Communication in Health

in Health

julie apker

Copyright © Julie Apker 2012
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First published in 2012 by Polity Press
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Detailed Table of Contents
List of Figures and Tables
1   Landscape of Healthcare Delivery
2   Organizational Assimilation
3   Identity and Power
4   Stress, Burnout, and Social Support
5   Change and Leadership
6   Health Teams
7   Health Organization Quality
8  Health Communication Technologies

Detailed Table of Contents

List of Figures and Tables
Introduction 1
Definitional Issues
Systems Principles and Evolution
Systems Approach in Organizational Communication
Systems Concepts
Chapter-by-Chapter Summary
Pedagogical Features
1   Landscape of Healthcare Delivery
A Systems Perspective on the Healthcare Environment
Economic Contingencies
Social and Demographic Contingencies
Box 1.1: Communication in Practice: Adapting Successfully to Health System Contingencies
Models of Health and Illness
Biomedical and Biopsychosocial Models
Relationship-Centered Care Model
Health Organization Contexts
Healthcare Provider Organizations
Box 1.2: Communication in Practice: Improving Communication Using a Relationship-Centered Approach
Public Health Organizations
Forms of Health Organizing
Fee-for-Service and Managed Care
Box 1.3: A Patient’s Experience in the Healthcare Landscape
Communication in the Managed Care Era
Box 1.4: Ripped from the Headlines: Practicing Medicine in the Managed Care Era
Chapter Summary
2   Organizational Assimilation
Professions Overview: Trends and Occupations
A Systems Perspective on Organizational Assimilation
Conceptualizations of Organizational Assimilation
Assimilation of Health Professionals
Assimilation of Medical Professionals
Box 2.1: Communication in Practice: Building Communication Competence in the Formal Medical Curriculum
Box 2.2: Ripped from the Headlines: Lessons Learned from the Hidden Curriculum
Assimilation of Nonmedical Professionals
Role Communication
Role Development and Negotiation
Box 2.3: Communication in Practice: “Best Practice” Role Communication in Health Organizations
Role Performances and Role Dialectics
Chapter Summary
3   Identity and Power
A Systems Perspective on Identity and Identification
Identification Messages and Targets
Box 3.1: Ripped from the Headlines: Identifying with Profession and Team in Health Social Work
Negotiating Identifications
Box 3.2: Communication in Practice: Constructing Professional Identity in Healthcare
A Systems Perspective on Power
Power in Health Organizations
Knowledge Power and Disciplinary Power
Power and Control
Box 3.3: Communication in Practice: Communicating Powerfully with Others
Power and Ideology
Chapter Summary
4   Stress, Burnout, and Social Support
A Systems Perspective on Stress and Burnout
Sources of Stress in Health Organizations
Role Stressors
Box 4.1: Ripped from the Headlines: “Good Grief:” Stress and Social Support in Nursing
Emotional Labor Stressors
Organizational Stressors
Burnout in the Health Professions
Burnout Dimensions
Box 4.2: Communication in Practice: Recognizing the Signs of Burnout
Costs of Burnout
A Systems Perspective on Social Support
Characteristics and Sources of Social Support
Box 4.3: Communication in Practice: Individual and Organizational Coping Strategies
Social Support Functions and Dysfunctions
Chapter Summary
5   Change and Leadership
A Systems Perspective on Change
Understanding Organizational Change
Models of Organizational Change
Forms of Health Organization Change
Managing Planned Change
Reactions to Change
Change Communication Processes
Box 5.1: Communication in Practice: Making Innovation an Organizational Reality
A Systems Perspective on Leadership
Leadership Challenges and Theoretical Approaches
Leadership Challenges
Box 5.2: Communication in Practice: Leading through Cross-Cultural Respect
Leadership Approaches
Box 5.3: Ripped from the Headlines: Leading the Global Movement to End Breast Cancer
Leaders’ Communication Competencies
Chapter Summary
6   Health Teams
A Systems Perspective on Health Teams
Health Teams Overview
Types of Health Teams and Qualities of Clinical Teams
Teamwork and Health Team Effectiveness
Team Communication Processes
Synergistic Communication
Box 6.1: Communication in Practice: Consensus Decision-Making in Health Teams
Conflict Communication
Cultural Diversity in Health Teams
Gender and Race/Ethnicity
Box 6.2: Communication in Practice: How to Get Along in Diverse Health Teams
Culturally Competent Communication in Health Teams
Attributes of Cultural Competence and Benefits to Health Teams
Medical Interpreter-Team Communication
Box 6.3: Ripped from the Headlines: Connecting Public Health Teams with Communities
Chapter Summary
7   Health Organization Quality
A Systems Perspective on Quality
Quality and Health Organization Culture
Organizational Culture Levels
Organizational Culture Contributions to Quality Performance
Box 7.1: Communication in Practice: Developing Culture to Optimize Quality
Communication and Quality
Box 7.2: Ripped from the Headlines: Enhancing Patient Safety Through Teamwork
Patient-Centered Care
Box 7.3: Communication in Practice: Speaking in Plain Language
Chapter Summary
8   Health Communication Technologies
A Systems Perspective on Health Communication Technologies
E-health Communication
Electronic Health Records
Box 8.1: Ripped from the Headlines: Going Paperless at Kaiser Permanente
Email and Health Organization Websites
E-health: Transforming Health Organizations
Changes in Communication Contexts
Box 8.2: Communication in Practice: Using Email in Patient–Physician Interactions
Changes in Communication Processes
Changes in Communication Relationships
Health Communication Technologies and the Globalization of Public Health
Global HCT Improvements
Box 8.3: Communication in Practice: Putting Information in the Hands of Healers
Global HCT Implementation Issues
Chapter Summary

Figures and Tables

1.1    Model of Relationship-Centered Organizations
3.1    Identification Questionnaires
5.1    Typology of Theories of Change and Innovation
6.1    Model of Synergistic Communication
7.1    Schein’s Levels of Organizational Culture
8.1    Model of Telemedicine Relationships
1       Systems Concepts, Definitions, and Health Organization Examples
1.1    Health System Contingencies
1.2    Examples of Healthcare Provider Organizations
1.3    Examples of Public Health Organizations
1.4    Glossary of Managed Care Organizing
2.1    Examples of Healthcare Professions
2.2    Examples of Public Health Professions
2.3    Newcomer Information-Seeking Tactics
2.4    Organizational Socialization Tactics
2.5    Research Conceptualizations of Roles
3.1    Identification Messages and Examples
3.2    Sources of Power and Examples
3.3    Forms of Organizational Control and Examples
4.1    Major Sources of Health Workplace Stress
4.2    Forms of Social Support and Examples
5.1    Change Models in Health Organizations and Examples
5.2:   Forms of Health Organization Change: Categories and Examples
5.3    Coping with Change: Sample Communicative Responses
5.4    Demands on Health Organization Leaders
6.1    Types of Groups and Teams in Health Organizations and Examples
6.2    Unique Qualities of Clinical Teams and Examples
6.3    Research Summary of Teamwork and Health Team Effectiveness Indicators
6.4    Promoting Team Synergy
6.5    Sample Cultural Competence Characteristics by Health Organization Levels
6.6    Medical Interpreters’ Co-Diagnostic Behaviors
7.1    Quality of Care Characteristics
7.2    Quality of Work Life Communication Themes
7.3    Communication Obstacles Contributing to Patient Safety Risks
7.4    Communication Functions of Patient-Centered Care
7.5    Work Environment Qualities that Promote Patient-Centered Team Coordination
8.1    List of E-health Technologies
8.2    E-health Advantages and Disadvantages
8.3    E-health Transformations in Health Organizations
8.4    Globalization Elements and Effects on the Global Health Environment


There are a number of people I wish to thank for their contributions to Communication in Health Organizations. The team at Polity for their assistance in the book development and production process: Lauren Mulholland, Clare Ansell, Tim Clark, and Susan Beer. I’m particularly grateful to Polity editor Andrea Drugan for her ongoing encouragement of the project and her helpful editorial feedback. My thanks also to Marianne Rutter and Breffni O’Connor for their promotional help.

Several scholars provided valuable commentary on the content and format of the book: Katherine Miller, Texas A&M University; Lisa Sparks, Chapman University; Shelly Rodgers, University of Missouri; Laura Ellingson, Santa Clara University; Kevin Real, University of Kentucky; Eileen Berlin Ray, Cleveland State University; Lynn Harter, Ohio University and Peter Northouse, Western Michigan University.

This book was made possible thanks to the time afforded by a sabbatical leave. I am grateful for the support of the School of Communication, College of Arts and Sciences, and Western Michigan University.

My thanks to research assistants Stephanie Ruhl and Caitlin Evans for researching literature, reviewing drafts, and providing ideas for the book’s pedagogical features.

I am deeply grateful for the ongoing encouragement of my husband, Rod Phares, who was an important sounding board and source of social support as I wrote the book. I also thank our daughters, Margaret and Eliza, for their understanding of the many hours I needed to research and write. Their love of learning continues to inspire me.


Students in the communication courses I teach often ask me, “Why study communication in health organizations?” While there are many answers to this question, the main reason is that the communication in these contexts influences human lives in profound ways, by affecting health and well-being. Perhaps the most visible example of this is the patient who turns to a health institution during a vulnerable moment. Patients depend on health professionals to display clear, timely, accurate, and responsive communication. A communication failure can have serious results and perhaps even life or death consequences.

The importance of communication in health organizations extends beyond the patient’s bedside. For those who work in health professions, good communication builds cohesive, positive work environments. Bad communication creates barriers that reduce the quality of work life and job satisfaction. Negative communication experiences can ultimately affect healthcare delivery (e.g., turnover, staff shortage). For the public, communication in health organizations produces credible and reliable information that can be used to raise awareness of illness, disease, and wellness. This data can help consumers make more informed health decisions about treatment and prevention.

Communication in health organizations spans a wide range of topics and levels of interaction. Here are a few examples:

image   A diverse yet cohesive hospital team communicates to solve a complicated medical problem.
image   The use of an electronic medical record (EMR) allows a physician to quickly access information from a specialist at another institution during a patient crisis.
image   A health organization’s leader struggles with communicating changes that will dramatically affect quality of work life for her employees.
image   A social worker seeks mentorship and social support from supervisors and colleagues to ease the strain of job burnout.

After reading this book, you will know more about the communication principles, processes, and behaviors present in United States health organizations. Using the systems approach of organizational communication, you will gain greater familiarity with how health institutions function communicatively and why the people who work in health professions interact as they do. You will be able to analyze communication occurring in health organizations and apply communication skills to health organization experiences. This knowledge may enable you to improve your own communication as a patient, employee, or consumer and, ultimately, enhance communication in health organizations.

This introduction will define the characteristics of organizations, describe the role of communication, explain the systems approach, and preview chapter topics.

Definitional Issues

Organizations take many forms and have multiple purposes. Your personal experience with various types of organizations may include: a company that you work for, a non-profit organization where you volunteer, or an online organization from which you make regular purchases or that advocates for social issues you consider important. Despite their differences, these organizations share several common themes.

Organizational communication researcher Katherine Miller (2009) offers five defining features of organizations. First, organizations are social entities that consist of two or more people who are organizational members. Second, these individuals participate in activities that require coordination or synchronization. Third, organizational members’ activities create and maintain structure, such as vertical hierarchies or flat, collaborative teams. Structure explicates who is in charge of particular responsibilities, who reports to whom, the priority of actions, etc. Fourth, organizational members work to achieve individual and organizational goals. Finally, organizations are situated within an embedded environment consisting of other organizations, and varied social, economic, and political forces.

Organizational communication consists of the dynamic interactions used to accomplish goals that satisfy individual and/or collective needs (Jablin and Putnam, 2001). Health communication is the “symbolic processes by which people, individually and collectively, understand, shape, and accommodate health and illness” (Geist-Martin, Ray, and Sharf, 2003, p. 3). Taken together, organizational health communication refers to the individual and collective communicative behaviors that constitute health organizations.

To summarize, organizations are complex, dynamic entities inextricably intertwined with the greater environment, and communication plays a central role in organizing healthcare processes. Next, you will learn more about the systems approach, including theoretical principles, evolution in organizational studies, and key concepts.

Systems Principles and Evolution

The systems approach is an enduring framework in organizational studies useful to understanding complex entities such as health organizations (Ray and Donohew, 1990; Wright, Sparks, and O’Hair, 2008). A system is a set of components, typically people, which interrelate with one another through sending and receiving messages. The interactions of these components form subsystems, such as work teams and departments, which form system structure. System components, and thus the system itself, form relationships with the embedded environment (Deetz, 2000).

Consider HealthWest, a large, comprehensive medical practice in the Southwest that has multiple components and subsystems: clinical (physicians and nurses representing different medical specialties), administrative (finance workers, medical record clerks) and service (receptionists, customer service employees). Working together, the subsystems form an overarching structure that cares for patients. In addition to forming internal relationships, HealthWest employees develop connections with people from outside the organization. For instance, physicians and nurses provide care to patients; receptionists take external phone calls to book appointments and answer questions; and billing clerks talk with insurance representatives about medical claims. HealthWest’s internal and external openness allows the organization to work effectively and, ultimately, promote its survival.

The systems approach originated in biology and engineering and was later used in other academic disciplines. Ludwig von Bertalanffy (1968) developed general systems theory to explore the interrelationships which constitute biological organisms (such as human beings) and to investigate the connections linking an organism to its environment. Bertalanffy argued that systems principles could also inform understandings of non-biological systems.

In the 1970s and 1980s, researchers in organizational studies used systems theory principles to better understand social relations and structures of organizations (Deetz, 2000). Scholars recognized its utility for describing how organizations function at multiple levels. At the broad interorganizational level or macro-level, systems principles explain how organizations interrelate with environmental contingencies. The systems approach also provides a micro-level perspective that examines how complex, interrelated components such as dyads and groups function in organizations. The range of ideas associated with systems theory also supplied scholars with a rich, conceptual vocabulary to more fully explain the intricacies of organizational life.

Systems Approach in Organizational Communication

The systems approach has been particularly influential on the study of organizational communication. Papa, Daniels, and Spiker (2008) argue that a systems perspective sheds new light on the organizing role of communication. As they explain, “communication is not merely an activity that occurs “within” an organization, nor is it merely a tool for managerial control. Rather, all of the human processes that define an organization arise from communication . . . The linkages and connections among subsystems depend on communication and information flow” (p. 109).

Modaff, DeWine, and Butler (2008) take this argument a step further, identifying specific communication functions inherent to organizational systems:

image   Constitutive function: Communication creates connections and acts as a binder that allows the system to coordinate activities and integrate components into a unified whole.
image   Adaptive function: Feedback allows organizations to adapt to environmental change. Individuals who perform boundary spanning take center stage, giving and receiving information between the organizational system and the environment.
image   Maintenance function: Communication provides information throughout organizational systems to ensure a dynamic steady state.

The systems approach has a substantial research history that informs our understanding of many different types of organizations. A systems approach to organizational communication theorizes that interactions form necessary components and relationships that promote organizations’ existence. Let’s take a closer look at specific systems concepts relevant to the study of organizational communication.

Systems Concepts

The systems perspective has a robust conceptual vocabulary designed to articulate the complexities of organizations. This section discusses relevant systems ideas and provides one extended health organization example. See Table 1 for a summary of systems concepts, definitions, and health organization examples.

Table I Systems Concepts, Definitions, and Health Organization Examples

Systems Term Definition Example

System and subsystems

A set of components, typically people,which interrelate with one another throughsending and receiving messages. Theinteractions of these components createinterrelationships that form subsystems.A home healthcare organization’s employeescommunicate to coordinate tasks and scheduling, withindividuals who work in related areas (e.g., clinical care,administration) communicating with each other the most.These interactions reinforce departmental (subsystem)structure.


Component permeability allows messagesand other sources of information to flow throughout and between the system andthe embedded environment. A community health clinic’s leaders hold regular “town hall” meetings with the public to assess citizens’ needs for health services.


Social, economic, and political forcespresent in the embedded environment thatinfluence system functioning. A community’s rapidly growing elderly population createsheightened demand for gerontology care, causing amedical group to add several gerontologists to its roster ofstaff physicians.


The reliance that system components havewith one another, creating interrelationshipsnecessary to the system. Data sharing between a public health institution’scommunication, research, and clinical departmentsin order to provide the public with accurate, timely,comprehensive health information.


System components work together to forma unified whole, forming complex reactions based on the interactions of components. A hospital’s provision of patient care typically involvingmultiple units (e.g., nursing services, various medicalspecialties, lab studies and testing).


Messages and other sources of dataenter the system from the embeddedenvironment, are altered by components forsystem use, and leave the system as an end product. Patients describe symptoms and communicate medicalhistory during ED visits. ED staff uses this information toform a clinical impression and provide treatment. Patientsleave the ED with improved health.


Responses obtained internally (from systemcomponents) and/or externally (from theembedded environment) that enable asystem to self-regulate. A hospice conducts an employee satisfaction surveyto assess employee perceptions about work (internalfeedback). The hospice also surveys patients’ families togain impressions of care quality (external feedback). Bothsets of feedback are used in organizational improvements.


The individual and collective aims of systemcomponents that tend to organize system activities. A retail pharmacy’s organizational mission is to “providequality, affordable, and accessible care to patients.”Employees’ personal goals support this mission (e.g.,achieving 100% patient satisfaction).


The complex arrangement of componentsand subsystems within a system. Alsorefers to how a system fits into the greater supersystem of which it is a part. A mental health clinic consisting of multiple therapeuticspecializations. Workers report to unit middle-managers, who in turn report to the clinic’s director. The clinic is onefacility in the larger mental health industry.

Dynamic homeostasis

A system’s ability to maintain a steady statewhile simultaneously adapting to change. Several staff hygienists leave a dental practicesimultaneously. To handle the immediate effects ofthe shortage, the dentists who own the practice addtemporary hygienists while searching for long-term hires.

Openness refers to component permeability in which messages and other sources of information flow throughout the system and between the system and its embedded environment. Openness creates linkages that are vital to system functioning. To illustrate the concept of openness, let’s consider the example of Jack, an elderly patient with a history of heart problems, who arrives in the Metro Hospital emergency department (ED) suffering from heart failure. Jack’s family communicates his past medical history and current symptoms to physicians. After stabilizing Jack’s condition, an ED physician contacts an internal medicine physician (hospitalist) to admit Jack for further testing and treatment. The open communication between the ED physician and hospitalist forms a critical link in Jack’s care continuum as he transfers between different caregivers and hospital units.

Contingencies are the forces in the embedded environment that can influence system functioning. The systems perspective tells us that organizations must adapt and respond to contingencies in order to survive. For example, Jack went to Metro Hospital because of its reputation for quality cardiac care. Metro developed this specialization after determining that a gap in cardiac care existed in the community so that patients were being sent to hospitals many hours away. Metro doubled the size of its cardiac facilities, purchased state-of-the-art equipment, and hired a leading cardiac team to spearhead clinical care.

Interdependence refers to the system components that rely on each other, which creates interrelationships necessary for system functioning. The internal medicine physicians and nurses involved in Jack’s care relied on ED clinical staff for information about Jack’s condition. Conversely, the ED staff relied on the internal medicine caregivers to arrange for Jack’s timely transfer to the inpatient floor in order to free up ED bed space for other patients with emergencies. The ED and inpatient staff coordinated care processes to achieve shared goals.

Holism occurs when system components work together interdependently to form a unified whole, forming complex reactions based on the interactions of components. Jack’s heart failure required the ED staff to work together quickly and effectively.

Triage nurses and physicians received information from Jack’s family and moved Jack immediately into an ED bed without wait time. Assistant personnel had prepared a clean and fully equipped bed space, which was ready with no delays. Nurses took Jack’s vital signs, executed physician orders, and comforted his family while physicians determined a clinical diagnosis and began treatment.

Input-Throughput-Output is a process in which messages and other sources of data come into the system from the embedded environment as inputs, are altered by components for system use (throughput), and leave the system as an end product or output. Jack enters Metro Hospital with an emergency care need. ED staff use information provided in triage, along with data communicated in subsequent clinical assessment and workup, to sufficiently stabilize Jack’s condition prior to inpatient admission. Days later, a much healthier Jack leaves the hospital with home nursing care.

Feedback refers to responses obtained internally (from system components) and/or externally (from the embedded environment) that enable a system to self-regulate. Feedback has a number of useful functions. First, feedback corrects a system when it deviates from the accepted status quo (corrective feedback). Second, feedback enhances a system by promoting efforts that further improve upon its current state (amplifying feedback). Finally, feedback provides opportunities for sensemaking about inputs brought into a system that can cause uncertainty (Weick, 1979). System components seek and give feedback to make sense of uncertain situations.

When he arrives in the ED, Jack’s health status immediately conveys the message that his condition requires urgent medical attention. ED clinicians make sense of Jack’s physical signs and communication, deciding to move him from the waiting room to an ED bed. Their ability to quickly secure an appropriate ED bed space is the result of housekeeping’s efforts to “turn” or make a bed ready for a new patient. Housekeeping staff implemented this policy following negative feedback that ED room cleaning had become slower than was acceptable (corrective feedback). Positive reinforcement in the form of praise and appreciation by ED nurses has motivated housekeeping staff to continuously improve their work (amplifying feedback). For instance, they brainstorm ways to cut turn time without sacrificing quality (sensemaking).

Goals are the individual and collective aims of system components that organize system activities. System components use communication to achieve goals. The collective goal of Metro Hospital is to provide Jack with quality care. Each system component (nurses, physicians, and others) may have specific individual goals as well. For example, given the emergent nature of ED care, the ED physician may be oriented to short-term care that reduces or eliminates the health crisis. The hospitalist who admits Jack will most likely be concerned about Jack’s long-term care on the inpatient floor, which is under internal medicine supervision.

Order is the complex arrangement of components and subsystems. Metro Hospital is able to deliver quality care to Jack through the collaboration of multiple subsystems such as the ED, inpatient care, cardiac care, laboratory and testing services, among others. Each subsystem has its own hierarchical reporting structure consisting of upper-level leaders, mid-level managers, and entry-level and/or front-line workers. The subsystems form clinical, support service, and administrative divisions that ultimately make up the hospital’s overall system structure.

Dynamic homeostasis is the final systems concept, referring to a system’s ability to maintain a steady state while simultaneously adapting to change. The resilience of a system can be found in its ability to respond and/or adapt to changes in the environment. Communication among components and subsystems provides information to ensure homeostasis. For instance, Metro Hospital faces an inpatient nursing shortage due to nurse turnover. Jack’s floor lacks several permanent nurses, and in the short term, the hospital fills the gap with temporary staff and nurse floaters (staff who rotate to different units). Metro’s leaders have also instituted long-term changes to improve nurse working conditions, such as enhancing nurse–physician communication and recognizing nurses’ achievements throughout the hospital in formal and informal statements of appreciation. The hospital maintains a steady level of nurse staffing even during times of nurse shortage.

Thus far, you’ve gained a familiarity with systems’ principles and concepts. These ideas provide the foundation for what you will learn about communication in health organizations.

Chapter-by-Chapter Summary

Chapter 1: Landscape of Healthcare Delivery

Chapter 1 begins by discussing the economic, social, and demographic contingencies influencing communication in health organizations. The chapter summarizes models of health and illness, healthcare contexts, as well as traditional forms (e.g., fee-for-service) and contemporary forms (e.g., managed care) of healthcare delivery. The chapter elaborates on communication in the managed care era, describing the different levels of communication in health organizations. Chapter 1 concludes by considering the different organizational contexts that comprise healthcare provision and public health in the U.S.

Chapter 2: Organizational Assimilation

Chapter 2 starts with an overview of health professions before examining the communication processes by which health professionals learn “the ropes” of their occupations and become familiar with institutional employers. After reviewing foundational issues pertaining to assimilation, you will consider the formal and informal processes and behaviors health workers use to transition into organizations. The chapter explores work roles in the assimilation experience, considering the individual behaviors and team dynamics that influence role enactment.

Chapter 3: Identity and Power

Chapter 3 begins by considering identity and identification from a systems perspective. Then, you will learn about key messages and important referent groups that develop and shape identity through the process of identification. The second half of the chapter focuses on power by first taking a systems approach. You will also learn about the intersecting dynamics of power, control, and ideology and how this influences communication in health organizations.

Chapter 4: Stress, Burnout, and Social Support

Professionals working in health organizations commonly experience multiple role and workplace stressors as part of performing their jobs. Chapter 4 considers major system contingencies that contribute to stress in health organizations. The chapter then overviews specific stressors and identifies the individual and organizational outcomes of chronic occupational strain, also known as burnout. Chapter 4 concludes by examining supportive communication processes in the healthcare professions.

Chapter 5: Change and Leadership

Health organizations are constantly transforming as they anticipate and respond to shifting contingences. Chapter 5 explores major changes affecting health organizations, responses to change, and the communication processes that enhance change adoption. Health system change creates a need for people who can lead successfully during organizational transformation. As such, this chapter examines the challenges facing health leaders, foundational leadership theories that inform their leadership behaviors, and attributes of effective leader communication.

Chapter 6: Health Teams

Health teams play an important role in healthcare delivery and public health. Today’s health teams vary in size, professional composition, goals, and structure, features that add to the health organizations’ complexity. Understanding teams requires exploring their defining qualities and health communication activities. Chapter 6 also considers team synergy and conflict before taking a closer look at health team diversity. You will learn about cultural variables that affect teamwork and culturally competent communication.

Chapter 7: Health Organization Quality

Even though patients expect safe, high-quality care, and health organizations and professionals work hard to meet these expectations, quality problems do exist throughout the nation’s health system. Chapter 7 explores the role of communication in quality-improvement efforts and considers quality as an important part of organizational culture. The chapter focuses on safety and patient-centeredness, two areas in which communication figures prominently.

Chapter 8: Health Communication Technologies

Advances in communication have dramatically altered communication in health organizations. Chapter 8 describes the major forms of health communication technologies and discusses how these innovations have affected health communication contexts, processes, and relationships. The chapter explores how communication technologies have been a factor in health globalization, especially in efforts to promote public health efforts worldwide.

Pedagogical Features

Each chapter presents two types of applications that encourage you to analyze, discuss, and relate concepts and skills to health organization experiences. First, “Communication in Practice” provides applied principles and strategies for enhancing communication skills in health organizations. Second, “Ripped from the Headlines” describes real media accounts of selected chapter topics and poses questions for reflection and discussion.


Health organizations play an important and unique role in our lives, as patients, as employees or members, and as consumers of health information. Health organizations share the defining characteristics of organizations: they are social, goal-oriented, structured, coordinated, and function in an embedded environment. Communication constitutes these characteristics and makes health organizing possible.

This book takes a systems approach to understanding communication in health organizations. The systems approach provides multiple views of organizational life, examining micro-processes occurring within internal organizational relationships as well as investigating the macro-processes taking place in relationships between a health organization and its embedded environment. Communication is central to these internal and external connections. Communication creates organizational linkages to form a unified whole as well as enables organizations to adapt to change while maintaining a dynamic steady state. Using the systems principles and concepts presented in this Introduction, you will learn more about the complexities of communication in health organizations in subsequent chapters. To begin your investigation, in Chapter 1 you will explore the contingencies and contexts that make up the health system landscape.


Landscape of Healthcare Delivery

As I write this chapter, the United States is revisiting healthcare reform, a policy debate that has arisen in each of the past six decades. The current national discussion is perhaps best characterized as intense and contentious, with members of the public and elected officials arguing passionately about the goals, structures, and processes of healthcare delivery. Everyone seems to have an opinion on healthcare reform—from the political pundits who dominate talk shows and virtual spaces to the citizens who actively participate in town halls and public meetings occurring nationwide.

As an organizational health communication researcher, I’m fascinated by the discourse of healthcare reform and accompanying civic engagement. Most people agree that the current health system does not work well enough to achieve affordable, quality, and accessible healthcare. The agreement ends when discussion of how to accomplish these goals begins. Messages such as “moral obligation,” “universal coverage,” “socialized medicine,” and “rationing,” grab public attention and stimulate difficult conversations at all levels of American society. Talk about how to reform the health system inherently involves examination of our cultural values and brings to the surface deep-seeded assumptions about how the world works. While lawmakers continue to hash out the legislative details, the debate over healthcare reform is far from over. The U.S. will continue to face challenging decisions with no easy answers.

This chapter addresses the complex landscape of the U.S. health system—the contingencies, delivery forms, and contexts— which are in constant transformation. Ongoing change requires structural and communication adaptations by health organizations and their members which ultimately affects patients and consumers. By understanding the environment of healthcare delivery and the role of communication within health organizing, health professionals, patients, and consumers may be better able to communicate in the health system.

This chapter focuses on the complicated environment in which

U.S. health organizations are embedded. Chapter 1 begins by exploring major economic, social, and demographic contingencies that influence communication in health organizations. The chapter then examines models of health and illness, health organization contexts, and forms of health organizing.

A Systems Perspective on the Healthcare Environment

This book takes a systems approach to understanding health organizations and uses systems concepts throughout its chapters to explore key issues and processes in health organizational communication. In this chapter, you will learn more about system contingences, which are forces in the embedded environment that influence system functioning (Table 1.1). Health institutions must remain open to these forces and respond with dynamic changes in communication structures and processes.

Economic Contingencies

Cost and access to healthcare are two major priorities of the health system. Regarding cost, the U.S. has the most expensive health system in the world and its health expenditures continue to skyrocket. The following trends demonstrate the problem’s magnitude:

image   Health spending has exceeded $2 trillion since 2007 and is projected to reach $4.4 trillion by 2018 (more than 20% of GDP) (Centers for Medicare and Medicaid, 2008; Kaiser Family Foundation 2009).
image   From 2005 to 2009, healthcare costs for a family of four rose from $12,214 to $16,771 (37%) (U.S. News and World Report, 2009).
image   Annual healthcare spending per person increased from $6,687 in 2005 to $7,420 in 2009, an 11% increase (Centers for Medicare and Medicaid, 2008).

Table 1.1  Health System Contingencies

ContingencyDescription and Communication Interdependencies
Economic affordabilityCare costs escalate and consume higher percentages of overall spending for governments, employers, and individuals. Demands for cost containment force health organizations to do more with less, resulting in altered communication due to speed ups, staff reductions, and changing roles.
accessMillions of Americans lack access to care because they are uninsured or can’t pay out-of-pocket. Lacking ability to pay causes more patients to seek care from safety-net organizations, often putting stress on resources and staff. These pressures exacerbate poor communication.
social consumerismTrends include demands for greater flexibility and convenience as well as for communication behaviors that improve patient satisfaction. Health organizations have altered their communication to meet these needs (e.g., varied care locations, interactions that heighten patient satisfaction).
preventionPreventative medicine is less costly than curative approaches yet can require more complex, multi-level communication responses from health organizations. Prevention necessitates heightened teamwork among caregivers as well as consistent and long-term communication with patients.
demographic aging populationAmericans are living longer and, as they age, they require more health services. Heightened demand means that members of health organizations will need to adapt their communication to meet the needs of those over 65 and emphasize communication about prevention.
racial and ethnic changesRising numbers of health workers and patients come from diverse racial and ethnic groups. Health organizations will need to bolster employees’ cultural communication competence and increase diversity initiatives and programs.

Several factors contribute to rapidly escalating costs: 1) advancements in medical technology; 2) the population growth of those over 65 years of age and subsequent increase in chronic and/or intensive care needs; 3) rising rates of uninsured and underinsured patients whose healthcare costs are passed along in the form of higher insurance premiums; 4) emphasis on medical specialization, which fragments care and adds to unnecessary duplication of services across multiple caregivers and; 5) reimbursement system incentives that reward curative medicine rather than prevention (Sultz and Young, 2009).

Cost is an economic contingency that profoundly affects communication in health organizations. Cost contingencies place heightened pressures on caregivers to do more with less and even speed up care. Faced with an increased workload and reduced institutional support, those working in health organizations may reduce or even stop all nonessential communication. Apker (2001) found that hospital changes brought about by cost containment efforts reduce nurse–patient communication as well as decrease the nurse–team communication that leads to group cohesion.

The next economic contingency to explore is access, a topic that closely relates to cost. Health insurance coverage is an important determinant of access to healthcare (Institute of Medicine [IOM], 2001). An estimated 47 million Americans either lack insurance or have inadequate insurance, with a disproportionate number represented by the poor and people of color (Sultz and Young, 2009). According to the National Center for Health Statistics (2008), major disparities exist by socioeconomic status, race/ethnicity, and insurance status. Such as:

image   People of color make up more than two-thirds of the uninsured population.
image   Individuals with incomes less than twice the poverty level are likely to have no health insurance coverage.
image   Uninsured children and adults under 65 years of age are substantially less likely to have a primary source of health-care than those insured.
image   Persons living in poverty are considerably less likely to use healthcare services, conditions which can result in reduced quality of life and shorter life spans.

Lack of access to care is a contingency that affects communication in health organizations. Consider the dilemma faced by health safety-net organizations (e.g., public hospitals, federally funded community health centers) that are “legally obligated to provide care to persons who cannot afford it” and, consequently, are common sources of care for people without health insurance (Gresenz, Rogowski, and Escarce, 2007, p. 240). The needs of millions of uninsured Americans have increased stress on safety-net organizations in ways that affect care quality, caregiver communication, and resource availability (IOM, 2006; 2009).

The circumstances experienced by many public hospital EDs provide an exemplar of these problems. Rising numbers of patients use EDs for their care needs, a phenomenon often attributed to poor access. Elevated patient demand often creates overcrowded ED conditions and an environment known for increasing communication barriers such as multitasking, interruptions, and distractions (Solet, Norvell, Rutan, and Frankel, 2005). These barriers hinder communication among caregivers in the form of information omissions, rushed interactions, etc. Ultimately, these problems exacerbate medical mistakes, treatment delays, and reduced care continuity.

Social and Demographic Contingencies

Multiple social and demographic contingencies have also altered the healthcare landscape. One notable social contingency is consumerism. Consumerism refers to attitudes, beliefs, and behaviors that commodify healthcare. This means that healthcare is sold in a competitive marketplace influenced by consumer expectations and supply and demand. For example, more and more health consumers demand flexibility and immediacy in care delivery (Wright, Sparks, and O’Hair, 2008). Health organizations have responded by providing patients with a wide range of options to receive health services. Patients receive medical care in traditional settings such as hospitals and physician offices as well as alternative contexts such as retail outlets and urgent care facilities. While the range of care outlets meets patient needs for convenience, it also complicates communication by increasing the number and variety of health encounters. Fragmented and inconsistent communication may result. To overcome such difficulties, patients and health professionals must display a wider repertoire of interaction skills and adapt to increasingly varied relationships (Miller and Ryan, 2001).

Consumerism has also encouraged health organizations to address patient satisfaction (Scalise, 2006). It is common practice for health organizations to survey patients about their satisfaction with care. Patients provide feedback about wait time, the physical environment, and caregiver communication, among many other factors. Health organizations use patient responses to identify institutional strengths and weaknesses and to make improvements. For example, a home health agency may implement communication training for clinicians whom patients identify as having a poor bedside manner. Or, a clinic may make changes to improve communication efficiency in response to patient dissatisfaction with long wait times.

The second social contingency is the heightened focus on prevention rather than curative medical care. Prevention typically involves holistic care that addresses behaviors, attitudes, beliefs, culture, and environmental conditions. It is now generally accepted that prevention improves patient quality of life and costs less than curative medical care. Thus, more organizations are implementing prevention as key parts of their health services. Prevention requires coordinated, consistent, and clear organizational communication.