Following my February column, the editors of this column asked me to talk a bit more about how it is to work in a setting that does not always embrace ambiguity. One of my premises in that column was that an anthropological orientation enables us to reframe and reformulate in an environment where each stakeholder has a different view of what is happening and what should be happening.
I work in health care and government, two settings and systems that work hard to be as concrete as possible. In the paradigms of these two systems, ambiguity equals chaos and chaos is not productive. For example, health care strategies, such as clinical practice guidelines, are designed to standardize care and reduce variation to improve quality of care. In government, laws, and the often voluminous regulations that accompany them, are designed to ensure that everyone knows exactly what to do.
It is not only health care and government that seek to be concrete. In general, as a society, we work to reduce ambiguity in our systems and for most individuals, this lack of ambiguity ensures that our needs are met and we do not fall through the cracks – we are educated, paid, protected, usually with few difficulties occurring. However, this striving for sameness and regularity overlooks the fact that success and innovation are often found in the interstices between, rather than within, the structures of our institutions and our society. One of the hottest trends in health care is the development of individual therapies that are tailored to each person’s illness and genomes. Our heroes are not those who enforce the rules of government but those who find ways around them, who “cut through the red tape.” Bureaucrat is more likely to be used as a pejorative than an accolade.
Despite our uneasy relationship with ambiguity, systems, no matter how rigid and unambiguous, do change. I was struck by this in reading Sarah Ono’s Anthropology in the Public Sector column from April on VA Blogging and Engaging New Media. As she says (and as we all know well) “We are creatures of habit,” and habit is the enemy of the new, or is, at the very least, the defender of the usual. Sarah writes about the practicalities in changing government culture as we expand our old modes of communication to include social media. You will notice that I did not say we are abandoning our old modes but rather incorporating new ones beside them.
For me, incorporating rather than immediate and complete replacing is the key to managing ambiguity in our organizations because moving through ambiguity is another way of changing culture. Culture, even government culture, is a constant mixture of continuity and change. There is a wonderful metaphor for this in the book Cold Mountain, where an axe has had several handles and heads but is still described as a 100 year old axe. Changes are made but they are grafted on to something that has bedrock (at least in people’s perceptions). Something new emerges but all change needs to have continuity with what has gone before.
As systems change, roles, functions, and procedures can become ambiguous and people become unsure of what they should do and what their value is as things change. This ambiguity causes anxiety. Change and the ensuing ambiguity can be widespread in an organization or localized. In my work group, we have always been researchers. However, as of 2011, we also have a service component and teach VA staff to implement our research interventions as part of clinical practice. Everyone was very excited about this new opportunity. However, as our research interventionists changed their role to trainers and coaches for staff, they had to give up a significant part of their identity as clinicians who helped caregivers. As we talked about the changes and their sadness at the loss of one-on-one caregiver contact, they re-conceptualized their new roles as still helping caregivers but in a different way and on a larger scale. They keep a close relationship with the staff they train and I believe this is partly to hear about and share in their caregiver successes.
Understanding culture, continuity and change can make the scale and timing of innovations and the management of expectations much smoother as an organization implements changes. For example, for any planned change, organization leadership has likely had time to talk about and process the change and has made the connections of how it will fit into the organization and how their lives will be impacted. Rank and file workers are often presented with a fait accompli and expected to make changes immediately, which does not usually go well. Sometimes the most helpful tool in the timing of change is the leaks that occur. As people process information from the grapevine, they, too, have an opportunity to try on the change and its ramifications. In his very excellent book, Thinking Fast and Slow, 2002 Nobel Prize winner Daniel Kahneman points out that even one repetition makes an event seem more normal and expected and reduces our ambiguity about the event.
As anthropologists, we are trained to name and translate changes in a way that makes sense to people, to fit ambiguity into a larger framework. Seeing the connections between A and B, and how what people value is not lost but only modified, helps to make everyone’s world more stable. Although we talk about 180° changes, hardly anyone is comfortable spinning around that much at one time. Organizations can and do make these kinds of changes but a great deal of preparation, after-work, and hand holding are necessary for implementation. Moving by degrees and making sure that the cultural context is preserved is slower but may be a safer bet to make sure that change sticks.
Linda Nichols is a medical anthropologist and health services researcher at the Memphis Veterans Affairs Medical Center and Professor of Preventive and Internal Medicine, University of Tennessee Health Science Center at Memphis. The Center provides training to VA staff to work with dementia, SCI and TBI caregivers and with spouses of Veterans.
Sarah Ono, Heather Schacht Reisinger and Samantha L Solimeo are contributing editors of Anthropology in the Public Sector.