Communication is essential

Fundamental and vital to all healthcare managerial functions, communication is a means of transmitting information and making oneself understood by another or others. Communication is a major challenge for managers because they are responsible for providing information, which results in efficient and effective performance in organizations. Every managerial function and activity involves some form of communication. For a manager to plan, organize, direct, or lead, he/she must communicate with and through others. Managerial decisions are only effective if they are communicated and understood by those responsible for enacting them. Furthermore, employee motivation and satisfaction are dependent on effective communication. Communication is essential to building and maintaining relationships in the workplace. Communication is the creation or exchange of thoughts, ideas, emotions, and understanding between sender(s) and receiver(s). Managers who understand this exchange can better analyze their communication patterns resulting in more effective communication within the workplace.

Although managers spend most of their time communicating (e.g., sending or receiving information), one cannot assume that meaningful communication occurs in all exchanges (Dunn,2006). Once a memorandum, letter, fax, or e-mail has been sent, many are inclined to believe that communication has taken place. However, communication does not occur until information and understanding have passed between sender and the intended receiver. For example, a receiver may hear a sender but may not have comprehended the sender’s actual meaning. Effective communication occurs when the message received is the same as the one intended. Communication enables one to establish and maintain positive interactions in the workplace. An effective communicator overcomes barriers to engage in more meaningful and successful communication.

COMMUNICATION PROCESS

Figure 4–1 illustrates the communication process. The message originates from the sender who uses words and symbols to put forth information into a message for the receiver, the individual(s) receiving the message. Messages are then received and decoded or interpreted by the receiver. Decoding is affected by the receiver’s prior experiences and frames of reference. Accurate decoding of the message by the receiver is critical to effective communication. The closer the decoded message gets to the intent of the sender, the more effective the communication. However, environmental and personal barriers can hamper the communication process. Details on barriers are described in a later section of this chapter. For ensuring that messages are received as intended, feedback is a necessary component of the communication process. The receiver creates feedback to a message and encodes it before transmitting it back to the sender. The sender receives and decodes the feedback. Feedback is the destination’s reaction to a message (Certo, 1992). It is an important element of communication since it allows for information to be shared between the receiver and sender in a two-way communication.

FEEDBACK

Feedback is any information that individuals receive about their behavior. Feedback can be information related to the productivity of groups in an organization or the performance of a particular individual. For instance, a manager requires feedback to determine staff acceptance of his or her newly set policy, whereby staff must call and confirm all patients’ appointments 48 hours in advance. Through the feedback process, senders and receivers may adjust their outputs as related to the transmitted information. In the absence of feedback, or in the case where the communication process does not allow for sufficient feedback to develop, or feedback is ignored, a certain amount of feedback will occur spontaneously and tends to take a negative form.

In one-way communication, a person sends a one-directional message without interaction. When a physician writes out a prescription and gives it to the nurse to hand to the patient, the physician’s order is an example of one-way communication and does not provide the opportunity for the patient to ask questions directly. Negative feedback may occur if the patient expresses frustration or anger at the physician for not directly explaining the necessity and functions of the medication. However, the same patient could express satisfaction and appreciation toward the nurse who explains the purpose of the medication. In this case, the opportunity for feedback results in two-way communication between the patient and the nurse. Two-way communication is more accurate and information-rich when the message is complex, although one-way communication is more efficient, as in the case of the physician’s written prescription.

To be effective, communication must allow opportunities for feedback. Feedback can take several forms, each with a different intent. Keyton (2002) describes three different forms of feedback: descriptive, evaluative, and prescriptive.

• • Descriptive Feedback: Feedback that identifies or describes how a person communicates. For instance, Manager A invites her friend and fellow Manager B to attend her staff meeting and comment on her form of communication. After the meeting, B told A that she was very clear and instructive as she introduced her staff to the new computer database for managing patient accounts. In this example, B provided descriptive feedback of A’s communication with her staff.
• • Evaluative Feedback: Feedback that provides an assessment of the person who communicates. In the preceding case, if Manager B evaluates Manager A’s form of communication and concludes that she was instructive and helpful which enabled her staff to feel comfortable when going to her for advice, then B has provided positive evaluative feedback of A’s interaction with her staff.
• • Prescriptive Feedback: Feedback that provides advice about how one should behave or communicate. For example, Manager A asks Manager B how she could have made changes to better communicate her message to her staff. B suggests for A to be friendlier and more cooperative by giving the staff specific times that A is available for help with the new computer database. This type of advice is prescriptive feedback.

In addition to forms and intent, there are also four levels of feedback. Feedback can focus on a group or an individual working with specific tasks or procedures. It can also provide information about relationships within the group or individual behavior within a group (Keyton, 2002).

• • Task or Procedural Feedback: Feedback at this level involves issues of effectiveness and appropriateness. Specific issues that relate to task feedback include the quantity or quality of a group’s output. For instance, are patients satisfied with the new outpatient clinic? Did the group complete the project on time? Procedural feedback refers to whether a correct procedure was used appropriately at the time by the group.
• • Relational Feedback: Feedback that provides information about interpersonal dynamics within a group. This level of feedback emphasizes how a group gets along while working together. It is effective when combined with descriptive and prescriptive forms of feedback.
• • Individual Feedback: Feedback that focuses on a particular individual in a group. For example, is an individual in the group knowledgeable? Does he or she have the skills helpful to this group? What attitudes does he or she have toward the group as they work together to accomplish their tasks? Is the individual able to plan and organize within a schedule that contributes to the group’s goal attainment?
• • Group Feedback: Feedback that focuses on how well the group is performing. Like the questions raised at the individual feedback level, similar questions are asked of the group. Do team members within the group have adequate knowledge to complete a task? Have they developed a communication network to facilitate their objectives?

Feedback can be in the form of questionnaires, surveys, and audio- or videotapes of group interaction. It can also occur in activities such as market research, client surveys, accreditation, and employee evaluations (Liebler & McConnell, 2008). Feedback should be used to help a group communicate more effectively by making group members identify with the group and increase its efficacy. Feedback should not be viewed as a negative process. Instead, it should be used as a strategy to enhance goals, awareness, and learning. As a managerial tool, feedback enables managers to anticipate and respond to changes. Structured feedback enhances managerial planning and controlling functions. Because of the value of feedback, managers should encourage feedback and evaluate it systematically.

The Johari Window

The process of feedback can also be illustrated by the Johari Window, a useful model for understanding the communication process created by Joe Luft and Harry Ingham (hence the name “Johari”) (Luft, 1984). The Johari Window model improves an individual’s communication skills through identifying one’s capabilities and limitations. As shown in Exhibit 4–1, windowpane 1 isconsidered the open area in which information about you is known both to you and to others. Tubbs (2001) described this area as the general cocktail party conversation in which an individual willingly shares information with others. For instance, at an office party, you reveal to your coworkers that you do not drink alcohol because of health reasons. Windowpane 2 refers to a blind area in which others know information about you that you are either unaware of or that you do unknowingly. As an example, your colleagues know that you are a “close” talker, that you unconsciously stand too close to people while in conversation with them.

Exhibit 4–1 The Johari Window

SOURCE: Based on Group processes: An introduction to group dynamics (3rd ed.), by J. Luft, 1984, Palo Alto, CA: Mayfield.

The third windowpane is the hidden area in which you have likes and dislikes that you are unwilling to share with others. This area includes all of your values, beliefs, fears, and past experiences that you would not wish to reveal. The last windowpane is the unknown. It is also an area of potential growth or self-actualization. It represents all the things that we have never tried, participated in, or experienced.

Increasing mutual understanding through feedback and disclosure allows an individual to increase the open area and reduce the blind, hidden, and unknown areas of oneself (McShane & Von Glinow,2003). In the Johari Window, Luft (1984) argues for increasing the open area so that you and your coworkers are aware of your limitations. This is done by receiving more feedback from others and decreasing one’s blind area (windowpane 2), and reducing the hidden area (windowpane 3) through disclosing more about oneself. The combination of feedback and disclosure may also help to produce more information in the unknown area (windowpane 4).

The Johari Window can be used for opening channels of communication. Open communication is important for improving employee morale and increasing worker productivity. Open communication allows supervisors and subordinates to openly discuss organization-related issues such as goals and conflicts. Nevertheless, Luft (1984) is cautious on the use of the Johari Window for all situations. He offers several guidelines for the appropriateness of self-disclosure. He recommends that self-disclosure is a function of an ongoing relationship. Timing and extent of disclosure are critical. A competent communicator knows when, with whom, and how much to disclose.

COMMUNICATION CHANNELS

Another important component of the communication process is selecting an appropriate communication channel. This is the means by which messages are transmitted. There are two types of channels: verbal and nonverbal. Various channels of communication and the amount of information transmitted through each type are illustrated in Figure 4–2.

BARRIERS TO COMMUNICATION

As shown in Table 4–1, several forms of barriers can impede the communication process. Longest et al. (2000) classify these barriers into two categories: environmental and personal. Environmental barriers are characteristic of the organization and its environmental setting. Personal barriers arise from the nature of individuals and their interaction with others. Both barriers can block, filter, or distort the messages when sent and received.

OVERCOMING BARRIERS TO IMPROVE COMMUNICATION

Recognizing that environmental and personal barriers exist is the first step to effective communication. By becoming cognizant of their existence, one can consciously minimize their impact. However, positive actions are needed to overcome these barriers (see Table 4–1).

Longest and colleagues (2000) provide us with several guidelines for overcoming barriers:

• 1. Environmental barriers are reduced if receivers and senders ensure that attention is given to their messages and that adequate time is devoted to listening to what is being communicated.
• 2. A management philosophy that encourages the free flow of communication is constructive.
• 3. Reducing the number of links (levels in the organizational hierarchy or steps between the sender in the healthcare organization and the receiver who is an external stakeholder) diminishes opportunities for distortion.
• 4. The power/status barrier can be removed by consciously tailoring words and symbols so that messages are understandable; reinforcing words with actions significantly improves communication among different power/status levels.
• 5. Using multiple channels to reinforce complex messages decreases the likelihood of misunderstanding.

Personal barriers to effective communication are reduced by conscious efforts of senders and receivers to understand each other’s values and beliefs. One must recognize that people engage in selective perception and are prone to jealousy and fear. Sharing empathy with those to whom messages are directed is the best way to increase effective communication.

Communicating effectively among a complex, multisite healthcare system is challenging. Barriers may be difficult to overcome. Porter (1985) offers several approaches for achieving effective linkages among business units in a diversified corporation and suggests ways in which managers can overcome some of these barriers.

• 1. Use techniques that extend beyond traditional organizational lines to facilitate communication. For instance, the use of diagonal communication that flows through task forces or committees enhances communication throughout the organization.
• 2. Use management processes that are cross-organizational rather than confined to functional or department procedures. Implementing management processes in the areas of planning, controlling, and managing information systems facilitates communication.
• 3. Use human resources policies and procedures (job training and job rotation) to enhance cooperation among members in organizations.
• 4. Use management processes to resolve conflicts in an equitable manner to produce effective communication.

EFFECTIVE COMMUNICATION FOR KNOWLEDGE MANAGEMENT

Communication plays an important role in knowledge management. Employees are the organization’s brain cells, and communication represents the nervous system that carries information and shared meaning to vital parts of the organizational body. Effective communication brings knowledge into the organization and disseminates it to employees who require that information. Effective communication minimizes the “silos of knowledge” problem that undermines an organization’s potential and, in turn, allows employees to make more informed decisions about corporate actions. Effective communication is one of the most critical goals of organizations (Spillan et al., 2002). Research suggests that an effective manager is one who spends considerable time on staffing, motivating, and reinforcing activities (Luthans et al., 1988).

Shortell (1991) identified multiple key elements to effective communication in a model developed for physicians and hospital administration to improve their communication abilities to disseminate knowledge within the organization. The following summarizes these key elements:

• • An effective communicator must have a desire to communicate, which is influenced both by one’s personal values and the expectation that the communication will be received in a meaningful way.
• • An effective communicator must have an understanding of how others learn, which includes consideration of differences in how others perceive and process information (e.g., analytic versus intuitive, abstract versus concrete, verbal versus written).
• • The receiver of the message should be cued as to the purpose of the message, that is, whether the message is to provide information, elicit a response or reaction, or arrive at a decision.
• • The content, importance, and complexity of the message should be considered in determining the manner in which the message is communicated.
• • The credibility of the sender affects how the message will be received.
• • The time frame associated with the content of the message (long versus short) needs to be considered in choosing the manner in which the message is communicated. More precise cues are needed with shorter time frames (see Figure 4–3).

A formula to evaluate an individual’s effectiveness in communicating to others can be calculated as shown in Exhibit 4–2.

The ICE is a percentage of the reaction to the intended message over the total number of messages sent. If managers find that their ICE is low over time, they should evaluate their communication processes to identify ways to make improvements (Certo, 1992). Research suggests that to improve healthcare organizational communication and cohesion, exchanges between employees and leaders should involve leaders’ direct support and encouragement of employees’ constructive expressions of dissatisfaction and innovative ideas (Sobo and Sadler, 2002) (see Case Study 4–2: What Should We Do Now?).

STRATEGIC COMMUNICATION

Strategic communication is an intentional process of presenting ideas in a clear, concise, and persuasive way. A manager must make an intentional effort to master communication skills and use them strategically, that is, consistently with the organization’s values, mission, and strategy. To plan strategic communication, managers must develop a methodology for thinking through and effectively communicating with superiors, staff, and peers. Sperry and Whiteman (2003) provide us with a strategic communication plan, which consists of five components.

• 1. Outcome: The specific result that an individual wants to achieve.
• 2. Context: The organizational importance of the communication.
• 3. Messages: The key information that staff need to know.
• 4. Tactical Reinforcement: Tactics or methods used to reinforce the message.
• 5. Feedback: The way the message is received and its impact on the individual, team, unit, or organization.

Strategic communication requires forethought about the purpose and outcome of the message. Managers must be able to link the needs of the staff to the organization’s mission and deadlines.

FLOWS OF INTRAORGANIZATIONAL COMMUNICATION

Communication can flow upward, downward, horizontally, and diagonally within organizations. Upward communication occurs between supervisors and subordinates. Downward communication primarily involves passing on information from supervisors to subordinates. Horizontal flow is from manager to manager or from coworker to coworker. Diagonal flow occurs between differentlevels of different departments. Longest et al. (2000) provides us with several forms of intraorganizational communication for healthcare organizations, which are described in the following paragraphs.

COMMUNICATION NETWORKS

Flows of communication can be combined into patterns called communication networks. These networks are interconnected by communication channels. A communication network is the interaction pattern between and among group members. A network creates structure for the group because it controls who can and should talk to whom (Keyton, 2002). Groups generally develop two types of communication networks: centralized and decentralized (Figure 4–4).

Decentralized networks allow each group member to talk to every other group member without restrictions. An open, all-channel or decentralized network is best used for group discussions, decision making, and problem solving. The all-channel network tends to be fast and accurate compared with the centralized network such as the chain or Y-pattern networks (Longest et al.,2000). Nevertheless, a decentralized network can create communication overload, in which too much information or too complex communication may occur (Keyton, 2002). When a communication overload is produced, messages may conflict with one another and result in confusion or disagreement. To reduce communication overload, a facilitator should be used to monitor group discussions.

A centralized network restricts the number of individuals in the communication chain. In a group setting where a dominant leader takes over group discussions by controlling the number of messages and amount of information being passed, group members do not interact except through the leader. Such a network can create communication underload, in which too few or simple messages are transmitted. In this type of network, group members feel isolated from group discussions and generally feel dissatisfied. In the chain network, communication occurs upward and downward and follows line authority relationships. An example is a staff nurse who reports to the charge nurse, who reports to the director of nursing, who reports to the vice president for clinical services, who finally reports to the CEO of a large hospital. This network delineates the chain of command and shows clear lines of authority.

Other types of centralized networks include the Y-pattern, the wheel, and the circle network. The Y-pattern is similar to the chain network, with its hierarchical structure, except it shows two employees at the same level who then follow the chain. An example is of two medical assistants in the organ transplant division who report to the clinical administrator for the division, who reports to the clinical administrator for the department of surgery, who reports to the vice president of clinical services, who finally reports to the CEO of the hospital.

The wheel pattern shows four subordinates reporting to one supervisor. Subordinates do not interact, and all communications are channeled through the manager at the center of the wheel. This pattern is rare in healthcare organizations and systems, although elements of it can be found in the example where four vice presidents report to a president if the vice presidents have little interaction. Even though this network pattern is not routinely used, it may be used when urgency or secrecy is required. For example, the president with an organizational emergency might communicate with the vice presidents in a wheel pattern because time does not permit using other modes. Similarly, if secrecy is important, such as when investigating possible embezzlement, then the president may require that all relevant communication with the vice presidents be kept confidential. The wheel pattern works well when there is pressure for time, secrecy, and accuracy.

The circle pattern allows communicators in the network to communicate directly only with two others. Since each communicates with another in the network, there is no central authority or leader. The circle network works well when there are open channels of communication among all parties; however, it can also slow down the communication process to enable everyone access to information.

Although there are different communication networks, there is not one that works for all situations. Different forms can be applied under varying circumstances. To be effective, healthcare managers must be able to select appropriate flows of communication for specific situations. Identifying an ideal communication network is critical to successful communication. Since health problems range from simple to complex, simple problems can be easily resolved using simple networks. As an example, scheduling patient appointments for Dr. Davis can be easily accomplished through the superior–subordinate chain network. However, complex problems require many levels of decision making. For instance, whether Horizons Hospital should merge with its major competitor to gain more market share at the risk of making a major capital investment can be accomplished through the all-channel network, which is more useful and effective for tackling complex problems. Hellriegel and Slocum (2004) compared the five communication networks using four assessment criteria. Figure 4–5 shows the specific criteria when making a selection among the different types of networks.

• 1. Degree of Centralization: Degree of centralization is the extent to which team members have access to more communication than others. In the case of the wheel network, because communication flows from and to only one member, this is the most centralized network. However, the allchannel network provides everyone in the network with the same opportunity for communication; thus, it is the least centralized network.
• 2. Leadership Predictability: Leadership predictability is the ability to anticipate which member of the communication network is likely to emerge as the leader. In the case of the Y and wheel, the most centrally positioned individual is the most likely person.
• 3. Average Group Satisfaction: Average group satisfaction reflects the level of satisfaction of members in the communication network. In the wheel network, average member satisfaction is the lowest compared to other networks, since the most centrally positioned person plays the most crucial roles and leaves less important decision-making responsibilities for those around the wheel.
• 4. Range of Individual Member Satisfaction: The range of an individual’s satisfaction within the communication network shows an inverse relationship with the average group satisfaction. Again, in the wheel, although average member satisfaction is low, the range of individual member satisfaction is high, because they are highly dependent on the individual in the middle. In the case of the all-channel, average group satisfaction is high since there is greater participation by all members of the communication network; yet, individual satisfaction tends to be low.

INFORMAL COMMUNICATION

In addition to formal communication flows and networks within healthcare organizations, there are informal communication flows, which have their own networks. Employees have always relied on the oldest communication channel—the corporate grapevine. The grapevine is an unstructured and informal network founded on social relationships rather than organizational charts or job descriptions. According to some estimates, 75 percent of employees typically receive news from the grapevine before they hear about it through formal channels (McShane & Von Glinow, 2003).

Early research identified several unique features of the grapevine. It transmits information very rapidly in all directions (Newstrom & Davis, 1993). Figure 4–6 illustrates four common patterns that the grapevine can take.

The typical pattern is a cluster chain, whereby a few people actively transmit rumors to many others. The grapevine works through informal social networks, so it is more active for employees who have similar backgrounds and are able to communicate easily. Many rumors seem to have at least a little bit of truth, possibly because rumors are transmitted through information-rich communication channels, and employees are motivated to communicate effectively. Nevertheless, the grapevine distorts information by deleting fine details and exaggerating key points of the message.

In this era of information technology, e-mail and instant messaging have replaced the traditional watercooler site of grapevine gossip. Instead, networks have expanded as employees communicate with one another inside and outside of the organization instantly through computer-aided communication. Furthermore, public Web sites have become virtual watercoolers for posting anonymous comments about specific companies for all to view. This technology extends gossip to anyone, not just employees connected to the social networks. A manager’s responsibility is to utilize the informal network selectively to benefit the organization’s goals (see Case Study 4–4: Did You Hear the Latest?).

CROSS-CULTURAL COMMUNICATION

Increasing information technology, globalization, and cultural diversity present a number of communication opportunities and challenges for organizations. Organizational personnel must be sensitive and competent in cross-cultural communication. While ethnic and racial diversity enriches the environment, it can also cause communication barriers and impede efficient and effective service delivery. Communication difficulties arise from differences in cultural values, languages, and points of view. For instance, in the healthcare industry, one major barrier is language because as many as 20 languages may be encountered among staff and patients. In the United States, more than 25 percent of the population is foreign-born, and 15 percent speak a language at home other than English (Thiederman, 1996). Since language is the most obvious cross-cultural barrier, words can be easily misunderstood in verbal communication (Dutton, 1998). Although the English language is relied on as the common business language, English words may have different meanings in different cultures.

Voice intonation varies by country. For instance, in Japan, communicating softly is an expression of politeness, whereas in the Middle East, the opposite holds true, for the louder the voice, the more one is believed to be sincere (Mead, 1993). To achieve effective communication, healthcare professionals can apply several strategies to reduce communication barriers. Thiederman (1996) provides us with several verbal and nonverbal techniques to improve cross-cultural communication.

• • Write down in simple English the issues that have been agreed upon in order to obtain feedback on accuracy.
• • Repeat a message when there is doubt.
• • Watch for nonverbal signs of a lack of understanding.
• • Listen carefully to an entire message, especially when there is a foreign accent involved in the communication.
• • Create a relaxed atmosphere so that tension is reduced to increase the flow of communication.
• • Phrase questions in different ways to make it easier for the receiver to understand.

Opportunities for working with individuals from other cultures have increased dramatically. As U.S. industries branch into world markets through the interconnectedness of the Internet, e-mail, fax machines, answering machines, electronic bulletin boards, and international cell phones, organizations are able to conduct business without ever meeting face to face. To be effective in cross-cultural communication, several guidelines are important.

• • Understand one’s own identity. To develop sensitivity to other cultures, you must first understand your own culture and identity. Your personal identity encompasses who you are and who you want to be. That is, you choose your lifestyle, goals, occupation or profession, and friends. The choices that you make or pursue are affected by racial, cultural, gender, and social class factors.
• • Enhance personal and social interactions. With globalization, we have increased opportunities to associate and develop close interactions with individuals who are different from us. The conscious decisions we make to become more accommodating, flexible, and tolerant of others broaden our views of the world and enrich our perspectives. Our relationships with those of different cultures help us to learn more about the world and to break typical stereotypes. These interactions also enable us to develop new skills for communicating with others and to learn from them.
• • Solve misunderstandings, miscommunications, and mistrust. Take the time and make the effort to study, understand, and appreciate individuals of different cultures. Through open, honest, and positive communication, this will resolve misunderstandings, miscommunications, and mistrust.
• • Enhance and enrich the quality of the work environment. Recognizing and respecting ethnic and cultural diversity through more open communication are the first steps toward valuing diversity and enriching the quality of the work environment (Hybels and Weaver,2007).

COMMUNICATING WITH EXTERNAL STAKEHOLDERS

In healthcare organizations, managers must be competent communicators, because they spend most of their time and energy communicating with large numbers of external stakeholders, individuals, groups, and organizations that are interested in the healthcare organization’s actions and decisions. A competent communicator is an individual who has the ability to identify appropriate communication patterns in a given situation and to achieve goals by applying that knowledge. Competent communicators quickly learn the meaning that listeners take from certain words and symbols, and they know which communication channel is preferred in a particular situation. Moreover, competent communicators use this knowledge to communicate in ways to achieve personal, team, and organizational objectives. A manager with high communication competence would be better than others at determining whether an e-mail, telephone call, or personal visit would be the best approach to convey a message to an employee.

To competently communicate with external stakeholders, organizations and their managers are responsible for assessing the environment to gain information in order to make strategic decisions. Managers must utilize their roles as liaisons and monitors to scan the environment for opportunities and minimize threats. Furthermore, managers must utilize their strategist role to formulate and implement policies that are consistent with their organization’s strategic goals and plans (Guo, 2003). Exhibit 4–3 shows steps for analyzing stakeholders to increase the acquisition of useful information.

First, scanning the macro- and microenvironments results in information about stakeholders. In the case of one state’s department of health, shown in Figure 4–7, the diversity of stakeholders is illustrated (Ginter et al., 1998).

Relationships between the organization and its external stakeholders are complex and affect communication since the organization is a dynamic, open system operating in a turbulent external environment. The size and variety of external stakeholders make communication complex, especially since stakeholders attempt to influence the decision making of organizations. Fottler et al. (1989) examined communication between a large hospital and its stakeholders and found different relationships. While some relationships are positive, others are neutral or negative. Positive relationships with external stakeholders are easier to manage, and communication tends to be more effective than negative relationships.

In the stakeholder analysis, important issues and stakeholders are identified through the environmental scan. Next, monitoring the activities of stakeholders is crucial. Managers must be able to take the views of stakeholders and use that information to incorporate trends into their decision-making process. Finally, managers must evaluate the value of the information, and take the information gathered and transmit it to those who need the information.

Another way to describe communication with external stakeholders is called boundary spanning. Boundary spanning, or external communication links, provides opportunities for organizational learning in areas such as strategic planning or marketing (Johnson & Chang, 2000). Communicating with all external stakeholders is essential; however, each may be viewed for its unique position and benefits to the organization. For instance, in interactions with the public sector, healthcare organizations are affected by public policies. Government is a major stakeholder because of its legislative and regulatory powers and as one of the largest purchasers of health services. For example, issues such as access to care, cost containment, and quality concerns have driven federal government debate, reforms, and involvement in health care. Thus, healthcare organizations cannot be insulated from public policies and must make strategic responses to reflect the needs of the public sector. A healthcare organization holds a special relationship with the geographical community where the organization is located. Meeting the particular needs of the community is a primary goal of healthcare organizations. For effective communication to take place, realistic expectations must be formed by both parties. There are six areas of responsibility toward their communities for healthcare organizations (Longest et al., 2000). They include:

• 1. Engaging in the core, health-enhancing activities in the community.
• 2. Providing economic benefits to the community.
• 3. Offering unique benefits or a niche to the community.
• 4. Pursuing philanthropic activities in a broad and generous manner.
• 5. Being in full compliance with legal requirements.
• 6. Meeting ethical and fiduciary obligations.

SUMMARY

Communication in the workplace is critical to establishing and maintaining quality working relationships in organizations. Communication is the creation or exchange of thoughts, ideas, emotions, and understanding between sender(s) and receiver(s). Feedback is information that individuals receive about their behavior. Feedback can be used to promote more effective communication. The Johari Window is a model to improve an individual’s communication skills through identifying one’s capabilities and limitations. The channels of communication are the means by which messages are transmitted. Verbal communication relies on spoken or written words to share information with others. Computer-aided communication, such as electronic mail, has greatly enhanced the communication process. Especially in health care, other forms of technology, such as high-speed, high-definition images, telemedicine, and wireless, hand-held digital electronic medical records can be used to bridge communications gaps between clinicians and administrators. Nonverbal communication is the sharing of information without using words to encode messages. This includes proxemics, kinesics, facial and eye behavior, and paralanguage.

There are two types of barriers to communication: environmental and personal. Barriers can be overcome by conscious efforts to devote time and attention to communication, reduce hierarchical levels, tailor words and symbols, reinforce words with action, use multiple channels of communication, and understand one another’s frame of reference and beliefs.

Key elements of effective communication include the desire to communicate; understanding how others learn; the intent; the content; the sender’s credibility; and the time frame. Strategic communication is an intentional process of presenting ideas in a clear, concise, and persuasive way. Five components of strategic communication are outcome, context, messages, tactical reinforcement, and feedback.

Intraorganizational communication flows upward, downward, horizontally, and diagonally. Various flows of communication can be combined to form communication networks, such as the chain, Y, wheel, circle, and all-channel. Certain networks work better than others in varying situations. A manager’s role is to determine the best network to use for simple or complex communications. Informal communication results from interpersonal relationships developed in the workplace. Although informal networks can be useful, they can also be misused.

Cross-cultural communication can be challenging. Communication difficulties arise from differences in cultural values, languages, and points of view. Organizational personnel must be sensitive and competent in cross-cultural communication. Several techniques and guidelines for improving cross-cultural communication are provided.

Healthcare organizations must manage relationships with large numbers of external stakeholders made up of individuals, groups, and organizations that are interested in the organization’s actions and decisions. Effective communication with external stakeholders involves environmental assessments to enable managers to identify and make strategic decisions for their organizations.