Running head: ENVISIONING SOCIAL CHANGE

Envisioning Social Change: Transforming Western Medical Organizations Power Imbalance by Designing Communication Technology to Co-Create Chart Narratives Dena M. Rosko Gonzaga University

ComL 515, Section B1 Dr. Heather Crandall 1 May 2010

Running head: ENVISIONING SOCIAL CHANGE

"Nothing is stranger than this business of humans observing other humans in order to write about them" (Behar, 1996, p. 5).

"I have a feeling this is only the tip of the iceberg" (C. Balloun, personal communication, April 25, 2010).

Running head: ENVISIONING SOCIAL CHANGE Table of Contents

Introduction............................................................................................................................................4 Article Review: Communication Choices.........................................................................................5 Ethical Dimensions..........................................................................................................5 Created Situation..............................................................................................................6 Integrating Interpersonal and Small Group Perspectives................................................................7 Symbolic-Interpretive (SI)...............................................................................................7 Conflict, Power, and Status..............................................................................................7 Confirming and Disconfirming Behaviors.......................................................................8 Application: Transforming WMOs through Narrative...................................................................8 Social Problem.................................................................................................................8 Social Change via Narrative............................................................................................8 Recommendation: Design Computer Mediated Communication (CMC) Systems that Allow Clinician and Constituent to Co-Create Chart Narratives...............................................................9 Conclusion.............................................................................................................................................10 References..............................................................................................................................................11

Running head: ENVISIONING SOCIAL CHANGE

Envisioning Social Change: Transforming Western Medical Organizations Power Imbalance by Designing Communication Technology to Co-Create Chart Narratives Introduction This paper will explore Connie Rice's communication choices to reduce gang and police violence (Lefer, 2008, April), and will explain the ethical dimensions of these choices as empowering community leaders through dialogue. These communication choices and ethical dimensions created a situation that invited people to collaborate for social change. This paper will then apply principles from Rice's work to a social problem important to me: transforming Western medical organizations (WMOs) power imbalance in one-sided chart narratives by introducing narrative ethics and by designing computer mediated communication (CMC) for clinicians and constituents to co-create chart narratives. I believe this recommendation will support ethical interactions and outcomes in WMOs by equalizing narrative agency for clinicians and constituents. I frame my recommendation within three interdisciplinary perspectives on interpersonal and small group communication: Patterns of (Dis)Confirmation, SymbolicInterpretive, and Conflict, Power, and Status. I draw on my 15 years experience as a constituent in WMOs and apply what Ive learned by suggesting autoethnographic performance narrative for future research. I then illustrate the holistic paradigm needed to implement my recommendations (Figure 1.1).

Running head: ENVISIONING SOCIAL CHANGE Article Review: Communication Choices

Rice centered her communication choices on her leadership ethic to prompt change: "If you don't say what you want to happen, it will never happen" (cited in Lefer, 2008, April, p. 10). As Block (2002), Rice compared this change to going out on a limb, where in the meantime, people who could be co-agents for change instead saw the limb off. The choice to speak to initiate social change takes the courage to say "I want..." because envisioning change for the self and community transcends peoples comfort zones (Block, 2002). When people say what they want, they promote real intimacy, or an act of "stepping out into the unknown with someone" without trying to control the outcome (Campbell, 2009, p. 275). Rice asked for what she wanted: to transform a geographic region segregated by violence and a legal and policing system that supported racism to a community of leaders who could continue this change process (Lefer, 2008, April). By leading by example, she can encourage others to do the same. Rice's communication choices required humility to acknowledge her limitations and powerlessness without people's help. She communicated to organize a social movement by networking with people on all sides of the dilemma. "I can't make change happen, but the community can" (cited in Lefer, 2008, April, p. 11). In other words, she communicated to strategize and dialogue with influential people for solutions. Ethical Dimensions Rice's communication choices called for a dialoguic and transformative ethic. She observed violence as power struggles, or a self-fulfilling prophecy. She viewed leadership as transforming this power struggle by forging a dialogic path to collaborate. She wanted to empower citizens to recognize their own power currency: familiarity with culture, dissatisfaction with the status quo, experience in their field, influence within their group, a neutral party, and so on (Lefer).

Running head: ENVISIONING SOCIAL CHANGE

Rice's (Lefer, 2008, April) communication ethics relied on humanizing people by empowering them to speak their own voice instead of repeating hers. Rice's ethics again required awareness, sensitivity, and humility to recognize her limitations and to allow people to contribute to changing the problems that affected them the most. Created Situation Context always communicates, and communicating in organizations creates systems that then shape the context (Conrad & Poole, 2005). Rice acknowledged the need to organize communication systems to promote change. "Real power is not in our political systems. It's in the structures that control capital... and it's becoming more concentrated every day" (cited in Lefer, 2008, April, p. 11). Rice desired to create a context to voice hope in despair and to challenge violence (Lefer). She also wanted to create a situation that puts the poor "back in the picture" (p. 11). In other words, her communication choices and ethics created a situation that invited people to represent themselves, their communities, and their wants through collaboration and dialogue. Rice also recognized that her choices fell within a historic timeline in which persons make choices that created systemic violence or empower movement. She admitted that she felt uncertain of the outcome of her choices and dialogic efforts and that there exists no guarantee that her efforts would work because "It's [change] a high-risk venture for everyone" (cited in Lefer, 2008, April, p. 10). Yet she founded her communication choices on her transformative ethics, rather than on what Handy (1996) called the illusion of certainty. This open-ended approach gave Rice flexibility to tread in many contexts of influence, such as with police and gang members, creating a situation that reduced a sense of urgency and increased a desire to consider alternative solutions.

Running head: ENVISIONING SOCIAL CHANGE Integrating Interpersonal and Small Group Perspectives

I integrate three interdisciplinary perspectives on interpersonal, small group, and organizational communication to understand a social problem important to me: WMOs communication system via medical chart narratives. Symbolic-Interpretive (SI) The symbolic-interpretive (SI) perspective describes groups as symbols, where groups symbolize their identity through predisposition and group practices, processes, and products (Frey & Sunwolf, 2005). Narratives symbolize the practice for organizations and groups to express their task, mission, and bond with people (Frey & Sunwolf). Symbols illumine group experiences, resources, and values, and predispose people to interact in certain ways (Frey & Sunwolf). Interpreting group behaviors through as symbols means people communicate their reality and language as ways to identify their selves in relation with others. The symbols create a context that drives interaction (Frey & Sunwolf). WMO chart narratives symbolize the relationship and influence the interaction and tasks that constituents have with clinicians, staff, and WMOs. Conflict, Power, and Status Positively, task conflict can lead to better quality in the outcomes, suggesting that groups can need conflict to succeed (Lovaglia, et. al). Conflict provides an opportunity for social change (Lederach, 2003; 2005; Lovaglia, et. al). People in impasse inquire, understand, listen, express, and raise viewpoints, concerns, and explore larger meaning (Folger, Poole, & Stutman, 2005). This inquiry process provides a dynamic instead of flat-lined approach that invites people to agree on the source of disagreement and clarify what they can do to move forward (Folger, et. al, 2005). This forward-looking model allows people to cease viewing each other as threats and to opt out of each other's viewpoints to define a positive course.

Running head: ENVISIONING SOCIAL CHANGE Confirming and Disconfirming Behaviors

People confirm each other when they acknowledge each other exists (Cissna & Sieberg, 2005). People disconfirm each other when they communicate that the other does not exist (Cissna & Sieberg). Disconfirming behaviors alienate, assume, and project ones self onto others, negatively impact identity, destroy relationships, and create degenerative instead of transformative conflict (Cissna & Sieberg). Laing (1961) explained that unwitting and "subtle but persistent disconfirmation" (cited in Cissna & Sieburg, p. 429) especially harms. In contrast, confirming behaviors pivot on peoples willingness to abandon controlinitiatives (Cissna & Sieberg, 2005). Confirming behaviors permit people to experience their being, significance, and their interconnectedness with others (Wilmot, 2005). Application: Transforming WMOs through Narrative Social Problem In WMOs, chart narratives comprise a communication support for the overall system. Solomon (1985) observed that medical and scientific rhetoric dehumanizes people as sites of disease and study. This dehumanization produces a power disparity that simultaneously reduces and uses people, reifying dual-disconfirmation and a double-bind, making medical discourse, such as found in charts, a passive-aggressive affair. Social Change via Narrative I aim to first share my experiences with conflict, power, status, and disconfirmation in WMOs as a path to changing what I perceive to be a power imbalance with clinicians only writing and interpreting constituents chart narratives. This one-sidedness requires constituents to support clinician agency, which I contend risks disconfirming constituents experiences twofold: by constituents lacking agency, and by constituents supporting this disempowerment.

Running head: ENVISIONING SOCIAL CHANGE

Stories touch, heal, share, and evoke imagination (Livo, 2001). Stories suggest new possibilities, and so help people to envision what Block (2009) called an alternative future. I apply Rices communication model by first expressing my desire for change and by performing through autoethnographic narrative how this social problem has impacted me. I desire these behaviors to invite participation from others and to encourage others to voice their desires for change in WMOs. Recommendation: Design Computer Mediated Communication (CMC) Systems that Allow Clinician and Constituent to Co-Create Chart Narratives As Werhane (2002), Rice saw the whole system. As Rice (Lefer, 2008, April), I recommend being strategic by organizing a system where people can dialogue and collaborate for social change. For starters, I suggest reframing organizations as Holos integrates frames of knowing (Bolman & Deal, 2008; Figure 1.1) that transition from models of dehumanizing medicine and scientific rhetoric (Solomon, 1985) to models that develop human potential and communities (Laszlo, 2001). WMOs must design just inquiry processes (Tyler, 2005) that center on dialogue. A relational and collaborative model must abandon the expert model and will move clinicians and constituents past impasse (Blackall, Simms, & Green, 2009). I recommend WMOs partner with academic, civic, community, and business organizations and hire a third party to design CMC technology that allows clinician and constituent to co-create chart narrative. This CMC must allow dynamic and immediate access for both parties and include text-fields and question items geared towards each partys goals and not just symptomatic complaints. Designing CMC for constituent and clinician to co-create chart narratives will provide what Roger's (1989) called a context for people to perceive safety, and will empower people, as Freire (1973) idealized, to advocate their health-related wants. Co-creating chart

Running head: ENVISIONING SOCIAL CHANGE

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narratives will help constituents to perceive themselves as owners of their health situation, give each participant agency and equality, foster collaboration, challenge clinician assumptions, and help constituents to perceive Tyler's (2005) just leadership process and so be more willing to participate and trust their clinicians. Conclusion Rices (Lefer, 2008, April) communication choices and ethics created a situation that helped people to stop camping in the problem and to envision and collaborate for change. Rice envisioned a healthy society without the disease of violence based on her leadership ethic to humanize people through dialogue and transformation. Likewise, WMOs can envision a healthy society as one that humanizes people through designing communication systems for clinicians and constituents to co-create chart narratives as a practical and ethical way to collaborate for health, for equality means drawing dialogue and ideas from all participants (Lefer). Given current challenges with healthcare reform, these recommendations provide a timely way for society to communicate change, equality, and caring in WMOs. Ultimately, as Rice observed, social change needs the public to become a community by owning its dilemmas and desires for social change (Lefer, 2008, April).

Running head: ENVISIONING SOCIAL CHANGE References Behar, R. (1996). The vulnerable observer: anthropology that breaks your heart. Boston, MA: Beacon.

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Blackall, G.F., Simms, S., & Green, M.J. (2009). Breaking the cycle: how to turn conflict into collaboration when you and your patients disagree. Philadelphia: ACP. Block, P. (2002). The answer to how is yes: Acting on what matters. San Francisco: BerrettKoehler. Block, P. (2009). Community: the structure of belonging. San Francisco: Berrett Koehler. Bolman, L.G., & Deal, T.E. (2008). Reframing organizations: Artistry, choice, and leadership. San Francisco: Jossey-Bass. Campbell, S. (2009). I want... In J. Stewart (Ed.), Bridges not walls: a book about interpersonal communication (10th ed.). New York: McGraw-Hill. Carey, M.R. (1999). Heraclitean fire: Journeying on the path of leadership. Dubuque, IO: Kendall/Hunt. Cissna, K.N., & Sieburg, E. (2005). Patterns of interactional confirmation and disconfirmation. In J. Stewart (Ed.), Bridges not walls: a book about interpersonal communication (9th ed.). New York: McGraw-Hill. Conrad, C., & Poole, M.S. (2005). Strategic organizational communication in a global economy (6th ed.). Belmont, CA: Thomson Wadsworth. Folger, J.P., Poole, M.S., & Stutman, R.K. (2005). Conflict and interaction. In J. Stewart (Ed.), Bridges not walls: a book about interpersonal communication (9th ed.). New York: McGraw-Hill.

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Frey, L., & Sunwolf. (2005). The symbolic-interpretive perspective of group life. In M.S. Poole & A.B. Hollingshead (Eds.), Theories of small groups: interdisciplinary perspectives. Thousand Oaks, CA: Sage. Gonzaga University. (2010). Conceptual framework. Retrieved April 22, 2010, from http://www.gonzaga.edu/Academics/Colleges-and-Schools/School-ofProfessional-Studies/Ph.D.---Leadership-Studies/About-DPLS/ConceptualFramework.asp Handy, C. (1996). Beyond certainty: The changing world of organizations. Boston: Harvard. Laszlo, E. (2001). Macroshift: Navigating the transformation to a sustainable world. San Francisco, CA: Berrett-Koehler. Lederach, J.P. (2003). The Little book of conflict transformation: clear articulation of the guiding principles by a pioneer in the field. Intercourse, PA: Good Books. Lederach, J.P. (2005). Conflict transformation. In J. Stewart (Ed.), Bridges not walls: a book about interpersonal communication (9th ed.). New York: McGraw-Hill. Lefer, D. (2008, April). Both sides: Connie Rice lays down the law to cops and gangs. The Sun, 388, 3-11. Livo, N.J. (2001). Story medicine: multicultural tales of healing and transformation. Englewood, CO: Libraries Unlimited. Lovaglia, M., Mannix, E.A., Samuelson, C.D., Sell, J., & Wilson, R.K. (2005). Conflict, power, and status in groups. In M.S. Poole & A.B. Hollingshead (Eds.), Theories of small groups: interdisciplinary perspectives. Thousand Oaks, CA: Sage. Rogers, C. (1989). On becoming a person: a therapists view of psychotherapy. New York: Houghton Mifflin.

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Solomon, M. (1985). The rhetoric of dehumanization: An analysis of medical reports of the Tuskegee syphilis project. Western Journal of Communication, 49(4), 233-247. Tyler, T.R. (2005). Process-based leadership: New perspectives and research. In D.M. Messick & R.M. Kramer (Eds.), The psychology of leadership: New perspectives and research. Mahwah, NJ: Lawrence Erlbaum. Werhane, P.H. (2002). Moral imagination and systems thinking. Journal of Business Ethics, 38(1/2), 33-42. Wilmot, W.W. (2005). Communication spirals, paradoxes, and conundrums. In J. Stewart (Ed.), Bridges not walls: a book about interpersonal communication (9th ed.). New York: McGraw-Hill.

Running head: ENVISIONING SOCIAL CHANGE Author's Note

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Special thanks to Chevas and Danielle for suffering with me, for cooking me a meal I could eat and enjoy, for praying for my healing, for encouraging me to persevere and to hope, and for your genuine dialogue as friends! Thanks to my husband, James, for being present with me in my suffering in part by going to clinician offices together.

Running head: ENVISIONING SOCIAL CHANGE

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Figure 1.1. Holistic framework and leadership ethic. This figure illustrates Holos as a center from which a leaders frames mediates mystery to move towards Logos, or a community truth that holds all frames together (Carey, 1999; Gonzaga University, 2010). Dialogue and narrative provide the communication processes that allow persons to communicate choices, behaviors, and ethics and so foster social change.