THREE BARRIERS TO COMMUNICATION Harold Korolenko

There is persuasive evidence to support the principle that successful group productivity depends on the ability of the members to ex- change ideas freely and clearly, and to feel involved in the decisions and the interaction among group members.

This principle is perhaps best illustrated

Harold Korolenko is the Personnel Oficer at the Veterans Administration Hospital, Bronx, New York. He has had over 15 years experience as a Personnel Oficer responsible for the direction and implementation of a comprehensive personnel management pro- gram in the Veterans Administration Hospi- tal system. While in military service he was a member of the Air Inspector’s Ofice of the Army Air Force Personnel Distribution Command, charged with the responsibility for the inspection of civilian and military personnel ofices. He has an M.A. in Public Administration from New Yolk University and is currently President of the Metropoli- tan New York Chapter of the Public Person- nel Association. This article is based on a talk given by Mr. Korolenko at the 12th Annual Congress of the Association o/ Operating Room Nurses, New York City, February, 1965.

by your own working relationships in the operating room. There the issue of life and death is so vivid, so dependent on optimum teamwork, that every member often takes his orders from the demands of the situation rather than from the normal channels of command.

“The changing needs of the patient, as they develop in the course of the operation, determine what everybody does. When a sur- gical team has worked long enough together to have developed true teamwork, each member has such a grasp of the total situa- tion and of his role in it that the needs of the patient give unequivocal orders. A small artery is cut and begins to spurt. In a chain-of-command organization the surgeon would note this and say to the surgical nurse, ‘Give me a hemostat,’ and thus co- ordinated effort would be achieved. What actually happens is that the bleeder gives a simultaneous command to all three mem- bers of the team, all of whom have been watching the progress of the operation with equal attention. I t says to the assistant ‘Get your hand out of the way until this is can- trolled.’ It says to the instrument nurse ‘Get a hemostat ready,’ and it says to the surgeon, ‘Clamp that off .’ This is the highest and most

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efficient type of cooperation known.”l Why then, if we can usually obtain such

a high degree of communication in our operating rooms, do we have difficulty in establishing and maintaining satisfactory re- lationships with people from other parts of the hospital? In my opinion, the answer lies in the three barriers inherent in the communication process in a hospital setting:

1. The very nature of the hospital or- ganization.

2. The kinds of heterogeneous people who comprise the organization.

3. The roadblocks to understanding which each of us, in some degree, possess.

COMPLEXITY OF HOSPITAL STRUCTURE

The hospital structure can best be de- scribed as a complex, self-sufficient organism. It differs from other kinds of organizations in the following ways.

1. The need for round-the-clock, 7-day a week coverage, with emergencies arising to upset planned programs with diabolical regu- larity.

2. In its daily operations, people must be dealt with at a time when they are likely to be upset, when their threshhold of toler- ance to frustrations is at a dangerously low level.

3. Anxieties are induced in its employee population by virtue of having to face the trauma of disease and death unequaled in other organizational settings.

4. The key role in the hospital hierarchy belongs to the doctor. He has been exposed (and still is in many medical schools, al- though this concept is changing) to a process of education which has tended to make him a rugged individualist. This kind of training can cause difficulties in interper- sonal relationships. In addition, discontent can occur because of the wide gap between the power and prestige of physicians and that of lower echelon staff members.

5. The hospital has two competing hier- archical systems of authority-one which considers that service to the patient is so important an objective as to override all other considerations, the other which is caught up in the economic and maintenance problems that may impinge on the quality and quantity of service. This is not to say that other disciplines or occupations are not committed to the objective of better patient care. They are, and will mince no words to tell you so. However, they are not as directly related to the patient’s immediate needs as is the procedure in the operating room or at the bedside. Rather, their activity is related to the indirect needs of the patient. This is a difference of degree and not necessarily of kind.

The hospital structure, then, is among the most complex of organizations and anyone alert to the social changes taking place in our intricate society must recognize the tell- tale signs of the hospital’s increasing com- plexity. In a most recent example, President Johnson in his special message to Congress on health, envisioned the “Great Society” to include multipurpose, regional, medical complexes which “represent a new kind of organization for providing coordinated teaching, research, and patient care.”

DIVERSE POPULATION In addition to the intricate mixture of

factors inherent in the hospital organization, and the tension-producing climate this mix- ture produces, there is a second aspect which obstructs the communication process-the diversity of the employee population. The typical hospital is inhabited by employees with a variety of skills, backgrounds, duties and points of view.

When no fewer than 23 different occupa- tional status groups can be counted on a typical ward or unit,z you can realize how easily failure in communications can cause a breakdown in coordination of service.

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However, while we are accustomed to evaluating and taking into account the fact that employees bring to the hospital a variety of skills, knowledges and experience, we tend to forget that, in addition, each brings a unique set of values, attitudes, motives, and a personality structure which may have an even greater bearing on how they act towards each other.

Before we discuss the individual’s barriers to communication, (the third aspect spoken of earlier) it may be of interest to illustrate additional composite dimensions of the prob- lems connected with interdepartmental liai- son. These items are taken from research findings.

SIZE OF ORGANIZATION The size of the organization has an impact

on the attitudes and behavior of the em- ployees involved. Research has suggested : first, that the small organization with in- formal face-to-face relationships between management and employees is most efficient from an economic view and most satisfying from the human point of view; secondly, that interaction among employees in the same or different departments affects employee feelings, attitudes and behavior; and finally, that the informal small group behavior can- not be divorced from the environment in which it occurs.

Size of an organization affects the em- ployees by changing the nature of their jobs; that is, as the organization grows larger there is increasing division of labor through specialization. This has the effect of nar- rowing both the work content and the func- tional responsibilities of the job. More persons and more departments are then re- quired to execute single tasks.3

SUPERVISORY BEHAVIOR Other studies have been aimed at determin-

ing the ways in which supervisory behavior in hospitals affected the performance of their

group. One study, which had specific refer- ence to the nursing supervisor, indicated that the manner in which she reacted to her supervisory role affected the behavior of the group members to each other and to mem- bers of other groups. Supervisors whose behavior showed concern for employee needs -indicating the establishment of mutual trust, respect and warmth-and which en- couraged employee participation in decision- making and two-way communication, had less internal conflict. This behavior had no discernible impact on the relationship with other groups. On the other hand, the group with a supervisor who focused clearly on organizational goals by actively assigning tasks, establishing ways of getting things done, and pushing for production, had less conflict with other groups.

Interestingly, this was true only insofar as the study pertained to voluntary hospitals and was not reflected in the governmental hospital. The researchers reasoned that this was so because of the relatively informal communications patterns of the voluntary hospitals, as against the rather well-defined and more rigid lines of communication which can be expected to exist in a large govern- mental hospital.4

PERSONAL ROADBLOCKS We cannot seem to escape the entangle-

ments of communication problems when we are concerned with interpersonal relation- ships. They will occur whenever people talk together. This, then, is the third part of the triad of barriers we spoke of previously.

Although not focusing on the communica- tion process per se, Sister Mary Virginia Clare, writing in your AORN Journal, in- cluded the proper mixture of ingredients needed for effective communications when she stated that “the OR nurse collaborates with a variety of individuals : supervisors, peers, nurses in clinical areas, doctors and . . . technical personnel.” She also says that

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this collaboration includes the sharing of information and knowledge (although not the same knowledge with all groups), and that “only in this way will the nurse become knowledgeable, understanding and observa- tive in a way of communication that leads to a high level of nursing care.”5 Selecting the ingredients of effective communications from these cogent remarks, we find a sharing of information and knowledge. This implies not only rapport and understanding among those communicating, but activity which culminates in something positive-in this case, better patient care.

The process of communications involves many forms-written, formal and informal communication systems, rumors, grape- vines, and so on. As indicated, successful interdepartmental liaison is dependent in large measure on collaboration between people. In most situations this collaboration (particularly between professions) consists of a person-to-person relationship. Since most of us have been communicating with others all our lives, why haven’t we learned to handle the problems that harass our rela- tionships with people not of our immediate group?

The answer to this question undoubtedly lies, in great part, in the misconceptions which many of us have about communica- tion. These misconceptions have been de- scribed by one authority in the following quotation. “One such fallacy is the assump- tion that communication is a mechanistic process. George wants to communicate an idea to Bill. From the reservoir of words George and Bill have in common, George selects those that will describe his idea. Since Bill has approximately the same pool of words, his mind will translate George’s idea into the proper image when he hears George’s words. This sounds simple and logical. The only problem is that it isn’t true.

“Seldom do two persons define the same

word in exactly the same way-national, racial, occupational and similar factors af- fect words and their meanings. The real meaning of a word is in the nervous system of the listener. Men listen to men with minds but also with their heart-their personality -their value system-their ‘nervous’ system. For each of us, this inner ‘me’ is quite unique. None of us have had the same ex- periences-even when exposed to identical situations. Out of the sum of our experiences, we fashion this inner ‘me.’ This is the ‘me’ that hears a communication. We hear with the mind-but we also ‘hear’ with our feel- ings and emotions and past experience.”6

The late Dr. Irving J. Lee of Northwestern University experimented in helping people become more sensitive to and understand- ing of the communication process-its po- tentials and its limitations. Much of what Dr. Lee attempted lies in the science of gen- eral semantics. This concerns itself not only with the history of words and their meanings but in its broader concept, with the relation- ships between words and things, language and human behavior.

Following are Dr. Lee’s descriptions of people who suffer typical communication barriers: the person who has a tendency to jump to conclusions, he who has a closed mind, and the one who listens only to words,

not their deeper import. These characteristics are but three of the many described by Dr. Lee. You can find them wherever men or women talk together, give and take assign- ments, discuss, plan and confer.

THE CONCLUSION JUMPER The first character described by Dr. Lee

is the person with the tendency to mistake subjective inference for objective fact. He is the person who jumps to conclusions. When something happens or is called to his at- tention, this person confuses the facts he has heard with the inferences he has made, and he behaves on the basis of the inferences

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rather than the facts. Notice that the trouble doesn’t come because an inference is made, but because the inference is believed to be the same as a factual observation. You are probably familiar with the man who said, “My mind is made up! Don’t confuse me with the facts!” That is the same man whose only exercise is jumping to conclusions.

Illustrative of the person jumping to a conclusion is the young mother who came to the door of the nursery and saw her hus- band, a lumber dealer, standing over the baby’s crib. Silently, she watched him as he stood looking down at the sleeping infant. In his face she read rapture, doubt, admira- tion, ecstasy, wonder. Deeply touched, with eyes glistening, she tiptoed to his side and put her arms around his neck. “A penny for your thoughts, darling,” she whispered. Startled into consciousness, he blurted, LLFor the life of me, I don’t see how they can make a crib like that for four bucks!”

Now a description of a man who did not make an inference. They tell the story about President Eliot of Harvard, who went to lunch at a club one day, and on the way in, handed his hat to the doorman. After his lunch, he returned to the entrance of the club, where the doorman quickly picked his hat out of the many others on the shelves and handed it to him.

“How did you know this was my hat?” asked President Eliot, admiringly.

“I didn’t know it was your hat,” the door- man replied.

“Then why did you hand it to me?” Because, sir, when you came in, you LC

handed it to me.”

THE CLOSED MIND The second character described by Dr.

Lee, typifying a barrier to communication, is the person who thinks that he has said all there is to say on a subject, when in fact he has said only all he can think of at the moment. He is the person who has closed his

mind. In our talking, in the way we see, sense or perceive things, we select some de- tails and omit others. The limitations of our nervous systems make it impossible ever to “know” all. We can never really finish all there is to be said in describing a situation, or in characterizing a person.

In describing an object, or event, or per- son, our tendency is to select those charac- teristics that seem important to us. But once we have said it, we tend to behave as if that is all there is to it. This is the man who, in an argument says LLThat’s it! I’ve said it, and that’s all there is to it.” He seems to put a big period at the end of his ideas. He fails to recognize that there is more to be said, that there is an et cetera. He stops thinking -he stops listening-he closes his mind, like the man with a know-it-all look who said to a woman, ‘50 you’re a nurse, eh?”

LLCertainly,7’ she answered, “and a wife and a mother and a cook and a golf addict and a student, etc.”

THE EMPTY WORD There is also the person who listens only

to words. This person’s tendency is to ig- nore the fact that the same words can mean different things to different persons. We know, of course, that most words have more than one dictionary meaning. Several words strung together in a phrase or a sentence may, therefore, have a very large number of possible meanings. But strictly speaking, words don’t “mean”-it is people who mean.” Words are just pointers used by

individuals. When an airline hostess passed out chew-

ing gum with the routine instruction ‘Lfor the ears,” a lady passenger later complained. “It worked all right, but couldn’t you use something not so sticky?”

Before leaving these personal roadblocks to understanding, I would like to quote briefly from a book called The First and Lust Freedom by J. Krishnamurti, which de-

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scribes listening-the other side of the communications coin.

“There is an art of listening. To be able really to listen, one should abandon or put aside all prejudices, preformulations and daily activities. When you are in a receptive state of mind, things can be easily under- stood; you are listening when your real attention is given to something. But un- fortunately most of us listen through a screen of resistance. We are screened with preju- dices, whether religious or spiritual, psycho- logical or scientific; or with our daily worries, desires and fears. And with these for a screen, we listen. Therefore, we listen really to our own noise, to our own sound, not to what is being said. I t is extremely difficult to put aside our training, our pre- judices, our inclination, our resistance, and, reaching beyond the verbal expression, to listen so that we understand instantaneously. That is going to be one of our difficulties.”g

OUR DILEMMA I have attempted to describe the dilemma

we face in our efforts to establish construc- tive interdepartmental liaison, in order to bring to bear all of our strengths and energies on attaining better patient care. The condi- tions described all too frequently dissipate our forces. The situation, to the extent it exists in your hospital, is not of easy resolu- tion. Too often, when we have found that there is an easy solution to a human prob- lem, it has been neat, plausible and wrong.

It has always seemed easier to describe a problem than to resolve it, and easier to offer a solution than to implement it. This reminds me of the fable about the grasshopper who spent a most pleasant summer. When cool weather neared, he began to worry about food for the winter. He told an ant he wished he, too, had stored food, as ants do. But the ant revealed that the food stored away was hardly enough for the teeming colony and advised the grasshopper to be-

come a cockroach. “The cockroach,’’ he said, “is nice and warm indoors all winter, and eats food that people drop on the floor.”

“But how do I go about becoming a cockroach?” asked the grasshopper.

“That,” said the ant, “is an administra- tive decision. I merely advise on policy.”

SUGGESTED APPROACHES Not following the sound example of the

ant, I would like to suggest some approaches to the problem of overcoming some of the many roadblocks to communication.

One approach might very well be to go back to basics in which we satisfy the need for each person-professional and non-pro- fessional alike-to know and understand how his small portion of activity fits into the total team effort-of taking care of our pa- tients. He needs to be encouraged to under- stand not only his own fragmentized part in this objective but also, what others are doing.

Another approach, which seems to hold some promise in reducing conflict between disciplines, is discussed in an article in a recent issue of Personnel, published by the American Management Association.9 Al- though focused on business, these suggest- ions, resulting from research in intergroup dynamics, may very well be applicable to a hospital setting, where the stakes in accom- plishment seem to me so much higher.

The article suggests that the members of two “competing” groups are brought to- gether “as groups, to talk about their rela- tionship : to exchange information on how they view themselves and the other group . . .” The objective would be to set up or develop “goals that are desired by both groups, but can be attained by neither side without help from the other.” It was found that when such goals were attained, “it was possible to overcome even intense inter- group rivalry and to obtain collaborative relations between the groups-without either group’s losing its identity.” Obviously, it

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will not be easy to apply these research find- ings because “long-rooted habits of thought and customs cannot be changed overnight.”

Finally, I would like to suggest that we begin to deal with matters of misunderstand- ing, disagreement, confusion and conflicts of interest through a series of lecture-dis- cussions based on those conducted by Dr.

Lee. The purpose would be to help us come to grips with the “barriers to communica- tion” and in so doing, to develop a better understanding of ourselves and the manner in which we communicate. It just seems logical to assume that men who are reason- able will be able to agree when they under- stand what they are talking about.

REFERENCES

Burling, Temple, “The Patient’s Needs and Hospi- tal Organization;’ Essays on Human Aspects of Administration, Bulletin #25, New York State School of Industrial and Labor Relations, Cornell University, August, 1953, pp. 10-11. Wessen, Albert F., “Hospital Ideology and Com- munication Between Ward Personnel,” Patients, Physician and Illness, edited by E. Garthy Jaco, The Free Press, New York, 1958, pp. 449-450. Talacchi, Sergio, “Organization Size, Individual Attitudes and Behavior: An Empirical Study,” Administrative Science Quarterly, December, 1960, pp. 398-420. Oaklander, Harold, and Fleishman, Edwin A., “Patterns of Leadership Related to Organizational Stress In Hospital Settings,” Administrative Sci- ence Quarterly, March, 1964.

5.

6.

I.

8.

9.

Clare, Sister M. Virginia, “Professional Collabora- tion in Operating Room Nursing,” AORN Iournol, March-April, 1964, pp. 37-43.

This, Leslie E., “The Leader Looks at Communi- cation,” Monograph #7, Leadership Resources, Znc., 1961.

Lee, Irving J., and Lee, Laura L., Handling Bar- riers in Communication, Harper & Brothers, New York City, 1956

Krishnamurti, J., The Firsr and Lost Freedom, Harper & Brothers, New York City, 1954, pp.

Buchanan, Paul C., “How Can We Gain Their Commitment?” American Management Associa- rion, Inc. Vol. 12, 8 1 , January-February, 1965.

19-20.

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