did try are really frustrated now.” (Punctuation, Adaptation, Trust)
Formalisation paradoxes focus on “institutionalizing democracy such that spontaneity is gone; that is, the routinization of that which should be inspired” (Stohl & Cheney, 2001, p. 360).
“We were to run the meeting as best we could with what we felt was not a lot of information available to us. The head nurse would come in and tell us everything that we didn’t know. ‘Well, no, that’s not right. That’s been changed since you went to the PDC [Professional Development Council] meeting. And that isn’t right.’ So after about 11 months of that, I thought, why are we even attempting to run the meetings on our own? We’ve come through the cycle now that there are only new CPC [Clinical Practice Council] people. . . . They don’t seem to understand how to effectively run meeting. I think administration has seen that and the managers and directors have kind of stepped in and tried to keep the meetings on track.” (Formalization, Trust, Regression, Responsibility, Design, Socialization, Autonomy, Involvement, Individualization, Boundary)
Paradoxes of structure also influence paradoxes of agency.
Paradoxes of Agency
Paradoxes of agency focus on “the individual’s (sense of) efficacy within the system” (Stohl & Cheney, 2001, p. 360). Paradoxes of agency include paradoxes of responsibility, cooperation, sociality, and autonomy. Responsibility paradoxes involve “relinquishing directly to a group one’s rights to make decisions, particularly while insisting that the right to participate be maintained” (Stohl & Cheney, 2001, p. 360).
“I think that people want the reward of all of this but they don’t want the responsibility. So, it’s like if I say something then I might have to do something and I don’t want to have to do anything so I don’t say anything. And what if I say something and do something and somebody doesn’t like it-which will always happen. Then is my name going to be mud and they’re just going to hate me. Well, let’s just have them hate somebody else, not me.” (Responsibility, Self-disclosure, Trust, Courage, Regression, Cooperation, Involvement)
Cooperation paradoxes concern “following formal or informal procedures in a way that hinders rather than promotes cooperation, including the pattern of ‘nonparticipation’ in the interest of furthering cooperation” (Stohl & Cheney, 2001, p. 360).
“Outside the meetings, I’m too independent to worry about what CPC [Clinical Practice Council] thinks or what other people think. I just go ahead and do my job. I don’t even do the process, I just go fix the problem. It’s just easier and faster to handle it your own way.” (Cooperation, Autonomy)
Sociality paradoxes address “intense involvement at work as an ironic limit on other forms of participation (e.g., in family and community) such that all types of participation become undermined” (Stohl & Cheney, 2001, p. 360).
“And you have to be willing to come in on your days off to make meetings.” (Socialization, Autonomy, Cooperation)
Autonomy paradoxes consider “giving up more individual rights than one intended to. . . surrendering individual agency for that of the collective” (Stohl & Cheney, 2001, p. 360).
“I have to admit that I don’t like the policy everyone decided on. But we did agree, in a majority vote. And it made a lot of people on our floor happy.” (Autonomy, Self-disclosure)
Paradoxes of agency are interwoven with paradoxes of identity.
Paradoxes of Identity
Paradoxes of identity address “issues of membership, inclusion, and boundaries” (Stohl & Cheney, 2001, p. 360). Paradoxes of identity include paradoxes of commitment, representation, and compatibility. Commitment paradoxes focus on “commitment to and enactment of the group’s espoused values and beliefs about voice and participation a test that ironically leads to exclusion rather than inclusion” (Stohl & Cheney, 2001, p. 360).
“If you take that attitude that we don’t care if people attend meetings and don’t worry about them, where does shared governance go? Shared governance becomes a dictatorship. So, that’s like defeating its purpose.” (Commitment, Involvement, Punctuation, Cooperation)
Representation paradoxes address “becoming co-opted by dominant interests; losing one’s “voice” unexpectedly” (Stohl & Cheney, 2001, p. 360).
“It came out in CPC [Clinical Practice Council] last month that the QRC [Quality Assessment and Improvement/Research Council] rep needs to bring quality assurance stuff back to the staff and let them know about all these surveys and things. Our CM [Clinical Manager] said, ‘I am not going to have her bring in all that stuff to the staff meeting. It comes through me. It does not come through her.’ I said, ‘I thought you had a QRC rep.’ She said, ‘All that stuff comes through me.’ I said, ‘Well, obviously it comes through you, but why do you have a nurse sitting on the committee as the rep if she’s just a figure head?’ I said, ‘I want it in the minutes that I brought it up that the QRC rep needs to be at this meeting and needs to bring this feedback back to the staff.'” (Representation, Courage, Trust, Power, Design)
Compatibility paradoxes involve “the potential problems with exporting a particular model of democracy or participation to another society or culture” (Stohl & Cheney, 2001, p. 360).
“And it’s like how the rumor mill and the grapevine are just going overtime right now. Most of those people never go to meetings, but they sure do gripe about every decision that is made in meetings. People have to understand that they are accountable for what they do and don’t do. It’s a hard concept that our profession is going through great changes. They have to be a part of it or get left behind.” (Compatibility, Trust, Self-disclosure, Intimacy)
Paradoxes of control were most central to nurses and through this paradox, other paradoxes are interwoven. Recognizing the inevitability of paradox when introducing SG requires that leaders understand how to manage paradox in ways that productively enhance organizational processes.
MANAGING PARADOX THROUGH LEADERSHIP
Despite feeling “burned out,” “rushed,” “tired,” and “overworked,” nurses shared: “SG gave us the idea that we had input. And now that we’ve got that idea, it’s not going away.” They also added, “I think we have a long way to go and maybe SG will start getting us there.” However, employees at Western Hospital were not managing communication paradoxes that emerged when SG was introduced into the NursingDepartment and the “frustration” persisted.
Nurses were interviewed for this study in 1997. In 2001 they were invited to discuss organizational changes since their first interview. All participants declined to be reinterviewed-saying that essentially nothing had changed. Interview transcripts reveal that several nurses recommended changes in the SG process that would keep them within the dialectic of a particular paradox-simply moving between two polarities. For example, nurses noted the Clinical Manager frequently takes control in the meetings where she is “not supposed to.” The suggestion was offered that nurses should take more control. Unfortunately, this suggestion does not move the department out of the control paradox and maintains unproductive tension. Moving between paradoxical polarities is a common response by organizational members who do not recognize “that a paradox exists or [are] acting under the assumption that one organization cannot do seemingly inconsistent actions simultaneously” (Blair & Payne, 2000, p. 44). Recognizing, explaining, and communicating to manage paradoxes can assist leaders in positively transforming the workplace.
We sought to consider how to best manage paradoxical shifts in organizational culture. This section addresses how leaders can revitalize the SG process when nurses and managers gravitate toward familiar (bureaucratic) patterns of social action due to paradoxical fatigue. The leadership challenge is not to get rid of tensions foregrounded by SG but to manage these tensions which can inspire creativity, innovation, and excitement within the workplace (Handy, 1995).
Communicating to Manage Paradox
Leaders must understand paradoxes that underlie an organizational problem. A paradox emerges because the perceptual frameworks people use to understand a situation leads them to contradictory conclusions.
According to personal construct theory (Kelly, 1955), most actors accentuate contradictions by interpreting data . . . through simple, bipolar concepts, constructing logical, internally consistent sets of abstractions that separate opposites. Such frames of references or schemes enable actors to make sense of complex realities, but they are biasing and, once entrenched, become highly resistant to change. (Lewis, 2000, pp. 761-762)
Managing paradox requires exploring contradictions and complexities in the situation by “reclaiming emotions and attributes that have been repressed, polarized, or projected elsewhere” (Lewis & Dehler, 2000, p. 712). This requires self-reflection that moves interactants toward a multidimensional view of the situation. Rothenberg noted that paradoxical thinking occurs when “in an apparent defiance of logic or physical possibility, the creative person consciously formulates the simultaneous operation of antithetical elements and develops those into integrated entities and creations. It is a leap that transcends ordinary logic” (as cited in Lewis & Dehler, 2000, p. 713).
Communication must be used to aid workers in managing the paradox, not to avoid or eliminate paradoxes. Leaders can help others understand that paradox has positive and negative aspects. Paradox is an inherent part of worker participation and may be used to enhance their potential, however, negative consequences of paradox can also result. Working with (rather than against) paradox enables people to “exercise control over competing demands” (Barge, 1994, p. 230). Appropriate responses to paradoxes will differ according to individual perspectives, group norms, and organizational cultures. Nurse comments indicated their need to communicate about how paradox was (not) being managed. Three interrelated ways to manage paradox are commonly addressed in the literature and include acceptance, confrontation, and transcendence.
Acceptance means “learning to live with paradox” (Lewis, 2000, p. 764). Stohl and Cheney (2001) recognize this as probably the most difficult approach to managing paradox. This stance acknowledges that paradox leading to fragmentation of goals and practices is inevitable when participation is introduced into the organization. Acceptance entails recognizing but not reconciling cognitive incongruity (see Festinger, 1957). In acceptance, “the imperfect realization of ideals, the imbalances of power, and the limitations to planning are explicitly acknowledged. This strategy is perhaps best accomplished in an organization with periodic and deep self-assessment, ombudspersons, jesters, and a sense of humor” (Stohl & Cheney, 2001, p. 396).
Several nurses seemed to accept paradoxes in the Nursing Department. They recognized that the theoretical strength of the SG literature carried to extreme reveals its weaknesses. Nurses said “I’ve heard from other floors how well it works for them and how wonderful it is. And we think that’s just great that it worked well for them. But, they have a different patient census. Certain things [units, issues within units] it’s probably useful for. On certain things, it’s just not.” When SG is integrated into a traditional hospital setting, management must be clear regarding issues that are appropriate for SG to handle, as determined by external and internal legitimizing factors. They must also insure that information regarding the issues is made available to the nurses in a timely manner. The SG process is compromised when this is not clear. Determining when to accept paradoxes assists in determining when it is necessary to confront paradoxes.
Confronting paradox means discussing paradoxical tensions to generate a different social practice. Discussing paradox provides a means for workers to analyze their situations and alter paradoxical tensions. Confronting paradox provides an opportunity for reframing the situation. “Refraining requires movement to a different level of analysis or to a new attitude toward the paradox that is perceived to be a problem” (Stohl & Cheney, 2001, p. 396). Reframing involves searching for a common denominator between the two conflicting elements and then viewing those elements not in terms of ‘either/or’ but ‘both and'” (Barge, 1994, p. 299). Hirschman identified possible ways to approach organizational decline: “exit (or departure), voice (or opposition), loyalty (a kind of rededication), and neglect (or ignoring the problem)” (as cited in Stohl & Cheney, 2001, p. 392). His work may be adapted to address ways organizational members may confront paradox. Each option for confronting paradox may be more/less appropriate in different situations as determined by an organization’s culture. The use of humor can allow tensions to be addressed while moving paradox to the foreground where it can become a topic for conversation that may lead to a change in the situation (Hatch & Erlich, 1993; Lewis, 2000; Stohl & Cheney, 2001).
In Western Hospital, some nurses advocated confronting paradoxes. Nurses noted that the number of councils/committees and meetings need to be assessed with an eye toward streamlining processes so that things can be accomplished in a more efficient manner. “We are committee’ed to death” and they were unwilling to give up any of the opportunities for input that SG provides. The goal is to encourage participation, foster communication, provide sense of shared power, and encourage well-informed and system-guided decisions. All management/administration must “buy into” SG by “giving up” some of their perceived power. Leaders need to be open to confrontation and the possibility of productively reframing the situation.
Transcendence “implies the capacity to think paradoxically” (Lewis, 2000). Working within the paradox, one can exercise critical thinking to engage in synthesis or reframing of the paradox. Synthesis entails creatively combining conflicting aspects of the process. This “prevents the degeneration of conflicts and can lift the participants to a new and more productive level of understanding” (Stohl & Cheney, 2001, p. 392). Watzlawick, Weakland, and Fisch discuss first-order thinking and second-order thinking (in Lewis, 2000). While first-order thinking will not alleviate paradoxical cycles, second-order thinking moves people to examine multidimensional characteristics of the situation and enables them to construct a “more accommodating perception of opposites” (Lewis, 2000, p. 764). Senge’s (1990, 1998) work on generative learning in organizations is also helpful in addressing paradoxical transcendence.
Nurses clearly expressed a desire for less meetings, which illustrates the structural design paradox (Stohl & Cheney, 2001). Within a paradoxical cycle, fewer meetings are seen as reducing voice and more meetings are seen as enhancing voice. From a transcendent perspective, fewer meetings may actually improve the quality of meetings and thereby enhance voice. Transcending paradox through reflection will aid workers to “reframe their assumptions, learn from existing tensions, and develop a more complicated repertoire of understandings and behaviors that better reflects organizational intricacies” (Lewis, 2000, p. 764). Nurses were also very clear about the need for continued involvement. Nurses say the way to manage SG is through communication processes. Workers need to manage paradox so they can continue to have a voice and enhance productivity. Nurses expressed:
“If you can’t stand it, and you can’t live with it, and you’re not willing to move on, then you need to do something about it.”
“Make it happen. It’s not going to happen by itself. You have to work at it. If you’re not willing to work and put forth effort, it ain’t never going to fly. But you have to be willing to put forth effort. You have to be willing to live with the consequences of your effort.”
Nurses recognize that despite the difficulties, SG offers great value. Part of the ongoing changes in healthcare are changes in the way nurses participate in their job. “Nursing is more than just going in and passing out a few drugs.” Although there is not the level of independence or perceived weight given to bedside/staff nurse input as was originally hoped (and theoretically conceived), the majority of nurses were unwilling to give up the voice that a SG structure allows them. They advocated characteristics of transcendental leadership.
Leaders can explain and manage paradox through accepting, confronting, and transcending paradox. However, taking a logical approach to paradox through “explicit recognition, clear intentionality, and deliberate strategy” (Stohl & Cheney, 2001, pp. 396-397) also requires acknowledging that paradox is illogical. Barker suggests that leaders
adopt a communicative approach that would enable teams to maintain not only their integrity, but also their individual and collective sense of what is and is not good for them as individuals and as a team. He calls for organizations to cultivate a continuing ability for teams to critique their own actions, (as cited in Krizek, 2000, p. 338)
Leaders must assign a priority to competing issues in the paradox-determining the amount of leadership time, attention, focus, and organizational resources that will be devoted to each issue. Each organization must determine what is appropriate for them. Each leader or leadership team faces different challenges that influence the priority placed on each issue (Blair & Payne, 2000). Since the basic building blocks of SG are trust and mutual respect, the old “us versus them” attitudes must be changed (Fagan, 1991; Fine & Buzzanell, 2000; Reich, 1991; Yamauchi, 1990). For this change to happen, members of the organization must begin with trust that communication and emergent paradox will be handled in a constructive manner.
Implementing SG radically changes the paradigm of communication practices within the hospital. All change is stressful, and this paradigm shift is no different. In SG, the culture changes; it shifts from one in which nurses simply come to work, feel that their daily actions have no real importance to administration, and go home-to one in which their participation counts (MacStravic, 1990). Participation at the hospital unit level is integral for identifying problems and implementing professional, positive solutions to emergent paradoxes.
This case study examined communication processes that occur in SG, an employee participation model frequently used in healthcare settings. Following a review of literature related to SG in professional nursing, a chronology of implementation in the Nursing Department at Western Hospital was introduced. Forms of paradox were reviewed and examples of paradoxes that emerged were identified. Processes for managing paradox through communication processes were addressed. Leaders must determine priorities in managing paradox; nurses offered suggestions consistent with literature to begin enhancing the SG process at Western Hospital.
This study raises additional questions related to understanding paradoxes in organizational communication. Wood and Conrad (1983) address the power of concepts such as paradox, double-bind, and mystification as metaphors for understanding the experiences of professional women. Given that nursing is traditionally a female profession, how do paradoxes that emerge in SG reflect paradoxes faced by professional women? When all workers exercise response to paradoxical situations (Watzlawick, Beavin, & Jackson, 1967), how does this enable the organization to use paradoxes to enhance organizational functioning? How is nurse communication about wrongdoing (Orbe & King, 2000) altered when paradoxes are effectively managed in health care organizations? How are paradoxes of leadership (Barach & Eckhardt, 1998) in health care organizations (Peirce, 2000) interconnected with paradoxes of empowerment? Research addressing these questions will help us further understand organizational paradoxes in health care settings, which when successfully managed through communication processes can enhance worker productivity and continually improve the quality of services offered to patients.
1 Western Hospital is a pseudonym used to protect the identification and interests of parties involved in this study. In Western Hospital, the Nursing Department consists of several divisions: Medical/Surgical, Critical Care, Emergency, and Women’s Pavilion. This study focuses on the Medical/Surgical division of the department of nursing. The six units that comprised the Medical/Surgical division at the time of this study were: Medical, Surgical, Cardiac, Orthopedics/Neurology, Renal, and Oncology.
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Lee Ann Carroll is a Registered Nurse at Western Hospital. She has practiced for over 15 years and worked in numerous hospitals. Pat Arneson is an Associate Professor in the Department of Communication & Rhetorical Studies at Duquesne University. Authors’ Note: The authors would like to thank Jay Carroll, Brian Harrigan, and three anonymous reviewers for their suggestions on earlier drafts of this work. Please direct all correspondence related to this manuscript to Dr. Pat Arneson, firstname.lastname@example.org. This project is not related to thesis or dissertation research. An earlier version of this paper was presented at the meeting of the Speech Communication Association of Pennsylvania, Seven Springs, PA, November 2001.
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