PUBLIC HOSPITAL’S INTERNAL COMMUNICATION
DURING WORKERS’ HEALTH CRISIS
Exploring the role of conceptual metaphors as sensemaking tools during the
COVID-19 crisis and the strategies used to guarantee staff’s safety
Cristina Bonillo Martínez
Master of Corporate Communication Extended Thesis Proposal
UvAnetID: 11373288 Word count: 9.787 words
Abstract
Since the world first turned eyes on COVID-19 in December 2020, this highly infectious pandemic has put an extra strain on Spanish healthcare institutions. With the highest reported infection rate among healthcare workers in the world, Spanish hospitals have managed this crisis and instructed their employees in self-protective action through their Health and Safety at Work Units in numerous ways. This study investigates the Internal Crisis Communication strategies used in public hospitals in the country, and explores internal stakeholders’ use of metaphorical thinking as a sensemaking tool during the COVID-19 crisis. Eleven qualitative semi-structured interviews were conducted with HSW workers in hospitals from the regions of Andalucía and Comunidad de Madrid. The findings of this study suggest diverse strategies were employed to reduce the uncertainty of employees, build a relationship with them and avoid liability in the management of the crisis. The second part of the article provides empirical applications of conceptual metaphors that enabled stakeholders’ sensemaking during the crisis, in so reducing the uncertainty associated with it. Therefore, this research introduces preliminary evidence to motivate future empirical research based upon this comprehensive approach to crisis management and metaphorical thinking. The implications of these results are thoroughly discussed, as well as the limitations of this study.
Introduction
COVID-19, the respiratory disorder China first reported in December 2019 (Sheikh, 2020) and that by March was already categorized as a pandemic by the World Health Organization (World Health Organization, 2020a), has turned the world upside down in a matter of months. By the time this study took place, COVID-19 had already infected more than nine million people, killed almost half a million (World Health Organization, 2020b), and generally disrupted established Healthcare Systems all around the globe. Reacting to this coronavirus pandemic has caused important shortages in protective equipment, ventilators and Intensive Care Unit beds worldwide, exposing healthcare workers to an unprecedented risk and depleting financial and physical resources of numerous National Healthcare Systems (Nicola et al., 2020). This impact has been particularly noticeable in Spain, where as of April 2020 hospitals reported around a 50% in over-capacity and seven times more UCI beds than before the virus (Arango, 2020). Currently Spain holds the highest infection rate among healthcare workers in the world (Güell, 2020), which has put an extra strain in Spanish healthcare institutions.
This global crisis has made occupational safety in the healthcare public sector a major concern during the COVID-19 crisis. The European Union stipulates in its Directive 89/391/EEC, that all organizations must designate a group of experts to conduct and supervise all activities related to the protection of workers and prevention of risks (European Agency for Health and Safety at Work, 2018). Spain responded by creating the Prevención de Riesgos Laborales (PRL) departments, here referred to as Health and Safety at Work (HSW) Units. This unit coordinates and evaluates the effectiveness of all risk prevention measures the organization engages in. The HSW Unit takes responsibility for communicating all protection procedures to employees during a health crisis as well as establishes the internal communication channels to ensure safety protocols are implemented. As such, they have a unique perspective of the current hospital crisis in Spain and may be able to provide a nuanced perception of the communication processes that crisis management entails.
This in turn leads to the high societal relevance of this topic, as healthcare professionals are key for a successful global response against COVID-19. It is necessary to explore how doctors and hospital staff communicate internally during the resolution of this crisis if we want to minimize the risk of contagion for employees at such a high-risk workplace environment. A systematic literature review by Spanish researchers Collado Hernández & Torre Rugarcía (2015) aimed to identify areas of improvement in the behaviour of health professionals during a pandemic, concluded that there is a need to better communicate about preventive measures to increase adherence and psychological support to health workers. Taking into account the extent to which HSW and protective measures have become an issue, widely communicated within both public and private organizations worldwide in since the outbreak took place; and how the health sector is a high-risk group in a pandemic situation (Collado Hernández & Torre Rugarcía, 2015), it is relevant from a scientific perspective to explore how public hospitals communicate internally to ensure staff´s safety. Moreover, an exploration of these communication strategies may provide relevant insights about the sensemaking process behind hospitals’ staff understanding of such a type of crisis. The Conceptual Metaphor Theory by Lakoff and Johnson (1980) elaborates on how a “metaphorical thinking” can sometimes facilitate, but also shape, the understanding of new concepts; ultimately influencing how we communicate about them and how we behave towards them.
In order to explore the implications of such a unique phenomena as the COVID-19 pandemic and expand on the limited literature regarding Internal Crisis Communication (ICC), this study aims to explore what internal communication strategies do public hospitals use internally to manage the COVID-19 healthcare crisis, as well as the role of conceptual metaphors to help internal stakeholders understand the situation of crisis.
Theoretical Framework Managing in Times of Crisis
Disasters and failures often happen to and in organizations, that is why the focus should not be on if, but when a crisis will arise (Heide & Simonsson, 2014). Crisis management has been a widely researched field in the past decades, where competing frameworks and
methodologies have led to little consensus on what defines an organizational crisis. Nevertheless, after a review of the literature two main approaches can be identified: a narrow understanding of a crisis, where the crisis is seen as an anomaly that demands reactive damage control (Kent, 2010); and a broad understanding of a crisis, where the crisis is rather seen as a natural stage, that destabilizes the system creating uncertainty and requires of a quick intervention to restore the normal order (Falkheimer & Heide, 2010).
Despite the numerous definitions of a crisis, scholars have notably supported the theoretical separation of the crisis process in three stages: pre-crisis, crisis and post-crisis (Coombs, 2012; Johansen, Aggerholm, & Frandsen, 2012). This three-stage model facilitated the description, understanding and analysis of the evolution of crises in organizations (Coombs, 2012; Frandsen & Johansen, 2011; Heide & Simonsson, 2014). Each stage of the crisis process focuses on different elements: signal detection, prevention and crisis preparation are key in the pre-crisis stage; during the crisis it is essential to handle it and to make sense of it; lastly the post-crisis stage demands learning and change within the organization (Frandsen & Johansen, 2011).
The definition of organizational crisis as “a low-probability, high-impact event that threatens the viability of the organisation” (Pearson & Clair, 1998. p.3) created the foundation of subsequent publications in the field. In line with this approach, research on crisis management increasingly focused on what message strategies would be most effective for communicating in times of crisis (Claeys & Opgenhaffen, 2016), concluding that an organizational crisis demands the corporation to reduce publics’ uncertainty and any damage to the corporate reputation by strategizing communication to different publics (Coombs, 2012). With this goal in mind, scholars have pointed out the role of collecting, processing and disseminating crisis information in the employees’ sensemaking during a crisis situation (Strandberg & Vigso, 2016). Nevertheless, research in crisis communication has traditionally focused on how to communicate to external publics almost exclusively, neglecting the crucial role of employees as a key public during a period of crisis (Kim, Kang, Lee & Yang, 2019). Crisis management is a field directly linked to the strategy of internal communication in times of crisis, therefore we find it necessary to incorporate this concept as a sensitizing concept for this study.
Communicating Within The Organization
The field of Corporate Communication aims to strategize the communication of organizations by studying processing of information, organisational views and objectives as well as the communication with different publics, having been recognized as an essential element of any successful management practice (Mohamad, Nguyen, Melewar & Gambetti, 2018). Despite the efforts both in theory and practice to attend for the internal and external dimensions of Corporate Communication equally, poor internal communication remains a major concern for organizations (Welch & Jackson, 2007). It is becoming a challenge for increasingly bigger organizations to focus on all employees of the organization from a managerial point of view, that is why internal communication theorists have called for research placing internal communications as a management function, arguing that it would be beneficial to see whether and how organizations focus on employees as relevant stakeholders (Foreman & Argenti, 2005, p. 262).
According to the Stakeholder Model originally introduced by Freeman (1984), all individuals or groups of people who can affect an organization or can be affected by it are defined as stakeholders. Stakeholder management has become crucial as a management tool to incorporate business ethics and corporate responsibility in the practice of organizations, To account for the managerial and organisational dimension of this model, the present study refers to the Refined Stakeholder Model introduced by Fassin (2009) that visualizes diverse internal and external publics in a way that also signals their relationship within the organization and with other main actors. Under this new model, the managerial board of the organization is placed in the centre, surrounded by four major internal stakeholders: financiers, employees, customers and suppliers (Fassin, 2009), which can be subsequently segmented in different interest groups, like departmental managers and team members (Welch & Jackson, 2007). Depending on their prior knowledge about the organization, stakeholders can interpret crisis communication and its context in different ways (Mazzei and Ravazzani, 2011; Welch and Jackson, 2007). .
Communication within an organization can be categorized into three sections: mass media communication (like email, blogs or newsletters), social networks (like Facebook and
LinkedIn) and hierarchical communication (Whitworth, 2006). All three of these sections are relevant for communication to successfully take place, and it is essential that they work together to help internal stakeholders interact with each other without any communicative disruption. Nevertheless, this study will pay special attention to the hierarchical dimension of internal communication, in which the executive officers and the board of directors enable information to travel down the administrative structure of the organization to reach all employees within it (Whitworth, 2006). This complex dimension of the communicative process allows all employees to know what is happening in and to the organization and how they are affected by it. Successful internal communication can lead to a relationship of trust and respect between employees and the organization (Mazzei & Ravazzani, 2015), which can in turn enhance corporate reputation as well as employee morale and performance (Mazzei, Kim & Dell’Oro, 2012). Therefore, facilitating employees’ communicative behaviours is essential to improve organizational effectiveness and hold a key role during the management of an internal crisis.
Internal Crisis Communication
Acknowledging that employees can be directly involved in an organizational crisis and that they are key internal stakeholders in the crisis management process (Heide & Simonsson, 2014), Internal Crisis Communication (ICC) is defined as “the communicative interaction among managers and employees, in a private or public organization, before, during and after an organizational or societal crisis” (Johansen et al., 2012, p. 271). Evidence shows that a crisis situation can induce feelings of ignorance, defensiveness, pessimism, trauma and betrayal; hindering the coordination of the organization internally (Bundy, Pfarrer, Short & Coombs, 2017). When a crisis arises, ICC is essential to create an environment in which the crisis can be overcomed successfully, as it can motivate employees to act as advocates of the organization during the crisis (Lee, 2017; Mazzei, et al., 2012; Mazzei & Ravazzani, 2015). Therefore, this field of research understands communication as a context-specific process, that is directly affected by the organizational environment it takes place in (Heide & Simonsson, 2015).
The integrative framework introduced by Frandsen and Johansen (2011) has established the theoretical foundation of this research arena by discussing and expanding on the conclusions
of previous literature. Their research facilitated the study of internal crisis communication in private and public organizations by providing an internal focus in a sector that almost exclusively emphasised external communication strategies in response to crisis situations (Frandsen and Johansen, 2011; Heide & Simonsson, 2014). A case study at a Swedish university hospital evidenced that employees experience a drastically higher information need from their co-workers during an acute crisis phase (Heide & Simonsson, 2014), for this reason academic evidence on crisis response points out the need to instruct employees and adjust information to their needs in order to manage a crisis successfully (Kim, Avery, & Lariscy, 2011). Instructing information teaches staff what to do to protect themselves from the crisis and adjusting information helps staff cope psychologically with the effects of the crisis (Adamu & Mohamad, 2019; Kim et al., 2011).
In order to successfully identify the communication strategies and processes that take place in the context of a crisis, it is crucial to account for how previous experiences have impacted employees’ perceptions. Employees’ previous knowledge on crisis management, as well as their opinions on how communication should differ from a ‘normal’ situation, affect the understanding employees have of the crisis (Heide & Simonsson, 2014), and therefore should be explored alongside the communication strategies. Johansen, Aggerholm, & Frandsen (2012) explored the protocols management implemented for the internal communication in both crisis and ‘normal’ scenarios, as well as how employees can become ambassadors of the organization during a crisis. In line with this, ICC can be beneficial for the organization, as it mitigates anger and word of mouth from internal stakeholders (Adamu & Mohamad, 2019). Following researchers’ call for further study of internal stakeholders during crises in different sectors (Adamu, Mohamad, & Rahman, 2018), this study aims to explore the ICC strategies used in public hospitals in Spain during the COVID-19 crisis. Therefore we pose the following research question:
RQ: What crisis communication strategies do Spanish public hospitals use
Conceptual Metaphors As Crisis Sensemaking Tools
The broad, meaning-oriented understanding of a crisis within the literature highlights the dynamics and the perceptual aspects of it, implying that understanding, sensemaking and enactment are essential in the process (Adamu et al., 2018). From a social constructionist standpoint, Heide and Simonsson (2015) defined sensemaking as the production and reproduction of understanding and socially constructed realities through communication. All human beings involve in sensemaking when they engage with their environment, therefore it should be considered an essential dimension of ICC. In line with this, recent research has explored managers’ sensemaking efforts in ICCInternal Crisis Communication, but there is a lack of integration of the stakeholder approach at an internal level of the organization (Bundy, et al., 2017).
Given that many doctors in Spain are currently comparing the situation of healthcare professionals to “being a war medic” (Nugent, 2020), this study aims to explore whether this or other metaphors are present in the interaction between UHSW Officials and internal stakeholders, and how they may be used as a ‘sensemaking tool’ during a healthcare crisis. Lakoff and Johnson (1980) elaborated on how comparing a crisis experience to a war generated a network of entailments, approaching it as a "threat to national security," which required "imposing sanctions" and "calling for sacrifices". In their book ‘Metaphors We Live By’, they presented a new approach to understand human thought processes, in which they described how our ordinary conceptual system is fundamentally metaphorical in nature (Lakoff & Johnson, 1980). Taking this definition at a broad relational sense, their Conceptual Metaphor Theory (CMT) argues that communication messages make us appreciate the relevance of metaphors as an ineradicable element of interpersonal communication (Brown & Wijland, 2018).
This approach to Conceptual Metaphor Theory as a ‘crisis sensemaking tool’ has not been researched before in the field of ICC. For this reason, the present study served itself of previous metaphors used in Corporate Communication and Crisis Management as a point of reference to research the conceptual metaphors employees’ and HSW Officials may use in
their sensemaking of a crisis. A review of popular crisis management books indicated that the comparison of crises to wars has been quite common in the field, with experts on crisis management even calling their experiences “war stories” and comparing internal crises to fire (arguing that it is a dangerous threat that needs to be extinguished, and comparing a crisis manager’s role to that of a firefighter) (Frandsen & Johansen, 2020). Moreover, the complex nature of a crisis demands the use of numerous metaphors to understand how organizations react or interact with it in terms of a single label or image, for example referring to organizations in terms of a body (Christensen, Morsing & Cheney, 2008), political system, machine or instrument of domination (Christensen & Cornelissen, 2011). In the context of Organizational Communication, eight metaphors have guided research to explain how communication flows both in and outside of organizational crisis: the organization as a conduit, as information processing, as a linkage, as performance, as discourse, as a symbol, as a voice and as a contradiction (Putnam & Boys, 2006). All these metaphors can inform and shape the way individuals address communication or crisis management, as well limit in a way the understanding of said object of sensemaking.
Taking into consideration the explanatory power conceptual metaphors can have during a crisis, the interviews in this study will aim to explore how metaphorical thinking influences the attitudes, beliefs, and actions of internal stakeholders. By doing so, this research will shed some light onto the impact metaphors can have on employee sensemaking in times of crisis. Therefore, the following question was presented:
Sub-RQ: How are conceptual metaphors used in the communication between internal stakeholders and Health and Safety at Work Officials to make sense of this hospital crisis?
Research Design
Choice Of Method
This study conducted qualitative research in the form of semi-structured interviews to identify communication strategies and explore the conceptual metaphors present during the health crisis that arose due to the COVID-19 pandemic. The choice of methodology for this
study was guided by how interviews provide a clear picture of how different people interpret a situation (Braun & Clarke, 2013). Therefore, interviewing HSW professionals allowed for a more comprehensive understanding of the internal communication during a crisis in a public hospital, as well as in-depth answers about how metaphorical thinking can play a role in it. Conducting the interviews in a semi-structured format with the help of an interview guide, allowed the data collection to be more adaptable in-situ: allowing participants to elaborate on the communication strategies they use when managing the hospital crisis and explore emotions, thoughts and behaviours related to the use of metaphors as addressed in our sub-RQ.
Sampling: Participants and Recruitment
Due to this unique and advantageous position UHSW Officials have as actors of the internal crisis management of hospitals, we conducted purposive sampling to recruit them as participants of this qualitative study. Originally thirteen interviews were conducted. Nevertheless, it was later established while the interviews were taking place, that two of the participants had worked mainly on managing Primary Care Centers during the crisis, not hospital centers. As Primary Care Facilities have different organizational characteristics than hospitals (they are smaller in size and do not process COVID-19 hospital admissions), these two participants were considered not to meet the sampling requirements to be included in the final sample. Nevertheless, as consent was granted to use them anyways, we used their insights to identify the areas of convergence and divergence between their crisis management experiences during the focused coding phase in the analysis.
A total of eleven interviews were included in our analysis, in which professionals engaging in Health and Safety at Work communication in Spanish public hospitals discussed the COVID-19 pandemic from a crisis management perspective. Most of the participants in this study operated in the southern region of Andalucía, while the remaining two operated in the province of Madrid, area that became the hotspot of Coronavirus in the country during the peak of the healthcare crisis between April and May. The expertise of participants in this study ranged from different technical specializations to occupational doctors and nurses. An
additional participant was recruited with a specialization in Preventive Medicine, as said person fulfilled the participation requirements, having designed and implemented crisis management plans during this crisis. Further information of the sample in this study can be found in Appendix A.
The accessibility to HSW professionals during the peak of coronavirus spread in Spain was limited. In order to reach the minimum sample size of this study, the purposive sample of this research entailed snowball methodology from the first 4 interviewees that were initially secured to participate. It is for this reason that the sample in this study presents a higher concentration of participants in the region of Andalucía. The recruitment of participants limited participation to a maximum of two professionals per hospital, to ensure enough variation in the data collection process. Snowball sampling was conducted by sharing a short video including a call to action to participate and explaining the basic information about the study, followed by a link to a contact questionnaire. The contact questionnaire was only available during the recruitment process, having removed the contact data from the database once participation was concluded.
Collecting Interview Data & Instruments
Although initially planned to be face-to-face, the interviews were adapted to a phone call format to preserve the social distancing measures implemented during the COVID-19 crisis worldwide. Coordination with participants to schedule the interviews was conducted through messages and email, and the interviews took place during the month of May 2020. Sound recordings were kept of all interviews to allow a thorough transcription of everything discussed in them. The recording of the interviews also facilitated the interviewer to create a more conversational approach to the interview, in order to let the interview run smoothly avoiding the interruption of note-taking. Before the interview took place, participants were informed of the ethical procedure of this study and how their identity would be anonymized.Before the sound recording was activated it was ensured the informed consent was signed by the participant and all necessary information was provided.
An interview guide was created prior to the interviews in order to ensure homogeneity in the data collection process. Interviews were conducted in Spanish and transcribed into the same
language, therefore the open coding of relevant information was conducted in this language to avoid any loss of information when translating the interviews. Appendix B shows a translation of the interview guide into English; in which initial questions were used to address first the research question, and then the sub-research question of this study. Following the interview guide, all interviewers talked first about the crisis communication strategies used within the organization, and later discussed specifically employee sensemaking of the crisis through the identification of metaphors from different internal stakeholders. Nevertheless, not all questions were used on every occasion, as interviews were adapted to the answers of each participant. Text underlined in Appendix B identifies the questions that were incorporated after the first few interviews took place. The questions underlined in the interview guide therefore replace or extend on the originally planned questions, in order to improve and adjust the data collection process to be more efficient.
Researching conceptual metaphors through semi-structured interviews proved challenging even under such a flexible format. When directly asked about it, participants struggled recalling metaphors that were used to explain the crisis. Nevertheless, after reviewing the voice recordings of the first three interviews, various references to conceptual metaphors, the ones exemplified and discussed by Lakoff and Johnson (1980), were identified in the transcribed data when describing or talking about the crisis. After reflecting on the theoretical approach of conceptual metaphors as sensemaking tools, we decided to analyze both the metaphors explicitly identified by the participants and those implicit in the descriptions of the crisis or narration of conversations with internal stakeholders. This allowed us to discuss at the second section of the interviews, first the metaphors participants may have heard or used, and then a more subjective evaluation of the sensemaking process of the main internal actors in the crisis. Only when it was evaluated to be appropriate in situ the second layer of discussion was associated with the metaphors listed by the participant. In order to avoid leading questions, direct questions about metaphors always allowed participants to provide criticisms or deny the representativeness of the metaphors if they were not relevant in their assessment.
Nevertheless, there were other limitations to this interview guide that could not be adjusted so effectively. Some participants answered in a very superficial manner when asked about the
internal communication strategies during the crisis, even when presented with follow-up questions. This may be explained by their lack of professional experience in the communication field of the professionals interviewed in this study, or due to the fact that the formulated questions required an enumeration of the channels and formats used, instead of discussing the communicative elements of the message and the strategy behind them. Lastly, the difficulty for reaching fitting participants during the COVID-19 crisis delayed the transcription of interviews. Even though the transcription process started during the weeks of data collection, the length of the interviews and sound quality of the recordings led to a significant delay on the analysis of the full collected data. As the analysis on the research questions demanded an overall evaluation of the collected data, it proved challenging to fulfil the timeline initially stipulated for this research.
Data Analysis
The transcripts of the conducted interviews were analyzed using Grounded Theory, in order to explore the experiences of the people being studied during the analysis and discussion of the research questions, and to root the theoretical foundation of the findings in the context researched (Glaser & Strauss, 1967). The analysis of the collected data began with a familiarization process, in which observational notes were taken casually during the first read of the transcripts. This immersion process started while still conducting the final interviews for this study and was guided by the main sensitizing concepts of ICC, Conceptual Metaphors and crisis sense-making. First, the transcribed data was coded in vivo using ATLAS.ti software to allow a constant comparison and combination of datasets in the following steps of analysis. Interview transcripts were coded on different project files, in order to distinctly code only relevant information for each RQ, and avoid confusion, as open coding took place by identifying the relevant observations in every transcript intervention. Every code answering RQ and Sub-RQ in each ATLAS.ti file was considered as a unit of analysis for the purposes of this study. If revised quotes were identified to fit an already established category, they were grouped under the same code, and notes were incorporated to each quotation. Appendix C shows the list of codes after open coding for each research question.
Focused coding, on the other hand, entailed a continuous iterative process between the data and the relevant literature. The theory-building process of RQ led to the differentiation of six main strategic elements in hospitals’ IC, that were grouped depending on their main strategic goal, leading to the three dimensions developed from the data: Strategies to Reduce Uncertainty, Relationship Building Strategies and Strategies to Avoid Liability. Lastly, a broken arrow connects bidirectionally the indicators of Honestyand Scapegoating in order to address the dilemma HSW professionals face when Management’s decisions do not incorporate HSW advice, exposing employees to a certain level of risk. It is in this moment when HSW workers either follow Management’s instruction for avoiding liability or engage independently in a Relationship Building Strategy instead, by being honest with employees -as it illustrated in Figure 1.
On the other hand, as focused coding for Sub-RQ demanded closer attention to the language through which internal stakeholders construct and give meaning to their experiences and environment, data was analyzed using a constructionist approach to Grounded Theory for answering this research question (Madill, Jordan & Shirley, 2000). Following Lakoff and Johnson’s (1980) explanation of conceptual metaphors as relational cognitive processes, any mention of a metaphor to explain the crisis was coded, as well as any observations explaining the sensemaking behind said comparison. The theory-building process started with the filtering of conceptual metaphors, re-coding of similar or same metaphors in the same code, and lastly a grouping of conceptual metaphors depending on the subject of sensemaking. The CIM created to answer the Sub-RQ places Uncertainty in Times of Crisis as a central concept, from which three dimensions of sensemaking derive: Threat sensemaking, Control sensemaking andExperience sensemaking, depending on what was the object of sensemaking on each of the conceptual metaphors present.
Quality Criteria
The procedural reliability of this research was preserved by a thorough documentation of the methodology implemented in this study, allowing data collection to be easily reproduced. Memo writing was often conducted during this research, in order to keep record of all last minute decisions or considerations that may have affected the results of this study in any way.
This procedure also increased the ecological validity of this study, that was also directly improved by conducting regular peer debriefings with my Masters thesis supervisor as well as by reaching out to researchers on communication metaphors and HSW experts to enable an informed analysis on the topic of this research. Additionally this study used member checking techniques after results are collected and organized when there the researcher had doubts about the insights provided in the interviews. As conceptual metaphors are latent constructs that are difficult to grasp, some interviews required further clarification from the participant´s perspective to ensure the reliability of the academic discussion on this topic. The procedural reliability of this study was also improved by using ATLAS.ti coding software, commonly used by scholars when conducting qualitative research research methods.
Results
Crisis Communication Strategies
Figure 1 presents Internal Crisis Communication Strategies as the central concept to explain how do Spanish public hospitals communicate internally to guarantee staff’s safety during a pandemic. Three dimensions distinctively emerged from the data as meaningful to our RQ1: Strategies to Reduce Uncertainty, for Relationship Building and to Avoid Liability.
Figure 1:
(i) Strategies to Reduce Uncertainty
Within this first dimension, we find all strategies used to reduce the uncertainty of employees. There are two levels at which hospital communication helped employees deal with the uncertainty that a pandemic brings: first by telling them what to do to protect themselves, and second by communicating with them in a way that helps them adjust to the crisis situation. From those two kinds of communication, we infer the two indicators that conform the first dimension of ICC Strategies: Protocols and Adjusting Information.
There appears to be a general level of consensus about the communication channels habilitated for disseminating these messages internally: ranging from in-person employee safety training, to online communication through email or the Intranet. Various participants expressed their need to instrumentalize mass media channels in order to reach such high number of employees in such short timeline:
P2: . . . We are such a big company. . . amongst all hospitals ((that the participant coordinates)) . . . 3000 to 5000 employees, and being three technicians in total, well, it’s difficult to cover everything. We have to prioritize doing mass dissemination through Intranet, but middle managers have to also help and support us, as in the end, this is a (domino effect) for both training and communication . . .
Protocols are first indicator within this dimension of Strategies to Reduce Uncertainty, and conform all procedures and guidelines to follow by employees in order to perform their job safely. Although all participants of this study base their safety management strategies on national and regional pre-established guidelines that are oficially referred to as Protocols, some participants dedicated particular attention to the communicative functionality of such format during times of crisis:
P6: . . . I think that formalising and defining with clarity what to do and how to do it is, is a tool (.) a very useful weapon for this kind of situations. In fact, it is a necessary weapon, I believe. Because in the end, look, misinformation generates lots of doubt, fear and anxiety on people.
In order to make these safety instructions: HSW professionals dedicate a lot of hours of documentation to craft reliable guidelines. They ensure they are in line with current legislation and the latest scientific evidence on safety measures and its organizational effectiveness. It is crucial to compile the appropriate information and ensure the protocols in place to have efficiently accounted for all costs and benefits it may entail for the organization.
P6: If it gets difficult, communication is vital. But it is also very important to establish . . . a criteria as well. It’s not because I want to make people wear or stop wearing something, but because there is a documentation process behind it. We have to research, we have to look for: what publications, what have they done about it, what are the risks… I mean, it’s our daily job, right?
To address the uncertainty that arises due to the psychological impact this crisis is having on employees, we turn to the second indicator of our first dimension.
Psychological Support is the second indicator of this first dimension of ICC Strategies.There was a big part of the communication aimed at reducing employees’ uncertainty that, instead of fostering self-protective behaviours, helped staff cope psychologically with the impact the crisis is having on them. Besides two notable examples of intra-organizational initiatives in which HSW Units from both Hospital 1 and Hospital 3 collaborated with their respective Mental Health Centers to provide psychological attention to all employees that may need it during the pandemic, many other participants narrated communicative interactions in which they helped employees cope with the diverse internal crises that have taken place in Public
Hospitals during the pandemic. Nevertheless, one particular example represents very well the value and utility of Psychological Support as part of every internal crisis speaking strategy:
P7: I remember once I went to the Internal Medicine floor, because they had asked me about something. I got up, I don’t know if they had patients of that kind [coronavirus]. Then, one of the things I told them was: “Well, you should take something into account. This will eventually be over.”. Suddenly, a nurse that was on her computer nearby . . . turned around and said: “At last I heard that today. Somebody had to say it. I really needed to hear that.”. Well, they were burnt out, you know? They had enough and just needed somebody to say something positive.
(ii) Relationship Building Strategies
All strategies aimed to build a solid relationship with employees during the crisis were grouped under this dimension. Some participants elaborated in depth on the importance of building a relationship between employees and the organization, highlighting the strategic importance these actions have in crisis management. Within it, we can differentiate two indicators: Listening and Honesty.
Listening groups all efforts made by the hospital to learn views, requests or proposals employees have related to this crisis. Hospitals 3, 6 and 9 show a good application of Corporate Listening in their crisis management operations by creating a Crisis Committee in which all relevant stakeholders and key experts during the crisis meet daily to decide how to manage the internal conflicts that may emerge:
P12: Each [Crisis Committee member] advised and gave his/her opinion (.) on those topics (.) that were of their competency . . . but, other kinds of decisions, everyone [in the cabinet] would discuss them but they would be made by Management . . . A physically present Committee . . . that makes decisions all together.
If hospital’s preventive and safety actions are made including HSW workers in the process, or at least accounting for their advice and technical insights, relevant stakeholders feel implicated in the hospital’s management of the crisis. Moreover, hospitals dedicated specific resources, time and attention to listen to the employees:
P8: . . . they all have a reason, right? Behind those doubts and fear . . . therefore is super important to walk in somebody else’s shoes and, well, you even start reconsidering things that you have been certain about for so long . . . you learn a lot from that.
Honesty conforms the second indicator in the dimension of Relationship Building Strategies, describing all communication aimed to build trust by showing transparency and transferring accurate and sincere information to employees:
P11: If you lie to me or hide information from me, I’m not going to believe you. I am not going to trust you and I am not going to listen to your message. But (.) if you treat us as intelligent, rational, grown up people . . . and you transfer us true information, we will trust in the criteria of experts and let ourselves be adviced and follow indications.
P6: We have to be honest . . . I believe it is just fair that people know the reason behind things.
These two Relationship Building Strategiesare not only useful during the management of a crisis, but also benefited significantly employee reactions when they had been cultivated throughout time.
(iii) Strategies to Avoid Liability
The third dimension within ICC Strategies englobes all communicative efforts by the organisation in order to avoid accusations or attacks by official and non-official institutions concerning their management of the crisis. Within this dimension of ICC Strategieswe can find Scapegoating and Keeping Record.
Scapegoating refers to the idea of delegating responsibility on individual people or actions in order to avoid a general attribution of responsibility toward the organization per se. After conducting the interviews in this study, it became evident that on more than one occasion Management had forced the participants in this study to communicate untrue information or extend HSW professional approval to decisions that they did not supervise or had actively denied. This indicates the presence of a Scapegoating strategy to avoid liability in times of crisis, but it leaves HSW workers at a complicated position. Besides the fact they are understaffed and continuously lacked resources during this crisis: they have no executive
power on how hospitals deal with the crisis at all. Traditionally, the position of HSW Units is to advise on, not enforce, preventive action to protect the health and safety of employees:
P7: We are an advisory body, we don’t have executive capabilities. We are an advisory branch of Hospital’s Management. So, there are times that the Directory Board . . . doesn’t want to take your points into consideration or suspects what you are going to tell them is not (.) in their interest; and they hate you . . . But that is normal, it’s not caused by the current crisis . . . there are times they don’t count on you (.) or do things without taking into consideration what you’re telling them, well; and we have to live with that . . . the problem is we end up having to justify some of them
Therefore HSW workers bridge the needs of employees and Management, but can’t engage actions that fully protect either, because they would put the other at risk. This becomes a clear dilemma when the hospital makes management decisions that do not follow HSW guidelines, as under their individual assessment is placing employees at an unnecessary risk, in contrast to their responsibility safeguarding employee well-being.
In such situations, numerous participants reportedly decided to separate their decisions from those of the organization, individually following a strategy based on Honesty and Relationship Building instead of the Scapegoating approach forced by the hospital:
P8: Many times we make the mistake of . . . that happens a lot with Management, right? “this shouldn’t be known”, “this shouldn’t be told”, “Let’s avoid this from…”. And I think people respond a lot better and have more of a. . . feeling of being informed . . . There are things people discover by other means, and I believe that it’s always better that you get to learn it from the original source . . . “Damn, if you already know it and you’re responsible for this center, tell your employees, right?”.
P1: . . . We have pressure . . . we have pressure . . . we have pressure but, yeah, the superior we’ve had through all this, and that we still have, from Preventive Medicine, has supported us . . . saying “No, no, no, here we DO have to say this, we have to say it like this” . . . and we have been clear.
On the other hand, Keeping record is the last indicator in the third dimension of ICC Strategiesand aims to leave a written track of all things said and done within the organization concerning crisis management in order to allow traceability in times of conflict:
P8: I register everything, right? (.) If there is any problem at any point in time, this way we can have a traceability that before was impossible (.) impossible to have.
P12: . . . since a long time ago, we have it very clear that we have to write everything down. Meaning that communication has to be verbal, but there has to also be a record of, of everything we transfer. And, people has to have a document in which everything we have said is written down.
Such reflection about the importance of written communication during a crisis directly attends to the need to assess liability during a crisis and to construct a solid narrative that can be preserved and disseminated as a point of reference for all stakeholders, hence the protocols directly link to the strategizing of Keeping record to avoid liability.
Conceptual Metaphors As Sensemaking Tool
As shown in Figure 2, the second CIM of this study uses Crisis Uncertainty as the central concept to explain the use of Conceptual Metaphors in our sample, from both HSW professionals and other internal stakeholders. As the literature suggested and the sample confirmed: conceptual metaphors sustain a wide comparative and relational association between two distinct elements to create an understanding about certain elements of the crisis.
The dimensions of this second CIM aim to group the main objects of sensemaking that were reported by our participants: sensemaking about the threat, about one’s ability to control/manage the crisis and about individual experiences and perceptions during the crisis. The metaphor of Crisis as a War was continuously present in both the wording and sensemaking processes of all participants, and distinctively applied to create an understanding of each of the three three dimensions of Uncertainty During Crisis, therefore it will be discussed as an indicator for each sensemaking function, evidencing how three different applications of the same metaphor were reported in our sample (Figure 2).
Figure 2:
CIM of Conceptual Metaphors used by hospitals’ internal stakeholders to make sense of the crisis during the COVID-19 pandemic
(i) Threat Sensemaking
The first dimension of Crisis Uncertainty in this CIM is Threat Sensemaking. This dimension addresses all metaphors that directly describe or build an understanding about the threat of the crisis. As in every other dimension of this CIM model, the object of sensemaking is not the same for every participant, but it always aims to specifically build understanding on the perception of a threat.
The first indicator within thisThreat Sensemaking dimension depicts all understandings of a threat that describe it as a big wave that is not possible to stop from happening: the Tsunami Metaphor. The understanding of a threat in terms of a tsunami (or avalanche, for comparability’s sake) can be seen in the following examples:
P7: We had to reorganize the hospital’s healthcare assistance because an avalanche was expected, and it could collapse the system. That has been the difference. Not because the treatment to patients had to be radically different.
P11: 95%-90% now . . . is coronavirus . . . it has absorbed us completely . . . like a Tsunami Both examples inform and provide meaning to the immediacy and big impact of the threat, in the case of Participant 7 it was used to illustrate that the size of the wave was the main challenge in for him in the crisis: the sea or waves are not so much of a threat, but when they
oversaturate and become as big as a tsunami the only option is to look for ways to deal with such a big wave of hospitalizations. Participant 11 focused instead on the impact the threat had directly on her, depicting coronavirus internal crises as the threat that was taking “95-90% of their full dedication”, and not the infections themselves. The third indicator within this dimension of Uncertainty addresses the use of the Crisis as War metaphor as a Threat Sensemaking tool.
The second indicator of this dimension, in line with the metaphors evidenced in Crisis Management books, was the Crisis as Fire metaphor. The idea of fire evokes imminent danger, a sense of urgency to deal with the incoming threat:
P11: . . . we are continuously turning off fires, waking up in the morning with no planification . . . because I don’t know what am I going to do when I get there or when am I going to be done.
As mentioned by Participant 11 and expanded on by Participant 7, the Crisis as Fire metaphor and the Crisis as War metaphors hold a shared understanding of crisis when they define the threat:
P7: [My job] is comparable to the mission of a firefighter or an army . . . when there is a crisis situation . . . and you have been preparing for this moment all along. Then (.) that is what we are there for, for these situations . . . I usually need to go and bring quick solutions to certain things.
In both associations: Crisis as Fire and Crisis as War, there is a generalized assumption that HSW professionals that have trained to know how to face the described threat, not unlike firefighters or soldiers, All three professionals are expected to reduce the threat as soon as possible and stop it from spreading (fire) or re-starting (war). These comparisons evidence a sensemaking specifically on how certain threats force HSW professionals and employees to take a direct response to quash the threat. In the case of information overload, internal crisis or a high rate of infection, metaphorical thinking allows participants to reflect on the psychological impact the threat has on them, independently of how it unveiled:
P3: My colleagues of another province used to say that we are talking about protection in times of war. Because, of course, it has been a threat with no precedent that I know of, in
what concerns paralyzing the country. It has changed our lives at a personal and professional level.
(ii) Control Sensemaking
The second dimension of Crisis Uncertainty grouped all metaphors that provided an understanding of one’s ability to fully control the situation. Three indicators emerged as relevant metaphorical thinking in what concerns the people’s control to manage this crisis. The first indicator in the Control Sensemaking dimension is the metaphor of Control as Riding a Motorbike:
P2: I love riding my motorbike, and when . . . you are very very very mindful of the road, it’s really difficult to have a car accident. Nevertheless, accidents usually come when you become confident and relax. And in a certain way, it’s impossible to pay full attention during all working day. There has to be a moment of distraction throughout it . . .
Following this approach to self-control of the crisis, Participant 3 points out how “we should not relax” with patients outside of the COVID-19 zone, to ensure that, even though risk is impossible to fully avoid, hospital’s staff start to train themselves to realize when they are “focused on the road” or when they’re not.
The second indicator of Control Sensemaking is Control as War, for hospital staff engaging in difficult decision making during the healthcare crisis. Taking into account the shortage in PPE, respirators and resources, doctors in Spanish Public Hospitals had to face very tough ethical decisions. With the intention of relieving the responsibility of the “soldiers” during the most ethically controversial decisions during the crisis, protocols were created so that Healthcare Professionals were not forced to make such complicated decisions themselves. Just like in war, hierarchical orders allow the soldier to merely be an executor of the assessed decision, not the judge of how to proceed:
P6: In our hospital . . . We have been lucky we didn’t have to make such tough decisions. But in Madrid, imagine: an Intensive Care Unit with four beds and six patients. And you have to decide which one is not going to get into IC, knowing that the patient will go to their own death. And you have to make a decision. It’s protocolized, eh? It has been defined as a guideline on how to make the decision. But nevertheless, it has to be absolutely devastating.
The last indicator of the Control Sensemakingdimension compares the lack of ideal resources and their need to prioritize when protecting the safety of employees to that of an Emergency Room doctor, arguing that the same way ER treats patients depends on urgency so does their assessment:
P1: our big problem was with PPE, of course, well (.) there were not enough, so ¿How could we manage it, so that people that were more exposed had them at the highest protection . . . and those that are less exposed with less? . But, well, everyone wanted maximum protection. This is where the ER metaphor comes in handy, to explain how this way of organising can help in this times of crisis:
P6: . . .Comparisons are devastating, “But you know, your colleague has a clinical casuistic and works in IC while you work on consultation and don’t even currently see patients. You are not at risk” . . . It’s like when you enter through the ER with a cold and they make you wait because a traffic accident has arrived and it’s dying, and you say “But I have a cold and I arrived first!”, “Well, yes, but the other one is dying”.
(iii) Experience Sensemaking
Differently than the first and second dimensions of Crisis Uncertainty, Experience Sensemaking doesn’t aim to group the sensemaking of a specific element of the crisis, but to identify all conceptual metaphors that add understanding or meaning to the context the crisis takes place in or the role individuals play in it. The discussion of the Experience as War metaphor aims to differentiate the emotional and psychological impact that staff in the front line has experienced, independently of the numbers of dead or the way the crisis arrived, it focuses on experiences and perceptions outside of self-control assessments:
P2: It’s like if you are in the front line and suddenly one of the generals that hasn’t stepped in… not even got mud on his shoes and asks you: “Hey, how are you? How’s it going?”. Well, obviously the person full of blood, wounds and bruises, when s/he sees somebody come in a wonderful horse and ask about the battle, well, s/he finds him/herself in a complicated situation. You try to put yourself in their shoes to make the war easier for him/her, but feel there is no . . . communication.
The second indicator of this dimension of Crisis Uncertainty is similar to the Control as Emergency Room, but instead of setting a priority of attendance, it aims to illustrate the meaning and value behind HSW efforts to protect safety in a technical manner. In the same way as medicine may seem aseptic, complicated and missing the human dimension; both HSW professionals and Healthcare workers focus on improving the wellbeing or safety of people what leads to the conceptual metaphor of Experience Taking Care of Caretakers:
P8: We take care of the caretakers, right? So, it is true that is a little, you manage through . . . you’re not a healthcare professional, right? But I have felt in that role, of trying to take care of those caring for others in these complicated times . . .
Experience as Everyone’s Maid has been the third and last indicator of this dimension. Various references to “maids”, “servants” and “less value of integrity” were associated with the feeling of some sub-groups of the hospital staff during the crisis, mainly those whose resources were oversaturated and with very high demand:
P8: It was like “we’re here everyone’s maid” they call us on one side saying “come here” like ordering and planning their job. They already had a plan and everyone kept questioning it. Even Management. So, a girl that had quite a hard time said: “Here we are, acting as everyone’s maid, everyone directs us as they please”.
Administrative and maintenance departments within the hospital (Porters, Kitchen, Laundry….) also voiced their experience in line with this observation. Their aim with this was to argue for how undervalued they had been within the hospital and make the point that they were not there to serve, but to be respected, valued and protected as any other employee in the hospital. The gathered insights addressing ICC and Conceptual Metaphors to enable certain kinds of crisis sensemaking have provided a complete overview of how Public Hospitals in Spain applied Internal Communication Strategies and to what end they brought successful results. Moreover, and in the face of such a historic event, in which hospitals had to confront a worldwide pandemic under extreme circumstances, we hope the Conceptual Metaphors in this study add an understanding to the Crisis Research on this topic and that they legitimize at least the understanding of the threat, the self-control ability, and our perceptions of the crisis.
Discussion & Conclusion
The goal of this study was to explore the Crisis Communication Strategies used internally by Spanish public hospitals during the COVID-19 pandemic (RQ) and the role of conceptual metaphors as enablers of crisis sensemaking (Sub-RQ).
The goal of this study was to explore the Crisis Communication Strategies used internally by Spanish public hospitals during the COVID-19 pandemic (RQ) and the role of conceptual metaphors as enablers of crisis sensemaking (Sub-RQ). An exploration of the strategic communication functions that took place internally during this crisis supported the separation between Instructive and Adjusting Information as described by Kim et al. (2011). Protocols were reported to help stakeholders know how to prevent being harmed or spreading harm during this crisis. This description fits perfectly into the idea of Instructing Information, as both the literature and the participants conclude that protection is key to avoid damage, but it requires stakeholders to believe in the threat itself, and to see the proposed solution as viable (Kim et al., 2011). On the other hand, psychological support is given through what Kim et al. (2011) defines as Adjusting information. This is communication focused on coping with the uncertainty of the crisis, and for that goal, organizational transparency and open information about how the crisis is being managed are key components to this. This directly links with the reasoning some HSW professionals followed when they faced a dilemma between Scapegoating or Honesty in Figure 1.
Macnamara’s (2016) observations that organizations tend to have a focus on distributing messages by speaking almost exclusively seems to be actively compensated by the dimensions of Strategies to Uncertainty and Relationship Building Strategies, nevertheless a further understanding of the data evidences that it is a slowly starting trend. Organisational Listening aims to reach a two-way communication, dialogue, engagement and relationship between the employees and the hospital (Macnamara, 2016). In order for Public Hospitals to engage in effective ethical listening, according to Husband (2009) they must pay attention to and give recognition to others’ right to speak; understanding their views and considering their proposals, in order to interpret and construct meaning. The indicators of Psychological Support, Listening and Honesty evidence how these elements are being nurtured by both HSW professionals and some management boards, and guides the way for other Management
Boards to acknowledge the benefits of honest and bilateral communication to build trust and reliability on future occasions. Moreover, effective ethical listening requires for the organization to respond in an appropriate way after consideration has been given to other’s proposals, implying that organizations, even when they decide to follow a non-compliance position with internal stakeholders during a crisis, need to provide an explanation or statement, specially in cases of wrongdoing (Macnamara, 2016). This non-compliance appropriate response is represented by Honesty in Figure 1, being a crucial element for building solid relationships with employees.
Our sample evidenced numerous situations in which Management didn’t comply with HSW advice and the HSW Unit in turn didn’t follow the message restriction Management imposed when dealing with PPE distribution. In situations in which Management lied to the employees, many HSW professionals broke their commitment to protect Management’s decisions by prioritising honesty and transparency towards the staff. This evidence suggests a slow shift by HSW professionals towards a listening crisis strategy; focused on integration and on building a more symmetrical communication practice toward public healthcare staff: by fostering listening, dialogue, openness and mutual understanding in order to improve successfully the Employee-Organization Relationship in times of crisis (Lee, 2020).
Exploring the use of Conceptual Metaphors used by internal stakeholders in this period of crisis may also help develop a Communication Strategy based on legitimizing and acknowledging others views and experiences of the crisis, by providing a framework in which there is no “literal” interpretation of the comparison. By exploring the subjective interpretation and attribution of meaning to certain elements of the crisis (threat, control and experience respectively) we aim to embrace a more nuanced format to discuss cognitive processes and understandings of a crisis, placing the uncertainty that triggered them as the central element from which sensemaking emerges. Discussing the understanding of hospital staff as “maids” and “caretakers”, the understanding of crisis threat as “tsunami” and “fire” and the association between Emergency Room logistics and the experience of riding a motorbike, metaphorical concepts empower a discussion about alternative explanations to reality without forcing a “right” way of understanding them. Therefore conceptual metaphors were shown to enable different kinds of sensemaking during periods of uncertainty, being
even more relevant in times of crisis. This incorporates a unique perspective to the Conceptual Metaphors Theory by Laköff and Johnson (1980) and introduces a promising application of said theory to the context of crisis sensemaking.
Limitations
As limitations, this research has mainly faced difficulties regarding finding participants. Due to the current COVID-19 pandemic, healthcare workers have very demanding schedules. Aside from this fact, participants were reluctant to open about internal management affairs, due to the issue of possible negative feedback or backlash from the work environment. Another limitation would be social distancing and quarantine measures, which limited interviews to only interviews via phone call. These events posed technical difficulties which derive from recording and transcribing voices recorded over a phone, which proved a challenge at occasions. This was specially true when attempting to fully interpret participant´s answers, and avoid mistakes due to poor quality audio. Lastly, the limited experience from the researcher as an interviewer could have also affected the results of this study, giving way to the notion that interviews could have been developed and handled in a more efficient and effective way with more training and experience.
Implications For Further Research
The communication aspects of Occupational Safety tend to be protocolized- The nuances that a CCO approach to Corporate Communication entail are just starting to be present in Occupational Safety Management; nuances that, as it can be seen in this research, yield positive outcomes for the management of a crisis. Future research should bridge these two fields to provide a wholesome and integrated approach to Safety Internal Communication, specially during times of crisis, in which trust, employee-organization relationships and reliability are properly accounted for. This would also help reduce downsides, such as resistance and distrust from employees towards management. Both the social and managerial importance of such measures resonate louder during this COVID-19 pandemic, which forces private and public organizations to adapt to the “new normal”, highlighting the public corporation problem, making key to strategize safety communication. The analysis of this communication should be undertaken by future research. The findings in this research
highlight the current function and potential of conceptual metaphors as sensemaking tools during a crisis. Future research should explore the validity of said approach to crisis sensemaking in other organizational contexts as well as the possible instrumentalization of conceptual metaphors in future internal crisis management strategies, due to the potential shown during this investigation to ease the sensemaking process and effectively reduce uncertainty among workers.
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