Writing in organisations

Trust between humans always has both history and context. Even when we first meet somebody, context plays a part. We may already have heard something about them, or we may be influenced by their status or job title – e.g. we probably respond differently to a nurse, a businessman, a teacher or a homeless person. So in my view, if we want to understand how trust works, abstract definitions have limited value. Perhaps what St Augustin said about time could also be said about trust:

“What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.”

If we can’t define trust satisfactorily, can we at least begin to understand how it develops between people – and between people and institutions – over time? That is what Rob Warwick and I explored recently with a group in Brighton, by using stories, group conversations and writing to stimulate thinking.

Overall, the day prompted me to reflect on how human relationships, and trust in particular, ebb and flow. If you cast your mind back to how one of your relationships has developed over time, you may recall some striking or memorable moments along the way. Perhaps something happened to unsettle or even destroy the trust between you. Maybe you managed to rebuild it. Maybe you didn’t.

Not surprisingly, I noticed just this kind of ebb and flow during the workshop. For example, I felt warmer towards people who smiled or responded constructively to something I said. In contrast, when someone spoke in a complaining tone (as if they were a consumer who had bought a faulty product), I noticed my trust in that person sag.

At the end of the day, I came away wondering again whether it isn’t a bit strange to focus solely on this “thing” called trust, when trust is only one of several aspects of human relating. What about fear, sadness, irritation, enthusiasm, love, disappointment, exclusion, rivalry or anger? Surely these all deserve our attention.

Talking of anger, I recall how an old friend once criticised me angrily at the breakfast table (there were five of us in the room at the time). His words felt pretty much out of the blue. The memory of that exchange has lingered in my mind ever since. I would still trust him in most things, but in that moment something precious was lost, and I have gone back to it in my memory many times. 

One person at the Brighton workshop wondered whether trusting someone could be understood as “anticipating that they won’t do harm to us”. I suspect we just need to feel safe enough with other people to be able to “go on together”. 

Note: The event was the AMED writers' annual workshop in Brighton on 20 May 2016: Writing, Conversation and Trust: a day of exploration by the seaside. The original research was funded by Roffey Park.

Related reading
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​Alison Donaldson & Rob Warwick: The emergence of trusting relationships: Stories and Reflections. Val Hammond Research Paper for Roffey Park, 2016. Available free as PDF.

Alison Donaldson & Rob Warwick: Trust and the emotional bank account: using stories to prompt learning. Strategic Briefing for Croner Publications, 2016. Available free online.

​Recently I visited an amazing project in Glasgow that is helping people affected by cancer get support for any worries they have, including physical problems but also emotional, financial and practical ones. It's called 'Improving the Cancer Journey' (ICJ). Afterwards I reflected on what a key role stories, conversation and writing play in the project.

Stories that move and convince

​When I sat down with Sandra McDermott, the head of the service, she started by telling me the experience that originally moved her to throw herself into it. She had seen a woman who was dying of cancer and who was due any moment to leave hospital to stay with her mother, as her own flat was damp. Within a couple of weeks, drawing on her own knowledge of local services, Sandra was able to arrange more suitable accommodation for the woman and her four children. When the end came, the woman died with her family around her in a warm and comfortable flat. Sandra also helped her make guardianship arrangements, so her children would be well looked after in future. 

Listening to this story, I could see just how powerfully it demonstrated the need for the service. But Sandra also gave some convincing figures – the sheer numbers of people affected by cancer in a city the size of Glasgow, the billions spent on cancer treatment in the UK, especially in deprived areas, and the relatively modest cost of running a service like Improving the Cancer Journey. It was a good example of how numbers and stories can complement each other.

Sandra was herself clearly moved by the woman’s story and she told me she was nervous of telling it to an audience she was going to speak to in London the next day. She feared she would feel too upset. We agreed that what made it so moving probably had something to do with the sense of the community pulling together and making a difference to somebody in need. (I was glad to hear later that Sandra did manage to tell the woman's story in London.)
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Sandra emphasised that it was luck that she had been there at the right moment for this particular woman. The experience convinced her of the need for a new joined-up service to make sure that others could get similar support.

Conversations that ease worry and point to help

I learned from Sandra and her colleagues how Improving the Cancer Journey works. Every person diagnosed with cancer in the Glasgow area now receives a letter inviting them to get in touch and to have a conversation with a link worker. So far, about 40% have taken up the offer. Family and friends who look after the person with cancer can also get help.

The link worker listens to what the person has to say and invites them to identify their needs and concerns, whether physical, practical, emotional or spiritual (in NHS-speak this is a “Holistic Needs Assessment”).

While in Glasgow, I met one of the link workers. Andy immediately struck me as a warm and open person with extensive local knowledge. I had no doubt whatsoever that he would set people at ease and listen with empathy. And the conversations would not be hurried – he told me they last up to 90 minutes, occasionally more than two hours.

​During the conversation, Andy will make suggestions about which of more than 200 local services might be able to help. This could include things like housing or benefits advice, an exercise programme, or a way to meet other patients to ease feelings of isolation. In other words, the service is very much about helping with “all the other things” that typically trouble people who have been diagnosed with cancer.

One woman said that her biggest fear was that her daughter would not remember her after she had died. The link worker in this case suggested that mother and daughter create some kind of memory box together, which the daughter could keep and look at in years to come. 

Paperwork that helps not hinders the conversation

I also noticed that the team makes good use of paperwork. One example is the simple one-page form providing people with a list of possible concerns. They can simply run down the list, ticking off the ones that apply.

Being sceptical about how paperwork is used, I asked Andy if he felt this checklist was helpful. He said, yes, it helps to get people started. It also makes it easy for him to explore with them which main concerns they want to focus on.

Also, there’s a space at the bottom where people can score their overall level of concern on a scale of 1 to 10 (1 = lowest, 10 = highest). This creates a “stress thermometer”, which gives an idea of how seriously worried they are now, but also becomes useful if they meet the link worker again, when they can provide a new score. The before-and-after comparison provides the team with a simple way of measuring how effective the service is (its 'impact').

At some point, patients are invited to record and share their personal story on a separate card, which simply asks, “Tell us briefly about your cancer experience.” This provides another measure of the service’s impact. It also allows the team to contact the person again and (with permission) use their story in the media to help publicise the service.
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The project has even formed a group of patients who can help improve the service, and these patients have already helped to reword the letter sent to all those diagnosed with cancer.
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All in all I felt that stories, conversations and intelligent uses of paperwork combine to make Improving the Cancer Journey very special. No wonder the team in Glasgow want it to spread all over the UK.

Notes
Improving the Cancer Journey is a partnership between Macmillan Cancer Support, Glasgow City Council, Glasgow Life, NHS Greater Glasgow & Clyde, Cordia Services and Social Work Services.

More information on the project's web pages. ​

“A desk is a dangerous place from which to view the world.” For me, that sentence, written by John Le Carré, instantly conjured up bureaucrats sitting comfortably in their offices deciding the fate of powerless people. But it also evoked other common habits – managers issuing instructions in emails that won’t engage people, researchers writing reports that will never be read properly, or people creating strategic plans that will never be followed.

There are several problems with these habits, not least of which is the implementation challenge. People may not read the written word (and in my experience, many people are reluctant to follow written instructions); those who are meant to implement the plan may be less rational than the author assumes; and by the time the plan has been completed, the environment will probably have changed.

Of course it is often vital to express ideas in writing to help others understand what we are trying to achieve. And the act of writing can help produce greater clarity, at least for the authors. But having produced a document, the risk lies in thinking that the job has been done, when in fact the work of making a difference has only just begun. This is the moment when we need to get away from our desk – or the boardroom table – and talk to people.

So why do some managers continue to spend so much time at their desks? Why do they remain detached from people on the ground? I suspect that for many the thought of a conversation with anybody other than a few trusted colleagues can seem quite scary. I have been there myself. When I worked for McKinsey as a communications specialist (a kind of writing coach and editor) in the late 1980s, one of my challenges was to convince the busy and brainy consultants about the benefits of working with me (it was optional for them). Sometimes I really had to steel myself to walk up to a table of consultants at lunchtime, seat myself down next to them and open a conversation. 

Conversations with strangers may take both confidence and courage. We never know how others will respond or how the conversation will unfold. That uncertainty can be exciting but it can also be uncomfortable. Sometimes it feels so much easier to put down our thoughts in writing and then just send them off. So let’s keep reminding ourselves that the desk is a dangerous place from which to view the world.

Related reading

Zaid Hassan, ‘The Social Labs Revolution: a new approach to solving our most complex challenges’ (which is where I came across the quote from John Le Carré).

Henry Mintzberg, ‘The Rise and Fall of Strategic Planning’ (also quoted by Hassan). See also @Mintzberg141 on Twitter.

In my writing I put a lot of effort into advocating things like dialogue and storytelling, but two striking moments in the past 24 hours have made me stop and think again. One was a conversation with a friend who had just read one of my papers bemoaning the lack of conversation in organisational life. His immediate response was to say that what he often sees is “too much dialogue”.

This exchange prompted me to wonder “What if, for a change, I were to take a critical stance towards conversation and to praise the use of writing to organise, analyse and manage?” After all, I am often the first to use writing in these ways. For instance, I reach for pen (or keyboard) whenever I want to develop clarity about a complex project, or to work out what I want a meeting or presentation to cover.

I also use the written word to keep important information in easy-to-find form. For example, I have a program called Evernote where I deposit all those bits of information that would previously have covered scraps of paper or filled little notebooks. My Evernote now has nearly 500 notes in it, which I can access from my laptop, ipad or phone. They are organised into no less than 21 searchable online “notebooks” with names like “House”, “Garden”, “Food”, “Money”, “Client work” and “My writing”. How organised is that?!

This all got me wondering why I so often argue that people overuse the written word and underuse conversation. I think the main reason is that I feel a need to counteract received wisdom. I feel I live in a world where people produce written strategies, plans, reports, agendas, minutes and wordy slide presentations without radically questioning their practical value. I also see unthinking documentation and measurement as habits of mechanistic management, based on inappropriate application of scientific methods to human affairs.

Scientific thinking has its place, and it has certainly changed our world. I am currently reading about the scientific revolution of the 17th century and I am struck by how sensible I find Francis Bacon’s thinking. He wanted to counteract old patterns of thinking and traditional prejudices and to develop a new method of acquiring knowledge:

“This method was to be fundamentally empirical: through the careful observation of nature and the skilful devising of many and varied experiments, pursued in the context of organised cooperative research, the human mind could gradually elicit those laws and generalisations that would give man the understanding of nature necessary for its control.” (Tarnas 1991, page 272)

Sounds refreshingly clear and reasonable. The trouble only arises when people use this rational, scientific approach to address everything, including complex social and political issues such as how best to run a large organisation like the NHS, how to achieve quality in education or how to stop destroying life on this planet.

Related reading

Richard Tarnas. The Passion of the Western Mind. Pimlico, 1991

Iain McGilchrist. The Master and his Emissary. Yale University Press, 2012

We have created a pretty mad world in some of our larger organisations. I am thinking especially of health and education, where bureaucracy and top-down control seem to have taken over – and that’s not just in the UK. 

Over the Christmas period we had a visit from an old friend of my husband who is a General Practitioner in southern Germany. Prompted by my curious questioning, he began to overflow with stories about documentation gone mad. For example, after every patient visit, he now has to enter his diagnosis into a computer system by selecting from a long list of codes. He is also supposed to note whether each diagnostic code he selects is: (a) certain, (b) suspected or (c) can be excluded. 

This system, he says, not only creates extra work but also encourages doctors to provide “invented” diagnoses. In other words, it distorts how they record a patient’s condition. The system originated in Australia, but “the Germans have perfected it”, he noted with a smile. The computer even offers blocks of text for cutting and pasting.

Documentation is not a bad thing in itself. But when taken to excess, it robs practitioners of time they could otherwise be spending in conversation with people. Our GP friend explained that he has always taken proper patient histories/stories (same word – Geschichte – in German). He also continues to handwrite his notes, as in his view patients prefer their doctor not to be glued to the computer. 

As I reflected on his words, it occurred to me that those who put in place these systems implicitly undervalue health professionals’ experience, memory and ability to make connections and patterns.

How has this madness come about?  As always, there are multiple influences at work. The one I immediately think of, given my interest in uses of writing, is that many people simply do not understand, or stop to think about, how written communication works – and how it can actually hinder communication. Managers and policy makers in particular seem to accept without question the value of detailed documentation. Additionally, they are often remote and disconnected from what is happening on the ground – they don’t and can’t be present to the human exchanges between patients and health professionals, for instance. And of course all the bureaucratic rules and procedures are reinforced and perpetuated by the inevitable power relations among practitioners, and between practitioners and managers or policy makers.

After talking to our doctor friend, I happened to be reading a book called “Wilful Blindness” by Margaret Heffernan. In it, the author describes how most people in organisations – even when they sense or know there is something wrong – tend to stay silent. She provides copious examples (in banking, in the army, in private companies, and also in the NHS) of people following orders, clinging to convictions or submitting to groupthink. And on top of all that, many work long hours and are under relentless pressure to pursue efficiency and cut costs. These conditions make them even more likely to develop tunnel vision and just do what they are told. 

In the face of what he sees as senseless bureaucracy, what does our German GP do? “Resignation” was the word he used. But he did nevertheless point to some small acts of subversion. For example, having handwritten his patient note, he only enters the absolute minimum information (the diagnostic codes) into the computer. Or he refuses to sign what he sees as time-wasting, superfluous documents presented to him by staff in the care home that houses some of his patients. He knows that the nurses there spend hours documenting everything in great detail, and presumably therefore less time really caring for patients. Why should he sign a piece of paper just because the computer system adopted by the home spits out a whole page detailing each patient’s medication? 

These small subversive acts make our friend unpopular with some of his colleagues. But he works in a single-handed practice and only has a few years left before he retires, so he can afford to risk being the odd-one-out. 

No doubt much of what he experiences is equally in evidence here in the UK. 

What would it take for this bureaucratic madness to change – a new generation of doctors willing to challenge and question? So far, according to our friend, junior doctors in Germany show little sign of starting a revolution. If anything they are more compliant than his contemporaries. 

He also regrets that the trainee doctors he comes across are no longer taught how to take proper patient histories and are less likely than their older colleagues to examine patients physically. Instead, they rely on technological scans and tests. People going through medical education today also get fewer opportunities to see patients than he did. This is because (mercifully perhaps) they no longer work such long hours.
 
Perhaps one day the current culture of bureaucratic control will just become outmoded. People may decide it has run its course or that it has simply generated too many distortions. I suspect it will take not only some very obstinate and courageous individuals but also some kind of collective rebellion. 

Related reading
Margaret Heffernan. Wilful Blindness, 2011.

It seems to be getting harder and harder to persuade anyone to read anything longer than a “tweet”. Does it matter? I think it does, and so I’ve been developing ways to encourage people to respond to what I have written for them. It’s all about giving documents a “social life”. 

One method is to seize an opportunity for a conversation. Some years ago I was doing some consulting work for a senior manager who had recently acquired a new management team. He asked me to interview each member of the team to surface their concerns and ideas. I then wrote a report and gave it to him, but noticed later that he hadn’t read it. Fortunately I found a chance, during a long motorway drive in his BMW, to read it out loud to him. Within hours he had acted on some of the ideas – e.g. arranging a gathering for his staff to get to know him and each other.

More recently, I have come to insist on face-to-face meetings to discuss drafts. True, some people still have the nerve to turn up and say “Sorry, I haven’t read this”, but more often than not they do look at it and a stimulating conversation develops. 

What I am drawing attention to is something about our role as writers: if we just write and hope people will take notice, we may be disappointed. But if we insist that people engage with what we have written, we have a chance of having an influence.

This does all mean of course that we need to be willing to take on board people’s comments, which may not be comfortable and usually means extra work. But in my experience, writing is a great way to develop thinking jointly. It becomes an “iterative” process, in the sense that it goes through several revisions, bringing in more voices and ideas at each stage. 

A propos the social life of documents, I was recently talking to a friend about what happens to public inquiry reports, such as the Francis report on the Mid Staffordshire hospitals in the UK. In such cases, the inquiry team usually makes sensible recommendations but inevitably implementation is left to others. I wonder if enough thought is given to the social life of the report? And for that matter, does anybody take into account the effect of the inquiry on staff in the organisation that is under the magnifying glass (which could be seen as another aspect of the social life of documents)?

The phrase itself first came to me a decade ago, prompted partly by the book “The social life of information” by Brown & Duguid. It had struck me that, without noticing it, many of us walk around with the sender-receiver model in our heads. Yet it is worth noting that this theory of communication was developed in the mid-20th century in the context of new technologies like telegraph and radio. It is wholly inadequate for describing human communication, with its divergent interpretations, ambiguities, politics and emotions. 

So it really is worth restating the obvious – that a piece of writing will only have any influence if it is read and thought about or discussed by human beings – i.e. if it gets a social life.