We usually think of organizations as bricks-and-mortar structures, organizational charts, financial assets, and so forth. But these are tangible manifestations of something deeper. At its most fundamental level, an organization is an ongoing conversation between employees, leaders, customers, suppliers, neighbors, regulators, and observers—anyone, in fact, who comes into contact with an organization in any capacity.2
The conversation addresses what the organization is, what it does, and how it does it. As the organization's conversation evolves, there are resulting changes in its more tangible attributes, such as buildings, programs, and budgets.
The language of organizational conversations consists not only of words, but also of symbols and gestures (meanings implicit in behavior); for example,
- the process of conversations (who gets to speak in what way to whom)
- the allocation of time and money, and
- the distribution of rewards and perquisites.
Organizational conversations both consist of and shape the thoughts, feelings, and behaviors of their individual participants. The prevalent ideas and values in organizations frequently become assimilated into the minds of individuals—often without their explicit awareness or deliberate choice. To some degree this happens through modeling and reinforcement, but a more subtle, yet powerful, dynamic is also at work: Organizations selectively direct our attention toward some phenomena and away from others. This determines what we perceive, which then affects our interpretations, expectations, and behavior. They in turn affect how others respond to us, which feeds back into our perceptions, and so on. This self-reinforcing circularity creates much of what we take to be reality.3
Well-being is harder to define, grounded as it is in each person's evolving matrix of experience, values, and meaning, but we can get a sense of it from the convergence of 3 different approaches. Self-determination theory identifies 3 basic psychological needs of individuals: competence, autonomy, and relatedness.1
These are similar to the hierarchy of needs—self-actualization, esteem, “belongingness,” and love—identified by the psychologist Abraham Maslow.4
Erickson describes the highest stages of human development as “generativity” and “ego integrity”—a sense that one's life has been worthwhile by virtue of working productively and contributing to something beyond oneself.5
Parker Palmer describes the search for authentic selfhood, particularly as expressed in one's vocation:
Before I can tell my life what I want to do with it, I must listen to my life telling me who I am. I must listen for the truth and values at the heart of my own identity, not the standards by which I must live—but the standards by which I cannot help but live if I am living my own life.6(p5)
Combining these perspectives, we can define well-being as a quality beyond physical and physiologic integrity that reflects the degree to which one is and becomes oneself fully and authentically, experiences connection with others and the world, and finds meaning in one's life and work. These elements correspond closely to factors associated with physician satisfaction and meaning.7,8,9,10
We are now ready to consider how health care organizations affect individuals' well-being. In light of the definitions above, we can state the question as: How do organizational conversations in health care affect the ability of people working within them to express who they are, grow, connect with others, and contribute meaningfully?