Making Sense of the Organization: Volume 2: The Impermanent Organization

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Author: Karl E. Weick

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Making Sense of the Organization Volume 2

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Making Sense of the Organization Volume 2 The Impermanent Organization KARL E. WEICK University of Michigan

A John Wiley and Sons, Ltd, Publication

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© 2009 John Wiley & Sons Ltd Registered office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com. The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Weick, Karl E. Making sense of the organization : the impermanent organization / Karl Weick. p. cm. Includes bibliographical references and index. ISBN 978-0-470-74220-4 (pbk.) 1. Organizational change. 2. Executives—Psychology. 3. Leadership. I. Title. HD58.8.W446 2009 658.4'06—dc22 2009013321 Set in 10/12 and HelveticaNeue & PhotinaMT by Macmillan Publishing Solutions. Printed in Great Britain by CPI Antony Rowe, Chippenham, Wiltshire

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Contents

Preface Acknowledgments

PART I

INTRODUCTION

1. Organized Impermanence: An Overview 2. Mundane Poetics: Searching for Wisdom in Organizational Theory 3. Faith, Evidence, and Action: Better Guesses in an Unknowable World

PART II

ATTENDING

4. Managing the Unexpected: Complexity as Distributed Sensemaking 5. Information Overload Revisited Kathleen M. Sutcliffe and Karl. E Weick 6. Organizing for Mindfulness: Eastern Wisdom and Western Knowledge Karl E. Weick and Ted Putnam

PART III

INTERPRETATION

7. Making Sense of Blurred Images: Mindful Organizing in Mission STS-107 8. Organizing and the Process of Sensemaking Karl E. Weick, Kathleen M. Sutcliffe, and David Obstfeld 9. Impermanent Systems and Medical Errors: Variety Mitigates Adversity

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1 3 9 27

45 47 65 85

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CONTENTS

PART IV

ACTION

10. Hospitals as Cultures of Entrapment: A Re-analysis of the Bristol Royal Infirmary Karl E. Weick and Kathleen M. Sutcliffe 11. Enacting an Environment: The Infrastructure of Organizing 12. Positive Organizing and Organizational Tragedy

PART V

LEARNING AND CHANGE

13. Emergent Change as a Universal in Organizations 14. Drop Your Tools: An Allegory for Organizational Studies 15. Leadership as the Legitimation of Doubt

Epilogue References Index

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175 189 207

223 225 243 261

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Preface

Jill Hawk, former Chief Ranger at Mt Rainier National Park, described to me how Search and Rescue units on Mt Rainier live by this credo: ‘It is what it is, it is in front of me, and I have to deal with it.’ That credo is stirring and action oriented. It also has a lot of play in it. ‘It’ is mentioned four times, yet one wonders what ‘it’ refers to and imagines that members of the rescue team have different interpretations. ‘Is’ is mentioned three times, suggesting a solidity that may be hard to find. ‘Me’ and ‘I’ are the people dealing with all this, but those actors could be individual people or ‘us’ and ‘we’ as a group. That credo, in practice, is much less vexing to team members than it is to me. That is comforting to those hiking on Mt Rainier, but it is discomforting to me because it raises the question of how people in general make sense of an indeterminate situation and how the ways they are organized affect this sensemaking. It is tough to craft intelligent conjectures about how ‘it’ and ‘us’ get defined because situations are changing, experience is streaming, and teams are transient. John Dewey describes the flux this way: ‘In every waking moment, the complete balance of the organism and its environment is constantly interfered with and as constantly restored. . . . Life is interruptions and recoveries. . . . At these moments of a shifting of activity, conscious feeling and thought arise and are accentuated’ (1922, pp. 178–179). The focus of the following essays is on the fugitive quality of organizing and sensemaking. The organizing is fugitive because people try to fold order into streaming, changing experience. My efforts to understand these ongoing efforts are guided by John Dewey’s imperative for action: ‘So act as to increase the meaning of present experience’ (1922, p. 283). I want to suggest that people in general try to follow this imperative. And I want to provide specific ideas and images that can become part of the reader’s attempt to increase the meaning of his or her experience or to craft a more compelling imperative. The streaming, the organizing, the sensemaking all are situated in what Taylor and Van Every (2000) call ‘the crucible of the quotidian” (p. x). That is hardly the language of a search and rescue unit. However, it is what they face. The quotidian is the commonplace, the everyday, the recurring, which is the crucible where efforts to make sense and hold events together are tested. This crucible is ‘the ultimately determining factor in what the organization will be like’ (p. x). The commonplace is a steady stream of interruptions

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PREFACE

and recoveries. Talk, texts, and activity may produce the interruptions but they can also stitch together the recoveries. With all this talk about transience and impermanence it seems only appropriate to acknowledge that my efforts to understand all of this are also transient. Search and Rescue team members as well as scholars trying to understand Search and Rescue teams all construct what Richard Rorty (1989) calls temporary theories, ‘a passing theory about noises and inscriptions being produced by a fellow human being that must be constantly corrected’ (p. 116). What this means is that the rescue team and I are all in this together. It is what it is.

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Acknowledgments

The word ‘acknowledgment’ always seems a little cold as a heading to set apart statements of one’s gratitude for help given. Writing is a seemingly solitary act, and yet many people turn what seems solitary into something that is infused with energy, conversations (imagined and actual), and encouragement. Several people help me by assuming this role and I want to honor their help. Kathleen Sutcliffe is co-author with me on three of these chapters, one on overload of which she is the senior author, one on sensemaking where David Obstfeld joins us, and one on medical tragedies. Kathie has an uncanny ability to separate central arguments from potential distractions. For example, she summarized the 394 pages we wrote in our two editions of Managing the Unexpected (2001) in one sentence: ‘Managing the unexpected is curbing the temptation to normalize and dealing with the consequences when you do.’ Far be it from me to craft something that compact. My appreciation for the help provided by the scholarship of others borders on awe. William James and John Dewey obviously inform much of what I write, but so do Michael Cohen, James Taylor, Elizabeth J. Van Every, Robert Chia, Hari Tsoukas, Gary Klein, William Starbuck, Karlene Roberts, Reuben McDaniel, Dave Schwandt, Barbara Czarniawska, Paul Schulman and the late Peter Frost. While the physical act of writing is solitary, it matters a great deal that I am part of an incredibly supportive, warm, and bright set of scholars in the Management and Organization group at the University of Michigan’s Ross School. Also at Michigan you’ll find a hearty band of inquirers including Dan Gruber, Danielle Molina, Jude Yew, Lisa Guzman, Pete Bacevice, and Ryan Smerek, who form the core of the Sensemaking Interdisciplinary Forum and stir up new insights with great frequency. I count on durable help from the Wildland Firefighting community and it always seems to be there. My gratitude runs deep for conversations with Ted Putnam, Dave Thomas, Paula Nasiatka, Paul Chamberlin, Paul Keller, Mike DeGrosky, Riva Duncan, Dave Christenson and Anne Black. And then there’s family. What surprises me is how those ties grow deeper and broader with age, so much so that enumerating those ties and fearing to omit some leaves one with gratitude for particulars but words of love for the assemblage. The love starts with my wife, Karen, and fans out from there.

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I Introduction 1. Organized Impermanence: An Overview 2. Mundane Poetics: Searching for Wisdom in Organizational Theory 3. Faith, Evidence, and Action: Better Guesses in an Unknowable World

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1 Organized Impermanence: An Overview Suppose we took seriously the idea that ‘Organization is a temporarily stabilized event cluster’ (Chia, 2003, p. 130). What would we notice if we believed that? William James provides an answer: Whenever a desired result is achieved by the cooperation of many independent persons, its existence as a fact is a pure consequence of the precursive faith in one another of those immediately concerned. A government, an army, a commercial system, a ship, a college, an athletic team, all exist on this condition, without which not only is nothing achieved, but nothing is even attempted. A whole train of passengers (individually brave enough) will be looted by a few highwaymen, simply because the latter can count on one another, while each passenger fears that if he makes a movement of resistance, he will be shot before anyone else backs him up. If we believed that the whole car-full would rise at once with us, we should each severally rise, and train-robbing would never even be attempted. There are, then, cases where a fact cannot come at all unless a preliminary faith exists in its coming (James, 1992, p. 474).

(See Quinn and Worline, 2008, for a stunning elaboration of this mechanism in their analysis of the intentional crash of UA flight 93 on 9/11.) The organized defiance of the coach passengers is a relatively stabilized relational order that is enacted into streaming experience. When social order is acted into ‘a sea of ceaseless change’ (Chia, 2003, p. 131) that order continues to change but at a slower rate. The shorthand for this transient social order with a slower rate of change is the ‘impermanent organization.’ Event clusters with slower rates of change tend to consist of a recurrent sequence (e.g. Czarniawska, 2006) held together by a closed, deviation-counteracting feedback loop. The phrase ‘impermanent organization’ may seem like a questionable choice of words because it can be read as both trivial and ambiguous. It sounds trivial because it suggests that organizations come and go. It sounds ambiguous because it fails to make clear just what it is that comes and goes. The essays in this book begin to tackle that ambiguity and to do so in a way that makes impermanence less trivial and more significant. If impermanence is inherent in organizations it matters greatly how people try to organize portions of this impermanence and redo these organized portions when they begin to unravel. The argument is that people build recurrence into

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portions of ongoing experience by means of texts, conversations, and interdependent activity. The result is that the rate of change in these more organized portions is slowed and therefore feels relatively stable. Change is slowed but it does not stop completely. Recurrent patterns can lose their shape, they can become obsolete, and the pattern can shift each time it is redone. So what does such organizing look like? A metaphorical answer is found in Taylor and Van Every’s (2000) use of Atlan’s (1979) contrast between smoke and crystal. As will be elaborated later in this book (p. 33 of Chapter 3 on faith, evidence, and action), the limiting conditions between which organizing unfolds are smoke, which they equate with variety, complexity, and conversations whose outcomes are unpredictable, and crystal, which they equate with repetition, regularity, and texts that stabilize. Organization resides between smoke and crystal just as it resides between conversation and text. Organization is talked into existence when portions of smoke-like conversation are preserved in crystal-like texts that are then articulated by agents speaking on behalf of an emerging collectivity. Repetitive cycles of texts, conversations, and agents define and modify one another and jointly organize everyday life (Taylor and Van Every, 2000, p. 31).

Atlan’s poetic depiction is not that far removed from more recent poetic descriptions that summarize complexity theory. Christopher Langton, in discussing ‘the edge of chaos,’ remarks that: . . . right in between the two extremes (of order and chaos), at a kind of abstract phase transition called ‘the edge of chaos,’ you find complexity, a class of behaviors in which the components of the system never quite lock into place yet never quite dissolve into turbulence either (cited in Waldrop, 1991, p. 293).

Organizing carves out transient order in the space between smoke and crystal. Or stated more compactly, permanence is fabricated. It is fabricated out of streaming experience. Robert Chia (2003) provides one sense of what organizing means in the context of streaming experience: The idea that organizing could be more productively thought of as a generic existential strategy for subjugating the immanent forces of change; that organization is really a loosely coordinated but precarious ‘world-making’ attempt to regularize human exchanges and to develop a predictable pattern of interactions for the purpose of minimizing effort; that language is the quintessential organizing technology that enables us to selectively abstract from the otherwise intractable flux of raw experiences; that management is more about the taming of chance, uncertainty, and ambiguity than about choice; and that individuals themselves are always already effects of organizational forces: all these escape the traditional organization theorist. Thus, the broader organizational questions of how social order is achieved; how the flux and flow of our lifeworlds are rendered coherent and plausible; how individual identities are established and social entities created; how taxonomies and systems of classification are produced and with what effects; how causal relations are imputed and with what consequences; how systems of signification are used to arbitrarily carve up reality and with what outcomes; these are left unanswered by traditional organizational theory (Chia, 2003, p. 123).

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5

One way to make the ‘generic existential strategy’ of organizing more concrete is to propose that organization emerges in communication. Taylor and Van Every (2000) argue that conversation is the site for organizational emergence and language is the textual surface from which organization is read. Thus, organizations are talked into existence locally and are read from the language produced there. The intertwining of text and conversation turns circumstances into a situation that is comprehensible and that can then serve as a springboard for action. The resulting network of multiple, overlapping, loosely connected conversations, spread across time and distance, collectively preserves patterns of understanding that are more complicated than any one node can reproduce. The distributed organization literally does not know what it knows until macro-actors articulate it. This ongoing articulation gives voice to the collectivity and enables interconnected conversations and conversationalists to see what they have said, to understand what it might mean, and to learn who they might be. For an organization to act, its knowledge must undergo two transformations: (1) it has to be textualized so that it becomes a unique representation of the otherwise multiply distributed understandings; (2) it has to be voiced by someone who speaks on behalf of the network and its knowledge (Taylor and Van Every, 2000, p. 243). One has to be careful here not to presume that there is a fixed sequence in which conversing produces texts that then produce action. Frequently, action is the pretext for subsequent conversations and texts that interpret the enacted event. Alternatively, to pose the question in the vernacular of sensemaking, how can we know what we think (texts) until we see (listening) what we’ve done (conversing)? Communication, language, talk, conversation, and interaction are crucial sites in organizing. Phrases such as ‘Drop your tools,’ ‘We are at takeoff,’ ‘If I don’t know about it, it isn’t happening,’ ‘This virus looks like St Louis Encephalitis,’ ‘Our pediatric heart cases are unusually complex,’ and ‘These fingerprints are a close enough match to the prints at the Madrid commuter train bombing,’ all represent textual surfaces constructed at conversational sites where people make sense of prior actions in ways that constrain subsequent actions. The resulting picture of impermanence and organization looks something like this: We perceive the processes of organization to be a restless searching to fix its structure through the generation of texts, written and spoken, that reflexively map the organization and its preoccupations back into its discourse, and so, for the moment, produce regularity. . . . It is the existence of such texts and the text-worlds they constitute that makes the organization visible and tangible to people (Taylor and Van Every, 2000, p. 325).

‘Restless searching’ (in an early draft I mistakenly (?) typed ’reckless') and ‘generation of texts’ both presume that action is a force on conversations and texts. If cognition lies in the path of the action, then texts and conversations also lie in its path. The preceding line of analysis is a composite of several familiar ideas. Most obvious is the affinity with several ideas in pragmatism. To depict impermanent organizing is to presume that people have agency, that there is an ongoing dialetic between continuity and discontinuity from which events emerge, that humans shape their circumstances, and that minds and selves emerge from action (Maines, 1991, p. 1532). Frequent citations to the work of William James and John Dewey will attest to the pragmatic grounding of this

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argument. Discussions of organizing that take the form of a garbage can (e.g. Cohen, March, and Olsen, 1972), temporary system (Meyerson, Kramer, and Weick, 1995), a site for self-organizing (e.g. Kramer, 2007), and an impermanent collaboration (Ferriani, Corriado, and Boschetti, 2005), all presume ongoing flows of experience punctuated by moments of relative order. The notion of ‘impermanence’ is prominent in Eastern psychology and philosophy, as is apparent in our discussions of mindful organizing in Chapters 6 and 7. Impermanence in Eastern thought ‘is the quality of experience that everything is shifting, going to pieces, slowly dissolving, rising and falling, and that moment-to-moment experience is all there is’ (p. 93 in Chapter 6). In the face of all of this shifting, dissolving, and discontinuity, people are not passive. They enact as well as search for anchors. They anchor by means of sensemaking, as we discuss in chapters on the properties of sensemaking (Chapter 8), doubt as a trigger for sensemaking (Chapter 15), information overload as both the occasion and the product of sensemaking (Chapter 5), enactment as a means of structuring flux (Chapter 11), and an example of collective sensemaking grounded in efforts by the Centers for Disease Control to make sense of the strange virus that was eventually recognized as West Nile Virus (Chapter 4). People also anchor by means of recurrent processes, as we discuss in chapters on distributed organization at NASA and how that distribution hindered prevention of the Columbia shuttle tragedy (Chapter 7), systems that are implemented to coordinate medical care but which are also vulnerable to error (Chapter 9); temporary organizing under extreme conditions of danger and uncertainty in wildland fire (Chapter 12), and what it means to organize change when change is already underway (Chapter 13). People also anchor by efforts to learn new patterns, hold recurrent patterns together, and bounce back when those patterns begin to unravel. This form of anchoring is discussed in chapters on faith as the glue of organizing (Chapter 3), dropping one’s tools as a means to preserve patterns (Chapter 14), mindful attention as a way of keeping up with change (Chapter 6), and the liabilities that can occur when processes are held together too tightly and too narrowly (Chapter 10). If we reinvoke the image of smoke and crystal, attempted anchoring by means of organizing is a move away from the impermanence of smoke toward the permanence of crystal. That movement, however, is slowed and counteracted by conditions such as continuing change, reorganizing, forgetting, and adaptation. All of these limit efforts to establish permanence. Organization, therefore, embodies continuing tension in the form of simultaneous pulls toward smoke and crystal. Under such dynamic conditions of continuous rise and fall, it makes sense to study processes of organizing and to treat organization as a reification in the service of stabilizing an event cluster. Organizations struggle to preserve the illusion of permanence and to keep surprise at a minimum. People create fictions of permanence by means of practices such as long-term planning, strategy, reification of temporary structures, justification, investments in buildings and technology, and acting as if formal reporting relationships are stable. When people drop some of these fictions, the firm doesn’t dissolve. Fictions can be selectively imposed on subunits, imposed with full appreciation of what they do and don’t accomplish, updated regularly, and sometimes enacted into relative permanence through processes that resemble self-fulfilling prophecies. Aside from working with fictions, there is the option of mindful organizing.

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7

When we talk about organizing rather than organization, we acknowledge impermanence (we accept that coordination and interdependence are not stable but need to be reaccomplished). To view the life of organizations as organizing is also to notice and reduce the discontent triggered by futile clinging to the impermanent as if it were permanent. The need to reorganize is not seen as a failure of strategy but as the inevitable rise and fall of patterns that are not rooted in one’s own personal agency. Organizing, viewed as an emergent unpredictable order, replaces a distinctive, stable self as the actor with dynamic relationships as the actor. Taken together, impermanence, discontent, and absence of ego suggest that the presumed solidity of organizations is not so obvious and nor are ways to manage within impermanence. If experience is impermanent, then the issue of organizing becomes an issue of freezing, not unfreezing. If you assume that improvisation is a fundamental means to cope with impermanence (e.g. Weick, 1987, pp. 284–304), then the question people face is ‘How do I get a sequence of events to recur?’ not ‘How do I get a sequence to change?’ (Weick and Quinn, 1999; see Chapter 13 in this book). The big deal is not unfreezing so that we can change and then refreeze. Instead, the big deal is to freeze some segment of an ongoing flow, learn how to make some portions of it happen again, and then unfreeze those portions not incorporated into the recurrent sequence. Sequences vary in the ease with which they can be made repetitive. Situations that are easy to convert from improvisation into repetition may well become the first and most basic organizational routines. It is the ease with which sequences of action can be extracted from improvisation and converted into routines, not mimesis, that may explain why organizations look so much alike. All organizations start out differently with idiosyncratic improvisations, but then they all also try to enact recurrence in the interest of predictability and uncertainty reduction. Now they begin to look and act alike as they find similar stretches of action to stabilize. Organizations look most alike in those sequences that are easiest to routinize. One form of organizing implied by these ideas closely resembles organizing for high reliability. High reliability organizations (HRO; see Chapter 7 for a description) pay more attention to failures than success, avoid simplicity rather than cultivate it, are just as sensitive to operations as they are to strategy, organize for resilience rather than anticipation, and allow decisions to migrate to experts wherever they are located. These may sound like odd ways to make good decisions, and that may be true, but decision making is not what HROs are most worried about. Instead, they are more worried about enacting a structure that makes sense of the unexpected. In the context of ceaseless change, processes associated with attention to failure, simplification, operations, resilience, and expertise make perfectly good sense. Those five processes are important because they mobilize resources for sensemaking (see Chapter 7), resources such as interaction and conversation (social), clearer frames of reference (identity), relevant past experience (retrospect), neglected details in the current environment (cues), updating of impressions that have changed (ongoing), plausible stories of what could be happening (plausibility), and actions that clarify thinking (enactment). When these sensemaking resources are mobilized, people are better able to spot the significance of small, weak signals of danger implicit in the unexpected and to spot them earlier while it is still possible to do something about them.

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Effectiveness in uncertain times lies as much in the capability for sensemaking as it does in the capability for decision making. Capabilities for making sense of the unexpected get activated, organized, strengthened, and institutionalized more or less effectively depending on how people handle failure, simplification, operations, resilience, and expertise. In compact form, the guidance implicit in these five is: 1. 2. 3. 4. 5.

Scrutinize small failures. Refine the categories you impose. Watch what you’re doing and what emerges. Make do with the resources you have. Listen.

As these five increase, transient organizing becomes more mindful and more responsive to the unexpected at earlier points in its unfolding. What does it mean then to manage under conditions where what you manage is an impermanent fabrication? It means that you need to get good at attentive action. Managing is firstly and fundamentally the task of becoming aware, attending to, sorting out, and prioritizing an inherently messy, fluxing, chaotic world of competing demands that are placed on a manager’s attention. It is creating order out of chaos. It is an art, not a science. Active perceptual organization and the astute allocation of attention is a central feature of the managerial task (Chia, 2005, p. 1092).

Whether managers construct recurrent action sequences or talk organization into existence, they attend, interpret, act, and learn (Daft and Weick, 1984; see Chapter 10 in Weick, 2001). We use these four activities to impose a crude order on the following chapters. All four activities help stabilize event clusters, including the cluster wherein passengers mobilized by faith in one another resist highwaymen who are up to no good. Before we get to these four sections, we include two chapters that show why people like William James, Robert Chia, James Taylor, and Elizabeth Van Every are valuable touchstones and exemplars. Chapters 2 and 3 preview the style of analysis used throughout the remainder of the book. Chapter 2 describes crucial assumptions, styles of thinking, and predecessors whose influence pervades the chapters. Chapter 3 provides a conceptual overview of key ideas and illustrates these ideas by applying them to the gradual discovery of the battered child syndrome.

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2 Mundane Poetics: Searching for Wisdom in Organizational Theory Setting the Scene Chapter 2 is an overview of ideas, a mindset, a way of thinking, and the style of analysis that defines this book. Fragments of biography are used to illustrate the way in which assumptions influence how impermanence can be described. The title ‘mundane poetics’ calls to mind the close ties between theory and poetry described by the famous economist, G. L. S. Shackle. Shackle, writing to Henry Boettinger on July 15, 1974 said: I have been a theoretician because that was the nearest I could get to being a poet. A theory is a poem, at any rate literally, a thing made, a work of art. The Greeks, you will tell me, believed that the poet told more truth than the historian. I have long thought that truth was too elusive and remote to be the real goal. The goal for the theoretician is beauty. The theoretician in excelsis, the mathematician, is all for beauty (elegance of proof and result). My wife has a book of crochet patterns, one of which is called ‘a supple trellis’. It is a shawl of very fine, gossamer wool with structure and coherence, yet with no rigidity, its mathematics are topological. Such is economic theory. It must stretch and twist, but must not tear (the invariants of topology are these). But this book I speak of is full of shawls, of all colours, designs, conformations and structures (stitches). We need that too. Find the one that fits the scene, is the only way (Littlefield, 2000, pp. 354–355).

The title of this essay contains three important words: mundane, searching, wisdom. The word ‘mundane’ signals a focus on ordinary, everyday organizing as the context for impermanence (recall ‘the crucible of the quotidian’ mentioned in the Preface). That focus on the mundane may seem out of place in this book given the scale and drama of the events that are explored in subsequent chapters, events such as child abuse (Chapter 3), firefighter fatalities (Chapter 12), space shuttle destruction (Chapter 7), adverse events in pediatric surgery (Chapter 10), and the West Nile Virus (Chapter 4). Dramatic breakdowns, however, are presumed to show explicitly the patterns that unfold less explicitly in mundane breakdowns.

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A pattern often associated with impermanence involves the sequence that starts with streaming experience, followed by interruption, recovery, and mundane streaming. The shorthand that we often use for this pattern of impermanence is borrowed from Heidegger (e.g. see Chapter 5 in this book). Streaming ⫽ ready-to-hand immersion in activity, interruption ⫽ unready-to-hand disruption in activity, and recovery ⫽ either present-at-hand atomistic analysis of the activity or resumption of ready-to-hand immersion. As will become clear, the restored mundanity seldom resembles the initial mundanity, a difference that is captured by scholars of emergence (e.g. Plowman et al., 2007). It is a linguistic challenge to create descriptions of these streaming patterns without the help of a ‘poetic’ voice. This was evident to Clifford Geertz who coined the word ‘faction’ to describe social science description as ‘imaginative writing about real people, in real places, at real times’ (Horgan, 1998, p. 155). Part of the craft of ‘searching’ for fleeting social order involves careful choice of one’s assumptions. Since these assumptions constrain what one will see (‘believing is seeing’), it is important to be explicit and deliberate about such choices. There is a note of wishful thinking in my use of the verb ‘choose’ since many assumptions we impose are invisible hard-wired templates created by socialization. That is partly why I try in this chapter to be clear about some of those whose assumptions have socialized me. Among the assumptions that I have found useful are those involving continuity, evolution, ambivalence, complexity, and levels of analysis. The assumption of continuity, in Putnam and Saveland’s words (2008), says that: Our mental routines go with us wherever we go. We don’t suddenly act differently when organizations are involved. We routinely go off on mental ‘side trips’ (such as daydreaming) throughout the day and seem surprised at our capacity to miss situational cues that can result in poor decisions in environments where the consequences are more severe (Putnam and Saveland, 2008, p. 107).

The assumption of evolution supplies a mechanism that orders and edits flux. The assumption of ambivalence highlights a criterion for editing flux, namely preserve adaptability. The assumption of levels does away with the distinction between macro and micro and grounds organizing in relationships rather than individuals. Finally, the assumption of complexity highlights the variety in both internal and external environments. Mismatched variety increases the frequency of impermanence. These five assumptions are developed in Chapter 2, and their influence is visible in subsequent chapters. The final key word in the title, ‘wisdom,’ points to a growing emphasis in organizational theory (e.g. Kessler and Bailey, 2007) on ‘the acquired ability to create viable realities from equivocal circumstances and to use informed judgment to negotiate prudent courses of action through the realities created’ (Gioia, 2007, p. 287). The ‘creation of viable realities’ is a continuing activity which means that no one reality is permanent. The ‘wisdom’ of impermanence lies in not clinging to that which will vanish anyway. It also lies in accepting the necessity to reaccomplish realities that seemed to be stable and in action that reflects an awareness of incomplete information, action that blends knowledge with ignorance. The following article was published in Organization Studies, 2004, 25(4), 653–668.

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Vita Contemplativa Mundane Poetics: Searching for Wisdom in Organization Studies Karl E. Weick The final, definitive version of this paper has been published in Organization Studies, Issue 25(4), Copyright © 2004 SAGE Publications Inc. Reprinted with permission.

Abstract The craft of idea generation is explored autobiographically, using as the core principle the theme that ideas generate their own contexts for development. Ideas generate their own contexts by means of conceptual affinities, as is illustrated by the author’s movement from ideas about unintended consequences to ideas about cognitive dissonance, enacted environments, organizational failures, and wisdom. Ideas also generate their own context by means of the assumptions they entail, in the author’s case, these entailments being assumptions of continuity, evolution, ambivalence, complexity, and levels of analysis. When activated, these diverse resources may generate portraits of human organizing that have poetic overtones, but that resemblance simply mirrors the fact that people do poetry in their everyday living. Keywords: idea generation, assumptions about organizing, organizational process, breakdowns

Barbara Czarniawska (2003) describes six styles of organizational theory including scientistic (e.g. Thompson), revolutionary (e.g. Burrell), philosophical (e.g. March), educational (e.g. Silverman), ethnographic (e.g. Van Maanen), and the one she identifies with my work, ‘poetic’.1 It is true that some of the more popular parts of the organizational behavior books I’ve written have been the poems I cite. How I work and who I am may be reflected in those choices more candidly than I realized or intended. The poems in the 1995 book on sensemaking (Weick 1995) would introduce me as a person of many selves (‘We are Many’: Pablo Neruda, pp. 18–22) concerned with crafting words that imaginatively capture the human condition in organizations (‘What I Remember the Writers Telling Me’: William Meredith, p. 196). Those many selves, realized within writing, continue to reveal themselves in additional poems contained in The Social Psychology of Organizing (Weick 1979). Here we find the author pursuing journeys to gain a new understanding of his confusion (‘In Broken Images’: Robert Graves, p. 224), journeys that are their own reward and will make sense only when they are viewed retrospectively (‘Ithaca’: C. P. Cavafy, pp. 263–264).

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What makes the poetic designation tricky, however, is that a poetic style is hard to describe and imitate because ‘uniqueness forms part of what is perceived as elegant’ (Czarniawska 2003: 255). Furthermore, poetic stylists ‘need not know how they are doing what they are doing in order to do it brilliantly’. These hurdles notwithstanding, I want to discuss ideas, their contexts and their development, with an eye to illustrating one ‘logic of creation’. The result may not be imitable, but at least it will demystify. I take my lead for this essay from Paul Valéry. ‘We say that an author is original when we cannot trace the hidden transformations that others underwent in his mind; we mean to say that the dependence of what he does on what others have done is excessively complex and irregular. There are works in the likeness of others, and works that are the reverse of others, but there are also works of which the relation with earlier productions is so intricate that we become confused and attribute them to the direct intervention of the gods. (To go deeper into the subject, we should have to discuss the influence of a mind on itself and of a work on its author).’ (Paul Valéry, cited in Bloom 2002: 494)

As a first anchor, let me mention some predecessors who have undergone ‘transformations’ in my mind. The identity of those ‘others’ is not hidden, nor is my dependence on them hard to spot. Harold Garfinkel and Leon Festinger taught me about retrospect, Gregory Bateson and Magorah Maruyama taught me about systems, Floyd Allport taught me about interaction, George Mandler taught me about interruption, Donald Campbell taught me about social evolution, Dick Neisser taught me about cognition, Alfred Schutz taught me about interpretation and expression in everyday life, James March taught me about organizations, Gary Klein taught me about experience and expertise, Marianne Paget taught me about mistakes, William James taught me about the human condition, and Norman Maclean taught me about the human condition in Mann Gulch. These teachers had their impact largely through contexts created by their writing. In order to make myself more open to these contexts, I read, imagine, connect, practice virtual ethnography in the armchair, write, and edit. Those are moves of the imagination working within soft constraints. The variety of these 13 topics — retrospect, systems, interaction, interruption, evolution, cognition, interpretation, organizations, experience, expertise, mistakes, the human condition, and Mann Gulch — suggests that Valéry is probably right. My dependence on the works of others is complex, irregular, intricate, and filled with ‘hidden transformations’. The problem then is that any effort on my part to talk about the development of ideas will be a plausible rendering at best. Hidden means hidden. But the author does deserve a say, since he or she has access to a different set of data such as activities underway, places where writing occurred, books that were spread out on the desk, the content of notes and marginalia, not to mention well intentioned aspirations and the improvisations that followed when those aspirations collapsed. I want to talk about the development of ideas largely by talking about the contexts that ideas and assumptions themselves set up. Since both of these contexts exert pressure simultaneously, often in ways that are contradictory, it is not surprising that one’s work lurches between topics and within topics due to complex dependencies. Analysts are basically thrown into the middle of ongoing intellectual traditions, styles, people, and problems. It’s all pretty

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chaotic. The trick is to make sense of the chaos, and in my case to then make sense of the making sense of chaos. There is certainly more to idea development than ideas and assumptions, but I have discussed these other autobiographical inputs (e.g. Weick 1993) and tactical inputs (e.g. Weick 1992) elsewhere. Here, I want to focus on ideas.

Ideas as Context Ideas can serve as their own context. If ideas are equated with plans or blueprints or patterns, then they are pragmatic tools that direct activities, including the activity of their own expansion and development. In my own case, Robert Merton’s discussion of unanticipated consequences, as summarized by March and Simon in Organizations (1958), was a powerful initial anchor that triggered several subsequent variants. I was fascinated by the idea that there were orderly but unintentional progressions by which people got into trouble, progressions that arose from situational complexity and selective perception. This fascination with Merton is already a bit ironic because I learned about his ideas while reading the classic work Organizations. Thus, I came away from a classic intrigued by the ideas of a person the authors of the classic were trying to replace. The idea of unanticipated consequences first became a tool for me in the context of a study of productivity in two research teams working on the design of heart valves and semi-conductors (Pepinsky et al. 1966). In both cases, team members spent considerable time doing what we came to call ‘façade maintenance’. The teams were more concerned with metrics that demonstrated their productivity to project monitors than with the problem itself. More façade maintenance was practiced by the less productive team, which meant that the better they looked, the worse they were doing. Looking productive didn’t serve to create latitude and autonomy to do the real work, as many thought it would. Instead, façade maintenance became the work. Tied to the then current idea of impression management (Goffman 1959), what we were watching was an initial separation between front-stage façade maintenance and backstage research, a separation that began to break down as people spent more time and effort maintaining the façade. A potential vicious circle was set in motion in which more maintenance meant less productivity which necessitated more maintenance which led to even less productivity, all triggered by the mundane requirement to file quarterly progress reports. In their efforts to see how people were doing, project monitors made it impossible for people to do things. The idea of unanticipated consequences set up a context in which I welcomed cognitive dissonance theory (Festinger 1957) as a more compact, more psychological, more manageable way to think about unanticipated consequences. Dissonance research produced findings such as decreased incentives for doing an activity led to increased attraction to the activity; disconfirmed expectations led to intensified adherence to the expectation; effort expenditure led to heightened evaluation of worthless activities in which the effort was invested. All of these seemed like instances of unanticipated consequences triggered by insufficient justification. So I was still watching the unexpected materialize, but now I had a way to think about it. In my dissertation I combined dissonance theory with a

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concept attainment task that modeled research team activity, and saw how productivity could be pressed into the service of dissonance reduction. In this microcosm were the precursors of an enacted environment, sensemaking under pressure, confirmation bias, mutual reinforcement of thought and action, and commitment. In other words, cognitive dissonance was and continues to be2 a way of thinking that serves as an entry point into all sorts of problems, including persistent medical errors such as occurred at the Bristol Royal Infirmary, wildland fire entrapments such as occurred at South Canyon, and withheld communications such as occurred at Tenerife. But, while vestiges of the idea of dissonance persist (e.g. Harmon-Jones and HarmonJones 2003), so too does the idea of unanticipated consequences. Concurrent with studies of dissonance, I did work on unanticipated consequences associated with overload, stress, interruption, breakdowns, and cosmology episodes. The bulk of the unanticipated consequences tended to be negative and included outcomes such as regression, flight, tunnel vision, self-justification, compartmentalization, and denial. But a more complicated story has also been developing. Unanticipated means just that, something that is not foreseen. And one could fail to foresee positive outcomes, recoveries, and learning just as much as more negative outcomes. I still find myself intrigued by what seem to be mistakes, errors, and adverse events, but now they seem to be a whole lot less straightforward. I marvel at Marianne Paget’s (1988) nuanced argument that actions become mistaken, they don’t start as mistakes. James Reason’s (1997) conceptualization of chains of errors speaks to systems that set up failure, as is true also for Charles Perrow’s (1984) work on normal accidents. Interruptions, when viewed in the context of Heidegger’s ‘unready to hand’ moments, become ideal sites where practice and theory meet and inform one another (Weick 2003). When people seem to forget the lessons they’ve learned, this may represent an adaptive move in which they discredit some of their experience because they find themselves in what seems to be a novel environment. This possibility shows up in discussions of the ‘attitude of wisdom’, which is acting as if one both knows and doesn’t what is happening and what to do about it. The stream of ideas here runs from unanticipated consequences, through dissonance and interruptions, and is currently visible in discussions of wisdom, becoming, and recovery. This progression seems to qualify as mundane poetics since it basically recapitulates what pragmatists, especially John Dewey, view as the natural logic by which people evaluate and reconstruct their experience. To see this, consider Thayer’s summary of Dewey’s ideas about truth. ‘Inquiry is initiated in conditions of doubt; it terminates in the establishment of conditions in which doubt is no longer needed or felt. It is this settling of conditions of doubt, a settlement produced and warranted by inquiry, which distinguishes the warranted assertion . . . The purpose of inquiry is to create goods, satisfactions, solutions, and integration in what was initially a wanting, discordant, troubled, and problematic situation. In this respect all intelligence is evaluative and no separation of moral, scientific, practical, or theoretical experience is to be made.’ (Thayer 1967: 434–435)

So, as I weave my way from ideas about unanticipated consequences to ideas about the attitude of wisdom, I simply act like any pragmatist who moves from conditions

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where doubt is paramount, to conditions where it is assimilated, accepted, and converted into coping and organizing and into warranted assertions about how people cope and organize. The point is, ideas shape ideas, they lead on to other ideas, they enact their own contexts. Tactically, to follow these leads one must trust in the power of free association to reveal unexpected connections. Mundane poetics may consist of warranted assertions, but the intelligence to get there is helped along by intuition (Klein, 2003), System 1 thinking (Kahnemann 2003), and trust in the plausibility of initially puzzling connections.

Assumptions as Context Assumptions provide a reality that is taken as given, a reality that exerts influence over what one notices and ignores and labels as significant. My work on topics such as sensemaking, organizing, and heedful interrelating hangs together (albeit tacitly) through many assumptions, a few of which I want to make explicit.

Assumption of Continuity This assumption was made explicit in 1969 (Weick 1969: 25–27) when I criticized the phrase ‘organizational behavior’ because it tempted us to look for uniqueness in reified places, and drew attention away from the fact that behavior is behavior. The argument went like this. ‘Events inside organizations resemble events outside; sensitivities of the worker inside are continuous with sensitivities outside. Since people have as much desire to integrate the various portions of their life as to compartmentalize them, what happens inside affects what happens outside, and vice versa. This is a roundabout way of saying that continuity from setting to setting is more likely than discontinuity . . . Rather than searching for unique behaviors that occur within an organization and then building a theory about this uniqueness, it seems more useful to build theories about particular ways that enduring individual dispositions are expressed in an organizational setting, and about the effects of this expression.’ (Weick 1969: 25–26)

A good example of this is found in the behavior of aircraft pilots (Allnut, in Weick 1995: 103–104): ‘A pilot may say that he does not allow his work and his domestic life to mix: but the statement can only be partly true. Human beings are 24 hour-a-day people, possessing only one brain with which to control all of their activities; and this brain has to cover both work and play. In sum, events which happen in one segment of daily life may therefore influence what happens in other segments. The pilot who has just quarreled violently is in a dangerous state, for although he may have moved away from the person with whom he has quarreled, and climbed aboard his aircraft, the physiological and psychological effects of the quarrel may last well into the flight, and the crushing retort which he wishes he had thought of at the time of the argument may crowd his single decision channel to the exclusion of more important information.’

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To put this assumption of continuity into practice is to treat all lived experience as relevant data for organizing and to presume that reflection on those data is relevant to organizational life. To assume continuity is to pay more attention to situations, contexts, roles, and processes of structuring by means of actions and perceptions, and less attention to structures, entities, boundaries. One effect of the assumption of continuity is that it favors an additional assumption, namely, ‘response repertoires control noticing’ (Weick 1969: 26). That implication continues to underlie my thinking about change, interpretation, and failure. Originally, the idea of response repertoires and noticing came from a gloss of George Herbert Mead’s assertion that ‘An act is an impulse that maintains the life process by selection of certain sorts of stimuli it needs. Thus, the organism creates its environment. The stimulus is the occasion for the expression of the impulse’ (Mead 1956: 120). If people notice stimuli that permit them to do what they want to do, then as wants vary so too do the features that are noticed. But ‘impulses that maintain life’ are broader than wants, and also include such things as abilities, functional attitudes, and values. This suggests that behavior can be viewed as responses in search of excuses for expression. Thus, people tend to see those problems and opportunities that their repertoire can handle, but they are reluctant to see those it can’t. Organizations now become salient as one among many sites of potential stimuli that will be noticed or ignored depending on the response repertoires that people activate. Organizational socialization, training, and culture can modify repertoires, but they seldom wipe out everything that was there before. Taken even further, assumptions about continuity and response repertoires affect inquiry about organizational life. ‘If one gains an understanding of response repertoires and the conditions under which attention is controlled by the content of these repertoires, then a more substantial theory about organizations and behaviors can be built. The theory would concentrate on attention rather than on action. It would essentially ask the question, “How are the processes and contents of attention influenced by the conditions of task-based interdependency found in those collectivities which we conventionally designate as organizations?”’ (Weick 1969: 26)

While I cringe at my earlier subordination of action to attention, since acting one’s way into understanding is a hallmark of later work, I continue to use the idea that capabilities, especially linguistic capabilities of categorizing, affect what one notices. To understand organizations is to start with the premise that organizations are noteworthy for the forms of interdependent action that they favor and discourage. These forms serve as repertoires that affect what people notice, affirm, label, and act upon as well as the stories they construct retrospectively to make sense of their actions. As forms of interdependence change (e.g. they become more or less heedful, they shift from pooled interdependence to reciprocal interdependence), so too do perceptions, actions, stories. Continuing influence from the assumptions of continuity and repertoires is visible in several recent co-authored discussions where we argue that collective mindfulness is constituted by processes that enhance capability, and this enhancement then allows earlier detection of weaker signals that unexpected events are unfolding, which increases the likelihood of recovery and continuing reliable performance.

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Assumption of Evolutionary Epistemology Nowhere are the pragmatics of poetics more evident than in my handling of evolutionary epistemology. I say that simply because evolution as I use it (and ‘use’ is the key word here) consists of an immense debt to Donald Campbell’s thinking which I tend to use as a platform rather than a vessel. Said differently, my thinking within an evolutionary framework retains less of Campbell’s stunning nuance than does the thinking of people like Azevedo (2002) and McKelvey (2002). An evolutionary epistemology highlights a distinctive set of themes in organized life. The context of evolution draws attention to such things as the inherent tension between retention and variation, the wise but wasteful practice of blind variation, the enactment of selection environments, imagination as simulated trial and error, life as the experience of thrownness where higher variation rates and playing the percentages increase chances for survival, requisite variety as a mechanism for adaptation that may produce a better match between variation and selection, and artificial selection based on deliberate intentions rather than natural selection based on exogenous determinants as a potential feature of organizational life. Organizing emerges as an ongoing stream of failed experiments and relentless mortality, updating, surprise, adaptations that threaten to reduce adaptability, winnowing, and occasional convergence. When an assumption about evolution is used to think about organizing, here, in Wanda Orlikowski’s (1996) artful description, is what one sees. Orlikowski watched what happens when people in a computer customer service center phased in a system of Lotus Notes to keep better track of the problems that were being phoned in. ‘Each variation of a given form is not an abrupt or discrete event, neither is it, by itself, discontinuous. Rather, through a series of ongoing and situated accommodations, adaptations, and alterations (that draw on previous variations and mediate future ones), sufficient modifications may be enacted over time that fundamental changes are achieved. There is no deliberate orchestration of change here, no technological inevitability, no dramatic discontinuity, just recurrent and reciprocal variations in practice over time. Each shift in practice creates the conditions for further breakdowns, unanticipated outcomes, and innovations, which in turn are met with more variations. Such variations are ongoing; there is no beginning or end point in this change process.’ (Orlikowski 1996: 66)

How can I know what I think about evolution until I see what Wanda says? Notice several features of these last two paragraphs. What I think comes in part from seeing what I say, but also in part from seeing what others say. I pick a quotation that helps me think, ponder why I think it is helpful, and then try to write in the spirit of what I’ve just read. That’s mundane poetics executed through the use of others’ well-turned phrases and arguments as ‘touchstones’ (Stinchcombe 1982) that shape rhythms, connections, and extensions in my own writing. That is an instance of style as theory. But it is also an instance of evolution itself. In the recipe, how can I know what I think until I see what I say, saying equates to variation, seeing equates to selection of meaning in what was said, and thinking equates to retention of an interpretation. The retained interpretation may then be imposed subsequently to interpret similar saying (retention is credited) in order to construct cumulative understanding, test past labels for their validity, or generalize older labels to newer events.

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But the retained interpretation may also be set aside (retention is discredited) in order to create newer meanings that produce greater differentiation, uncover previously taken-for-granted qualities, or raise new questions about what the story is. Sensemaking is evolution writ small. Just as adaptation can preclude adaptability on a larger scale, repetitive saying and seeing on a smaller scale can blunt sensitivity to changing circumstances. The same old saying enacts the same old seeing which enacts the same old thinking. Poetics can be an antidote to that sameness, but it runs the opposite risk that adaptability will preclude adaptation. A system that produces only variation and remembers nothing is not demonstrably better than a system that produces only retention and remembers everything. The first system is overcome by events because efforts to produce one variation after another soon lag behind current demands for a swift response. The second system is overcome by events because repetition of older routines lags demands for updating to address unique contingencies. The evolutionary wisdom that avoids such a trap involves ambivalence, and that is the assumption to which we now turn.

Assumption of Ambivalence A byproduct of my exposure to evolutionary thought has been a deepening appreciation of ambivalence. I know how that must sound. To make things appear even worse, that appreciation extends even further to the assumption that ambivalence is the optimal compromise. The phrase is Donald Campbell’s (1965). The inspiration for the phrase comes from William James. First, the inspiration. ‘The whole story of our dealings with the lower wild animals is the history of our taking advantage of the way in which they judge of everything by its mere label, as it were, so as to ensnare or kill them. Nature, in them, has left matters in this rough way, and made them act always in the manner which would be oftenest right. There are more worms unattached to hooks than impaled upon them; therefore, on the whole, says Nature to her fishy children, bite at every worm and take your chances. But as her children get higher, and their lives more precious, she reduces the risks. Since what seems to be the same object may be now a genuine food and now a bait; since in gregarious species each individual may prove to be either the friend or the rival, according to the circumstances, of another; since any entirely unknown object may be fraught with weal or woe, Nature implants contrary impulses to act on many classes of things, and leaves it to slight alterations in the conditions of the individual case to decide which impulse shall carry the day. Thus, greediness and suspicion, curiosity and timidity, coyness and desire, bashfulness and vanity, sociability and pugnacity, seem to shoot over into each other as quickly, and to remain in as unstable equilibrium, in the higher birds and mammals as in man.’ (James 1890, Vol. 2: 392) ‘Curiosity and fear form a couple of antagonistic emotions liable to be awakened by the same outward thing, and manifestly both useful to their possessor. The spectacle of their alternation is often amusing enough, as in the timid approaches and scared wheelings which sheep or cattle will make in the presence of some new object they are investigating. I have seen alligators in the water act in precisely the same way towards a man seated on the beach in front of them — gradually drawing near as long as he kept still, frantically

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careering back as soon as he made a movement. Inasmuch as new objects may always be advantageous, it is better that an animal should not absolutely fear them. But, inasmuch as they may also possibly be harmful, it is better that he should not be quite indifferent to them either, but on the whole remaining on the qui vive, ascertain as much about them, and what they may be likely to bring forth, as he can, before settling down to rest in their presence. Some such susceptibility for being excited and irritated by the mere novelty, as such, of any movable feature of the environment must form the instinctive basis of all human curiosity.’ (James 1890, Vol. 2: 429)

Here is Campbell’s (1965) interpretation of James. ‘The presence in moral codes, proverb sets, and motivational systems of opposing values is often interpreted as discrediting the value system by showing its logical inconsistency. This is a misapplication of logic, and in multiple-contingency environments, the joint presence of opposing tendencies has a functional survival value. Where each of two opposing tendencies has survival relevance, the biological solution seems to be an ambivalent alternation of expressions of each rather than the consistent expression of an intermediate motivational state. Ambivalence, rather than averaging, seems the optimal compromise.’

In the world of wildland firefighting, one of my favorite microcosms of organizing, ambivalence is visible in the minimal design for organizing that is practiced by fire crews. This design was first formulated by the late Paul Gleason (1991) whose LCES system prescribes that a crew should not attack a fire until its lookouts, communication links, escape routes (at least two), and safety zones are in place and known to everyone. What’s interesting about an LCES design is that it is an optimal compromise of knowledge and doubt. The placement of lookouts and the activation of communication imply that one knows what is going on and how the local conditions are related to the bigger picture of an active fire. The attention to escape routes and safety zones, however, implies that what one knows may be incomplete and that this potential ignorance needs to be recognized and hedged. The crew is simultaneously confident and cautious. Escape routes and safety zones preclude hubris. Lookouts and communication links preclude timidity. The combination of these four structures is respectful of both knowledge and ignorance, which means that this configuration exhibits both the ambivalence of wisdom and the wisdom of ambivalence. Meacham (1990) underscores my conclusion in his discussion of wisdom. ‘The essence of wisdom . . . lies not in what is known but rather in the manner in which that knowledge is held and in how that knowledge is put to use. To be wise is not to know particular facts but to know without excessive confidence or excessive cautiousness . . . [to] both accumulate knowledge while remaining suspicious of it, and recognizing that much remains unknown, is to be wise.’ (pp. 185, 187)

Thus, ‘the essence of wisdom is in knowing that one does not know, in the appreciation that knowledge is fallible, in the balance between knowing and doubting’ (Meacham 1990: 210). Wisdom is a quality of thought that is animated by a dialectic in which the more one knows, the more one realizes the extent of what one does not know.

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However, ambivalence should not be confused with indecisiveness. Ambivalence concerns co-existence of competing tendencies, and can be seen as simultaneous efforts to adapt yet retain adaptability and to treat past experience as a guide as well as a trap. Oxymorons such as ‘controlled burn’ epitomize ambivalence, which suggests the odd possibility that systems so characterized may be highly effective in rapidly changing environments since they retain a wider range of ways to adapt. Jerry Salancik (1977) worries that ‘commitment is too easy’ since any action that is public, irreversible and volitional tends to be binding and prods people to come up with reasons that justify the binding action. Success in finding such reasons aids sensemaking, but also predisposes to escalation, unwarranted persistence, and biased reasoning. If commitment is ‘too easy’, then one way to make it ‘harder’ is through ambivalence. Ambivalence weakens irreversibility, scales down the importance of the choice, and provides a ready-to-hand justification (e.g. I did what I did in order to stay agile).

Assumption of Complexity The idea that people need to complicate themselves and that it takes a complex organization to cope with a complex environment flies in the face of the counsel that people need to focus, simplify, and keep it simple. Why all the clamor in favor of complication? Why is it dangerous to dwell on simplicity? I take seriously William Schutz’s (1979) argument that understanding progresses through three stages: superficial simplicity, confused complexity, profound simplicity. I am not against simplicity per se, but I am against mistaking superficial simplicity for simplicity that is profound. That’s what I find fascinating about more effective high reliability organizations (HROs) (Weick et al. 1999). HROs strive for profound simplicity. They understand that the means to move toward profound simplicity is through doubting the completeness of their assumptions, through experimenting, and through entertaining a wider variety of possibilities. They realize that when they distrust their simplifications they will feel confused, but they also know that out of that confusion may come fuller understanding of what they face. When we are confused we pay closer attention to what is happening in order to reduce the confusion. Later, all we remember is that this period of confusion was an unpleasant experience. What we often fail to realize is that we also learned a lot of details while struggling with the confusion. Those struggles and their consequences comprise learning, even if momentarily they don’t feel that way. After a period of confused complexity, we often see that many of our initial simplifications were superficial, but we also see that a handful of those initial simplifications still hold true, although for different reasons than we first thought. And we also see that a handful of new simplifications help us make sense of the earlier confusion. These outcomes are the profound simplicities that are sometimes labeled ‘wisdom’. If people examine mindful HROs, those organizations often appear to be no more complex than mindless organizations. What people miss, however, is the fact that mindful organizations have struggled through periods of confused complexity on the way to their profound simplicities (e.g. they looked closely at their own failures and have examined them with candor). Mindless organizations, however, tend to settle for

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the first superficial simplicities they stumble onto, and as a result know neither themselves nor their environment very well. This by the way is why benchmarking seldom works. You can borrow the simplicities but you can’t borrow the confused complexity that gives meaning to the profound simplicity. Without that background, you have no idea why the simplifications are profound, why they work, or what lessons they summarize. Hence, the borrowing is superficial. It fails to come to grips with either your own resources or the environment, and typically fails when implemented. Most people would agree that the business environment is complex. The complexity is due in large part to the fact that the environment is unknowable and unpredictable. In the face of all of this complexity, everyone simplifies the data they receive. But there are better and worse simplifications. Better simplifications arise from deeper knowledge of the environment and deeper understanding of what the organization is and what it can do. That deeper knowledge develops when people attend to more things, entertain a greater variety of interpretations, differentiate their ideas, argue, listen to one another, work to reconcile differences, and commit to revisiting and updating whatever profound simplicities they settle on as guidelines for action. Practices such as these are institutionalized in the better HROs. But they don’t come easily. It takes a complex organization to see the value of confused complexity, to weather the messiness of confused complexity, and to have faith that confused complexity is not terminal but can lead on to the hardwon lessons summarized in profound simplicity. It also takes a complex organization to retain and value the diverse resources needed to spot which assumptions are superficial and to tolerate the mess when people contest different interpretations of what the organization faces. The assumption of complexity is also simply another take on the theme of adaptation and adaptability which pervades much of my writing. Complexity is important because it fosters adaptability. Complex organizations have extensive response repertoires, which means they are in a better position to cope with environments that failed to show up in their forecasts. People are not very good at forecasting, as Bill Starbuck keeps showing. If that’s the case, then it makes more sense to invest in generalized resources that can fit a variety of new environments than in better models of forecasting. The problem with better models of forecasting is that they tend to move away from generalized resources toward specialized resources. And specialized resources may produce better adaptation to current problems, but less adaptability to handle future problems. In a dynamic environment, future problems materialize swiftly and unexpectedly. Generalized, adaptive resources are more likely to be retained in complex structures. Thus, complex structures preserve both adaptation and adaptability, proving once again that ambivalence is the optimal compromise.

Assumption that Levels Impede Inquiry If behavior is behavior, then what is gained by arbitrarily carving that continuity back into the discontinuity of micro and macro phenomena? Latour (1987) asks this question. Taylor and Van Every (2000) ask this question. And I address the question by ignoring it. That choice may hinder my work, but it is a deliberate choice. And it is choice that may seem to breach a postmodern sensitivity.

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I assume that distinguishing among levels of analysis is of minor importance, and I do so for several reasons. To be concerned with processes means that one is attuned to sequences, unfolding, generative settings, amplification, and small events with large consequences. Small beginnings generate unanticipated consequences, as is argued by people who adopt complexity theory. But those same small beginnings often don’t stay small. They change size, constrain other events, and spread through what others reify into groups, organizations, and institutions. For example, at the time of this writing, the report of the shuttle Columbia Accident Investigation Board (Gehman 2003) has just been released. A one-pound piece of foam has triggered questions about the future of space exploration, the space industry, and space science. Those ‘larger’ questions and institutions will eventually be translated into budget decisions made by smaller units. ‘Macro’ enters into this scenario in the form of presumptions that actors make about constraints and meanings and consequences. Some of these presumptions are material, some are not. But it is the presumptions that shape and are shaped by actions. Larger sets of actors come under the influence of much smaller sets, due in part to presumptions about one’s allies. This feature of organizing was captured in the first ‘poem’ that anchored my writing, Piet Hein’s poem ‘Majority Rule’ (Weick 1969: 2–3). Hein depicts a larger world, an ‘entire state’ in his imagery, where the majority that rules turns out to be ‘one alone who stood at the peak’. Presumptions set the stage for this unanticipated outcome in the poem, just as they do in everyday organized life. The macro–micro distinction also seems dispensable in the sense that there are ideas that finesse the distinction. This happens when people postulate generic qualities of systems (e.g. Miller 1978), work within an evolutionary epistemology, or propose first principles that involve social rather than ‘individual’ action. For example, in 1969 I mentioned that ‘an important caution must also be introduced [into analyses]. Even though we have used the phrase “observable individual behavior,” this should not be read as the “observable behavior of a single person.” Given that interdependence is the crucial element from which a theory of organizations is built, interacts rather than acts are the crucial observables that must be specified. The unit of analysis is contingent response patterns, patterns in which an action by actor A evokes a specific response in actor B which is then responded to by actor A. This is the pattern designated a “double interact.” . . . Since organizing involves control, influence, and authority, a description of organizing must use the double interact as the unit of analysis for specifying observable behavior.’ (Weick 1969: 33)

Obvious as all of that now sounds, it still gets ignored by analysts who equate interacts with a micro, psychological, individual perspective. Double interacts apply as much to interactions between contentious nations as to interactions between individuals. Thompson’s (1967) pattern of task interdependence that he labels ‘reciprocal interdependence managed by mutual adjustment’ is basically a double interact constrained by the nature of the task. What is sometimes missed in discussions of the double interact is that Actor B is already doing something when Actor A ‘starts’ the sequence. Thus, any double interact is also an interruption (p. 34), which suggests that an undercurrent of arousal pervades most organizing.

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To focus on double interacts is also to find larger meanings in smaller occasions such as the Mann Gulch fire, Naskapi use of cracks in caribou bones to decide where to hunt, or a military unit lost in the Alps during a snowstorm. Careful attention to small short moments often brings the realization that, in fact, these moments are microcosms of larger, recurrent, fundamental processes. That realization obviously is affected by the quality of the ideas one carries to the microcosm and ‘sees’ in its unfolding (believing is seeing). But in many ways, ‘it’s all there’ if one looks at an event patiently, mindful of the fact that it takes variety in the ideas imposed to sense variety in the event itself. Microcosms disregard the boundaries of levels of analysis, and in so doing may be responsible for producing what looks like a poetic style.

Ending William James (1897/1956) concludes his essay The Will to Believe with a quotation from Fitz James Stephen that captures the elusive quality of a poetic style. But more important, it suggests that a poetic style may well be universal. At a fundamental level, what I do and how I do it is not all that different from what you do. Here’s what I mean by that. ‘What do you think of yourself? What do you think of the world? . . . These are questions with which all must deal as it seems good to them … In all important transactions of life we have to take a leap in the dark . . . If we decide to leave the riddles unanswered, that is a choice; if we waver in our answer, that too is a choice: but whatever choice we make, we make it at our peril . . . Each must act as he thinks best; and if he is wrong, so much the worse for him. We stand on a mountain pass in the midst of whirling snow and blinding mist, through which we get glimpses now and then of paths which may be deceptive. If we stand still we shall be frozen to death. If we take the wrong road we shall be dashed to pieces. We do not certainly know whether there is any right one. What must we do? “Be strong and of a good courage.” Act for the best, hope for the best, and take what comes.’ (James 1897/1956: 30–31)

People do that. Organizations do that. Poetic stylists do that. It’s mundane. But it’s also wise.

Notes I am grateful to Barbara Czarniawska, Karen Weick, Kyle Weick, and Kathleen Sutcliffe for their comments on this essay. 1 ‘Poetic’ comes from the latin poeticus and the Greek poietikos, meaning ‘inventive’ (American Heritage Dictionary, 3rd edn.) The term is variously used to refer to ‘literary criticism that deals with the nature, forms, and laws of poetry, a study of poetry or aesthetics, the practice of writing poetry’ (p. 1397). 2 See Weick (1995: 11–13) for ways in which my discussion of sensemaking owes a debt to cognitive dissonance theory.

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References Azevedo, J. 2002 ‘Updating organizational epistemology’ in The Blackwell Companion to Organizations. J. A. C. Baum (ed.), 715–732. Malden, MA: Blackwell. Bloom, H. 2002 Genius. New York: Warner. Campbell, D. T. 1965 ‘Variation and selective retention in socio-cultural evolution’ in Social Change in Developing Areas. H. R. Barringer, G. I. Blanksten, and R. Mack (eds), 19–49. Cambridge, MA: Schenkman. Czarniawska, B. 2003 ‘The styles and stylists of organization theory’ in The Oxford Handbook of Organization Theory. H. Tsoukas and C. Knudsen (eds), 237–261. Oxford: Oxford University Press. Festinger, L. 1957 A theory of cognitive dissonance. Stanford, CA: Stanford University Press. Gehman Jr, H. W. 2003 Columbia Accident Investigation Board: Report, Volume One. Washington, DC: US Government. Gleason, P. 1991 ‘LCES: A key to safety in the wildland fire environment’. Fire Management Notes 52/4: 9. Goffman, E. 1959 The Presentation of self in everyday life. New York: Doubleday. Harmon-Jones, E., and C. Harmon-Jones 2003 ‘Whatever happened to cognitive dissonance theory?’ The General Psychologist 38/2: 28–33. James, W. 1890 Principles of psychology. New York: Dover. James, W. 1897 The will to believe. New York: 1956 Dover. Kahnemann, D. 2003 ‘Maps of bounded rationality: Psychology for behavioral economics’. Unpublished manuscript, Princeton University. Klein, G. 2003 Intuition at work. New York: Doubleday. Latour, B. 1987 Science in action. Cambridge, MA: Harvard University Press. McKelvey, B. 2002 ‘Model-centered organization science epistemology’ in The Blackwell companion to organizations. J. A. C. Baum (ed.), 752–780. Malden, MA: Blackwell. March, J. G., and H. A. Simon 1958 Organizations. New York: Wiley. Meacham, J. A. 1990 ‘The loss of wisdom’ in Wisdom. R. J. Sternberg (ed.), 181–211. New York: Cambridge University Press. Mead, G. H. 1956 Social psychology. Chicago: University of Chicago. Miller, J. G. 1978 Living systems. New York: McGraw-Hill. Orlikowski, W. J. 1996 ‘Improvising organizational transformation over time: A situated change perspective’. Information Systems Research 7/1: 63–92. Paget, M. 1988 The unity of mistakes: A phenomenological interpretation of medical work. Philadelphia, PA: Temple University Press. Pepinsky, H. B., J. Riner, M. Moll, and K. E. Weick 1966 ‘Research team productivity’ in Studies on behavior in organizations. R. Bower (ed.), 135–156. Athens, GA: University of Georgia. Perrow, C. 1984 Normal accidents. New York: Basic Books. Reason, J. 1997 Managing the risks of organizational accidents. Aldershot: Ashgate. Salancik, G. R. 1977 ‘Commitment and the control of organizational behavior and belief ’ in New Directions in Organizational Behavior. B. M. Staw and G. R. Salancik (eds), 1–54. Chicago: St. Clair Press. Schutz, W. 1979 Profound simplicity. New York: Bantam. Stinchcombe, A. L. 1982 ‘Should sociologists forget their mothers and fathers?’ The American Sociologist 17 (February): 2–11.

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Taylor, J. R., and E. J. Van Every 2000 The emergent organization: Communication as its site and surface. Mahwah, NJ: Erlbaum. Thayer, H. S. 1967 ‘Pragmatism’ in The encyclopedia of philosophy, Vol. 6. P. Edwards (ed.), 430–436. New York: Macmillan. Thompson, J. D. 1967 Organizations in action. New York: McGraw-Hill. Weick, K. E. 1969 Social psychology of organizing. Reading, MA: Addison-Wesley. Weick, K. E. 1979 The social psychology of organizing, 2nd edn. Reading, MA: Addison-Wesley. Weick, K. E. 1992 ‘Agenda setting in organizational behavior: A theory-focused approach’. Journal of Management Inquiry 1/3: 171–182. Weick, K. E. 1993 ‘Turning context into text: An academic life as data’ in Management Laureates: A collection of autobiographical essays. A. Bedeian (ed.), 285–323. Greenwich, CT: JAI Press. Weick, K. E. 1995 Sensemaking in organizations. Thousand Oaks, CA: Sage. Weick, K. E. 2003 ‘Theory and practice in the real world’ in The Oxford handbook of organization theory. H. Tsoukas and C. Knudsen (eds), 453–475. Oxford: Oxford University Press. Weick, K. E., K. M. Sutcliffe, and D. Obstfeld 1999 ‘Organizing for high reliability: Processes of collective mindfulness’ in Research in organizational behavior, Vol. 21. B. Staw and R. Sutton (eds), 81–123. Greenwich, CT: JAI Press.

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3 Faith, Evidence, and Action: Better Guesses in an Unknowable World Setting the Scene Chapter 3 describes an infrastructure that makes impermanent organization possible. That claim may seem surprising since words like organization, sensemaking, and organizing are not in the title. Instead, words like ‘faith,’ ‘guesses,’ and the ‘unknowable’ imply a set of reflections on the human condition rather than presumptions about organizational life. However, if you blur the line dividing the human from the organizational, as I did in 1969 (Weick, 1969, pp. 25–27), then you begin to see how organizing wraps around the flow of human experience. When you bring organizations back in on human terms, this fosters a richer appreciation of how to live with and manage organized experience. Consider the five words in the title: faith, evidence, action, guesses, and unknowable. They provide a synopsis of organizational experience. Faith points to expectations, presumptions, future perfect thinking, beliefs, self-fulfilling prophecies, all of which, under the press of culture and institutional logics, can convert the imagined into the material. Action often generates evidence that retrospectively strengthens these outcroppings of faith. When people say things to see what they think, that action of saying stirs up evidence that is seen selectively and finally thought about in the form of conjectures and presumptions. This edited thinking then informs subsequent saying. There is a steady progression from the less orderly saying, through the more ordered editing that occurs when people selectively see what they say, to the even more selective ordering bestowed by controlled inference and conjecture. Organizing increases as we progress from saying to seeing to thinking. The organizational context provided by norms, culture, and organizational logic shapes the substance of what is said, seen, and thought. ‘Faith’ in organizations takes the form of a future perfect presumption that ‘actions’ will have made sense. ‘Evidence’ in organizations typically consists of traces, clues, and fragments that are made sensible by actions that combine cues and ‘guesses’ into meaningful patterns. These are the basic tools we have to construct transient meaning in an unknowable world.

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There are regularities in the experience of organizing, as the six headers in Chapter 3 suggest. The routines, agreements, and goals in impermanent organizations, by definition, are subject to unraveling. Impermanence forces people to redo patterns that keep falling apart. To organize is to reaccomplish a sequence of acts and get them to recur. Recurrence is the source of order and redoing is the means to preserve that order. Labeling imposes order, but often at a cost. When organizations generalize and compound their abstractions, they put increasing distance between direct perceptions of continuous flow and indirect recasting of those perceptions into discrete conceptions. The benefits of compounded abstractions are that they facilitate shared images and allow collective coping. The cost of compounded abstractions is that people lose sight of differences that make a difference. Discarding is about the practice of dropping one’s tools in order to adapt to changed circumstances. Discarding reverses the compounding of abstractions and moves closer to mindful perception of change. Enacting reiterates the basic notion that people organize and create the environments that provide many of their constraints and opportunities. Enacting resembles improvisation, albeit ‘wary improvisation’ lest the order already achieved be entirely abandoned. Believing recapitulates many of the dynamics already suggested by our quick gloss of the word ‘faith.’ However, believing is more than faith (e.g. Weick, 1995, pp. 133–154). In the face of ceaseless change, people who organize strive for simultaneous belief and doubt since change is not total. Today’s truth may be partially false tomorrow. Finally, substantiating points to organizing as ongoing efforts to hold collective action together despite a relentless flurry of interruption and recovery (p. 39). These five themes and six regularities are all in play in the story of how child abuse was discovered, itself ‘a story of impermanence’ (p. 32). Ron Westrum’s (1993) published account of the surprisingly recent articulation of the ‘battered child syndrome’ was the lead incident (p. 1) in my book about sensemaking (Weick, 1995). I later met Westrum, a remarkably insightful man, and he asked, ‘Would you like to hear the rest of the abuse story?’ I then learned about how an expansion of treatment team capability through the addition of social workers helped pediatricians ‘see’ the child abuse they had previously explained away as brittle bones, spontaneous brain bleeding, and poor memory for details of injuries. Today’s truth, crystallized by social workers who knew how to deal with abusing parents, turned yesterday’s evasive rationalizations into falsehoods. Previously pediatricians and radiologists had organized a recurring diagnostic sequence that shielded them from darker possibilities. When they redid their recurring pattern of medical care, and changed the personnel and interactions, they made better guesses about the source of problems because the evidence became more meaningful. The takeaway that Westrum crafted from these data is a cornerstone of the perspective that is articulated throughout this book: ‘A system’s willingness to become aware of problems is associated with its ability to act on them’ (Westrum, 1993, p. 340). How can I know what I face until I see what my limited actions uncover. Limited actions lead to limited seeing leads to limited awareness. Limited awareness is a big liability in times of impermanence. Mindful practices and mindful structures remove some of these limits (see Chapter 6). Diagnosis followed by treatment is a generic sequence that is inherent in most organizing (e.g. Patriotta, 2003, on ‘breakdowns’). However, the crucial twist, implied by the idea that people act their way into cognition, is that diagnosis follows treatment; it lies in

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the path of the action (Starbuck, 2006; see Chapter 7). I know what I have been treating late in the game when I see differential responses to treatment. A child who supposedly bruises easily, develops no bruises at all when treated in a hospital. That outcome, interpreted by a social worker who is knowledgeable about protective services, yields a belated diagnosis of battered child syndrome. Physicians act their way into cognition, just like everyone else. In the case of child abuse, they abandoned their old cognitions when new personnel (social workers) offered new interpretations. Physicians began to talk differently. Just like everyone else, when people talk differently, what they see is different, what they think and do are different, and the consequences are different. This compounding of differences involves change and impermanent structures made sensible by continuous organizing. The following article was published in Organization Studies, 2006, 27(11), 1–14.

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Faith, Evidence, and Action: Better Guesses in an Unknowable World1 Karl E. Weick The final, definitive version of this paper has been published in Organization Studies, Issue 27(11), Copyright © 2004 SAGE Publications Inc. Reprinted with permission.

Keywords: alertness, sensemaking, mindfulness, enactment, improvisation

‘What the Romantics expressed as the claim that imagination, rather than reason, is the central human faculty was the realization that a talent for speaking differently, rather than arguing well, is the chief instrument of cultural change.’ (Rorty 1989: 111)

That reminds me of a story. Up until the mid 1950s pediatricians refused to believe that parents were beating their children even though they kept seeing X-rays where long bones in arms and legs had been broken and were in different stages of healing. This pattern suggested multiple traumas. But when pediatricians asked parents about these patterns, the parents usually said they didn’t remember and the physicians then diagnosed the child as having ‘brittle bones’. Here’s how Ron Westrum describes this troublesome period. Pediatricians, ‘were used to operating in a clinical context, with little control over what went on beyond the clinic. Many physicians, including pediatricians, had difficulty seeing themselves as the advocate of a child against the parents, even when the child had been savagely beaten. Thus, there was no immediate way to help the children, and it is tempting to hypothesize that the problem would not be recognized until somebody could see a solution. This is a particular application of a more general law: The system cannot think about that over which it has no control.’ (Westrum 1993: 336)

The breakthrough in diagnosing and treating child abuse occurred in the late 1950s when Henry Kempe formed interdisciplinary treatment teams in a Boulder, Colorado, hospital. These teams brought together radiology, pediatrics, and social work. The big change was the addition of social workers. Once social workers joined the team, there was no need for the other members to feel helpless in the face of manifest signs of child abuse because now there was a way to deal with it. Physicians didn’t know what to do with abusing parents but social workers did. They were familiar with protective services and how to separate abusing parents from the children that pediatricians kept handing back to them. With the addition of social workers, ‘Physicians now became more willing to see child abuse, to talk about it, and to prevent it. . . . Child abuse could 1

The main text of this article is reproduced without amendment.

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thus be better seen when there was an explicit social organization to deal with it’ (p. 338). The important message about alertness in this example is that ‘A system’s willingness to become aware of problems is associated with its ability to act on them’ (Westrum 1993: 340). When people develop the capacity to act on something, then they can afford to see it. More generally, when people expand their repertoire, they improve their alertness. And when they see more, they are in a better position to spot weak signals which suggest that an issue is turning into problem which might well turn into a crisis if it is not contained. This is a story of imagining and speaking differently. The social workers spoke differently of ‘protective services’. Physicians spoke differently when they stopped talking about cases of ‘multiple unsuspected trauma syndrome’ and started talking about the much more vivid ‘battered child syndrome’. Henry Kempe spoke differently when he partitioned his staff into ‘teams’ rather than individual stars. This is also a story of redoing, labeling, discarding, enacting, believing, and substantiating. These six themes reflect a handful of assumptions common to my work and they reflect some of what is discussed in the preceding papers.

Redoing The story of child abuse is a story of impermanence. In William James’s familiar imagery, ‘The world is a buzzing, pulsating, formless mass of signals, out of which people try to make sense, into which they attempt to introduce order, and from which they construct against a background that remains undifferentiated’ (cited in Patriotta 2003). People make sense, try to introduce order, and then selectively single out manageable moments from a vast undifferentiated background. When people ‘introduce’ ‘order’ there is no guarantee that it will persist. Typically, order is transient and needs to be reaccomplished repeatedly. Thus, an undifferentiated background is a constant threat (opportunity?) to swallow up the order people keep trying to establish. But that undifferentiated background has been part of our theorizing for a long time in such forms as Katz and Kahn’s (1978) discussion of entropy, chaos in complexity theory (Stacey 1992), smoke in Taylor and Van Every’s (2000) adaptation of Atlan’s (1979) imagery of smoke and crystal (see below), the notion of Cartesian anxiety (Varela et al. 1993), and Eric Eisenberg’s ‘groundlessness’. Impermanence imposes odd constraints on truth. ‘(W)e have to live to-day by what truth we can get to-day, and be ready to-morrow to call it falsehood . . . When new experiences lead to retrospective judgments, using the past tense, what these judgments utter was true, even though no past thinker had been led there’ (James 1975: 107). Marianne Paget makes a similar point in the context of medical errors: ‘A mistake follows an act. It identifies the character of an act in its aftermath. It names it. An act, however, is not mistaken; it becomes mistaken. There is a paradox here, for seen from the inside of action, that is from the point of view of an actor, an act becomes mistaken only after it has already gone wrong. As it is unfolding, it is not becoming mistaken at all; it is becoming.’ (Paget 1988: 56)

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For both James and Paget, a fundamental property of everyday life is that people believe ahead of the evidence. Pediatricians momentarily believe in brittle bones only to find later that the damage was more intentional. Things that seemed truthful at the time seem less hard and fast later. Anthropologists are well aware of this: ‘The after-the-fact, ex post, life-trailing nature of consciousness generally — occurrence first, formulation later on — appears in anthropology as a continual effort to devise systems of discourse that can keep up, more or less, with what, perhaps, is going on.’ (Geertz 1995: 19)

One way to focus the ‘life-trailing’ nature of consciousness on issues of organizing is to adopt the poetic imagery that Taylor and Van Every (2000) found so useful in depicting the emergent organization, the contrast between crystal and smoke (pp. 31, 324–326). They introduce this distinction, borrowed from Atlan (1979), in the context of self-organizing systems where life occupies the space created by the boundary conditions of crystal and smoke. ‘Crystal is a perfectly structured material, in its repeated symmetry of pattern, but because its structure is perfect, it never evolves: It is fixed for eternity. It is not life. But it is order. Smoke is just randomness, a chaos of interacting molecules that dissolves as fast as it is produced. It is not life either. But it is dynamic. Life appears when some order emerges in the dynamic of chaos and finds a way to perpetuate itself, so that the orderliness begins to grow, although never to the point of fixity (because that would mean the loss of the essential elasticity that is the ultimate characteristic of life.’ (Taylor and Van Every 2000: 31)

Applied to issues of organization, the boundaries formed by smoke and crystal become the limiting conditions between which organizing unfolds. Taylor and Van Every equate crystal with repetition, regularity, redundancy, and the preservation of many distributed conversations in the form of texts that stabilize and reproduce states of the world. They equate smoke with variety, unpredictability, complexity, and conversations whose outcomes are unpredictable and transient. Organization resides between smoke and crystal just as it resides between conversation and text. Organization is talked into existence when portions of smoke-like conversation are preserved in crystallike texts that are then articulated by agents speaking on behalf of an emerging collectivity. Repetitive cycles of texts, conversations, and agents define and modify one another and jointly organize everyday life.

Labeling The story of discovering child abuse is also a story of labels that make a difference (multiple trauma, brittle bones, battered child, child abuse, protective services). What becomes clear in the story is that vocabularies are tools for coping rather than tools for representation (Rorty 1989: 119). The question then becomes: What is the object that is at the focus of the coping? In the case of child abuse is it a child, parents, fellow pediatricians, medical teams, a reputation, symptoms, diagnosis, or getting through

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the day? Some of these objects are more social, some less so. And therein lies part of the issue for the vocabularies that are associated with organizing. The issue is what Robert Irwin has called ‘compounded abstraction’. That phrase summarizes the fate of initial perceptions as they are reworked in the interest of coordination and control. The essence of compounded abstraction is found in one of Irwin’s favorite maxims: ‘seeing is forgetting the name of the thing seen’ (Weschler 1982: 180). The naming that transforms originary seeing into consensual seeing is done to introduce order into social life. But the conceptions that accomplish this often come to ‘mean something wholly independent of their origins’ (p. 25). It is this potential for meanings to become divorced from their origins that predisposes to failures of inference. Baron and Misovich (1999) argue that sensemaking ‘starts’ with knowledge by acquaintance that is acquired through active exploration. Active exploration involves bottoms-up, stimulus-driven, online cognitive processing in order to take action, and naming plays a secondary role. But if people want to share their cognitive structures, those structures have to take on a particular form. As social complexity increases, people shift from perceptually based knowing to categorically based knowing in the interest of coordination. Now they develop knowledge by description rather than knowledge by acquaintance, their cognitive processing becomes schema-driven rather than stimulus-driven, and they go beyond the information given and elaborate their direct perceptions into types, categories, stereotypes, and schemas. The result is that now people know less and less about more and more. Knowledge by description is largely the language of organizations, as Tsoukas makes clear when he argues that generalizing is the prototypic act of organizing: ‘A distinguishing feature of organization is the generation of recurring behaviours by means of institutionalized roles that are explicitly defined. For an activity to be said to be organized implies that types of behaviour in types of situations are connected to types of actors . . . An organized activity provides actors with a given set of cognitive categories and a typology of action options . . . On this view, therefore, organizing implies generalizing; the subsumption of heterogeneous particulars under generic categories. In that sense, formal organization necessarily involves abstraction.’ (Tsoukas 2005: 124)

By this reading, both the organization and its people are concepts, mentally formed collections of direct experience with a name. Although ultimately neither people, selves, nor organizations exist, conventionally these concepts convert James’s ‘formless signals’ into activities and people and then hold them together long enough for people to couple actions with reasons. Nevertheless, these conceptual moves toward shared meaning and permanence generate a durable tension. In order to see something we need concepts. Perception without conception is blind. But concepts, abstractions, and schemas without perception are empty. The tension? Believing is seeing except that seeing is forgetting the name of the thing seen. To manage this tension we need observing that is more mindful, concepts that are more refined, and constraints on sharing that are less tight. Organizational designs that move in these directions should be associated with more reliable performance, less turnover, and greater innovation (Weick 2004).

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Organizational designs that accomplish these ends are often simultaneously loose and tight in their structures. They are tight around a handful of key values but loose around everything else. These softer constraints on coordination serve to increase the number of independent sensing elements that can register changes in the pattern of events (Campbell 1979). This increased capability for differentiated sensing allows for perceptually based knowledge to be better preserved in an otherwise schema-driven coordinated world. Differentiated sensing is the cornerstone of Western ideas about mindfulness. The progression from undifferentiated perception to shared public perceptions that are named, dimensionalized, reified, and treated as facts (Irwin 1977), can be done more mindfully if there is (1) active differentiation and refinement of existing distinctions, (2) creation of new discrete categories out of the continuous streams of events that flow through activities, and (3) a more nuanced appreciation of the context of events and of alternative ways to deal with that context (Langer 1989). This combination of differentiation, creation, and appreciation captures more details, evokes more varied roles. And converts those details into richer conjectures. What is new in all of this is the possibility that mindful acts as defined by Western philosophy incorporate more of the properties of Eastern mindfulness than has previously been recognized (Weick and Putnam, this book, chapter 6; Weick and Sutcliffe, 2006). When people engage in enriched distinction-making, their efforts often resemble acts with meditative properties. For example, when people make distinctions they may see some of the limits of a category and sometimes even of categorizing; they experience focused attention and see the costs of distraction; they pay more attention to what is happening here and now; they experience ‘entities’ as less substantial and more transient than they appear; they see the liabilities of swift thinking when they slow down to register finer distinctions and see how much is missed and distorted in the interest of speed; and there is gradual recognition that changes in events as well in oneself as perceiver are often not of one’s own making. When people engage in distinction-making, they begin to realize just ‘how quickly we put our experiences into tidy and unexamined conceptual boxes’ (Kabat-Zinn 2002: 69), how reluctant we are to examine those conceptual boxes, and how much is discovered when we do examine those boxes. Langer’s interventions to disrupt mindlessness tend to promote discrimination of subtle cues that had gone unnoticed before. When these cues are noticed, routines that had been unfolding mindlessly are interrupted. And when routines are disrupted, the resulting void is similar to the void induced by quiet meditation. When either void is created, past experience no longer serves as a firm guide and the disruption ‘stirs the cognitive pot’. Since the void is momentarily tough to categorize and label, it serves as a moment of overlap between Western conceptual mindfulness and Eastern non-conceptual mindfulness. During this moment more is seen and more is seen about seeing itself.

Discarding The story of child abuse is a story that is filled out by the irony that people enlarge their repertoire for acting by dropping some of their tools. Pediatricians dropped their belief

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that child abuse was unthinkable. They dropped the bizarre diagnoses that had dominated pre-social-worker days, diagnoses such as spontaneous subdural hematoma (child suddenly develop serious brain bleeds), non-specific bleeding disorders, family history of being easily bruised, born with brittle bones. They dropped the tepid label under which they grouped these cases, ‘multiple unsuspected trauma syndrome’, and replaced it with the much more vivid label, ‘battered child syndrome’. They stopped arguing that child abuse was rare and was confined to insane parents (Westrum 1993: 333). And toughest of all, they stopped trusting parents who remained silent about relevant history when x-rays of their children revealed signs of trauma that parents didn’t remember. It’s also instructive to ask why the pediatricians didn’t drop their tools sooner, since those reasons closely resemble the reasons other groups such as wildland firefighters refused to drop their tools and perished (Weick 1996). Physicians refused to drop their face-saving diagnoses because, if they did, they would have to admit a terrible reality. In the words of one pediatrician, ‘if I believed the parent could abuse the child I would leave pediatrics immediately’ (Westrum 1993: 335). That’s no different than a firefighter keeping his chain saw while trying to outrun a fire because, to drop it, means that he has to admit the terrible reality that he’s trapped and the end is near. Pediatricians maintained the belief that they were central players in medical practice, which lured them into what Westrum calls the ‘fallacy of centrality’. They reasoned, ‘If abuse were going on, I in my central position would know about it. Since I don’t know about it, it’s not going on.’ That belief pretty much put an end to curiosity. Pediatricians also refused to drop their diagnoses because those diagnoses were questioned by radiologists who were lower status medical personnel. Pediatricians also didn’t know how to drop their face-saving diagnoses (e.g. what do I do if I suspect that abuse is the problem?). But most of all, pediatricians kept their tools because none of the other pediatricians were dropping theirs. The larger point for learning may be this: ‘In pursuit of knowledge, every day something is acquired. In pursuit of wisdom, every day something is dropped’ (Lao Tzu, cited in Muller 1999: 134).

Enacting The abuse story is a story of enacting. Pediatricians create the environment which then constrains them. Having publicly chosen to make the irrevocable diagnosis of brittle bones, they then have no choice but to hand the abused child back to the abusing parents with the chilling counsel to pay closer attention to the child. Reuben McDaniel captures the essence of enacting in a way that meshes with James’s portrayal of a buzzing world: ‘Because the nature of the world is unknowable (chaos theory and quantum theory) we are left with only sensemaking. Even if we had the capacity to do more, doing more would not help. Quantum theory helps us to understand that the present state of the world is, at best, a probability distribution. As we learn from chaos theory, the next state of the world is unknowable. And so we must pay attention to the world as it unfolds. Therefore, it is a good thing that we can’t do more than sensemaking . . . because then we would only

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be frustrated by our inability to know. But believing enables actions which leads to more sense (sometimes) and taking action leads to more sense (sometimes) and sensemaking connects actions to beliefs (sometimes).’ (Reuben McDaniel, personal communication)

Enacting involves shaping the world (e.g. a self-fulfilling prophecy verifies itself) as well as stirring the world so that it yields what we then treat as ‘answers’. Typically all it takes to trigger and guide enactment is a small structure such as a melody, a map (even any old map under the right circumstances), a crack in a caribou shoulder bone, a simple if-then plotline, or a nudge at a tipping point. These minimal structures often are sufficient to produce order since they animate activity, calm fears, get people in motion, and focus attention, all of which serve to update the initiating structures. These sequences are moments of enactment. They inhabit and structure the territory between smoke and crystal, which means that enactment, faith, and improvisation are foundational in enactment. The close ties among faith and enactment are visible in Gilbert Ryle’s (1979) description of the improvisational quality of everyday life: ‘To be thinking what he is here and now up against, he must both be trying to adjust himself to just this present once-only situation and in doing this to be applying lessons already learned. There must be in his response a union of some Ad Hockery with some know-how. If he is not at once improvising and improvising warily, he is not engaging his somewhat trained wits in a partly fresh situation. It is the pitting of an acquired competence or skill against unprogrammed opportunity, obstacle or hazard. It is a bit like putting some new wine into old bottles.’ (p. 129)

The important point is that improvisation does not materialize out of thin air. Instead, it materializes around a simple structure that provides the pretext for realtime enacting. Some of that composing is built from precomposed phrases that become meaningful retrospectively as embellishments of that structure. And some comes from elaboration of the embellishments themselves. The use of precomposed fragments in the emerging action is an example of Ryle’s ‘wary improvisation’ anchored in past experience. The further elaboration of these emerging embellishments is an example of Ryle’s opportunistic improvisation in which one’s wits engage a fresh, once-only situation. Considered as a noun, an improvisation is a transformation of some original model. Considered as a verb, improvisation is composing in real time that begins with embellishments of a simple model, but increasingly feeds on these embellishments themselves to move farther from the original structure and closer to the flexibility that Martha Feldman (2000) observes in routines and that John Dewey (1922/2002) sees in habits.

Believing Belief and faith are prerequisites of organizing and sensemaking. Enactment and improvising both represent bets that an unfolding action will have made sense. Such action often verifies itself. ‘Again and again success depends on energy of the act; energy depends on faith that we shall not fail; and that faith in turn on the faith that we are

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right — which faith thus verifies itself ’ (McDermott 1977: 339). Applied to this essay and the work it describes, James’s deviation amplifying feedback loop looks like this. In the beginning I bet that the vocabularies of sensemaking and organizing will help people cope [this is James’s step which he labels ‘faith that we are right’]. I’m also betting that if I look for sensemaking and organizing, I’ll find them when I observe coping and recovering [‘faith that we shall not fail’]. I look persistently and enthusiastically in varied settings, mostly in the work of others, to see what their story is [‘energy of the act’]. And I find what looks to me like sensemaking and organizing [‘success’]. And so I place further bets on these concepts, which strengthens faith, which . . . This is not what you would call a rhetoric of falsification. Nor is it a particularly calming rhetoric. Think about the variable that James calls ‘faith that we are right’. Taken to the extreme that phrase raises the specter of the true believer, unwilling and unable to listen, and self-righteous to the core. While faith creates order, doubt (Ryle’s ‘wary improvisation’) fine tunes that faith by differentiating things known from things not known. Simultaneous believing and doubting (Weick 1979), the signature of a wise act (Meacham 1990), do not sever the links in James’s depiction. Instead, that simultaneity weakens the link that goes from success to ‘faith that we are right’. Enthusiasm is the friend of action but the enemy of wisdom. Nevertheless, in an unknowable, unpredictable world, the energy of the act may temporarily displace wisdom, since we need to act in order to see what we think. Cognition lies in the path of the action but the forcefulness of that action makes a difference. Thus, despite the seeming emphasis on thought, belief, faith, and other ‘neck up’ determinants, the ideas being discussed are also about hard work, the energy of the act, intensity (Weick 1979: 54), effort expenditure (Weick 1964), enthusiasm, and forcefulness while ‘acting thinkingly’ (Weick 1983). Descriptions of the world are up for grabs, so presumptive descriptions (e.g. this music has been composed by a novice composer1) are sufficient to mobilize confirming actions (e.g. minimal attention to the music score while rehearsing), selective attention (e.g. novel passages are treated as signs of incompetence rather than creativity), the result being error-filled music that sounds bad and confirms the ineptness of the composer. There is order in the sound produced, order in the rehearsing, and order in the sense made of it all, but musicians tend to underestimate their centrality in producing this outcome. I’ve treated belief and faith as if they were synonymous, but dictionaries warn against doing this. ‘Belief, faith, credence, credit are comparable when they mean the act of one who assents intellectually to something proposed or offered for acceptance as true or the state of mind of one who assents’ (Merriam-Webster 1984: 96). What sets faith apart from belief is intensity, full assent rather than mere mental acceptance. It is often that difference between ‘mere acceptance’ and ‘full assent’ that determines the likelihood of verification. Sooner or later bets are made. And it is not clear that hedging solves much of anything. When vocabularies of the invisible (e.g. faith, belief) are focused on organizing, questions change. In what ways does an organizational culture based on belief differ from one based on faith? What is the role of guesses in organizing? Is distributed abduction a model for organizing in the face of unknowability? When considering issues of belief and faith, it is crucial that we reach outside traditional notions of deduction and induction, and revisit Charles S. Peirce’s third form

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of reasoning which he called abduction. Abductive reasoning is reasoning that forms and evaluates hypotheses in order to make sense of puzzling facts (Magnani 2001). Discussions of abductive reasoning are found in the work of people such as Ginzburg (1988), Harrowitz (1988), and Patriotta (2004) who argue that the conjectural paradigm, grounded in abductive reasoning, is the foundation of inquiry. The basic idea is that when people imagine reality, they start with some tangible clue and then discover or invent a world in which that clue is meaningful. This act of invention is an act of divination. The Naskapi Indians, for example, heat the shoulder bones of caribou until they crack, and then treat the cracks as a map of where hunters will find caribou. The crack is a tangible clue that gives meaning and becomes meaningful in the surrounding physical world (Moore 1957; Weick 1979: 262). The essence of conjecture and divination lies in the faith that a fragment is a meaningful symptom which, if pursued vigorously, will enact a world where the meaning of the fragment becomes clearer. Conjecture essentially utilizes ‘obscure or remote clues in a speculative manner to build an epistemological model’ (Harrowitz 1988: 183). Clues enable people to ‘leap from apparently significant facts, which could be observed, to a complex reality which — directly at least — could not’ (Harrowitz 1988: 184). ‘The importance of the conjectural model is not found in the notion of reading coded signs such as imprints [animal footprints], but rather in the fact that the systems . . . were developed and invested with meaning through a process much like abduction. The rules were postulated to explain the observed facts . . . As in abduction, a cultural or experiential knowledge is required to codify a system. Abduction is literally the groundwork necessary before a sign is codified.’ (Harrowitz 1988: 184).

When an observed fact is read through an imagined rule, this action can generate a world not previously thought of.

Substantiating So what is the thread in all of this? These ideas represent an effort to get a better grasp on what John Dewey portrayed as a fundamental dynamic in life: ‘In every waking moment, the complete balance of the organism [system] and its environment is constantly interfered with and as constantly restored. Hence the “stream of consciousness” in general, and in particular that phase of it celebrated by William James as alternation of flights and perchings. Life is interruptions and recoveries.’ (Dewey 1922/2002: 178–179)

Order, interruption, recovery. That is sensemaking in a nutshell. And organizing is the act of trying to hold things together by such means as text and conversation, justification, faith, mutual effort (heedful interrelating), transactive memory, resilience, vocabulary, and by seeing what we say in order to assign it to familiar categories. Efforts to hold it together are made necessary by interruptions such as regression, thrownness, inconsistency, cosmology episodes, forgetting, the unexpected, threats, and disasters. Our job

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as researchers is to develop theories about what ‘holding it together’ means, what it depends on, and when what it depends on happens (Gilbert 1998: 139). We can do better at such theorizing, Many people resonate to Kierkegaard’s statement that ‘It is perfectly true, as philosophers say, that life must be understood backwards. But they forget the other proposition, that it must be lived forwards’ (Gardiner 1988: 90). Fewer people are able to talk about the quandary of living forward with limited foresight and understanding backward with unlimited hindsight. To produce better theories means in part to make them more isomorphic with living forward. That means we have to find better descriptions of thrownness, making do, and expectations, all of which may amount to something, although we seldom know what that something will be until it’s too late to do much about it. Living forward that is unsettled, emergent, and contingent contrasts sharply with our backward-oriented theoretical propositions that depict that living as settled, causally connected, and coherent after-the-fact. Better theorizing lies in ‘keeping up with what perhaps is going on’ through the use of tactics that weaken hindsight, highlight interruptions, articulate the nature of ready-to-hand alertness, fold action and cognition together, and focus on projects as the unit of analysis. As an example of such tactics, consider a hybrid formulation that combines Heidegger (1962) and Thorngate (1976). When people act forward with what Heidegger (1962) calls ‘absorbed coping’ in a ready-to-hand mode of engagement, they are aware of the world holistically as a network of interrelated projects rather than as an arrangement of discrete physical objects such as tools. If one of these projects is interrupted, then their experience changes into an unready-to-hand mode. Problematic aspects of the whole situation stand out, but people still do not become aware of context-free objects. It is only when people step back from the project in a present-at-hand mode, and reflect on it using analyses that are general and context-free, that tools, artifacts, and objects emerge. These tools are treated as independent entities, removed from tasks, endowed with distinct measurable properties of mass and weight, and manipulable by distinct subjects. If we align Heidegger’s threefold distinction with Thorngate’s (1976) postulate that no explanation can be simultaneously general, accurate, and simple (Weick 1979: 35–42), then we arrive at an intriguing possibility. Thorngate’s postulate may hold true for present-at-hand theories, but not for implicit theories associated with ready-to-hand engagement. A present-at-hand explanation, by definition, is stripped of context, situation, configuration, relational meaning, and particulars, which means it has some combination of generality and simplicity but lacks accuracy. General-simple explanations fail to move us because they misrepresent the world of involved actors. They miss the fact that reason may take the form of ready-to-hand abduction rather than presentat-hand deduction and induction. Ready-to-hand reasoning tends to consist of reasons that are simultaneously plausible (general), accessible (simple), and consensually valid (accurate). Thus, the gap between living forward and understanding backward may be created by theories that are insensitive to context and situational particulars. If a theory incorporates more context, then it should be seen as either general-accurate or simpleaccurate. And theories that incorporate some measure of accuracy should be seen as closer to ready-to-hand patterns found in absorbed coping. We all would like to create theories that contribute to absorbed coping. In my case I often come up short because of issues such as boundary conditions and self-referential

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inconsistency. For example, I’m prone to talk universals and to say things like, ‘everything we ever wanted to understand about the human condition is all right there in Mann Gulch: understand Mann Gulch, and you’ve got it!’ That’s a stretch to say the least. I wish I were better at crafting the differentiations that are found in the rich 2 ⫻ 2 matrices that anchor work by Schulman (2004), Eden (2003), Perrow (1984), and Tsoukas and Shepherd (2004). Harvard’s Steve Kelman (personal communication 7 March 2006) recently spotted a boundary condition in my work that I had never noticed, namely, most of that work is grounded in public sector organizations including CDC, US Navy carriers, United States Forest Service, Central Intelligence Agency, FAA air traffic control, NTSB accident investigations, UK health system, FBI laboratories, public schools, state universities, NASA, teaching hospitals, and the Bureau of Land Management. The small commercial remainder includes Union Carbide’s Bhopal plant, GE’s globalization efforts, Frank Gehry’s architecture firm, and AES when it was flying high partly because of its association with Bob Waterman. The issue of self-referential inconsistency is a different kind of shortcoming. The term was coined by Richard Rorty (1989: 123, note 2) to describe those who claim to know things that they claim cannot be known. An example would be people who claim that what we call real is not really real. If that claim is true, how could they know it’s true? In my case I sometimes act as if I have an accurate view of a world in which only plausibility is possible. I claim to know that it’s all flux, that prophecies fulfill themselves, that a contour gauge somehow registers plausible accounts (this is Walter Nord’s nomination for my most blatant inconsistency). I claim to know how others make sense, but my efforts are nothing more or less than that same sensemaking, subject to the same resources of SIR COPE I attribute to others (social setting, identity, retrospect, cues, ongoing development, plausibility, enactments; Weick 2001: 461), which resources are themselves merely one reflective account of life between smoke and crystal. And who’s to say that SIR COPE matters anyway? The world is up for grabs, except that’s not true for the insight that the world is up for grabs. So is this the grand discounting of sensemaking, the ultimate sacrifice to help people shorten their readings lists? Nope. It is more like paying close, reflexive attention to social moves while staying as close as possible to people’s experience and what they do with what seems to happen to them, all the while accepting the fact that, regardless of how interesting the portrait may seem, things are likely to be otherwise. This should not be heard as a voice of nihilism resigned to the fact that we’re all in this alone, craving more crystal and less smoke. The message is just the opposite. Cognition and feeling lie in the path of the action. Is life worth living? When William James asked that question, he made it very clear that either answer is correct. Answer ‘no’ and that presumption generates the withdrawal and bad times that eventuate in suicide, the ultimate verification. Answer ‘yes’ and that presumption generates the engagement and good times that make for good company. The question then becomes, what kinds of vocabularies foster faith, coping, and better guessing? The answer, in science as in everyday life is that, if the goal is to compose useful vocabularies, then tests of usefulness lie in the outcomes of actions that take place in the presence of these vocabularies. The words I struggle with seem to contribute to resilience. But if they don’t, if interruptions lead instead to further collapse rather than resilience, then we need to find a different set of words, a different way of saying so we see and think differently, and a different way to imagine more energetically.

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On the wall above my desk is a smudged sign from a machine shop that was run by the old New York Central Railroad. The sign reads, ‘Be where you are with all your mind.’ That message influenced the content of this brief essay. But so did a second, more troubling sign. It reads, ‘A true philosopher says only one thing in his lifetime because he enjoys but one contact with the real’ (Wagner 1983: 115). As I’ve said elsewhere (Weick 2001: ix), my one contact with the real seems to have been my dissertation in 1961 on cognitive dissonance (Weick 1964). Vestiges of these ideas still appear in my thinking (e.g. Weick 1995: 11–12; Weick 1993). This continuing affinity for cognitive dissonance undoubtedly can be traced back to pre-dissertation moments of consequential interruptions fostered by the unexpected, the inconsistent, the inexplicable. The two signs seem to pull in different directions, one toward the present, the other toward a consequential past. But those opposing pulls are more apparent than real. While it may be true that we have only one contact with the real, that one contact with the real is the present contact since that’s the only reality that ever exists. So, neither my remarks nor those of the others in this special issue are a leisurely stroll down memory lane. Instead, they represent our current joint best efforts to convert the terrain between smoke and crystal into mindful intensity, mindful ordering, and mindful listening.

Note 1 See Weick et al. (1973) for a field experiment that demonstrates the effects on performance of the presumption of logic when it is attached to a skilled composer and to an unskilled composer.

References Atlan, H. 1979 Entre le cristal et la fumee (Between crystal and smoke). Paris: Editions de Seuil. Baron, R. M., and S. J. Misovich 1999 ‘On the relationship between social and cognitive modes of organization’ in Dual-process theories in social psychology. S. Chaiken and Y. Trope (eds), 586–605. New York: Guilford. Campbell, D. T. 1979 ‘A tribal model of the social system vehicle carrying scientific knowledge’. Knowledge: Creation, Diffusion, Utilization ½: 181–201. Dewey, J. 1922/2002 Human nature and conduct. Mineola, NY: Dover. Eden, L. 2003 Whole world on fire: Organizations, knowledge, and nuclear weapons devastation. Ithaca, NY: Cornell University Press. Feldman, M. S. 2000 ‘Organizational routines as a source of continuous change’. Organization Science 11/6: 611–629. Gardiner, P. 1988 Kierkegaard. Oxford: Oxford University. Geertz, C. 1995 After the fact. Cambridge, MA: Harvard University. Gilbert, D. T. 1998 ‘Ordinary personology’ in The Handbook of Social Psychology, Vol. 2. D. T. Gilbert, S. T. Fiske, and G. Lindzey (eds), 89–150. Boston, MA: McGraw-Hill. Ginzburg, C. 1988 ‘Morelli, Freud, and Sherlock Holmes: Clues and scientific method’ in The sign of three: Dupin, Holmes, Peirce. U. Eco and T. A. Sebeok (eds). Bloomington, IN: Indiana University Press.

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Harrowitz, N. 1988 ‘The body of the detective model: Charles S. Peirce and Edgar Allan Poe’ in The sign of three: Dupin, Holmes, Peirce. U. Eco and T. A. Sebeok (eds). Bloomington, IN:Indiana University Press. Heidegger, M. 1962 Being and time. New York: Harper & Row. Irwin, R. 1977 ‘Notes toward a model’ in Exhibition catalog for the Robert Irwin exhibition, Whitney Museum of American Art, April 16 – May 29,1977. 23–31. New York: Whitney Museum of American Art. James, W. 1975 Pragmatism. Cambridge, MA: Harvard University Press. Kabat-Zinn, J. 2002 ‘Meditation is about paying attention’. Reflections 3/3: 68–71. Katz, D., and R. L. Kahn 1978 The social psychology of organizations, 2nd edn. New York:Wiley. Langer, E. 1989 ‘Minding matters: The consequences of mindlessness-mindfulness’ in Advances in Experimental Social Psychology, Vol. 22. L. Berkowitz (ed.), 137–173. San Diego, CA: Academic. Magnani, L. 2001 Abduction, reason, and science: Processes of discovery and explanation. New York: Kluwer Academic. McDermott, J. J. 1977 The writings of William James. Chicago, IL: University of Chicago Press. Meacham, J. A. 1990 ‘The loss of wisdom’ in Wisdom: Its nature, origins and development. R. J. Sternberg (ed.), 181–211. New York: Cambridge University Press. Merriam-Webster 1984 Merriam Webster’s Dictionary of Synonyms: A Dictionary of Discriminated Synonyms with Antonyms and Analogous and Contrasted Words. New York: Merriam-Webster. Moore, O. K. 1957 ‘Divination-a new perspective’. American Anthropologist 59: 69–74. Muller, W. 1999 Sabbath: Restoring the sacred rhythm of rest. New York: Bantam. Paget, M. 1988 The unity of mistakes: A phenomenological interpretation of medical work. Philadelphia, PA: Temple University. Patriotta, G. 2003 ‘Sensemaking on the shop floor:Narratives of knowledge inorganizations’. Journal of Management Studies 40/2: 349–376. Patriotta, G. 2004 Organizational knowledge in the making: How firms create, use and institutionalize knowledge. Oxford, UK: Oxford University Press. Perrow, C. 1984 Normal accidents. New York: Basic. Rorty, R. 1989 Contingency, irony, and solidarity. Cambridge, UK: Cambridge University Press. Ryle, G. 1979 ‘Improvisation’ in On thinking. 121–130. London: Blackwell. Schulman, P. R. 2004 ‘General attributes of safe organizations’. Quality and Safety in Health Care 13/Supplement II: ii39–ii44. Stacey, R. D. 1992 Managing the unknowable. San Francisco: Jossey-Bass. Taylor, J. R., and E. J. van Every 2000 The emergent organization: Communication as its site and surface. Mahwah, NJ: Erlbaum. Thorngate, W. 1976 ‘Possible limits on a science of social behavior’ in Social psychology in transition. L. H. Strickland, F. E. Aboud, and K. J. Gergen (eds), 121–139. New York: Plenum. Tsoukas, H. 2005 Complex knowledge: Studies in organizational epistemology. Oxford, UK: Oxford University Press. Tsoukas, H., and J. Shepherd, editors 2004 Managing the future: Foresight in the knowledge economy. Oxford, UK: Blackwell. Varela, F., Thompson, E., and E. Rosch 1993 The embodied mind. Cambridge, MA: MIT Press. Wagner, H. R. 1983 Phenomenology of consciousness and sociology of the Life-World: An introductory study. Edmonton, Alberta: University of Alberta Press. Weick, K. E. 1964 ‘The reduction of cognitive dissonance through task enhancement and effort expenditure’. Journal of Abnormal and Social Psychology 68: 533–539.

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Weick, K. E. 1979 The social psychology of organizing, 2nd edn. Reading, MA: Addison-Wesley. Weick, K. E. 1983 ‘Managerial thought in the context of action’ in The executive mind. S. Srivastava (ed.), 221–242. San Francisco, CA: Jossey-Bass. Weick, K. E. 1993 ‘Sensemaking in organizations: Small structures with large consequences’ in Social psychology in organizations: Advances in theory and research. J. K. Murnighan (ed.), 10–37. Englewood Cliffs, NJ: Prentice-Hall. Weick, K. E. 1995 Sensemaking in organizations. Thousand Oaks, CA: Sage. Weick, K. E. 1996 ‘Drop your tools: An allegory for organizational studies’. Administrative Science Quarterly 41/2: 301–313. Weick, K. E. 2001 Making sense of the organization. Oxford, UK: Blackwell. Weick, K. E. 2004 ‘Rethinking organizational design’ in Managing as designing. R. J. Boland and F. Collopy (eds), 36–53. Stanford, CA: Stanford University Press. Weick, K. E., and T. Putnam in press ‘Organizing for mindfulness: Eastern wisdom and Western knowledge’. Weick, K. E., and K. M. Sutcliffe in press ‘Mindfulness and the quality of organizational attention’. Weick, K. E., D. P. Gilfillan, and T. Keith 1973 ‘The effect of composer credibility on orchestra performance’. Sociometry 36: 435–462. Weschler, L. 1982 Seeing is forgetting the name of the thing one sees: A life of contemporary artist Robert Irwin. Berkeley, CA: University of California Press. Westrum, R. 1993 ‘Thinking by groups, organizations, and networks: A sociologist’s view of the social psychology of science and technology’ in The social psychology of science. W. Shadish and S. Fuller (eds), 329–342. New York: Guilford.

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II Attending 4. Managing the Unexpected: Complexity as Distributed Sensemaking 5. Information Overload Revisited 6. Organizing for Mindfulness: Eastern Wisdom and Western Knowledge

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4 Managing the Unexpected: Complexity as Distributed Sensemaking Setting the Scene The West Nile Virus became established in the United States, in part, because information was distributed unevenly among agencies, the agencies were loosely coordinated, and people developed different explanations of an odd pattern of human and animal deaths. The picture of this distributed sensemaking is complex, thereby exemplifying the ‘assumption of complexity’ mentioned in Chapter 2 (see p. 20). The formal set of concepts fashioned to make sense of this complexity, complexity theory (e.g. Axelrod and Cohen, 1999), provides insight into what happened in the West Nile incident. As this essay begins to show, the ideas of complexity theory, when combined with those of sensemaking theory, provide a powerful combination to understand thick, dense events that have high stakes. Buried in this essay are several points that may help analysts and practitioners think differently about organizations. For example, new possibilities are raised by the juxtaposition of James Thompson’s older formulation of forms of interdependence with newer work on cognition by Hutchins and Rasmussen (see p. 54 in this chapter). The key idea is that different forms of interdependence induce different forms of thinking. These forms of thinking range from automatic to controlled. For example, the Center for Disease Control and Prevention’s (CDC) initial work on the puzzling West Nile Virus was done mainly by people who contributed different hunches that were assembled without much interaction. This pooled interdependence appears to evoke automatic thinking which means that odd, outlier symptoms tend to be dismissed and routine diagnoses are produced. The more reflective and controlled styles of thinking tend to emerge when interdependence moves from pooled to sequential to reciprocal. We see these more relationally rich styles appear within smaller diagnostic labs, across labs among scientists who have worked together, and within the larger community of animal disease experts, but less so in the community of human disease experts. These relational ties are important because, as mentioned on page 57, intelligence is a product of interconnectivity. Less connectivity means less intelligence, and more likelihood of misdiagnosis.

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THE IMPERMANENT ORGANIZATION

The reader should be attentive to the themes of distribution and sensemaking in this essay, since they are present in almost any discussion of organization and impermanence. Robert Chia’s reference to ‘a loosely coordinated but precarious “world-making” attempt to regularize human exchanges’ alerts us to the reality of dealing with distributed resources. His reference to ‘world-making’ alerts us to the difficulty of sensemaking and finding common ground when resources are distributed. It is important to make one’s peace with the reality of distribution, if for no other reason than that no two people have had identical experiences. This means that no two people see things exactly the same. Compound that differential by the 1000s in large organizations, and impermanence and conflict become givens. However, if they are givens, then one thing this suggests is that the much discussed problem of poor communication is not the catchall diagnosis of dysfunction that most people claim. Reeves and Turner (1972) saw this more than 35 years ago. The distributed sensemaking and loose coordination that we see in the CDC’s handling of the West Nile Virus look a lot like the ‘variable disjunction of information’ that Reeves and Turner observed when they studied production scheduling (1972). Variable disjunction refers to ‘a complex situation in which a number of parties handling a problem are unable to obtain precisely the same information about the problem so that many differing interpretations of the problem exist’ (Turner, 1978, p. 50). In the scheduling study, Reeves and Turner were struck by the vast number of amendments that had to be made in production plans for the manufacture of complex electronic equipment and precision hydraulic equipment to accommodate ‘differing sets of information about stock levels and work in progress, and their relation to customer demand’ (p. 90). These amendments were necessary because people had different sets of information, something that was due less to poor communication than to the complexity of the situation. This state of affairs was conceptualized as ‘the variable disjunction of information’ and described this way: The inability to gather all the necessary information in each of the two batch production factories may be characterized as a state of variable disjunction of information. It is variable because the state is not one in which no information can be exchanged or amplified to remove discrepancies: such exchanges are constantly being made, so that the content of the sets of information which are disjoined is always varying. However, no single agreedupon description of the situation exists. People who have to operate in a situation in which there is disjunction of information are unlikely to reach complete consensus about the information which describes the total situation, simply because of the problem of convincing others of the status of their own set of information and thus of the validity of their analysis of the situation and their suggestions for action (Reeves and Turner, 1972, p. 91).

Situations that give rise to hazards like the West Nile Virus are like batch production problems in the sense that they are not well structured. In both instances information is distributed among numerous parties, each of whom forms a different impression of what is happening based on what they see. The cost of reconciling these disparate views is high so discrepancies and ambiguities in outlook persist. There is no agreed upon single authoritative description, which means multiple theories develop about what is happening and what needs to be done. While the costs of reconciling these discrepancies are high at the CDC, it is their job to incur those costs and accomplish reconciliation.

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Athough the CDC strives for a ‘single authoritative description,’ that is easier said than done because of things like emerging infectious diseases, different diagnostic technologies, diverse specialties of diagnosticians, competition for scarce funding, and changes in a talented workforce. The CDC is not simply a batch production facility, although many of its interactions resemble those of batch production (e.g. pooled and sequential interdependence). While competition and a steady stream of winning and losing produce impermanence, we must not lose sight of the fact that people fight against this impermanence with attachments that they presume will produce permanence (recall Chia’s phrase ‘develop a predictable pattern of interactions for the purpose of minimizing effort’). The Fort Collins laboratory, for example, is attached to its diagnosis of St Louis Encephalitis (SLE) because it means they can focus on a huge backlog of specimens to see which patients might suffer from this known disease. Attachment to the SLE diagnosis also means that personnel at Fort Collins do not have to expend effort with their scarce resources on tracking reasons why their test specimens show such weak indications of SLE. Chapter 4 reintroduces the concept of sensemaking by means of practitioner Paul Gleason’s (p. 56) powerful statement that he is a better leader when he views himself as a sensemaker rather than as the decider. This quotation appears more than once in this book simply because it is a compact way to differentiate sensemaking from decision making, it reflects one way that practitioners implement sensemaking, and the statement itself has widespread relevance since Gleason, like so many others, practices sensemaking in the context of rapidly changing complex events, in his case extreme wildland fires. The seven properties of sensemaking, summarized by the acronym SIR COPE, are described in the context of the CDC, yet in such a way that they can be transferred to other settings. An updated view of work on sensemaking is found in Chapter 8. However, the brief discussion in the current chapter is sufficient to sensitize the reader to what sensemaking entails. On a concluding note, while there is plenty of drama already in the West Nile case, that drama intensifies when we realize that many influential people saw this event as a dress rehearsal for how the United States would deal with a bioterrorism attack. Their verdict was largely that we have a lot to learn and are quite vulnerable. Less often mentioned in these critiques, but crucial to this book, is the further lesson that a major way we can reduce vulnerability is to redesign organizing processes so that richer thinking is activated more quickly among a greater number of people, all of whom try to update what they know regardless of its source. That is a tall order considering the preexisting variety in language used, distribution of information, sensemaking tactics, rivalries, and past experience.

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Managing the Unexpected: Complexity as Distributed Sensemaking Karl E. Weick The following article was published as Chapter 5 in Reuben R. McDaniel Jr and Dean J. Driebe (Eds), Uncertainty and Surprise in Complex Systems: Questions on Working with the Unexpected, Springer-Verlag, 2005, pp. 51–78. Reprinted with kind permission of Springer Science⫹Business Media.

In 1998 the Centers for Disease Control (CDC) published a statement of their strategy entitled “Preventing Emerging Infectious Diseases: A Strategy for the 21st Century.” They described their central challenge this way: “because we do not know what new diseases will arise, we must always be prepared for the unexpected” (p. vii). Soon after they published that statement CDC was confronted with an unexpected emerging disease, the West Nile Virus, which they misdiagnosed initially. Much of what we think of as crucial in organizational life is visible in this incident. The question is, to what extent do concepts dealing with complexity help us understand what is visible in this incident? The juxtaposition of the concept of complexity and the activity of diagnosing sets up a tension that was anticipated by Immanuel Kant when he said, ‘perception without conception is blind, and conception without perception is empty.’ Do concepts associated with complexity remove blindness when we watch how CDC wades into a puzzling set of symptoms? And do observations of diagnostic activity that unfolded at CDC remove some of the emptiness associated with ideas of non-linear dynamics, emergence, turbulence, complex adaptive systems, heterogeneous agents, self-organization, and messes? I do not intend to interweave complexity theory with organizational theory as is already being done by people like Anderson (1999) and Eisenhardt and Bhatia (2002). Instead, I want to talk about organizing in the face of the unexpected. I want to use the West Nile episode as my running illustration and I want to juxtapose ideas about complexity, cognition, and sensemaking in order to argue that if complexity ideas3 are made more cognitive and more relational, they look like human sensemaking. And if you make that translation, then complexity ideas would have even more relevance to human organizing.

Overview of the Event The basic story of the West Nile diagnosis is this4. The Centers for Disease Control (CDC) were contacted on August 27, 1999 by the NYC Health Dept., and formally invited on August 30, 1999, to help diagnose a cluster of patients who had been

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admitted to intensive care at Flushing hospital with unusual symptoms: fever, headache, mental confusion, severe muscle weakness. Some of these admissions died. Among the suspected causes were botulism (a potential bioterrorism agent), and Guillain Barre disease. But analysis of spinal fluid had also suggested a viral infection. After testing samples of blood serum, CDC and NYC jointly announced on September 3 that there was an outbreak of mosquito borne St. Louis Encephalitis (SLE). An intense mosquito eradication program was initiated by the Giuliani administration within 2 hours. The initial picture of SLE had several loose ends, however. For example New York State laboratories also analyzed serum samples using 2 different tests. With serological tests they found evidence supporting a diagnosis of SLE. But with PCR test they found evidence inconsistent with a diagnosis of SLE (GAO, 2000, p. 44). CDC’s Vector Borne laboratory in Fort Collins, Colorado used a third type of test, Elisa. An Elisa test is a blunt instrument in the sense that it identified the family of the suspect virus (a flavivirus) but not the specific virus itself (Gill, 2000, pp. 9–11). Since almost all of the 70 varieties of virus in this family were alien to North America, this seemed to pose no problem. CDC announced that they found “a reaction characteristic of SLE” and that SLE was the “most likely cause.” Lost in this diagnosis was evidence contrary to the diagnosis. SLE is not associated with muscle weakness, or with local outbreaks only, nor does it affect birds and horses. At the same time that humans were dying, an increasing number of birds were dying in the NYC area. A staff person in the NYC health department phoned CDC on September 4 suggesting that there might be a bird-human connection (GAO, 2000, p. 46). But since SLE, the announced diagnosis, does not kill birds, CDC saw these bird deaths as merely coincidental. People concerned with wildlife, domestic animals, and zoo animals were less certain than CDC that the deaths were unconnected. Repeated testing within the animal community began to confirm that birds were dying from a virus other than SLE, and it was a virus that no one could identify. For example, birds had been dying at the Bronx zoo, a facility located close to the area where the majority of the human victims lived. By August 25 the bird deaths had become a concern to pathologist Tracey McNamara at the zoo. And by September 9, she had contacted CDC for help. CDC did not return her call, so McNamara began to activate her own network of animal laboratories to examine the samples of zoo deaths. She was worried about a danger that directly straddled the human-animal connection, namely, one of her technicians who was doing necropsies on the birds had suffered a needle stick injury. That could have serious health consequences. Thus, CDC knew the possibility of a bird-human connection almost from the beginning. But if such a connection were taken seriously, then this meant that their initial public diagnosis was wrong, since SLE does not kill birds. In truth, their initial diagnosis was wrong. On September 23, three weeks after announcing that NYC was experiencing an outbreak of SLE, it was re-announced that NYC was actually experiencing an outbreak of a virus never before seen in the New World, a virus called West Nile. Other laboratories at Fort Dietrich, Ames Iowa, and UC Irvine converged on this finding shortly before CDC did. From an organizational standpoint, what is interesting about this incident is that even though CDC tried to expect the unexpected, they wound up expecting the expected. Faced with an emerging disease, CDC initially saw a well-established disease. That slip-up had ominous overtones for many who viewed this episode as a dress

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rehearsal for how well the U.S. could cope with bioterrorism. The post mortems on the event were predictably varied and included statements such as, “CDC officials didn’t do anything wrong, but they did not do all the right things” (Gill, 2000, p. 22); “CDC had tunnel vision and should have had a more open-minded approach” (Gill, 2000. p. 22). What we have here is an organization, CDC, with a reputation for reliable accuracy that gets it wrong, with eight million New Yorkers looking on, while other local, state, and federal organizations have different hunches of the right answer. A closer look at this incident affords a chance to explore what it means to work at the edge of codified knowledge, using distributed cognition, in an effort to make sense and save lives. Here’s where complexity comes in. I want to start with the working assumption that “The cognitive properties of human groups may depend on the social organization of individual cognitive capabilities” (Hutchins, 1995, p. 176). Thus, if we spot flaws in collective induction, then we may find an explanation for their genesis in the way people are organizing. Stated more compactly, the degree of intelligence manifest by a network of nodes may be determined by the quality, not just the quantity of its interconnectivity (Taylor and Van Every, 2000, p. 213).

Organizations are Loosely Connected Like many people writing about complexity, I start with the assumption that organizing emerges among agents who are loosely connected. A loosely connected organization looks something like the picture that Pfeffer and Salancik drew: An alternative perspective [to that of the rational organization] on organizations holds that information is limited and serves largely to justify decisions or positions already taken; goals, preferences and effectiveness criteria are problematic and conflicting; organizations are loosely linked to their social environments; the rationality of various designs and decisions is inferred after the fact to make sense out of things that have already happened; organizations are coalitions of various interests; organization designs are frequently unplanned and are basically responses to contests among interests for control over the organization; and organization designs are in part ceremonial. This alternative perspective attempts explicitly to recognize the social nature of organizations (Pfeffer and Salancik, 1977, pp. 18–19).

In order to better adapt that image to complexity thinking, we can describe organizations as social order where “Groups5 composed of individuals with distributedsegmented, partial-images of a complex environment can, through interaction synthetically construct a representation of it that works; one which, in its interactive complexity, outstrips the capacity of any single individual in the network to represent and discriminate events. . . . Out of the interconnections, there emerges a representation of the world that none of those involved individually possessed or could possess” (Taylor and Van Every, 2000, p. 207). The basic theme implied by this statement is that variations in interconnection produce variations in the representations that are synthetically constructed. This suggests again that different forms of network have different cognitive consequences. Some network forms may produce ignorance, tunnel vision, and normalizing, whereas other forms may produce novel insights, original syntheses, and unexpected diagnoses.

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Loosely Connected Systems can be Variously Organized In order to conceptualize network forms in a way that juxtaposes cognition, complexity, and organizing, we can talk about distributed problem solving using the classic ideas proposed by James Thompson (1967). He suggests that work, such as distributed information processing, tends to exhibit three forms of task interdependence that lend themselves to three forms of coordination. Our proposal is that these forms of task interdependence also induce distinct forms of cognitive interdependence. Thompson distinguishes among pooled interdependence that is coordinated by standardization, to which we add the possibility that this form induces skill-based action6 and automatic cognition7; sequential interdependence coordinated by plan, to which we add the possibility that this form induces rule-based action and heuristic cognition built around recipes (memorized rules, if-then); and reciprocal interdependence coordinated by mutual adjustment to which we add the possibility that this form induces knowledge-based action and controlled cognition. All 3 forms can co-exist, and Thompson treated the three as if they were a Guttman scale. Reciprocal interdependence presumes the existence of pooled and sequential. If you have an emerging, unexpected infectious disease, it is most likely to be detected by controlled cognition. But, in the West Nile episode, in the early stages, there appears to be coordination by standardization and pooled task interdependence. The task of analyzing samples is partialed out among laboratories, the laboratories run their tests, and they send the results to CDC. “Each part renders a discrete contribution to the whole and each is supported by the whole” (Thompson, 1967, p. 54). The piece I want to add is that the organization of the workflow can affect the way people think. The cognitive interdependence in the early stages of West Nile looks like pooled workflow interdependence in the sense that different people have different pieces of information and they contribute those pieces for assembly into a meaningful diagnosis. The problem is, mere assembly does not guarantee meaning. Each part is meaningless until it is related to some other part whose meaning, in turn, is dependent on the meaning of the initial part. Making meaning is an iterative process. Recall that what we are dealing with in the West Nile event is an emerging disease, a non-routine problem, equivocal cues, and ambiguity. Pooled task interdependence won’t generate the reciprocal cognitive interdependence that is needed to reduce the ambiguity of the strange cluster of symptoms. Pooled interdependence is the interdependence of routines and standardization in work; but pooled workflow interdependence is also the cognitive interdependence of stereotypes, confirmation, codification, and automatic thinking. That is precisely the form of cognition that is not suited to detect emerging diseases. To see this more clearly, think about the tendency of people to normalize the unexpected, as happened for example in the events leading up to the Challenger disaster. People often handle the unexpected by normalizing it out of existence8. The temptation to do this should be especially strong when the disease is “emerging” since, taken literally, something that emerges resembles its neighbor quite closely in its early stages. As it emerges more fully and becomes more distinct, it is less likely to be confused with its neighbor. Notice also that, in the beginning stages, you don’t know that it is an emerging disease. It looks more like a variant of an old disease, and this is an ideal situation for fixation of attention and a failure to revise a situation assessment as new information comes in (see Cook & Woods, 1994, pp. 274–277 on ‘fixation problems’). Therefore, if you want

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to prepare for the unexpected, then you have to weaken or neutralize the tendency to normalize. You have to encourage ambivalence. You have to question your associates and argue with them, even though the paradigm is underdeveloped (remember, people are working at the edge of codified knowledge). You have to think in a more mindful, less automatic manner. You have to engage in controlled thinking that is more commonly associated with doubt, inquiry, argumentation, and deliberation. That is the thinking of reciprocal interdependence and coordination by mutual adjustment. There were moments of reciprocal interdependence among animal laboratories in the West Nile incident, and these seemed to hasten the realization that people in NYC were dealing with an anomalous virus. Moments of reciprocal interdependence and controlled cognition were less frequent on the human side where “inquiry” basically took the form of routine diagnosis to see if sick people had the known SLE virus. Less common was the question, does the initial diagnosis remain viable and what symptoms remain inconsistent with it? The basic point is that forms of task interdependence may induce forms of cognitive interdependence that hinder solution of the presenting problem. For example, if the problem is non-routine and requires controlled thinking, and if the task interdependence is pooled, then the task may induce automatic, skill-based thinking which is better suited to routine problems. If the non-routine problem is treated as if it were routine, then a puzzling member of the flavivirus family may well be interpreted to be familiar member of the family, namely, SLE. The tricky part of a multi-organization network is that any one group may be capable of all 3 forms of task interdependence and all 3 forms of cognitive interdependence. When groups are strung together in a network, however, the network itself tends to be dominated by a single form of interdependence, either pooled with a central assembler, sequential with progressive assembly, or reciprocal with joint assembly. The problem with network structures is that reciprocal interdependence is most readily achieved on a local basis among small sets of players. As more subsets are hooked together, the interdependence drifts from reciprocal to sequential to pooled. Coincident with this drift is a shift from controlled cognition to heuristic cognition and finally to automatic cognition. If the network is faced with a non-routine problem, and if controlled collective cognition is weakened and replaced by collective cognition that is more automatic, then network failure is more likely. Networks may be faulty forms for emerging problems unless they are managed mindfully. This line of analysis predicts that a disproportionately large number of network failures occur when problems require controlled thinking (i.e. the presenting problem is ambiguous, equivocal, confusing). Failures occur because the pooled and sequential interdependence that is typical of networks induces inappropriate modes of thinking. Automatic thinking is imposed on problems that require controlled thinking.

Collective Cognition Affects Sensemaking I now want to enlarge the analysis and bring in the theme of sensemaking which “involves turning circumstances into a situation that is comprehended explicitly in words and that serves as a springboard into action” (Taylor and Van Every, 2000, p. 40). Sensemaking is a diagnostic process directed at constructing plausible interpretations of ambiguous cues

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that are sufficient to sustain action. Interorganizing, thus, is understood as a cue interpretation process that requires cognitive coordination in the interest of wise action. While self-organizing and emergence and co-evolution are crucial concepts for complexity theorists, when it comes to organization it is crucial that we also not lose sight of the reactive quality of organizations. This property is clearly visible in the West Nile episode and in the way CDC operates. There is often no good way to anticipate the next disease outbreak short of waiting for a few people to get sick. Henig (1993) asks, “What is the next AIDS?” Her answer, “You can’t do much until the first wave of human infection occurs. You can’t prevent the next epidemic. Furthermore, signs get buried among other diseases. If you find a new virus, you don’t know whether it is significant or not until a human episode occurs. The trouble is that by the time you do establish that it is significant, the virus has already settled into hosts, reservoirs, and vectors and is being amplified. Edwin Kilbourne, a microbiologist at Mt. Sinai hospital states the reactive quality of diagnosis: “I think in a sense we have to be prepared to do what the Centers for Disease Control does so very well, and that is put out fire….It’s not intellectually very satisfying to wait to react to a situation, but I think there’s only so much preliminary planning you can do. I think the preliminary planning has to focus on what you do when the emergency happens: Is your fire company well drilled? Are they ready to act, or are they sitting around the station house for months” (Henig, 1993, pp. 193-194). Notice that in a reactive world, a highly refined planning system is less crucial than the capability to make sense out of an emerging pattern. There are several sensemaking puzzles in the west Nile incident including: Is this bioterrorism?, Is this botulism?, I’ve never seen muscle weakness associated with brain inflammation before, SLE shouldn’t be in NYC, these profiles of SLE actually look “borderline,” why are flamingos dying but emus in the next cage thriving?, I have never seen brain lesions that are this severe. The dynamics of sensemaking9 have some subtle properties. These subtleties were described by the late Paul Gleason, one of the best wildland firefighting commanders in the world. Gleason felt he was most effective as a leader when he viewed his job as one of sensemaking rather than decision making. In his words, “If I make a decision it is a possession, I take pride in it, I tend to defend it and not listen to those who question it. If I make sense, then this is more dynamic and I listen and I can change it. A decision is something you polish. Sensemaking is a direction for the next period.” When Gleason perceives himself as making a decision, he reports that he postpones action so he can get the decision “right” and that after he makes the decision, he finds himself defending it rather than revising it to suit changing circumstances. Both polishing and defending eat up valuable time and encourage blind spots. If, instead, Gleason perceives himself as making sense of an unfolding fire, then he gives his crew a direction for some indefinite period, a direction which by definition is dynamic, open to revision at any time, self-correcting, responsive, and with more of its rationale being transparent.

Complexity and Cognition as Sensemaking Earlier we described the organizing of WNV as socially distributed cognition among interdependent players with differing priorities and local resources. Socially distributed

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cognition can be analyzed as a structural problem of task interdependence and coordination as we just saw. But it can also be analyzed as a set of socially organized resources for sensemaking. Here we focus on a different set of issues. Now we ask whether social resources at CDC were organized to create a plausible story that was actively updated through ongoing attention to shifting patterns of cues. This shift from a structural analysis to a more processual analysis aligns us even more closely with complexity ideas. Seven different resources for sensemaking are implied by this description, and they are captured by the acronym SIR COPE10. Social. “S” stand for social, and captures the fact that organizational sensemaking is interactive, relational, and in Eric Eisenberg’s (1990) words, consists of “coordination of action over alignment of cognitions, mutual respect over agreement, trust over empathy, diversity over homogeneity, loose over tight coupling, and strategic communication over unrestricted candor” (p. 27). The crucial idea here is that intelligence is a product of interconnectivity (Taylor and Van Every, 2000, p. 213). Interconnectivity and its role in cognition and sensemaking can be depicted more formally in terms of the concept of heedful interrelating. The basic idea in heedful interrelating is that a collective mind capable of varying degrees of intelligence emerges as a kind of capacity in an ongoing activity stream when activities among people are tied together as contributions that constitute and are subordinated to a joint system (Weick & Roberts, 1993). The mind is more fully developed if those interrelations occur with greater heedfulness 11. Identity. Sensemaking unfolds from some standpoint, some frame of reference, some identity. Several potential identities are at work in the West Nile incident. These include CDC as “detective,” “expert,” “public health guardian,” a “reference lab” for World Health Organization (WHO), the go-to unit when diagnosis gets tough (akin to the wildland firefighting crews of hotshots), and the expert at shoe-leather epidemiology (Last, 2001, p. 168). CDC’s identity is less that of an “integrator” where the network becomes the expert. Furthermore, CDC’s claimed identity as a site that practices “basic science” makes the issue of misidentification less clearcut. Stephen Ostroff, a central player in the West Nile incident, was quoted in the NYT as saying, “This [WNV] was not a mistake. This is how science proceeds in outbreak investigations. Confusion is a normal part of an emerging disease investigation” (Steinhauer & Miller, 1999). Retrospect. Action is always just a tiny bit ahead of cognition. We always see a little too late what we have done and what its consequences are. For example, the Annual Report for 1999 published by Applied Energy Systems (AES) contains this statement: “Strategy is typically developed through a series of business experiments carried out by our people as they seek to achieve that purpose [serve the electricity needs of the world]. Describing strategy, then, is more of a retrospective look at what has happened than a road map to the future” (p. 39). Applied to issues of diagnosis, retrospective thinking is understood as belated understanding of what one illness or condition one was facing back then, though didn’t realize it at the time. Marianne Paget (1988) is quite insightful on this point: “A mistake is situated in the conduct of medical work. It is discovered in the aftermath of action and activity, in reflection about medical action. ‘I made a mistake. If I knew then what I know now I would have done x, but I did not know then. If I had it to do all over again I would do x, but I do not always have it to do all over again. I mistook x for y. Was I distracted? Was I ’misled’ by the patient?” (p. 124). Physicians don’t count errors that occur in diagnosis and therapy as errors. Instead, “they count them as

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progressive approximations of their understanding of the character of illness.” (p. 137). This may be one reason interviewers get blank stares when they say, “let’s talk about medical errors”. The notion of approximations and updating is a crucial aspect of retrospect. “The work process unfolds as a series of approximations and attempts to discover an appropriate response. And because it unfolds this way, as an error-ridden activity, it requires continuous attention to the patient’s condition and to reparation” (p. 143). In other words, the risk of medical action, including outbreak diagnosis, is often exposed retrospectively. Cues. Part of the problem in the West Nile incident is that CDC is comparing cues in 1999 with outdated information about WNV. The misidentification occurs because of a close family resemblance between new inputs and older indicators. When you work at the edge of codified knowledge, with an outdated classification system, then you work with vague equivocal cues. And you may or may not know that this is the case. The newer cues are, in Diane Vaughan’s (1996) image, weak, mixed, routine. Ongoing. Crows are dying, people are dying, people are calling with questions and crow sightings, samples are piling up on the loading dock, some of them better labeled than others. Malathion is being sprayed, an election campaign for the senate is being waged between Giuliani and Hilary Clinton, and there are suspicions of bioterrorism, all in the context of emerging infectious diseases. Any interruption in an ongoing project creates either a prompt repair and recovery, or a detached, atomistic analysis. The goal is to stay in the action because, once you pull away and adopt a detached atomistic view, you lose context, information, situated cognition, and tools made meaningful by actual use. Plausibility. The initial story says that there is a high probability that NYC is faced with an outbreak of SLE that is spreading. This story is incomplete, is based on selected data, but it also triggers action and potential new inputs that could revise the initial story. Plausibility gets people in action, which is helpful when accuracy is a moving target. The environment continues to change, and action based on the SLE diagnosis stirs up new puzzles. Fort Collins begins to see that their positive readings for a SLE reaction are weak (“borderline”), and that there is a stronger reaction for WNV. A fuller story needs to be crafted. If people fixate on their first plausible story and stop there, then they do have a sense of sorts, but one that holds together only if newer cues and consequences are ignored. Enactment. Nigel Nicholson (1995, p. 155) has described enactment in the following way: enactment is a concept developed “to connote an organism’s adjustment to its environment by directly acting upon the environment to change it. Enactment thus has the capacity to create ecological change to which the organism may have subsequently to adjust . . . . Enactment is thus often a species of self-fulfilling prophecy. . . . One can expect enactment processes to be most visible in large and powerful organizations which have market-making capacity, but they are no less relevant to the way smaller enterprises conceive their contexts and make choices about how they will act in relation to them.” Examples of enactment include physician-induced disease (iatrogenic) which when diagnostic tests or lines of questioning create sickness that was not present when the patient first consulted with a physician; an air traffic controller who creates a holding pattern by stacking several aircraft in a small area of airspace near a busy airport and, in doing so, enacts a cluttered display on the radarscope that is more difficult to

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monitor; or organizations that encourage closeness to the client enact a permissive world that encourages outrageous customer demands that can only be remedied by firing the client they tried so hard to recruit. In each case, individual work can enact conditions that other people and other systems have to cope with. For example, iatrogenic disease does not stop at the physician’s door as the newly troubled patient walks out. Instead, the altered patient walks into the medical care system where the consequences of the initial treatment spread and where the patient’s problems with the physician become other people’s problems as well. Enactment creates contingencies as well as events. The initiating conditions seem small in comparison to macro events only because these examples articulate the local turning point, the point of bifurcation, the moment of initiation. These triggering moments often serve to implant small but uncontained outcomes in larger systems. These embedded, uncontained outcomes continue to grow undetected until they spawn unanticipated consequences that threaten legitimacy, competence, and control.

Conclusions I have argued that how you are organized (the ‘social’ dimension in sensemaking) determines the depth of your resources for sensemaking. Organizing is about workflow interdependence, cognitive interdependence, and the intelligence enacted by the way the interconnection occurs. The quality of that interconnectivity, the degree of heed involved in interrelating, affects the quality of representations constructed by members. Recall the earlier image of organizations as “Groups composed of individuals with distributed—segmented, partial-images of a complex environment can, through interaction, synthetically construct a representation of it that works; one which, in its interactive complexity, outstrips the capacity of any single individual in the network to represent and discriminate events. . . . Out of the interconnections, there emerges a representation of the world that none of those involved individually possessed or could possess” (Taylor and Van Every, 2000, p. 207). Different “interaction” produces different “synthetic construction of a representation”. When interrelating is less heedful12, there tends to be more normalizing, more susceptibility to the fallacy of centrality13, and less noticing of what is being set aside. How does all of this connect with complexity? Complexity themes that are implicit in my story include self-organizing (e.g. A Bronx zoo pathologist wires together a network of laboratories that make accelerated progress in isolating the virus), emergence (e.g. interactions generate an error and then a recovery from error), nonlinearity (e.g. unreturned phone calls trigger an effective workaround that solves the problem), semi-independent agents (e.g. conference calls are restricted to a small subset of players), dynamic unfolding (e.g. later results recast the meaning of earlier results), and turbulence in the form of overload, interruptions, understaffing, media pressure, unanticipated surge. When I talked about these complexity themes, I replaced complexity concepts with concepts from cognition, sensemaking, workflow interdependence, and interrelating. My argument is that these substitutions retain the spirit of complexity analysis but customize those insights so that they better fit human organization. Examples of these substitutions include,

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In place of CAS, I talked about retrospective sensemaking. Agents pay attention to such things as open-ended acting, meaning as emergent, small actions that can have large effects, and surprise as an outcome. In place of Unknowability I talked about partial connections that produce multiple realities; plausibility supported by justification rather than accurate representation; uncertainty as an issue of ontology rather than an issue of epistemology. In place of Partial connections I talked about distributed sensemaking, semiindependent agents, reciprocal reference, identities that hold agents together, loosely coupled systems, and self-organizing fragments whose significance does not lie in the fact they there were once part of a greater whole. In place of Chaos I talked about ambivalence, equivocality, ambiguity, and the unexpected. In place of Emergence I talked about becoming, organizing, and juxtapositions that force novel meaning. In place of Dynamic I talked about fluid, impermanent, process, ongoing, updating, exploration. In place of Co-evolution I talked about reciprocal enactment of both the organization and the environment. In place of Self-organizing I talked about organization that emerges IN communication. In place of Simple rules applied locally I talked about micro states that are central in organizing. In place of Non-linear I talked about deviation amplifying feedback and small actions that can have large consequences (e.g. an unreturned phone call). In place of Entropy I talked about normalizing, codification, shareability constraints, labeling. In place of Diversity I talked about requisite variety, conflict, multiple drafts. The resulting picture suggests that, as people connect and represent their joint contributions, more heedfully, they are more likely to differentiate and refine existing categories, create new categories, and perceive and enact a more nuanced context. When heedful interrelating produces mindful action, this is an example of people acting in order to think. What is different is that the acting is more relationally sensitive and the thinking is more situationally mindful. With fuller attention there is less confirmation bias. This line of argument is an example of the more basic point that different forms of task-based interdependence among players seem to induce different ways of thinking. In other words, “the cognitive properties of human groups may depend on the social organization of individual cognitive capabilities” (Hutchins, 1995, p. 176). To prepare for the unexpected means that you have to offset strong cognitive predispositions such as confirmation bias, fallacy of centrality, hubris, normalization, typification, and bottom-up salience of cues. This is a complex map of interorganizing, but then the territory of everyday distributed sensemaking that it maps is no less complex. What matters is whether the map is useful. At this stage, I think it is. The model suggests that people misdiagnosed the West Nile Virus because of the way they were organized. Flawed interrelating enacted a flawed collective mind that was prone to lock-in familiar interpretations until interrelating became more heedful.

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And what did all of this boil down to? What was the takeaway of this entire incident for CDC? The answer is a perfect example of non-linear relations. The West Nile incident taught people to return their phone calls!

Notes 1 Investigation of the West Nile incident is an ongoing joint project that involves Joe Porac, Huggy Rao, and Karl Weick, with the assistance of Katherine Lawrence. I am indebted to my collaborators for ongoing discussions that have helped all of us see the larger significance of this incident for organizational theory. 2 Renis Likert College Professor of Organizational Behavior and Psychology, Professor of Psychology, University of Michigan, [email protected] 3 My synoptic view of complexity theory would include the following. Complexity ‘theory’ essentially is a collection of intuitions about complexity grounded in computer demonstrations of bit strings interacting, chemical clocks, fluid dynamics, weather, and lightning. The central derivative social insight that tends to be used in organization theory is this: “partially connected agents operating within simple rules drive complicated adaptive behavior at the system level“ (Eisenhardt & Bhatia, 2002, p. 462). The essential shift in organization theory is that complexity is NOT viewed as a structural variable. Complexity analyses focus on systems pushed away from equilibrium. 4 Although we are currently interviewing people connected with the West Nile diagnosis, all references to the West Nile in this chapter come from readily available public documents. Key sources that I used include Steinhauer & Miller 1999, Gill 2000, Government Accounting Office 2000, Scott 2002, Hall 2003, Asnis et al. 2000, Wadler 1999, Steinhauer 1999, Despommier 2001, White & Morse 2000, and Drexler 2002. 5 We could substitute the word ‘networks’ for the word ‘groups’ and this image still works. 6 The three levels of action were described by Rasmussen (1983). Skill-based behavior represents sensori-motor performance during acts or activities that, after a statement of an intention, take place without conscious control as smooth, automated, and highly integrated patterns of behavior. In rule-based behavior a sequence of subroutines in a familiar work situation is typically consciously controlled by empirical cue-action correlation. The person is aware that alternative actions are possible and has to make a choice. During unfamiliar situations for which no know-how or rules for control are available, the control moves to a higher conceptual level, in which performance is goal-controlled and knowledge-based. Viewed as a hierarchical control structure, the skill-based level represents the continuous real-time control of activities, the rule-based level reflects the adaptive choice among preplanned decision rules and the knowledge-based level reflects intelligent self-organization of behavior. 7 George Mandler (1984) describes forms of cognition this way: “As a first approximation, I assume that actions and thoughts that issue from automatic processes require no intention or choice. Nonautomatic actions and thoughts are ‘conscious’-they may have equivocal outcomes, they sometimes require intentions, and, in particular, they usually require choices, decisions, and selections. . . . The well-known phenomenon that skills are conscious when first acquired but become unconscious once they are well practiced describes the availability of choices in the form and the inevitability of outcomes in the latter kind of performance. It should be obvious that selective-search mechanisms require access to schemas that are

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activated. Activation is thus a necessary condition for selective retrieval, but it is both necessary and sufficient for the occurrence of automatic thoughts and action. . . . Another way of distinguishing automatic and Nonautomatic processes is to refer to them as nondeliberate versus deliberate. Deliberate retrieval implies that the target or goal state is not immediately available, that choice need to be made and searches and selection initiated.“ For a more detailed discussion of the automatic-controlled duality, see Chaiken and Trope (1999). 8 See William James (1992, p. 512⫹) for an insightful description. 9 The challenge for people at CDC is a lot like the challenge that faces incident commanders at the scene of a disaster. As Rhona Flin says, Incident commanders face 1. extremely difficult decisions 2. ambiguous and conflicting information 3. shifting goals 4. time pressure 5. dynamic conditions 6. complex operational team structures 7. poor communication 8. every course of action carries significant risk -Flin, 1996, p. 37 Their challenge is to continually make sense of an unexpected and dynamic situation that is characterized by unfamiliarity and scale and speed of escalation (paraphrase from Flin, 1996, p. 105). 10 The seven resources, captured by the acronym SIR COPE, vary along dimensions whose anchor points can be labeled thusly: 1. social-solitary resources; 2. defined-vague identity; 3. backward-forward noticing; 4. equivocal-confirmed cues; 5. continuous-episodic flow of events; 6. possibility-probability as criterion for narratives; 7. enactive-reactive as form of action. Sensemaking resources characterized by the left-hand terms are presumed to be more effective in reducing ambiguity than are sensemaking resources characterized by the right hand terms. This line of argument predicts that in the early stages of the West Nile episode, the sensemaking resources that CDC directed at the problem were toward the right hand end of each of these dimensions. As the pattern of resources began to move more toward the lefthand end of each dimension, people were better able both to notice anomalies that didn't fit and to invent a newer story into which they did fit. 11 An example of less heedful interrelating is Winston Churchill’s reconstruction of why he failed to see that Singapore was vulnerable to land invasion in WW II. Allinson (1993) notes that “A good illustration of the awareness of multiple causality may be found in Churchill’s response to his horrified discovery that Singapore, rather than being impregnable, proved to be highly vulnerable to a Japanese land invasion. In his history of World War Two, Churchill comments: “I ought to have known. My advisors ought to have known and I ought to have been told, and I ought to have asked“ (p.11). What is crucial here is that all 4 lapses are lapses of interconnection. Participants are not attentive to their contributions, representations, and subordination to a possible emerging system for gathering information about unexpected events.

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12 The degree to which contributing and representing and subordinating are heedful, within a network of laboratories may influence the accuracy of diagnoses. For example, the initial reluctance to examine dead crows can be interpreted as a lack of subordination to and recognition of the system that is working the problem, since birds are reservoirs for vector-borne viruses, bird deaths are sentinels of larger human problems, and since human serum, which is what they were analyzing for NYC, was half of what pathologist Tracey McNamara wanted CDC to examine. 13 The ‘fallacy of centrality, first described by Ron Westrum and elaborated by Weick (1995) and Snook (2000, p. 173) consists of this logic: If there was viral traffic from the Old World to the New World, I would know about it. I don’t know about it. Therefore, it isn’t going on . . . and we can stop thinking about it! The fallacy is the belief that I am at the center of the flow of information. If crows and people were dying of the same thing, I’d know about it. CDC initially conducts a general, generic footprint test that is “adequate“ to detect things they DO know about. (Gill, 2000, pp. 9, 11). It is conceivable that even though CDC says publicly that its biggest challenge is to “be prepared to expect the unexpected,“ privately they believe that the unexpected is extremely rare, and that they know most of what there is to know.

References Allinson RE (1993) Global Disasters: Inquiries into Management Ethics. Prentice Hall, New York. Anderson P (1999) Complexity theory and organization science. Organization Science 10(3): 216–232. Asnis DS, Conetta R, Teixeira AA, Waldman G, Sampson, BA (2000) The West Nile Virus outbreak of 1999 in New York: The Flushing Hospital experience. Clinical Infectious Diseases 30: 413–418. Boyle RH (2000) Flying Fever. Audubon 102 (14). Chaiken S, Trope Y (eds) (1999) Dual-Process Theories in Social Psychology. Guilford, New York Cook RI, Woods DD (1994) Operating at the sharp end: The complexity of human error. In: Bogner MS (ed) Human Error in Medicine. Erlbaum, Hillsdale, pp 255–310. Despommier D (2001) West Nile Story. Apple Tree Productions, New York. Drexler M (2002) Secret Agents: The Menace of Emerging Infections. Joseph Henry Press, Washington DC. Eisenberg E (1990) Jamming! transcendence through organizing. Communication Research 17(2): 139–164. Eisenhardt KM, Bhatia MM (2002) Organizational Complexity and Computation. In: Baum JAC (ed) The Blackwell Companion to Organizations. Blackwell, Oxford, pp 442–466. Flin RH (1996) Sitting in the Hot Seat: Leaders and Teams for Critical Incident Management. John Wiley, New York. GAO (General Accounting Office) (2000) West Nile Virus Outbreak: Lessons for Public Health Preparedness (Report No. GAO/HEHS-00-180). Washington DC: General Accounting Office. Gill JM (2000) Expect the unexpected: The West Nile Virus wake up call, Report to Senator Joseph I. Lieberman. Washington DC: Minority Staff of Senate Governmental Affairs Committee. Hall SS (2003) On the trail of the West Nile Virus. Smithsonian, 14(4): 88–102. Henig RM (1993) A Dancing Matrix: How Science Confronts Emerging Viruses. Vintage, New York. Hutchins E (1995) Cognition in the Wild. MIT Press, Cambridge.

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James W (1992) Writings 1878–1899. The Library of America, New York. Last JM (ed) (2001) A Dictionary of Epidemiology 4th edn. Oxford, New York. Mandler G (1984) Mind and body: Psychology of Emotion and Stress. Norton, New York. Nicholson N (1995) Enactment. In: Nicholson N (ed) Blackwell Encyclopedic Dictionary of Organizational Behavior. Blackwell, Cambridge, pp 155–156. Paget M (1988) The unity of mistakes: A phenomenological interpretation of medical work. Temple University, Philadelphia. Pfeffer J, Salancik GR (1977) Organizational design: The case for a coalition model of organizations. Organizational Dynamics, Autumn, 6(2): 15. Rasmussen J (1983) Skills, rules, and knowledge: Signals, signs and symbols, and other distinctions in human performance models. IEEE Transactions on Systems, Man and Cybernetics 13(3): 257–266. Scott E (2002) The West Nile Virus Outbreak in New York City (A): Case C16-02-1645.0. Harvard University: Kennedy School of Government, Boston. Snook S (2000) Friendly Fire. Princeton University, Princeton. Steinhauer J (1999, October 16) Battles over turf in health arena: Response to a viral outbreak highlights city-state tension. New York Times, Section B, p1. Steinhauer J, Miller J (1999, October 11). In New York outbreak, glimpse of gaps in biological defenses. New York Times, Section A, p 1. Taylor JR, Van Every EJ (2000) The Emergent Organization: Communication as its Site and Surface. Erlbaum, Mahwah. Thompson JD (1967) Organizations in Action. McGraw-Hill, New York. Vaughan D (1996) The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA. University of Chicago, Chicago. Wadler J (1999, October 1) Passionate life in a lab with dead animals. New York Times, Section B, p 2. Weick K E (1995) Sensemaking in Organizations. Sage, Thousand Oaks. Weick KE, Roberts KH (1993) Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly 38: 357–381. White DJ, Morse DL (eds) (2001) West Nile Virus: Detection, Surveillance and Control. New York: The New York Academy of Sciences.

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5 Information Overload Revisited Setting the Scene People in organizations often experience a decrease in the quality of their attention because they feel overwhelmed by demands and limited in the time and resources they have to respond. This phenomenon has been called information overload, and it is the focus of Chapter 5. The content of complaints about overload is familiar. Managers, for example, report that they experience excess load when they (1) collect information to ‘indicate a commitment to rationalism and competence;’ (2) receive unsolicited information; (3) seek information to check information already acquired; (4) compile information to justify decisions; (5) collect information in case it might be useful; (6) acquire ‘all’ information and play it safe; and/or (7) use information as currency so they won’t get left behind (Butcher, cited on p. 22 in Edmunds and Morris, 2000). In each case there is input load, and in each case there is some action or output that responds to these variations in input. In the case of the Butcher list, outputs include demonstrable rationality, doing something with the unsolicited, follow-up, constructing justification, indexing what may prove useful, hoarding, and/or building intellectual capital. These output options may balance the demands over some finite time frame, or they may not. If we transfer this pattern into an organized setting it remains much the same. For example, the same balancing of demand (input) and supply (output) can be observed among dispatchers who control the distribution of electricity in response to customer demand (Roe and Schulman, 2008). The focal organization: . . . balances load and generation in real time (that is, in the current hour or for the hour ahead) by developing and maintaining a repertoire of responses and options in the face of unpredictable or uncontrollable system instability produced either within the network (e.g. by generators acting in a strategic fashion) and from outside the network through its open system features (e.g. temperatures and climate change). ‘Load’ is the demand for electricity and ‘generation’ is the electricity to meet that load, both of which must be balanced (i.e. made equal to each other) within proscribed periods of time, or otherwise service delivery is interrupted as the grid physically fails or collapses. We call this need to balance load and generation, the ‘reliability requirement’ of the ISO [independent system operator] control room operators (Roe and Schulman, 2008, p. 18).

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What we try to make clear in this chapter is that the traditional picture of overload as something akin to a finite container that overflows is misleading. What we propose instead is that operations of interpretation and sensemaking can alter the size of the container and the magnitude of perceived overload. This means that ‘significance’ is crucial for managing load (p. 76 in the following reprinted article). What we find particularly compelling in this chapter is the idea that overload increases when there is an enlargement of understanding. Kock (2000, p. 261) captured this nuance when he described information overload as ‘a transitory sensation that is experienced by individuals developing schemas that will allow them to upgrade their performance in job-related tasks’ (p. 73 in the reprinted article). Overload is a phenomenon of transitions. This implies that when people engage in ‘continuous learning,’ they invite continuous overload. However, continuous overload does not necessarily mean that information processing is faulty. Instead, the presence of overload becomes a sign of progress. John Dewey (1922) captured this possibility: ‘Progress means increase of present meaning, which involves multiplication of sensed distinctions as well as harmony, unification. . . . If history shows progress it can hardly be found elsewhere than in this complication and extension of the significance found with experience’ (p. 283). As Dewey notes later, once we accomplish something: . . . new struggles and failures are inevitable. The total scene of action remains as before, only for us more complex, and more subtly unstable. But this very situation is a consequence of expansion, not of failures of power, and when grasped and admitted it is a challenge to intelligence. Instruction in what to do next can never come from an infinite goal, which for us is bound to be empty. It can be derived only from study of the deficiencies, irregularities and possibilities of the actual situation (Dewey, 1922, pp. 288–289).

If analysts shift to an interpretive perspective on overload then so-called ‘limits on attention’ are less important. What is more important is that an excessive number of unrelated bits and pieces of information strip away context and meaning. That is why John Dewey’s imperative makes sense: so act as to increase the meaning of present experience. Action and enactment (see Chapter 11) often clarify meaning within streams of experience, which means that the likelihood of overload decreases. Action can shape a pile of cues into a coherent cluster that is then easier to name and label and handle and update.

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Information Overload Revisited Kathleen M. Sutcliffe Karl E. Weick The following article by Kathleen M. Sutcliffe and Karl E. Weick was published as Chapter 3 in W. H. Starbuck and G. Hodgkinson (Eds), Handbook of Organizational Decision Making, Oxford, UK: Oxford University Press, in press, pp. 56–75. Reprinted with permission.

INTRODUCTION During morning rush hour on March 11, 2004, near simultaneous blasts hit a commuter train station in Spain’s capital of Madrid, killing 191 people and injuring 2000. In the aftermath, Interpol Washington1 asked a team of United States FBI personnel to analyze a set of latent fingerprints found by Spanish police on a plastic bag of detonators left at the crime scene. Within two weeks FBI examiners had analyzed a digital photograph of the fingerprints received electronically from the Spanish national police and reported a match with a candidate print from an integrated automated fingerprint identification (IAFIS) computer search (Stacey 2004). That led to a decision in early May to arrest, jail, and label as a terrorist, Brandon Mayfield—an Oregon lawyer. Mayfield’s prints were on file as he had been arrested as a juvenile and had served in the Army (Heath 2004). Two weeks after Mayfield’s arrest Spanish national police fingerprint examiners verified that the prints actually matched a foreign terrorist. The FBI quickly released Mayfield. Nonetheless, they could not avert attacks on the fingerprint lab’s credibility or stop an investigation into the root causes of the mistake. This erroneous identification and the decision to arrest an innocent victim could easily have been attributed to poor evidence: the electronic images of the latent prints found at the crime scene were of “low resolution and without a scale” (Stacey 2004: 708). But the case is not that simple. In fact, Mayfield had never traveled to Madrid, which should have been evidence enough—at least a red flag to investigators that things were not as they seemed (Heath 2004). But there is more. After the FBI team identified a match (and before Mayfield’s arrest), they sent their findings to Spanish national police who had been conducting a concurrent analysis. When Spanish police compared the evidence to the subject’s fingerprints (i.e., Mayfield’s prints), instead of seeing a match, they arrived at an inconclusive finding (Stacey 2004). This precipitated face to face meetings between FBI finger-print unit personnel and Spanish fingerprint examiners, a US court appointed independent examination (which confirmed the original FBI analysis), and an additional review by personnel from the FBI Laboratory Quality Assurance and Training Unit. Following a face to face meeting with Spanish officials in Madrid, FBI personnel returned to the US and after an all night discussion, recognized their error. A secondary team of FBI examiners under the direction of a different unit chief concurred with the Spanish national police that the latent fingerprints indeed belonged to a different suspect (Stacey 2004: 711).

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The subsequent examination revealed the following sequence (see Stacey 2004: 712–14). The initial fingerprint examination was made by a highly respected and experienced supervisory fingerprint examiner. The examiner initially encoded seven identifying characteristics of the latent fingerprint, initiated a search of the automated information system (IAFIS), received a list of possible candidates from the search, compared the existing print to the candidates’ prints, and identified the subject. The existing rule at the time required that a supervisor verify every latent print analysis with less than 12 characteristics; moreover, it was routine for verifiers to know the previous examiner’s results. Thus, the original examiner notified the unit chief who reviewed the on-screen images and who concurred. The unit chief then assigned the case to a second verifier (a retired supervisory fingerprint examiner working as a contractor) who requested original fingerprint cards from another FBI division, and after three days, also verified the original fingerprint examiner’s identification. While the FBI may not resemble a “typical” organization, this event is typical of organization events because it involves a high stakes, high profile decision coupled with performance pressures, time pressures, role pressures, and distributed information all of which can trigger a regression to a less expert stage (Barthol and Ku 1959) and subsequently increase the likelihood of flawed decision making. In the Madrid case, pressures overloaded “expert” decision makers and transformed them into “advanced beginners” who were more easily overwhelmed and made a high profile decision “by the rules” (Dreyfuss and Dreyfuss 1986). Specifically “the power of the IAFIS correlation [candidate match], coupled with the inherent pressure of working an extremely high-profile case, was thought to have influenced the examiner’s initial judgment and subsequent examination . . .” (Stacey 2004: 713) and led decision makers to see what they expected to see. Such influence would have been less marked had less regression occurred. There are additional symptoms of overload visible in the Madrid episode. For example, information search and retrieval became less systematic and less thorough (Eppler and Mengis 2004: 333). The analysis and organization of information became more arbitrary which is evident in a lack of critical evaluation. When people become credulous they are more likely to make superficial analyses. The investigators lost differentiation as the relationship between details and overall perspective weakened and as they “overestimated” the importance of peripheral cues (Eppler and Mengis 2004: 333). There was more abstraction in the interest of more meaning and that abstraction led to more misinterpretation. There were problems of workload bottlenecks in that the FBI examiners had too many inputs and too many cases to examine in the time available (Woods et al. Roth 2002: 25; Stacey 2005, personal communication). And finally, there were covert production pressures on personnel to place production and not “reliability” as their primary priority (Stacey 2004: 714–16). Overload might have been less of a problem for the FBI if the examiner and the people who checked the work, had been more resilient and more accustomed to daily pressures and media visibility. Fingerprint examiners routinely have heavy caseloads, but they work most of the time by themselves in relative isolation and obscurity. In the Madrid case overload led decision makers to omit consideration of some data, restrict attention to other portions of the data, filter out discrepant information, and seek to confirm their initial expectations that a match existed.

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While the FBI problems are organizational problems and system problems, it is not obvious that they are information processing problems. They are that, but they are more. And it is the “more” that this chapter is about.

Conventional Definitions of Overload Individuals typically describe information overload2 as the situation of receiving too much information. Organizational scholars define overload as a state induced when the amount of input to a system exceeds its processing capacity (Speier et al. 1999) or when information processing capabilities and the information loads3 encountered are mismatched (O’Reilly 1980: 684). Perception plays a key role in overload as in this definition: overload is the “perceived inability to maintain a one to one relationship between input and output within a realizable future with an existing repertoire of practices and desires” (Weick 1970: 68). The readily available Wikipedia definition of overload reads, overload “involves large amounts of currently available information, a high rate of new information being added, contradictions in available information, a low signal to noise ratio, and inefficient methods for comparing and processing different kinds of information.” Prevailing treatments of overload posit that when a system (individual or organization) is no longer able to process information and becomes overloaded, primary and secondary symptoms are manifested (Schneider 1987). For example primary symptoms of overload include a general lack of perspective, an inability to select out relevant information, and increasing “distraction by irrelevant and interfering cues” (Schneider 1987: 148), which lead to cognitive strain and stress and a feeling of lack of control (Lipowski 1975). These changes prompt a variety of coping strategies (Wright 1974) and mechanisms of adjustment (Miller 1960). Mechanisms of adjustment may mitigate immediate pressures but they often result in increasing errors or negative affect (stress, frustration, and confusion), and under certain conditions can negatively affect the timeliness and quality of decisions (see Speier et al. 1999; Eppler and Mengis 2004). These adjustments can lead to a set of secondary symptoms such as reduced scanning, narrowed and internally focused attention, increased control and centralization, and rationalization and legitimation (Schneider 1987: 145) that can exacerbate the very problems they are trying to fix. The idea that inputs are excessive and increasingly overwhelm individuals and organizations is not surprising. There are continuing organizational and institutional pressures for decision makers to collect information to demonstrate a commitment to rational decision making and to justify decisions (Feldman and March 1981), to validate information already acquired, to have it on hand in case it is useful, to keep up with colleagues, or to use it as currency (Edmunds and Morris 2000). In addition, as Sparrow notes (1999: 144; see also Hodgkinson and Sparrow 2002), the information decision makers face is increasingly problematic in that it is of low quality, low value, highly ambiguous, and has a short period of relevance (i.e., a short half-life). These four qualities compound both the mental effort and the time required to make sense of the information, which can divert decision makers’ attention to irrelevant issues or blind them to more important matters (Sparrow 1999: 144).

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Although load can become excessive as inputs increase, it also can become excessive when capacity is limited. Increasing task demands, competing task demands, increasing complexity of tasks, too few resources (i.e., skills or knowledge that exceed requirements), hallmarks of today’s organizational contexts, can limit capacity and thereby increase overload. Capacity is also limited when time is short; when production or performance pressures exist, when there is too little control over the processing of inputs (Hahn et al. 1992), and too little time to process inputs (Kock 2000). In fact, the issue of time as it pertains to overload has become more explicit and more prominent. This is evident in recent descriptions suggesting that overload occurs when “the demands on an entity for information processing time exceed its supply of time (Schick et al. 1990: 315), when the time needed to meet decision makers’ processing requirements exceeds the time available for processing (Speier et al. 1999: 339; Kock 2000), or “when the attentional system is no longer able to allocate its resources in a manner which results in adequate performance” ( Hahn et al. 1992: 366). Time pressures also increase as a result of distractions and interruptions (Perlow 1998; Speier et al. 1999; Jett and George 2003). But distractions and interruptions in and of themselves do not constitute overloads. It depends on how one interprets them. Furthermore, distractions lead to the buildup of queues which can lead directly to overload, or can lead indirectly to overload by decreasing the amount of time to work on something and increasing time pressure. Interruptions break the flow of work and often bring it to a halt. As interruptions take time away from present activity, they fuel feelings of time pressure. Interruptions also increase information processing demands by forcing decision makers to shift attention to the interruption, to contemporaneously attend to competing inputs, or to focus or narrow attention on one task at the expense of others. There are costs to refocusing and returning to the primary task. Decision accuracy may decrease as decision makers lose or forget cues, and decision time may increase as decision makers take time to get back up to speed (Speier et al. 1999). As the information load increases and a decision maker experiences less control over the processing system, arousal and stress elevate, and consequent coping adjustments such as narrowing attention are the result (Speier et al. 1999). Still there are occasions when time pressures are not all bad—time pressures act like a double-edged sword. Laboratory studies show that under some conditions, such as when the task is simple, time pressures can actually improve decision quality in terms of decision time and decision accuracy (Hahn et al. 1992; Speier et al. 1999; see also Chajut and Algom 2003). Time pressures can help decision makers narrow their attention and focus on the most relevant information (i.e., as attention is narrowed decision makers dismiss or ignore irrelevant cues). But after a certain point as the information load is increased (when time pressures are high and a task gets more complex), the speed and quality of decisions decline (Hahn et al. 1992; Speier et al. 1999).

Overload: Assumptions and the Information Processing Perspective Overload has been subject to much speculation and conceptual attention for decades, yet empirical research on overload, particularly in organizational theory (and as

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it pertains to organizational decision making), is surprisingly sparse. The few empirical studies that have been conducted in organization studies over the past four decades mainly “focus on the satisfaction of the person experiencing the overload” (Eppler and Mengis 2004: 338). Conventional views of overload in organization theory originate in the information processing approach to organization design (e.g., Thompson 1967; Galbraith 1974), an approach that Lant and Shapira (2001a, b) call a computational perspective as contrasted to an interpretive perspective. From a computational perspective, the problem decision makers and organizations face is “one of searching and processing relevant information when such search is costly and decision makers are boundedly rational” (Lant and Shapira 2001a: 2). Herbert Simon’s (1971) summary description of overload is an uncommonly rich statement of this perspective and begins to bridge computation and interpretation. Whether a computer will contribute to the solution of an information-overload problem, or instead compound it, depends on the distribution of its own attention among four classes of activities: listening, storing, thinking, and speaking. A general design principle can be put as follows: An information processing subsystem (a computer or new organization unit) will reduce the net demand on the rest of the organization’s attention only if it absorbs more information previously received by others than it produces—that is, if it listens and thinks more than it speaks.

Recall James Thompson’s (1967) claim that the key “problem for complex organizations is one of coping with uncertainty,” which is reduced through information. Organization scholars typically define uncertainty as the difference between the amount of information an organization needs to possess for task performance and the amount that it possesses (Galbraith 1974; Tushman and Nadler 1978). Organizations must determine how best to organize to process the information they do possess that decision makers confront. This raises the issue of processing capacity. From the information processing perspective, organization design matters; that is, the information processing capacity depends on the organization’s goals, hierarchy, relational infrastructure and patterns of interaction. An organization’s design can increase or reduce the information processing requirements and affect capacity (Hodgkinson and Sparrow 2002). For example, changes due to centralization or interdisciplinary teams increase information processing requirements (and decrease capacity) by increasing the need for intensive coordination and communication (Eppler and Mengis 2004: 330). In contrast, better coordination through standard operating procedures, rules, and other coordination processes can decrease information processing requirements and increase capacity (Eppler and Mengis 2004: 330). Several assumptions underlie the view that overload is a problem in information processing. The first is that representation and computation rather than construction and interpretation are the primary organizational activities (from a computation standpoint there are too many separate objects to attend to). The second is that the organization is a finite container that is overfilled with demands. The third, that communication channels are conduits with fixed information limits (i.e., channel capacity). The fourth, that the goal of a transformation process is a one to one correspondence between input and output (i.e., quick response). The fifth, that output must be formulated in response

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to input within a fixed time interval. The sixth, that short-term storage is limited. The seventh, that attention is a scarce resource (e.g., Simon 1973). And the eighth, that overload is a disease that ought to be fought (Eppler and Mengis 2004).

Rethinking the Information Processing Assumptions Computational information processing perspectives tend to neglect the more interpretive aspects of information processing or the idea that part of organizational information processing necessitates the creation of “meaning around information in a social context” (Lant 2002: 345). When scholars view organizations as interpretation systems (Daft and Weick 1984), the problem of overload takes on a different meaning. Overload is not necessarily a case of too much data, rather it is an inability to make sense of demands, capabilities, and context as well as data. In fact, some have argued that the issue of significance is at the heart of the information overload problem (Woods et al. 2002: 25); that assessing “the significance of data when it is not known a priori what data from a large data Weld will be informative” is vital. This suggests that overload is a problem of interpretation as much as it is a problem of computation and information processing. Overload is a particular way of bracketing a stream of experience. This means that overload is not a discrete, discontinuous, sudden event. Instead, it waxes and wanes, comes and goes. It is embedded in the experiences of becoming (Tsoukas and Chia 2002) and thrownness (Weick 2004) and ready to hand (Heidegger 1962) and making sense of these experiences. Taking interpretation more seriously brings a different set of assumptions to the forefront. John Dewey provides the basic infrastructure for our ideas. His analysis enables us to recast the setting of overload as a normal part of living rather than as a disease or something extraordinary. Present activity is not a sharp narrow knife-blade in time. The present is complex, containing within itself a multitude of habits and impulses. It is enduring, a course of action, a process including memory, observation and foresight, a pressure forward, a glance backward, and a look outward. It is of moral moment because it marks a transition in the direction of breadth and clarity of action or in that of triviality and confusion. Progress is present reconstruction adding fullness and distinctness of meaning, and retrogression is a present slipping away of significance, determinations, grasp. (Dewey 1922: 281)

When individuals increase present meaning, they multiply sensed directions and they complicate and extend the significance they find within their experience. Dewey expresses this in the form of a categorical imperative: “So act as to increase the meaning of present experience” (p. 283). Thus, complexity and perplexity increase hand in hand with an increase in significance and meaning. What discussions of overload often miss is that apparent setbacks are actually complications, extensions, and growth in complexity resulting from new interpretations. Thus, no matter how much any moment reflects sense and meaning, that same moment of accomplishment is also a moment of complication (p. 285). In Dewey’s (1922) words, each achievement

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creates a new distribution of energies which then has to be employed in ways for which past experience gives no exact instruction. Every important satisfaction of an old want creates a new one; and this new want has to enter upon an experimental adventure if it is to find its satisfaction. From the side of what has gone before achievement settles something. From the side of what comes after, it complicates, introducing new problems, unsettling factors. There is something pitifully juvenile in the idea that “evolution,” progress, means a definite sum of accomplishment which will forever stay done, and which by an exact amount lessens the amount still to be done, disposing once and for all of just so many perplexities and advancing us just so far on our road to a final stable and unperplexed goal. (p. 285)

To make progress is also to increase the intricacy of the problems an entity must deal with and the amount of instability it must face in subsequent situations. Said differently, whenever wants, tools, and possibilities are multiplied this increases: “the variety of forces which enter into relations with one another and which have to be intelligently directed” (p. 286). Such increases are what some have labeled overload. This emerging complication creates a crucial moment of interpretation. Dewey observed: The facts are not the kind that yield unthinking optimism and consolation because new struggles and failures are inevitable. The total scene of action remains somewhat as it did before except that is has become more complex and more subtly unstable. But this very situation of greater complexity and instability is the result of the expansion of power, not its contraction, and the expansion comes from the success, not the failure, of power. When this is grasped and admitted it becomes a challenge to intelligence. Instruction in what to do next can never come from an infinite goal, which for us is bound to be empty. It can be derived only from study of the deficiencies, irregularities and possibilities of the actual situation. (Dewey 1922: 288–9)

Complication and instability are hallmarks of human activity, sensemaking, and meaning. Another way to label these same complications is as excess load. But to settle for this label is to miss their significance for learning. Information overload “is a transitory sensation that is experienced by individuals developing schemas that will allow them to upgrade their performance in job-related tasks” (Kock 2000: 261).

Overload Through a Sensemaking Lens When people act in the world portrayed by Dewey, their circumstance may be one of projects, action in context, or concerns that shift as their needs shift. Heidegger (1962) refers to this “absorbed coping” as a ready-to-hand mode of engagement. When people act in this engaged mode, they are aware of the world holistically as a network of interrelated projects rather than as an arrangement of separate physical objects such as tools. It is this holistic awareness that forestalls overload. If one of those projects is interrupted, then people shift to an unready-to-hand mode of experience. Even though problematic aspects of the interruption stand out, people still do not become aware of context-free objects nor do they report feelings of overload. Instead, they and the objects they work with remain situated but they treat them as temporarily unusable. As Heidegger puts it,

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The modes of conspicuousness, obtrusiveness, and obstinacy all have the function of bringing to the fore the characteristics of presence-at-hand in what is ready-to-hand. But the ready-to-hand is not thereby just observed [italics in original] and stared at. Such equipment still does not veil itself in the guise of mere Things. It becomes “equipment” in the sense of something which one would like to shove out of the way. . . [W]hen an assignment has been disturbed [italics in original]—when something is unusable for some purpose—then the assignment becomes explicit4 . . . The context of equipment is lit up,5 not as something never seen before, but as a totality constantly sighted beforehand in circumspection. (Heidegger 1962: 103–5)

It is only when people step back from the interrupted project into a present-at-hand mode that they engage in reflection using analyses that are general, abstract, and context-free. In a present-at-hand mode, tools, artifacts, and objects appear as independent entities, removed from tasks, endowed with distinct measurable properties of mass and weight, and manipulated by distinct subjects. Most important, it is not until people step back and separate themselves from the world, that sensations of overload are experienced. Detached inspection creates more overload than does immersion in ongoing activity. Thus, overload is a present-at-hand moment, not a ready-to-hand moment or an unready-to-hand moment. Overload is partly an act of reflecting on an interrupted, detached moment of thrownness rather than an immersion in and acceptance of thrownness. To disassemble a flow into separate objects creates more things to notice, more detached observing, more data points, less clustering, and more likelihood of overload. When people step back either partially (unready-to-hand) or fully (present-at-hand), they try to make sense. What they face is something like William James’s description: “The world is a buzzing, pulsating, formless mass of signals, out of which people try to make sense, into which they attempt to introduce order, and from which they construct against a background that remains undifferentiated” (cited in Patriotta 2003). What James describes as a “formless mass of signals” is true more for present-at-hand moments than for unready-to-hand moments, and more for novices than for experts. This is the core of the argument that interpretation plays a more significant role in overload than has been acknowledged. When people introduce “order,” there is no guarantee that it will persist. Typically, order is transient and people must recreate it repeatedly. These transitions are occasions of overload. As an example of the close ties between sensemaking and overload, consider Schulman and colleagues’ (Schulman et al. 2004) finding that electricity dispatchers often reset the criteria of adequate performance in order to preserve a sensible task. “Reliability becomes that bar that the operators can actually jump” (p. 22). Operators redefine the standards (e.g., “Who said we had to recover in 10 minutes, why 10, why not 15 minutes?'', p. 22). People in the control room “adapt reliability criteria to meet circumstances that they can actually manage, where those circumstances are increasingly real time in their urgency” (p. 21). Although these adjustments may sacrifice eficiency, they improve comprehension. A network with fixed performance criteria run by confused dispatchers is replaced by a network with malleable criteria run by knowledgeable dispatchers. Notice also that sensemaking facilitates action and the resumption of ready-to-hand functioning (see Weick et al. 2005). A direction for the next period that takes the form of a temporary synthesis, pattern, or plausible story reduces excess load and enables

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people to keep going. Sensemaking that is focused on interpretation and meaning mitigates overload whereas computation and choice associated with decision making often amplify overload. As an expert wildland fire crew chief said: “A decision is something you polish” (Weick 2002: S9), polishing eats up time, investments of time build pressures to justify the time expenditure, and justification makes it harder to drop the decision or revise it and harder to handle information that could undo it. Sensemaking skills are a means to manage excess load. Part of the reason the load is excessive is because it seems inexplicable, irrelevant. If context makes it more relevant, then the overload is lowered. Making something more relevant is primarily an issue of context in the sense that: “the meaning of a particular piece of data depends on what else is going on, what else could be going on, what has gone on, and [what] the observer expects or intends to happen” (Woods et al. 2002: 27). The same datum can change meaning as context changes, which means that is fruitless to mount a search for the “important stuff.” Meaning is sensitive to some but not all details of the current situation. For example, alarm codes in control rooms mean different things depending on what else is occurring (Woods et al. 2002: 27). Depending on the context, an alarm may be unimportant, unimportant even if it goes off repeatedly, needs immediate attention, or needs immediate attention but only if other alarms are going of repeatedly, etc. The contexts for sensemaking often resemble what Heidegger has described as “the prereflective experience of being thrown into a situation of acting without the opportunity or need to disengage and function as detached observers” (Winograd and Flores 1986: 97). As an example, Rhona Flin (1996: 105) argues that the challenge for the incident commander at an unfolding disaster is to continually make sense of an unexpected and dynamic situation that is characterized by unfamiliarity, scale, and speed of escalation. Incident commanders have to deal with: (1) extremely difficult decisions; (2) ambiguous and conflicting information; (3) shifting goals; (4) time pressure; (5) dynamic conditions; (6) complex operational team structures; (7) poor communication; and (8) courses of action that all carry significant risks (Flin 1996: 37). These same eight characteristics, albeit scaled down, show up in less disastrous situations of thrownness. Thrownness is one way to describe situations where people are engaged and subject to moments of overload.

Expertise as an Antidote to Overload The effects of thrownness on sensemaking and overload depend on the expertise of the individuals and system that are thrown into disordered situations. Consider the case of variations in expertise among nurses. Advanced beginners [in nursing] seldom have sufficient experience to manage rapidly changing critical care situations smoothly. Consequently, in situations that call for rapidly changing priorities for patient’s management, they miss cues and continue care in a relatively unchanging and rule-governed way . . . Without an experientially learned sense of salience, the care of critically ill patients can become a flat landscape of anxiety-producing tasks to be accomplished. Advanced beginners speak of ‘prioritizing’ their actions, but the basis for their judgments about what to do first seems most driven by what they know

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how to do (physical care procedures) and by what, in their limited experience, seems most important. (Benner et al. 1996: 63–4)

Notice this description references issues of significance, attention, and expertise. This brings us back to the idea that significance is at the heart of the information overload problem, particularly “when it is not known a priori what data from a large data field will be informative” (Woods et al. 2002: 25). Significance and expertise go hand in hand which suggests that overload is predominantly a phenomenon of novices and advanced beginners, less so those whose functioning is competent, and least so for those whose functioning is proficient and expert. It also raises the possibility that overload can become an issue for anyone, including experts, if under pressures for regression to less expert stages of functioning. Just such regression is a strong possibility in the Madrid case discussed at the beginning of this chapter.

Reconceptualizing Overload Adding the variable of differences in expertise to the rethinking done so far brings together various concepts. The work of Dreyfuss and Dreyfuss (1986) and others (e.g., Ericsson et al. 2006) who explore the nature of expertise facilitates much of this convergence. Dreyfuss and Dreyfuss (1986) propose that skilled performance passes through five levels of proficiency (i.e., novice, advanced beginner, competent, proficient, and expert). The move from novice to expert reflects changes particularly in three aspects (see Benner 1984: 13–14): The first is a move from relying on abstract principles (rule-based behavior) to using past concrete experience as paradigms; the second is a change in the perception of the demand situation such that the situation is seen less as a compilation of bits and more as a complete whole with certain relevant parts; the third is a move from being an observer outside the situation to being an involved performer engaged in the situation. Classifying gradations in the expertise of individuals and systems enables prediction of the duration and intensity of overload (see Box 3.1 for representative descriptions of each stage that have been selected for their relevance to issues of overload). Several propositions follow from this line of thinking. Firstly, the progression from novice to expert suggests a progression from more time in a present-at-hand mode to less time in this mode and a growth of meaning and significance in what people observe and respond to. Secondly, as people progress from novice to expert they experience longer periods of ready-to-hand functioning that are subject to fewer interruptions and unreadyto-hand moments. Thirdly, overload is predominantly a phenomenon of present-at-hand functioning and limited response repertoires. Overload is an interpretation that people make in response to breakdowns, the interruption of ongoing projects, or an imbalance between demand and capability. For example, in the nursing scenario noted earlier: “anxiety is generated when . . . patients’ changing needs and concerns are experienced as an interruption in the flow of the nurse’s care, rather than the focus of that care” (Benner et al. 1996: 62). A novice nurse interprets procedures as the salient project and the interruption of that project by changes in patient needs, as the threat. The shift from procedures as the project to caring for patient needs directly relates to experience, repertoire, and stage of expertise.

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Descriptions of Five Stages of Expertise Novice: “The instruction process [in skill acquisition] begins with the instructor decomposing the task environment into context-free features which the beginner can recognize without benefit of experience, The beginner is then given rules for determining actions on the basis of these features, like a computer following a program. Through instruction, the novice acquires rules for drawing conclusion or for determining actions, based upon facts and features of the situation that are recognizable without experience in the skill domain being learned” (p. 37). Advanced beginner: “Performance improves to a marginally acceptable level only after the novice has considerable experience coping with real situations. While this encourages the advanced beginner to consider more objective facts and to use more sophisticated rules, it also teaches the learner an enlarged conception of what is relevant to the skill . . . With the addition of many new elements now known by the learner to be relevant to the skill, the task appears to become more difficult, and the advanced beginner often feels overwhelmed by the complexity of the skill and exhausted by the effort required to notice all relevant elements and to remember an increasing number of more and more complicated rules” (p. 38) Competence: “With more experience, the number of potentially relevant elements of a real-world situation that the learner is able to recognize becomes overwhelming. At this point, since a sense of what is important in any particular situation is missing, performance becomes nerve-wracking and exhausting . . . To cope with this problem and to achieve competence, people learn through instruction or experience to adopt a hierarchical perspective. First they must devise a plan, or choose a perspective, which then determines which elements of the situation are to be treated as important and which ones can be ignored. By restricting themselves to only a few of the vast number of possibly relevant facts and features, decision making becomes easier . . . The problem is that there are a vast number of different situations that the learner may encounter, many differing from each other in subtle, nuanced ways, and in each a plan or perspective must be determined. There are, in fact, more situations than can be named or precisely defined, so no one can prepare for the learner a list of what to do in each possible situation. Thus, competent performers have to decide for themselves what plan to choose without being sure that it will be appropriate in the particular situation. Now coping becomes frightening rather than exhausting, and the learner feels great responsibility for his or her actions” (p. 39) Proficient: As the “performer acquires the ability to discriminate between a variety of situations entered into with concern and involvement, plans are intuitively evoked and certain aspects stand out as important without the learner standing back and choosing those places or deciding to adopt that perspective. Action becomes easier and less stressful as the learner simply sees what needs to be achieved rather than deciding, by a calculative procedure, which of several possible alternatives should be selected. There is less doubt that what one is trying to accomplish is appropriate when the goal is simply obvious rather than the winner of a complex competition. In fact, at the moment of involved intuitive response there can be no doubt, since doubt comes only with detached evaluation of performance . . . The proficient performer simply has not had enough experience with the wide variety of possible action in each of the situations he or she can now discriminate to have rendered the best response automatic. For this reason, the proficient performer, seeing the goal and the important features of the situation, still must decide what to do. To do this, he or she falls back on detached, rule-based determination of actions” (p. 41).

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Expert: “The expert not only knows what needs to be achieved, based on mature and practiced situational discrimination, but also knows how to achieve the goal. A more subtle and refined discrimination ability is what distinguishes the expert from the proficient performer. This ability allows the expert to discriminate among situations all seen as similar with respect to the plan or perspective, distinguishing those situations requiring one action from those demanding another . . . [T]he expert not only sees what needs to be achieved, but also how to achieve it. When things are proceeding normally, experts don’t solve problems and don’t make decisions, they simply do what experience has shown normally work, and it normally works” (p. 42). Source: Exerpts are from Benner et al. 1996.

The ability to remain focused on the project that was interrupted influences the content of interpretations in the face of breakdowns. Other influences include: the ability to make sense of the interruption without detaching from and dissecting the event, familiarity with related events, and capability to discriminate among similarities and differences between the current event and previous related events, and capabilities for recovery from the interruption. When ongoing projects are interrupted by an imbalance between demand and capability there are four increasingly effortful ways to handle it (see Schulman et al. 2004: 19–21). Individuals rebalance demands and capabilities initially by activating responses that they have developed previously “just in case” an imbalance occurs. If the imbalance persists, they activate responses “just in time” to handle instabilities (e.g., queue). If instabilities still persist despite just-in-time adjustments, then they make more extreme adjustments “just for now” (e.g., they filter demands according to a priority scheme). And if those just-for-now adjustments fail, then the last resort is to activate an extreme response that is executed “just this way” (e.g., they change criteria for what constitutes an acceptable performance). The smaller the response repertoire, the faster a system will move through this sequence to “just this way” functioning. Novices will move through this sequence faster than advanced beginners who will move through faster than competent performers who will move through faster than proficient performers who will move through faster than expert performers. Interruption can produce either an unready-to-hand or a present-at-hand mode of engagement. The perception of overload is greater in the present-at-hand mode than in the unready-to-hand mode. Higher levels of overload occur in present-at-hand engagement because individuals must attend to more separate elements, know fewer patterns to connect the elements, and, as a consequence, feel more pressure to rely on what they already know. There are limits to what novices and advanced beginners know, which means they miss or intentionally ignore more clues. Missed clues mean that subsequent action may make things worse and lead to more frequent and more intense subsequent breakdowns. By contrast lower levels of overload occur in unreadyto-hand engagement, because experts preserve the context of the interrupted project. And this preservation provides a meaningful frame for what they then notice. Noticing occurs in the service of resumption, recovery, and resilience. And the size and content of the response repertoire determines noticing.

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The larger and more heterogeneous the response repertoire, the more that a person, a team, or an organization can afford to see (Sutcliffe and Vogus 2003). And the more one sees, the more ways one can see to recover from an interrupted project. And the more options for recovery the lower the likelihood that one will detach in a presentat-hand mode and experience more unconnected elements and more overload. Stated differently, the larger the repertoire, the lower the likelihood that unready-to-hand will be converted into present-at-hand, and the higher the likelihood that unready-to-hand will be converted into ready-to-hand. The more limited the response repertoire, the greater the likelihood that decision makers will treat interruptions as present-at-hand rather than unready-to-hand. In the case of a limited response repertoire, there are fewer ways to recover from an interruption that preserve the project (i.e., less likelihood of converting unready-to-hand to readyto-hand), hence, decision makers are more likely to disassemble the project in the interest of a detached analysis to determine what caused the interruption. Disassembling and detached analysis (present-at-hand) create separate parts, and separate parts without connections or context place greater demands on attention and therefore induce greater load. Thus, a present-at-hand mode of engagement creates more imbalance than does an unready-to-hand mode of engagement. As experience develops people are able to stay in ready-to-hand and unready-to-hand modes of engagement for longer periods of time and over a greater variety of conditions. Consequently, they spend less time in present-at-hand modes of engagement, which means that they experience fewer occasions of overload. It may not be simply amount of experience that matters since generalists may be in better positions to moderate overload than are specialists. Generalists tend to have larger and more varied response repertoires (Bunderson and Sutcliffe 2002) that enable them to stay in a ready-to-hand mode for longer periods of time, to bounce back more quickly from an unready-to-hand interruption, and to be less overloaded when they experience a present-at-hand mode.

Implications and Conclusion Although this volume is devoted to the topic of organizational decision making, our treatment of overload seldom mentions decision making. There are two reasons for that omission. Firstly, we take seriously the observation that: “To ‘decide’ presupposes previous consideration of a matter causing doubt, wavering, debate, or controversy and implies the arriving at a more or less logical conclusion that brings doubt or debate to an end” (Webster’s New Dictionary of Synonyms 1984: 215). Overload, treated as an issue of interpretation rather than computation, has its effects on “previous consideration of matters causing doubt” and therefore affects what is bracketed as being in need of deciding and what resources are available for the deciding and its aftermath. Second, overload is about action, interpretation, and sensemaking. And, as we have mentioned elsewhere (Weick et al. 2005: 409), when action is the central focus, interpretation, not choice, is the core phenomenon. Scott Snook (2001) made a similar point in his analysis of a friendly fire tragedy. Reflecting on his research, Snook says: I could have asked, “why did they decide to shoot?” However, such a framing puts us squarely on a path that leads straight back to the individual decision maker, away from

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potentially powerful contextual features and right back into the jaws of the fundamental attribution error. “Why did they decide to shoot?” quickly becomes “Why did they make the wrong decision?” Hence, the attribution falls squarely onto the shoulders of the decision maker and away from potent situation factors that influence action. Framing the individual-level puzzle as a question of meaning rather than deciding shifts the emphasis away from individual decision makers toward a point somewhere “out there” where context and individual action overlap. . . . Such a reframing—from decision making to sensemaking— opened my eyes to the possibility that, given the circumstances, even I could have made the same “dumb mistake.” This disturbing revelation, one that I was in no way looking for, underscores the importance of initially framing such senseless tragedies as “good people struggling to make sense,” rather than as “bad ones making poor decisions”. (pp. 206–7)

Previous literature reviews make it clear that there is scant empirical work on which to build an inductive picture of overload. To encourage more empirical work, we have come at the problem of overload from a perspective other than the prevailing perspective of information processing. By mixing the complexities of everyday activity, the situation of thrownness, sensemaking of interruptions, and levels of expertise, we position overload as transitory, commonplace, embedded, influenced by experience, and driven by diverse interpretations of demand–capability imbalances. The research questions that flow from such an analysis mainly fall into the domain of learning. Overload links to learning in two different ways. Firstly, overload is high at the novice and advanced beginner stage of learning since present-at-hand and unready-to-hand modes of engagement prevail at these stages. Secondly, the activity of learning itself, whatever the stage of expertise, initially involves novice-like moments when elements prevail and when a “big picture” is difficult to achieve. This suggests that a learning organization is an overloaded organization. It also suggests that a learning orientation is an invitation to overload (Bunderson and Sutcliffe 2002, 2003). The proposed conceptualization of overload also has implications for practice. For example, decision makers will want to develop capabilities that enable people to move out of an unready-to-hand moment swiftly and to resume action. Important capabilities that further this movement are resilience, intuition, and improvization (Weick and Sutcliffe 2001). Furthermore, decision makers may want to encourage sensemaking that focuses on plausibility rather than accuracy (Weick et al. 2005). The pursuit of accuracy may increase overload to debilitating levels. Plausibility preserves the framework provided by the ongoing project and holds the performer in a state of unready-to-hand engagement, whereas the pursuit of accuracy tends to generate a present-at-hand way of operating, which may fracture the project, increase the difficulty of subsequent sensemaking, and make it harder to reassemble a coherent big picture. In many ways our analysis boils down to the conclusion, overload just is. People interact, do what is ready to hand, bracket portions of flowing events, get interrupted by what they bracket and by their efforts to learn, sometimes detach from the flow to take a closer look, but always keep going. Moments of overload arise from the way in which people handle fluctuating demands with fluctuating resources. This is not to trivialize the topic of overload. Far from it. Instead, it is an effort to reposition overload in the context of everyday practice. Thus, we want to animate Herbert Simon’s four present participles—listening, storing, thinking, and speaking—by contextualizing them amid

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ongoing thrownness, sensemaking, complicating, recovering, and learning. It is only by adding in these parameters of interpretation that we can assure a system that listens and thinks more than it speaks.

Endnotes 1 The USNCB (United States National Central Bureau) for INTERPOL (international police organization) is an office under the control and direction of the Departments of Justice and Homeland Security. The US authority for INTERPOL functions rests by law with the US Attorney General. The USNCB serves as a point of contact for both American and foreign police seeking assistance in criminal investigations that extend beyond their national boundaries. Known within the international community as INTERPOL Washington, the USNCB brings together US police at all levels, providing a neutral territory where jurisdictions and mandates are interwoven to permit cooperation and assistance to the fullest extent possible. 2 Other labels for overload include cognitive overload, sensory overload, communication overload, knowledge overload, data smog, information fatigue, overkill, overabundance, breakdown, explosion, deluge (see Eppler and Mengis 2004: 329). The claim that overload is both a recent and growing phenomenon (see Kock 2000) belies its prominence in the literature for at least a century. For example, the information glut in the 1880s led manufacturers to advertise a particular desk as a solution for filing books and papers (Noyes and Thomas 1995; Edmunds and Norris 2000). In the 1920s, H. G. Wells pondered over how to organize the large mass of knowledge that was being collected by civilized man (Wells 1921, 1933). 3 The amount of data to be processed per unit of time is generally conceived of as the information load accompanying the work. 4 John Dewey (1922: 178–9) makes a similar point: “In every waking moment, the complete balance of the organism and its environment is constantly interfered with and as constantly restored . . . Life is interruptions and recoveries . . . At these moments of a shifting in activity, conscious feeling and thought arise and are accentuated.” 5 See also David Woods et al.’s (2002) use of spotlight as a positive selectivity in dealing with overload.

References Barthol, R. P. and Ku, N. D. (1959). ‘Regression Under Stress to First Learned Behavior.’ Journal of Abnormal Psychology, 59: 134–6. Benner, P. ( 1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice Hall. —— Tanner, C. A., and Chesla, C. A. (1996). Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. New York: Springer. Bunderson, J. S. and Sutcliffe, K. M. (2002a). ‘Comparing Alternative Conceptualizations of Functional Diversity in Management Teams: Process and Performance Effects.’ Academy of Management Journal, 45/5: 875–93. —— —— (2002b). ‘Why Some Teams Emphasize Learning More than Others: Evidence from Business Unit Management Teams’, in M. Neal, E. M.nnix, and H. Sondak (eds.), Research on Managing Groups and Teams. New York: Elsevier Science Ltd., 49–84.

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—— —— (2003). ‘Management Team Learning Orientation and Business Unit Performance.’ Journal of Applied Psychology, 88/3: 552–60. Chajut, E. and Algom, D. (2003). ‘Selective Attention Improves Under Stress: Implications for Theories of Social Cognition.’ Journal of Personality and Social Psychology, 85: 231–48. Daft, R. L. and Weick, K. E. (1984). ‘Toward a Model of Organizations as Interpretation Systems.’ Academy of Management Review, 9/2: 284–95. Dewey, J. (1922/2002). Human Nature and Conduct. Mineola, NY: Dover. Dreyfuss, H. L. and Dreyfus, S. E. (1986). Mind Over Machine. New York: Free Press. Edmunds, A., and Morris, A. (2000). ‘The Problem of Information Overload in Business Organizations: A Review of the Literature.’ International Journal of Information Management, 20: 17–28. Eppler, M. J. and Mengis, J. (2004). ‘The Concept of Information Overload: A Review of Literature from Organization Science, Accounting, Marketing, MIS, and Related Disciplines.’ The Information Society, 20: 325–44. Ericsson, K. A., Charness, N., Feltovich, P. J., and Hoffman, R. R. (2006). The Cambridge Handbook of Expertise and Expert Performance. New York: Cambridge University Press. Feldman, M. S., and March, J. G. (1981). ‘Information as Signal and Symbol.’ Administrative Science Quarterly, 26: 171–86. Flin, R. H. (1996). Sitting in the Hot Seat: Leaders and Teams for Critical Incident Management. New York: Wiley. Gaba, D. M., Howard, S. K., and Jump, B. (1994). ‘Production Pressure in the Work Environment.’ Anesthesiology, 81: 488–500. Galbraith, J. R. (1974). ‘Organization Design: An Information Processing View.’ Interfaces, 3: 28–36. Hahn, M., Lawson, R., and Lee, Y. G. (1992). ‘The Effects of Time Pressure and Information Load on Decision Quality.’ Psychology and Marketing, 9/5: 365–78. Heath, D. (2004). ‘FBI’s Handling of Fingerprint Case Criticized.’ Seattle Times. June 1, online version. Heidegger, M. (1962). Being and Time. New York: Harper and Row. Hodgkinson, G. P. and Sparrow, P. R. (2002). The Competent Organization: A Psychological Analysis of the Strategic Management Process. Philadelphia, PA: Open University Press. Jett, Q. R. and George, J. M. (2003). ‘Work Interrupted: A Closer Look at the Role of Interruptions in Organizational Life.’ Academy of Management Review, 28: 494–507. Kock, N. (2000). ‘Information Overload and Worker Performance: A Process-Centered View.’ Knowledge and Process Management, 4: 256–64. Lant, T. K. (2002). ‘Organizational Cognition and Interpretation,’ in J. A. C. Baum (ed.), The Blackwell Companion to Organizations. Oxford, UK: Blackwell, 344–62. —— Shapira, Z. (2001a). ‘Introduction: Foundations of Research on Cognition in Organizations,’ in T. K. Lant and Z. Shapira (eds.), Organizational Cognition: Computation and Interpretation. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 1–12. —— —— (2001b). ‘New Research Directions on Organizational Cognition,’ in T. K. Lant and Z. Shapira (eds.), Organizational Cognition: Computation and Interpretation. Mah-wah, NJ: Lawrence Erlbaum Associates, Inc., 367–76. Lipowski, Z. J. (1975). ‘Sensory and Information Inputs Overload: Behavioral Effects.’ Comprehensive Psychiatry, 16/3: 199–221.

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Lord, R. G. and Foti, R. J. (1986). ‘Schema Theories: Information Processing and Organizational Behavior,’ in H. P. Sims and D. A. Gioia (eds.), The Thinking Organization. San Francisco, CA: Jossey-Bass, 20–48. Miller, J. G. (1960). ‘Information Input Overload and Psychopathology.’ American Journal of Psychiatry, 116: 695–704. O’Reilly, C. A. (1980). ‘Individuals and Information Overload in Organizations: Is More Necessarily Better?’ Academy of Management Journal, 23: 684–96. Patriotta, G. (2003). ‘Sensemaking on the Shop Floor: Narratives of Knowledge in Organizations.’ Journal of Management Studies. 40/2: 349–76. Perlow, L. A. (1999). ‘A Time Famine: Toward a Sociology of Work Time.’ Administrative Science Quarterly, 44: 57–81. Schneider, S. C. (1987). ‘Information Overload: Causes and Consequences.’ Human Systems Management, 7: 143–53. Schick, A. G., Gordon, L. A., and Haka, S. (1990). ‘Information Overload: A Temporal Approach.’ Accounting, Organizations and Society, 15: 199–220. Schulman, P., Roe, E., van Eeten, M., and de Bruijne, M. (2004). ‘High Reliability and the Management of Critical Infrastructures.’ Journal of Contingencies and Crisis Management, 12/1: 14–28. Simon, H. (1971). ‘Designing Organizations for an Information-Rich World,’ in M. Green-berger (ed.), Computers, Communications and the Public Interest. Baltimore, MD: Johns Hopkins Press, 37–72. Simon, H. A. (1973). ‘Applying Information Technology to Organization Design.’ Public Administration Review, 33/3: 268–78. Sparrow, P. R. (1999). ‘Strategy and Cognition: Understanding the Role of Management Knowledge Structures, Organizational Memory, and Information Overload.’ Creativity and Innovation Management, 8: 140–8. Speier, C., Valacich, J. S., and Vessey, I. (1999). ‘The Influence of Task Interruption on Individual Decision Making: An Information Overload Perspective.’ Decision Sciences, 30: 337–59. Stacey, R. B. (2004). ‘A Report on the Erroneous Fingerprint Individualization in the Madrid Train Bombing Case.’ Journal of Forensic Identification, 54/6: 706–18. —— (2005). Personal Communication, Washington, DC. Sutcliffe, K. M. and Vogus, T. ( 2003). ‘Organizing for Resilience,’ in K. S. Cameron, J. E. Dutton, and R. E. Quinn (eds.), Positive Organizational Scholarship. San Francisco, CA: Berrett-Koehler, 94–110. Thompson, J. D. (1967). Organizations in Action. New York: McGraw-Hill. Tsoukas, H. and Chia, R. (2002). ‘On Organizational Becoming: Rethinking Organizational Change.’ Organization Science, 13/5: 567–82. Tushman, M. L. and Nadler, D. A. (1978). ‘Information Processing as an Integrating Concept in Organization Design.’ Academy of Management Review, July: 613–24. Weick, K. E. (1970). ‘The Twigging of Overload,’ in H. B. Pepinsky (ed.), People and Information. New York: Pergamon Press, 67–131. —— (2002). ‘Puzzles in Organization Learning: An Exercise in Disciplined Imagination.’ British Journal of Management, 13(Special Issue): S7–S17. —— (2004). ‘Designing for Thrownness,’ in R. J. Boland, and F. Collopy (eds.), Managing as Designing. Stanford, CA: Stanford University Press, 74–8.

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—— Sutcliffe, K. M. (2001). Managing the Unexpected: Assuring High Performance in and Age of Complexity. San Francisco, CA: Jossey-Bass. —— —— Obstfeld, D. (1999). ‘Organizing for High Reliability: Processes of Collective Mindfulness,’ in R. Sutton and B. Staw (eds.), Research in Organizational Behavior. Greenwich, CT: JAI, 81–124. —— —— —— (2005). ‘Organizing and the Process of Sensemaking.’ Organization Science, 16: 409–21. Wells, H. G. (1921). The Salvaging of Civilization. New York: Macmillan, 141–66. —— (1933). The Shape of Things to Come. New York: Macmillan, 420. Winograd, T. and Flores, F. ( 1986). Understanding Computers and Cognition. Norwood, NJ: Ablex. Woods, D. D., Patterson, E. S., and Roth, E. M. (2002). ‘Can We Ever Escape from Data Overload? A Cognitive Systems Diagnosis.’ Cognition, Technology and Work, 4: 22–36. Wright, P. ( 1974). ‘The Harassed Decision Maker: Time Pressures, Distractions, and the Use of Evidence.’ Journal of Applied Psychology, 59/5: 555–61.

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6 Organizing for Mindfulness: Eastern Wisdom and Western Knowledge Setting the Scene Ten years ago we began to interpret data about high reliability organizations using Ellen Langer’s ideas of mindfulness (Weick, Sutcliffe, and Obstfeld, 1999, and summarized on pp. 95–96 in the following reprinted article). We defined mindfulness as a ‘rich awareness of discriminatory detail coupled with wise action, both being generated by organizational processes.’ Two years later Kathie Sutcliffe and I refined that definition and described mindfulness as: . . . the combination of ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences, willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning (Weick and Sutcliffe, 2001, p. 42).

Both descriptions imply that conceptual refinement is an important means to improve attention. However, that implication is incomplete because organizations are vulnerable to error for more reasons than conceptual inadequacy. Organizations break down when their attention is scattered, unstable, short lived, and dominated by abstractions, all of which predispose people to misestimate, misunderstand, and mis-specify what they think they face (Schulman, 2004). This larger set of problems is addressed if we retain the concept of mindfulness, but go back 2500 years to recover its earlier meaning in Eastern philosophy and psychology. That is the agenda of Chapter 6. We retain Langer’s emphasis on distinction making but take a closer look at its consequences. When people refine the distinctions they make they often see the limits of simple categories and even of categorizing itself; their attention focuses on what is left out and what seems lumped together

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arbitrarily; they become more focused and see the costs of scattered attention; they pay more attention to what is happening here and now; they experience entities as less substantial and more transient; they see the liabilities of swift thinking when they slow down to register finer distinctions; and there is gradual recognition that changes in events as well as in oneself as perceiver are continuous. When people become more reflective about distinction making, they also begin to realize how readily we categorize our experiences, how reluctant we are to examine these categories, and what happens when we become less dependent on categories. Concepts are important, not because they represent but because they enable us to cope. To cope more effectively we need to refine the concepts. This is Langer’s contribution. To see more clearly in general, we also have to understand how conceptualizing itself affects seeing. This is what Eastern mindfulness contributes. Issues of attention begin to change when we move from West to East. Mindfulness now becomes associated with qualities of attention such as its focus, stability, sustainability, filtering, and vividness. Mindfulness is about remembering, but it is remembering an intended object in the present, not an object from the past. Buddhist texts describe this capability to remember as ‘not wobbling.’ Eastern mindfulness means having the ability to hang on to current objects, to remember them, and not to lose sight of them through distraction, wandering attention, associative thinking, explaining away, or rejection. As described in A Comprehensive Manual of Abhidhamma, the Buddhist analysis of mind and mental processes, mindfulness has ‘the characteristic of not wobbling, i.e., not floating away from the object. Its function is absence of confusion or nonforgetfulness’ (Bodhi, 2000, p. 86). The image of not wobbling is meant to convey the quality that mindfulness ‘keeps the mind as steady as a stone instead of letting it bob about like a pumpkin in water’ (Bodhi, 2000, p. 371). To wobble in perceiving an object is to acquiesce in its conceptual associations before full awareness and nonforgetfulness can occur. The practical importance of not floating away from the object for organization theory is that the failure to accomplish this is viewed by many as a primary causal factor in organizational accidents (e.g. Turner, 1994). If a discrepancy occurs when an unexpected event materializes or an expected event fails to materialize, this discrepancy interrupts a routine. The discrepancy momentarily becomes the object of attention, but this object is often lost soon thereafter when the discrepancy is glossed over, normalized, and treated as if it were a familiar event already encountered, named, and understood in the past. These associations interfere with continuing direct perception of the discrepancy, they draw attention away from the object, and they typically replace nonjudgmental observations with thoughts and concepts and emotional reactions that distort perceptions of the object. To wobble in perceiving an object is to acquiesce in its associations rather than to see its current meaning and context more fully. As you study Chapter 6, pay close attention to several discussions that are compact versions of key assumptions found throughout this book. The ‘cardinal meditation involving impermanence, suffering, and egolessness’ (p. 93 of the reprinted article) is presumed to be the major dynamic that underlies organizational dysfunction (p. 101). With the knowledge that my co-author, Ted Putnam, is one of the leading investigators of wildland fire fatalities, take your time reading the brief discussion of fatality investigations on p. 98. Ted practices mindful investigation (see Putnam and Saveland, 2008) and his work is a perfect example of how complex ideas become synthesized into

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practical routines of inquiry. As further ‘grist’ for thinking, recall that up to this point in the book we have assumed that believing is seeing. We see what we have the tools to see. Among these tools are concepts, frameworks, labels, and expectations. Notice that the thrust of the current analysis is, in Robert Irwin’s phrase, ‘seeing is forgetting the name of the thing seen’ (Weschler, 1982). Names help us see, but also blind us to what we see. Concepts are sometimes tools we need to drop in order to see more. The following article by Karl E. Weick and Ted Putnam was published in Journal of Management Inquiry, 2006, 15(3), 1–13.

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Organizing for Mindfulness Eastern Wisdom and Western Knowledge Karl E. Weick University of Michigan, Ann Arbor

Ted Putnam Mindful Solutions, Missoula, Montana Journal of Management Inquiry, Vol.15 No. 3, September 2006 1-13 DOI: 10.1177/1056492606291202 © 2006 Sage Publications Inc. Reprinted with permission.

A sign on the wall of a machine shop run by the New York Central Railroad reads, “Be where you are with all your mind.”1 If one assumes that “order or confusion of society corresponds to and follows, the order or confusion of individual minds” (Thera, 1996, p. 22), then the New York Central is moving in the right direction by trying to reduce confusion and mistakes through greater mindfulness. But exactly what they are moving toward is unclear, because mindfulness means something quite different in Eastern and Western thought. In Eastern thought, to be where you are with all your mind means to pay more attention to internal processes of mind rather than to the contents of mind. Eastern mindfulness means having the ability to hang on to current objects; remember them; and not lose sight of them through distraction, wandering attention, associative thinking, explaining away, or rejection. As described in the Abhidhamma, the Buddhist analysis of mind and mental processes, mindfulness has “the characteristic of not wobbling, i.e. not floating away from the object. Its function is absence of confusion or non-forgetfulness” (Bodhi, 2000, p. 86). Commentators have noted that the image of “not wobbling” is meant to convey the quality that mindfulness “keeps the mind as steady as a stone instead of letting it bob about like a pumpkin in water” (Bodhi, 2000, p. 371). To wobble in perceiving an object is to acquiesce in its conceptual associations before total awareness and nonforgetfulness can occur. Not wobbling is characteristic of powerful AUTHORS’ NOTE: Mindfulness meditation is a prominent theme in this article. The authors have complementary experience with this topic. Weick is not an active practitioner of mindfulness meditation. His exposure to mindfulness meditation is mainly through ongoing discussions and interviews with practitioners of mindfulness meditation and ongoing study of documents generated by practitioners of meditation. Putnam, who holds a PhD in experimental psychology and whose career was in wildland firefighting, has practiced meditation for 20 years with more intensive mindfulness meditation for the past 5 of those years. He has promoted mindfulness meditation practice in the wildland fire community for more than 10 years. Both authors have an intense interest in the articulation of pathways that lead to wisdom and in the development of safer practices for wildland firefighting.

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mindfulness and, in combination with one-pointed concentration, produces penetrative insights or wisdom. In Western thought, to be where you are with all your mind means to pay more attention to external events and to the content of mind, these contents including things such as past associations, concepts, reifications, and semblances of sensed objects (DeCharms, 1998). Ellen Langer’s (1989) work is representative of Western treatments of mindfulness. She describes mindfulness as (a) active differentiation and refinement of existing distinctions (p. 138); (b) creation of new discrete categories out of the continuous streams of events that flow through activities (p. 157); and (c) a more nuanced appreciation of context and of alternative ways to deal with it (p. 159). To see more clearly the organizational complexities associated with mindfulness, consider Robert Chia’s (2005) insightful description of managing. “Managing is firstly and fundamentally the task of becoming aware, attending to, sorting out, and prioritizing an inherently messy, fluxing, chaotic world of competing demands that are placed on a manager’s attention. It is creating order out of chaos. It is an art, not a science. Active perceptual organization and the astute allocation of attention is a central feature of the managerial task” (p. 1092). This description seems to capture Western conceptual mindfulness quite well. Acts of managing are seen to sort competing demands, prioritize those demands, and create order out of chaos. Sorting and prioritizing are acts of differentiation and conceptualizing. Demands are a cluster of experiences gathered into a concept. And the creation of order is an act that ignores impermanence, instills a belief in permanence, yields to a craving for predictability, and perhaps produces clinging. Attempts to create order freeze a dynamic reality into something that people then cling to. The ordering and clinging are useful and necessary for managing, but the dominant action is still clinging, and the order is still subject to inevitable rise and fall, and the rise and fall of order is still the occasion for stress, tension, and anger. But Chia’s description also implies change, acceptance of flux and impermanence, avoidance of a static self, awareness of workings of the mind, attention directed both outward and inward, and preoccupation with here and now. These implications suggest managing that is more mindful and less infused with conceptualizing. Under the assumption that “all things are preceded by the mind” (Wallace, 1999, p. 185), it is important that organizational scholars have a deeper understanding of mindfulness, both as a practice to improve their own minds and inquiries and as a template to judge the potential effects of organized activity on capabilities for mindful perception, choice, and action. In this essay, we selectively examine both Eastern and Western views of mindfulness as they converge on organizational issues. We take note of overlooked properties that are potentially relevant to organizational scholars. We speculate about possible effects when these properties are added to inquiring and inquiries.

Eastern Perspectives on Mindfulness Eastern lines of thinking about mindfulness are grounded in Buddhism. Buddhism “suggests means of enhancing attentional stability and clarity, and of then using these abilities in the introspective examination of conscious states to pursue the fundamental issues concerning consciousness itself ” (Wallace, 2005, p. 5). The core of the Buddha’s

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message is “Be mindful” (Thera, 1996, p. 23). Mindfulness is said to be the core because “In its elementary manifestation, known under the term ‘attention,’ it [mindfulness] is one of the cardinal functions of consciousness without which there cannot be perception of any object at all.” The Four Foundations of Mindfulness answer the questions: “To be mindful of What, To be mindful of How” (Thera, 1996, p. 24). The four, and only four, foundations of mindfulness are introspective awareness of: body, feelings, consciousness, and mental objects. The development of mindfulness with time is learning the skill of dampening down “internal attention wobbling.” Mindfulness is important, because it counteracts an undisciplined mind. An undisciplined mind comes from a combination of habituation, mindlessness, laxity, and scattered attention. If left in this condition, a mind is an unreliable instrument for examining mental objects, processes, and the nature of consciousness (Wallace, 1999, p. 176). Remedies for an unreliable instrument proposed in Eastern thought work directly on attentional processes such as scatter, vividness, duration, a focus on the present, and the letting go of concepts. Generally, Eastern mental development proceeds from an emphasis on virtue to concentration to mindfulness; from grosser to more subtle levels of mind. Virtue involves changing unskillful states of mind to skillful states and then maintaining the skillful states. Actions that are motivated by one of the three mental toxins—greed, hatred, or delusions—are unskillful. Actions motivated by generosity, loving kindness, or clarity of mind are the skillful antidotes to the three toxins. Concentration and mindfulness work together to control attention. Concentration excludes mental hindrances or interferences leading to a calmer, focused mind. Mindfulness notes when we lose either our momentary focus or longer term focus and reminds us to refocus. The most effective but effortful way to work directly on attentional processes is to develop virtue, concentration, and mindfulness concurrently. The nature of mindfulness is implicit in the original Pali word for mindfulness, Sati. (Pali is the Prakrit language in which Buddhist philosophy and psychology were first written). Sati “derives from a root meaning [in Pali] ‘to remember,’ but as a mental factor it signifies presence of mind, attentiveness to the present, rather than the faculty of memory regarding the past” (Bodhi, 2000, p. 86). As noted earlier, mindfulness is the mental ability to hang on to current objects by bringing wandering (wobbling) attention back to the intended object. A glimpse of Eastern mindfulness is found in the thin slices of perception that precede conceptualizing. “When you first become aware of something, there is a fleeting instant of pure awareness just before you conceptualize the thing, before you identify it. That is a state of awareness. Ordinarily this state is short lived. It is that flashing split second . . . just before you objectify it, clamp down on it mentally, and segregate it from the rest of existence. . . . That flowing, soft-focused moment of pure awareness is mindfulness. . . . Mindfulness is very much like what you see with your peripheral vision as opposed to the hard focus of normal or central vision. Yet this moment of soft, unfocussed awareness contains a very deep sort of knowing that is lost as soon as you focus your mind and objectify the object into a thing. In the process of ordinary perception, the mindfulness step is so fleeting as to be unobservable. We have developed the habit of squandering our attention on all the remaining steps, focusing on the perception, cognizing the perception, labeling it, and most of all, getting involved in a long string of symbolic thought about it. . . . It is the purpose of vipassana meditation to train us to prolong that moment of awareness” (Gunaratana, 2002, p. 138).

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Formally, “Mindfulness is moment-to-moment, nonreactive, nonjudgmental awareness. . . . You don’t seek such an experience or turn it into a concept. You just sit, not pursuing anything, and insights come up on their own timetable, out of stillness and out of spacious open attention without any agenda other than to be awake” (KabatZinn, 2002, p. 69). Meditation or mental development focuses on three sets of internal mental objects that are relevant for developing mindfulness: Factors of Sense Contact (sense–contact, feeling, perception, volition, and consciousness), Factors of Absorption (thought, examination, rapture, pleasure, and mental one-pointedness (concentration), and Faculties (faith, energy, mindful-ness, concentration, wisdom, mind, joy, and vitality; Thera, 1998).The significance of these three groups is that both the factors within a group and the groups themselves are in linear development order. The factors are also holographic and improvement in one factor improves all the other factors. The holographic effect is strongest within a group, because the group has an overall function. The overall functions for the groups in order are Sense Contact, Concentration, and Mindfulness. The factors in the first group are present in every moment of consciousness and therefore embody everyday thinking. Those who follow intellectual pursuits (e.g., academics) intensify concentration as they develop the second group, but only those who move beyond Western psychology and cultivate the first five factors of the third group— the so-called Spiritual Faculties—develop transformational mindfulness. The third set is dependent on faith in the meditation process and extreme effort, which lead to stronger mindfulness and deeper concentration which in turn induce insights and wisdom. A simple analogy for the way mindfulness works is the movie theater: When we are watching the screen, we are absorbed in the momentum of the story, our thoughts and emotions manipulated by the images we are seeing. But if just for a moment we were to turn around and look toward the back of the theater at the projector, we would see how these images are being produced. We would recognize that what we are lost in is nothing more than flickering beams of light. Although we might be able to turn back and lose ourselves once again it the movie, its power over us would be diminished. The illusion-maker has been seen. Similarly, in mindfulness meditation, we look deeply into our own movie-making process. We see the mechanics of how our personal story gets created, and how we project that story onto everything we see, hear, taste, smell, think, and do. (Niskar, 1998, p. 26)

To develop fuller mindfulness, people need to learn both where to focus attention and how to focus attention. Guidelines for doing so are described in the four frames of mindfulness (Satipatthana; Thanissaro, 1996, p. 72). Sati means mindfulness. And patthana means foundation, condition, or source, which refers to the object that is kept in mind as a frame of reference for giving context to one’s experience (i.e., where to focus attention). The word sati-patthana can also be seen as a compound of sati and upatthana, which means establishing or setting near; thus referring to the approach or the how of keeping something loosely in mind; of maintaining a solid frame of reference (in the present). Both the proper object and proper approach are crucial for getting the proper results (mindfulness). Thanissaro (1996) further clarifies that if one takes the breath as the frame, “One remains focused on the breath in and of itself—ardent, alert and mindful, putting aside

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greed (desire) and distress with reference to the world” (p. 74). Four key terms in this description are the following: Remaining focused—keeping track, staying with one object out of the many competing for attention; thus an element of concentration. Ardent—a factor of effort or exertion, which contains an element of discernment (wise attention) so as to stay with skillful mental qualities. Alert—being clearly aware of what is happening in the present; also an element of discernment. Mindful—being able to remember or recollect. Here it means keeping one’s task in mind. Specifically, to remain focused on one’s frame of reference and putting aside the distractions of greed and distress that come from shifting one’s attention back to the narratives and world views that make up one’s sense of the world. In essence, being ardent, alert, and mindful foster concentration much the same as Thera’s (1998) second Abhidhamma group. “Mindfulness keeps the theme of meditation in mind. Alertness observes the theme as it is present to awareness and also is aware when the mind has slipped from its theme. Mindfulness then remembers where the mind should be focused and ardency tries to return the mind to its proper theme as quickly and skillfully as possible” (Thanissaro, 1996, p. 75). These three qualities help shield the mind from its normal sensual preoccupations and unskillful mental qualities, thus steadily improving concentration and mindfulness.

Qualities of Organizational Experience A crucial input to organizational theorizing is what has been called “the cardinal Buddhist meditation” (Thera, 1996, p. 26): All phenomena are seen as impermanent, liable to suffering, and void of substance or ego. “Insight is the direct and penetrative realization of the Three Characteristics of Existence, i.e. Impermanence, Suffering, and Impersonality. It is not a mere intellectual appreciation or conceptual knowledge of these truths, but an indubitable and unshakeable experience of them, obtained and matured through repeated meditative confrontation with the facts underlying those truths” (Thera, 1996, p. 44). Although unshakeable experience of these characteristics does not occur until advanced stages in the development of mindfulness (Goleman, 1988), people do develop a deeper appreciation of them as they focus their attention internally in a systematic manner. This growing appreciation of the three characteristics is crucial because it makes it easier for people to let go of events, ideas, and identities to which they have been clinging. One rendering of what this growth is like is the following: [Novice meditators] begin to have insight into what the mind, as it is experienced, is really like. Experiences, they notice, are impermanent. This is not just the leaves-fall, maidenswither, and kings-are-forgotten type of impermanence (traditionally called gross impermanence) with which all people are hauntingly familiar but a personal penetrating impermanence of the activity of the mind itself. Moment by moment new experiences happen and are gone. It is a rapidly shifting stream of momentary mental occurrence.

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Furthermore, the shiftiness includes the perceiver as much as the perceptions. There is no experiencer, just as Hume noticed, who remains constant to receive experiences, no landing platform for experience. This actual experiential sense of no one home is called selflessness or egolessness. Moment by moment the meditator also sees the mind pulling away from its sense of impermanence and lack of self, sees it grasping experiences as though they were permanent, commenting on experiences as though there were a constant perceiver to comment, seeking any mental entertainment that will disrupt mindfulness, and restlessly fleeing to the next preoccupation, all with a sense of constant struggle. This undercurrent of restlessness, grasping, anxiety, and unsatisfactoriness that pervades experience is called Dukkha, usually translated as suffering or stress. Suffering arises quite naturally and then grows as the mind seeks to avoid its natural grounding in impermanence and lack of self. (Varela, Thompson, & Rosch, 1993, pp. 60–61)

Mindfulness is said to be fully developed when there is ongoing awareness that “(a) all conditioned [i.e. caused] things are inherently transitory; (b) every worldly thing is, in the end, unsatisfying; and, (c) there are really no entities that are unchanging or permanent, only processes” (Gunaratana, 2002, p. 144). These are the qualities of impermanence, unsatisfactoriness, and the selflessness of phenomena. Impermanence is the quality of experience that everything is shifting, going to pieces, slowly dissolving, rising and falling, and that moment-to-moment experience is all there is (Gunaratana, 2002). Thoughts, for example, are experienced “as temporary phenomena without inherent worth or meaning, rather than as necessarily accurate reflections of reality, health, adjustment, or worthiness” (Baer, 2003, p. 130). To understand impermanence is also to understand that all mental fabrications have a feeling tone which is positive, negative, or neutral. Once mental feelings tones are fused with concepts, people then cling to concepts associated with a positive feeling tone, reject the concepts associated with a negative feeling tone, and ignore concepts associated with a neutral tone. All three reactions blind people to the inevitable rise and fall of events and the dissatisfaction that clinging produces. Unsatisfactoriness is the sense of fearfulness—fearfulness because “whatever is impermanent provides no stable sense of security and thus is to be feared” (Bodhi, 2000, p. 351). The mere fact of impermanence does not in itself necessarily cause suffering. But what does cause suffering is that people become attached to impermanent things and suffer when they disappear. As stated in the Abhidhamma, “Suffering is the mode of being continuously oppressed by rise and fall” (p. 346). Oppression stems from a “selfcentered attempt to make things and relationships permanent or to have them be just the way we want for our own selfish motives” (Magid, 2002, p. 141). The third quality of existence, selflessness, refers to the nonexistence of an unchanging self (Gunaratana, 2001, p. 196). “I” is a concept that is added to experience. But what it adds is a conceptual gap between reality and awareness of that reality. When people refer to a stable “me” identified with permanent qualities, they “have taken a flowing vortex of thought, feeling, and sensation and solidified that into a mental construct. . . . Forever after, we treat it as if it were a static and enduring entity. . . . We view it as a thing separate from all other things. . . . We ignore our inherent connectedness to all other beings and decide that “I” have to get more for me; then we marvel at how greedy and insensitive human being are . . . and we grieve over how lonely we feel” (Gunaratana, 2002, p. 37).

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To see the difference these three qualities can make in organizational life, consider the concept of commitment (e.g., Salancik, 1977). To become committed is to make a public irrevocable choice, cling to it, and justify that clinging by means of self-vindicating reasons. Acts of commitment often increase attachment to an object. And self-justification of these attachments strengthens a fixed identity for self. Fearfulness and dissatisfaction are triggered when justified actions begin to disintegrate and throw doubt on the justifier, the justifications, and the commitment itself. The more we strive for behavioral commitment, the less mindful we become. To pull the plug on a commitment is to reaffirm impermanence, diminish attachment, and dissolve a self defined by the commitment. To move toward nonattachment and less suffering “doesn’t mean giving up the things of the world, but accepting that they go away” (Magid, 2002, p. 141).

Western Perspectives on Mindfulness Ellen Langer’s description of mindfulness is representative of Western thinking and has been adopted by several organizational researchers (e.g., Fiol & O'Connor, 2003; Weick, Sutcliffe, Obstfeld, 1999). As noted earlier, Langer (1989) argues that mindfulness has three characteristics: (a) active differentiation and refinement of existing distinctions (p. 138); (b) creation of new discrete categories out of the continuous streams of events that flow through activities (p. 157); and (c) a more nuanced appreciation of context and of alternative ways to deal with it (p. 159). Stated more compactly, “mindfulness is a flexible state of mind in which we are actively engaged in the present, noticing new things and sensitive to context” (Langer, 2000, p. 220). Langer’s original view of mindfulness is more conceptual; her newer version is less so. Nevertheless, her primary focus is on “active distinction making and differentiation” (Thornton & McEntee, 1995, p. 252). People act less mindfully when they rely on past categories, act on “automatic pilot,” and fixate on a single perspective without awareness that things could be otherwise. Langer describes her ideas as grounded in research and a Western perspective, focused on learning to switch modes of thinking [from mindless to mindful] rather than on meditation and concerned with the process of noticing new things that involves both seeing similarities in things thought different and differences in things thought similar (Langer, 2005, p. 16). Her interventions to reduce mindlessness tend to promote discrimination of subtle cues that had gone unnoticed before. When these cues are noticed, routines that had been unfolding mindlessly are interrupted. What is interesting is that these interruptions by themselves may increase mindfulness. They create a void that is similar to the void induced by quiet meditation. When either type of void is created, past experience no longer serves as a firm guide and the disruption “stirs the cognitive pot.” Because the void is momentarily tough to categorize and label, it can induce a moment of concept-free mindfulness. When people draw novel distinctions in the face of disruptions, several things happen. There is “(1) a greater sensitivity to one’s environment, (2) more openness to new information, (3) the creation of new categories for structuring perception, and (4) enhanced awareness of multiple perspectives in problem solving. The subjective ‘feel’ of mindfulness is that of a heightened state of involvement and wake-fulness or being

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in the present. . . . Mindfulness is not a cold cognitive process” (Langer & Moldoveanu, 2000, p. 2). These outcomes have some similarity to outcomes attributed to Eastern mindfulness. It is important to notice these similarities, because they suggest early stages in the movement toward fuller development of mindfulness, and they suggest indicators that track this development. Still, although Langer does emphasize flexible awareness in the present, she is more concerned with awareness of external events rather than inner experiences such as thoughts and emotion and more concerned with goal-oriented cognitive tasks than nonjudgmental observation (Baer, 2003). The organizational literature tends to focus on mindfulness as content rather than mindfulness as process, a preference that would be expected, given the grounding in Western, scientific thought and in Langer’s work. The literature, for example, contains claims that mindful conceptualizing can disrupt bandwagons (Fiol & O’Connor, 2003), improve coordination (Weick & Roberts, 1993), reduce the likelihood and severity of organizational accidents (Weick et al., 1999), aid information system design (Swanson & Ramiller, 2004), produce creative solutions (Langer, 2005), heighten adaptation (Vogus & Welbourne, 2003), foster entrepreneurship (Rerup, in press), and reduce stress (Davidson et al., 2003). In most cases, these claims overlook an important issue involving process. To illustrate this oversight, consider the following description of processes associated with organizing for high reliability (Weick et al., 1999): Stable attention to failure, simplification, current operations, capabilities for resistance, and the temptation to overstructure induces a rich awareness of discriminatory detail and wise action. Now bracket all the words in the phrase that starts with the words “to failure” and ends with the words “to overstructure.” Remove those words. The sentence now reads, “Stable attention induces a rich awareness of discriminatory detail and wise action.” That revised sentence raises the possibility that stable attention by itself, and not attention to specifics such as failure, simplification, or operations, may explain considerable variance in reliable performance. If that is plausible, then it means that greater awareness of how attention functions may be a precondition for greater alertness.

Mindfulness in the Context of Organizational Studies Attempts to increase mindfulness in an organizational context are complicated, because organizations are established, held together, and made effective largely by means of concepts. Tsoukas (2005) makes this clear when he argues that generalizing is the prototypic act of organizing: A distinguishing feature of organization is the generation of recurring behaviours by means of institutionalized roles that are explicitly defined. For an activity to be said to be organized implies that types of behaviour in types of situations are connected to types of actors . . . An organized activity provides actors with a given set of cognitive categories and a typology of action options. . . . On this view, therefore, organizing implies generalizing; the subsumption of heterogeneous particulars under generic categories. In that sense, formal organization necessarily involves abstraction. (p. 124)

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By Tsoukas’s reading, the organization, its people, and its activities are mentally formed collections of direct experiences with names. Although ultimately people, selves, and organizations do not exist, conventionally, they not only exist, but they are also necessary foundations for mindfulness to come into existence. Conceptual reality is necessary for day-to-day individual and organizational functioning, and mindfulness can bring the added benefits of insights and wisdom. However, now we might predict that conceptual moves that are intended to create permanence, attachment, and distinctiveness (e.g., competitive advantage, brands) encourage people to reject or ignore concepts associated with negative and neutral feelings (e.g., uncertainty absorption) and to develop misperceptions of themselves, their work, and their context. The most direct way to forestall conceptual moves that mislead is through mindfulness meditation. In the West, mindfulness meditation is practiced at two levels: Today the practice of insight meditation has gained global popularity, yet in achieving this success it has undergone a subtle metamorphosis. Rather than being taught as an integral part of the Buddhist path, it is now often presented as a secular discipline whose fruits pertain more to life within the world than to supramundane release. Many meditators testify to the tangible benefits they have gained from the practice of insight meditation, benefits that range from enhanced job performance and better relationships to deeper calm, more compassion and greater awareness. (Bodhi, 2000, p. 1)

These secular benefits are those most relevant to organizations, especially greater awareness, clearer thinking and better decisions (Putnam, 2001). There are two different starting points for meditative practice, either concentration as a vehicle or mindfulness as a vehicle with a third possibility being an integrated combination of both. These are the three main headings under which all the traditional subjects of meditation may be classified (Goleman, 1988). For example, transcendental meditation, Samadhi, Siddha Yoga, and kasina (colored disc) are concentration exercises focused on a discrete object or words leading to calmness. Gurdjieff ’s self-remembering and Krishnamurti’s self-knowledge are mindfulness based and entail continuous, full watchfulness of each successive moment leading to insights into mental and thus physical reality. Zen (zazen) and Tibetan and Theravadan (vipassana) represent mixtures of the two, depending on the specific meditation (i.e., discrete mental object or the mind watching itself). The significance of calmness (or concentration) and insight (or mindfulness) being paired is that you can only go so far in one without advancing in the other. Making one stronger induces or makes the potential for advancing in the other pair go up dramatically. Insights from mindfulness meditation may arise in two ways, depending on whether attention is directed inward or outward. A characteristic of insights, when they arise, is that the resultant insight is related to the focus of meditation. Because mindfulness meditation involves attending to the mind itself, the insights will be of the nature to further improve mental skills that benefit organizations in all the meditator’s activities. A second benefit, having more to do with increased concentration than mindfulness, comes with prolonged focus directed toward organizational goals. The insights here are associated with the particular expertise of the person. Promoting mindfulness

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meditation to complement skillful concentration can increase the likelihood of organizational and expert specific insights. An example of mindful fatality investigations shows how this process works. A basic observation in meditation is that your mind is always aware of some object—thus the impossibility of ever being mindless. Because people are always paying attention to something when accidents occur, that is part of what you should be looking for as an investigator. Too often, the conclusions of investigations are in the format of the victims’ failure to note something important rather than on what they were attending to at crucial moments. Thus, very basic information is missing when investigators try to form a causal link between flawed behaviors (they avoid the question of “In whose view are these behaviors flawed?”) and tragic outcomes. Most likely, the investigator and the victim are paying attention to the same things routinely paid attention to in their everyday lives, such as habitually thinking about food, sex, family, sports, image, stresses, and so on as they perform their tasks. Not only is mindfulness central to better performance, but there is also a necessity to practice it in everyday life to become skillful at managing attention before a severely stressful event occurs. In mindfulness meditation, you begin to track where your mind takes off to when it leaves your target task and then you ardently bring it back to that task more quickly. You are less willing to let your mind dwell in negative emotions that dull it. Once you mindfully observe how much time is wasted on cognitive distractions and how that leaves you vulnerable to missing what is really going on around you now, you begin to work toward the vividness of a better focused mind and wisdom. A mindful investigator brings extra skills into the investigation by keeping track of their internal processes as they investigate and what the victims were likely attending to as events unfolded. Organizational actions themselves may incorporate meditative properties of mindfulness and concentration. For example, the five mindful processes associated with organizing for high reliability (e.g., Weick et al., 1999) can be viewed in terms of their possible effects on calmness (concentration) and strength of insight (mindfulness). Preoccupation with failure involves a search for incipient failures to the exclusion of all else, suggesting that such preoccupation, if intense enough, induces stable concentration and potentially vivid insights. Reluctance to simplify and sensitivity to operations both involve replacing remembered abstractions with current awareness of details, which suggests an increase in vividness but at the possible expense of concentration (e.g., the term operations is plural) if we intentionally monitor one object to the exclusion of others. Commitment to resilience is about concentration complemented with mindfulness as the means to achieve insights for future actions.2 To bounce back from a disruption involves vivid attention to whatever is at hand in an effort to ascertain how it can be cobbled together to resume whatever was interrupted. But again, those vivid moments are scattered among diverse objects and therefore potentially unstable without both strong concentration and mindfulness. And finally, deference to expertise that is made possible by underspecified structures, involves efforts to stabilize attention by routing decisions to experts who are best able to hold onto the intended object without distraction. What is interesting in these five scenarios of reliability is the suggestion that High Reliability Organizations (HROs) may be better suited to see things clearly than to maintain a stable focus on what they do see.

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A more direct application of mindfulness in the HRO example would occur if a mindful person would look at the effect that being “preoccupied with failure” was having on their mind as they tried to hold failure in focus in the present moment. Introspective questions might include “Am I able to concentrate to remove distractions so that I can focus calmly?” and “Do I return quickly to my task when my mind wanders?” A mindful person would look for subtle stresses that preoccupation creates and then look for ways to reduce the stresses so they could more clearly perceive the underlying processes. Ardency demands that mindfulness be mentally proactive in the present moment as mindfulness attends to the failure task at hand. At advanced stages of mindfulness, if the person would merely focus on failures with meditative calmness, the failures present would come into awareness on their own as insights. Notice that we are beginning to establish connections between Eastern thinking, Western thinking, and organizational thinking. To further this connecting, we look more closely at two Western definitions of mindfulness and at the ideas of organizing, expertise, and organizational design. Brown and Ryan (2003), working within a Western tradition, define mindfulness as enhanced attention to and awareness of current experience or present reality. . . . [A] core characteristic of mindfulness has been described as open or receptive awareness and attention . . . which may be reflected in a more regular or sustained consciousness of ongoing events and experiences. (pp. 822–823)

They attempt to assess mindfulness as a state using the Mindful Attention Awareness Scale (Brown & Ryan, 2003). Sample items include “I find it difficult to stay focused on what is happening in the present,” “It seems I am ‘running on automatic’ without much awareness of what I’m doing,” “I rush through activities without being really attentive to them,” and “I find myself doing things without paying attention.” Regardless of one’s reaction to the item content, the larger point we want to make is that this Western formulation does not preclude actions that are consistent with the development of Eastern, nonconceptual mindfulness. For example, “enhanced attention and awareness” in Brown and Ryan (2003) corresponds to focus in Eastern work; “current experience and present reality” correspond to being attentive to the present rather than to the past and future; “open and receptive” correspond to attending that is calm, quiet, undistracted, and free of self-talk; “ongoing” corresponds to impermanence and the rise and fall of events; and reference to “events and experience” corresponds to attention directed both inward and outward. When we label these similarities as points of correspondence, what we mean is that intentional development of those Western capabilities moves people toward increased skill at conceptual mindful-ness. Ironically, such movement also leads to greater realization of the need to engage in meta-examination of those very acts of conceptualizing and greater interest in the question of what happens when one sheds concepts. These acts of meta-examination are an early stage of mindfulness meditation corresponding to Thera’s earlier “Factors of Absorption.” As the examination becomes more focused, more stable, and more vivid, the person is drawn more fully into introspection of the mind and its workings rather than to its content alone. Implicit connections between Eastern and Western thinking are also found in Langer (2000). For example, when people make distinctions, they often see some of

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the limits of a specific category, and occasionally they even see the limits of categorizing itself. Furthermore, efforts to differentiate a crude category tend to focus attention on the here and now, highlight the costs of distraction, reveal that entities are more transient than they appear, and create gradual recognition that changes in events are often not of one’s own making. When people engage in distinction making, they begin to realize just “how quickly we put our experiences into tidy and unexamined conceptual boxes” (Kabat-Zinn, 2002, p. 69), how reluctant we are to examine those conceptual boxes, and how much is discovered when we do examine those boxes. Another way to strengthen the connection between Eastern and Western views of mindfulness is to redirect attention away from organization toward organizing. Such a shift emphasizes that organizing involves ongoing mental action infused with rising and falling, becoming and declining, emerging and disappearing. The shift in language from the concept of organization to the concept of organizing makes room for greater individual awareness by investigators and employees alike of one or more of the three characteristics of existence. When researchers invoke the concept of organizing (e.g., Heath & Sitkin, 2001), they imply that the objects of their study show impermanence (we have to keep reaccomplishing the coordination and interdependence associated with collective action); they accept the inevitability of suffering (reaccomplishment is necessary, because order keeps rising and falling, appearing and disappearing, and forming and dissolving despite our efforts to hold it permanently in place), and/or they discard the view that a (permanent) material self is in control of the efforts to enact order (there is no entity or stable agent that is in control of order, but only flow and constantly changing ways of relating). An intriguing issue stirred up by the argument that Eastern and Western views are incompatible and cannot be connected involves the comparison that is often implied. If we invoke the fivefold classification of skill acquisition proposed by Dreyfuss and Dreyfuss (1986, 2005)—novice, advanced beginner, competence, proficiency, expertise—then existing discussions of mindfulness often compare novice conceptualizers with expert nonconceptualizers. For example, people who practice conceptual mindful-ness are often described either as people who process information by means of context-free rules (novice), people who process information by means of rules and perceptions that are more attuned to the situation (advanced beginner), or as people (competent) who process information by means of a plan that organizes situational data and allows the person to examine “only the small set of factors that are most important given the chosen plan” (Dreyfuss & Dreyfuss, 1986, p. 24). It is when we move to the stages of proficiency and expertise that conceptual skills and mindful practice begin to shade into one another. In the case of a proficient conceptualizer, what stands out is that deliberation is less detached and rule bound and more reliant on intuition and the know-how to see patterns in situations without decomposing them into component features. And the even more advanced expert conceptualizer is described as a person who acts ara-tionally. If rational action is understood as calculative thought in which component parts are combined to form a whole, then arational action “refers to action without conscious analytic decomposition and recombination” (p. 36). Experts do not solve problems or make decisions, they do what works. Although expert performance is ongoing and nonreflective, experts can and often do reflect critically on their intuitions, decisions, and things that do not work out.

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Here is how an expert psychiatric nurse, widely admired for her judgment, describes her work: When I say to a doctor, ‘the patient is psychotic,’ I don’t always know how to legitimize the statement. But I am never wrong. Because I know psychosis from inside out. And I feel that, and I know it, and I trust it. (Benner, 1984, p. 32)

This description, which represents expert skill in nursing, portrays that skill as one that may involve both conceptual and nonconceptual mindfulness depending on the source of the knowing. If the knowing is based solely on past experience, then it is conceptual mindfulness. If, however, the knowing is based on present experience of the patient as a directly perceived object, then the knowing is non-conceptual mindfulness. The expert nurse also hints at the possibility that not all concepts are equally fine grained (Tsoukas, 2005) and not all conceptualizing is context relevant. This raises the possibility that there may be better and poorer concepts and that better concepts sweep in more interconnected details so that people know more fully what is happening. It is these variations that may mask the possibility that mindfulness is already present in more mundane features of organizing. Finally, the preceding arguments suggest that organizations can be designed (Boland & Collopy, 2004) in ways that transcend the constraints of conceptual mindfulness and incorporate Eastern insights. This suggestion can be illustrated by the five processes used by HROs to sustain alertness and become more aware of the nature, strengths, and weaknesses of their own internal functioning (Weick et al., 1999). The processes used by organizations such as air traffic control systems, nuclearpowered aircraft carriers, and wildland firefighting teams often consist of efforts to enrich discriminations, as would be expected from organizations steeped in Western views of mindfulness. But processes used by HROs also exhibit analogues of meditative properties meaning that, occasionally, these organizations stumble onto insights that are not tied directly to concepts. The pattern of mindfulness found in these HRO settings is one where people pay more attention to failures than success, avoid simplicity rather than cultivate it, are just as sensitive to operations as they are to strategy, organize for resilience rather than anticipation, and allow decisions to migrate to experts wherever they are located (Weick & Sutcliffe, 2001; Weick et al., 1999). Those five processes of mindfulness are clearly conceptual, because they preserve detail, refine distinctions, create new categories, draw attention to context, and guard against misspecification, misestimation, and misunderstanding. But these same five processes also reflect an indirect grasp of impermanence, unsatisfactoriness, and selflessness. In addition, a mindfulness meditation practice can add an internal awareness of how these same five processes affect the observer’s mind during the times they are in use. Preoccupation with failure designates continuous attention to details to detect small discrepancies that could be symptoms of larger problems in a system. HROs watch for early warning signals, because they know that they have neither experienced all ways in which a system can fail, nor have they imagined and deduced all possible modes of failure. This preoccupation with continuous change is compatible with Eastern mindfulness in the sense that people see events that keep changing and internal responses that keep changing. Success and failure are neither permanent nor completely under the control of an unchanging agent.

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Reluctance to simplify designates that more effective HROs hesitate to live by generalizations and generic categories. Those categories that are used in HROs tend to be more fine grained and register differences between present situations and past experience more fully. When people simplify with reluctance, they often discover that what they are noticing is different and changing and impermanent and slowing down. Furthermore, the observed differences tend not to be of a person’s own making. Reluctance to simplify also tends to induce closer attention to what is happening here and now, hesitation to label whatever is observed until the moment is seen with clarity, and greater wariness of labels and routines inherited from the past. However to simplify, letting everything go is fundamental to mindfulness. It is all that attachment, which is making the mind foggy. This aspect of high-reliability functioning might better be labeled a reluctance to conceptualize to align it more precisely with mindfulness. Sensitivity to operations designates close attention to connections between immediate actions and distal consequences (Cooper & Law, 1995). This sensitivity involves less attention to plans and more attention to emergent outcomes that are set in motion by immediate actions. Sensitivity to operations is an action with meditative properties, because it necessitates being fully present here and now with a focus on immediate experience and not on “theories, attitudes, abstractions, projections, expectations” (Epstein, 1999, p. 835). It is important to note that sensitivity to operations means “sensitivity to interconnected operations.” Perception of interconnections makes it clearer that relations and networks determine outcomes and that the nodes (agents) in a network change continuously as a function of changes in connections. To be sensitive to operations is to be sensitive to interconnections and also to the absence of an unchanging organization or self. Because perceiving an interconnection is to freeze the flow of reality to solve an immediate need, one also needs skill in letting that same interconnection go so that the next instance of reality is not frozen as well. Commitment to resilience refers to processes that recover from setbacks, especially through improvisation. There is a premium on using whatever is at hand both to assemble a means to bounce back from a specific unexpected event and to restore the ability to bounce back a second time. To focus on resilience is to acknowledge that surprises will occur that are not of your own making, that unintended consequences will always occur, that nothing stays the same, and that pleasant experiences are short lived. The “underspecification of structure” to foster a “deference to expertise” is the process of allowing decisions to migrate to those with the expertise to make them rather than migrate to those higher in a hierarchy. The fact that different people keep making different decisions is an indication that specific decision structures are impermanent as is the expertise identified with specific people or positions. Deference to expertise embodies being mindful that expert decision making can arise spontaneously where it is needed most and is independent of rank, position, or expectations.

Conclusion If all things are preceded by mind and if our current ideas about mind in organizational studies are too narrow, then the versions of conceptual mindfulness that we now use will prove too weak to improve organizational functioning. Narrowness occurs

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partly because we overlook preconceptual moments, virtue, concentration, and mindfulness as ways to further develop the mind to control attention and actions. Existing warnings that we need transformative organizational change tend to ignore subtle improvements in the qualities of attention and instead encourage reframing the contents of attention. Too much is expected from mindfulness directed solely at content, and too little effort is invested in observing the ways in which the conceptualizing of content is itself the problem. To focus on the nature of conceptualizing mind is to develop awareness of how gross attention functions, but it is also to see that there is more to attention than the fact that it is limited. Distinction making and differentiation remain important, but now their capabilities to mislead are more apparent. The necessity to identify acts with meditative properties in organizations that move underneath these conceptual processes is overdue. Mindfulness meditation is a direct means to move toward less dependence on conceptualizing. It adds awareness of the mind itself as a new skill. But there are forms of organizational design, such as practices of high reliability organizing, that currently foster less dependence. By “foster,” we mean that these practices have meditative properties, such as intensifying concentration, which are necessary precursors for greater development of Eastern noncon-ceptual mindfulness. The emphasis is on the word development. High-reliability organizing does not replace Eastern mindfulness. Rather, it suggests benchmarks by which the presence of shortcomings in the process of constructing Western knowledge can be detected, altered, and superseded or complemented by greater wisdom.

Notes 1 This sign now hangs over the desk of the first author. 2 Focusing on failure does not necessarily result in more powerful concentration. It does so only if the focus finally excludes interference from other mental states. There is a difference in clinging to “finding failures” and looking for them during a meditative calm of one-pointed concentration, free from hindrances.

References Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125–143. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Reading, MA: Addison-Wesley. Bodhi, B. (2000). A comprehensive manual of Abhidhamma. Seattle, WA: Buddhist Publication Society Pariyatti Editions. Boland, R. J. Jr., & Collopy, F. (Eds.). (2004). Managing as designing. Stanford, CA: Stanford University Press. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. Chia, R. (2005). The aim of management education: Reflections on Mintzberg’s ‘Managers not MBAs’. Organization Studies, 26(7), 1090–1092.

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Varela, F., Thompson, E., & Rosch, E. (1993). The embodied mind. Cambridge, MA: MIT Press. Vogus, T. J., & Welbourne, T. M. (2003). Structuring for high reliability: HR practices and mindful processes in reliability-seeking organizations. Journal of Organizational Behavior, 24, 877–903. Wallace, B. A. (1999). The Buddhist tradition of Samatha: Methods for refining and examining consciousness. Journal of Consciousness Studies, 6(2–3), 175–187. Wallace, B. A. (2005). Balancing the mind. Ithaca, NY: Snow Lion. Walsh, J. P. (1995). Managerial and organizational cognition: Notes from a trip down memory lane. Organization Science, 6, 280–319. Weick, K. E., & Roberts, K. H. (1993). Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly, 38, 357–381. Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected. San Francisco: Jossey-Bass. Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (1999). Organizing for high reliability: Processes of collective mindfulness. In B. Staw & R. Sutton (Eds.), Research in Organizational Behavior (Vol. 21, pp. 81–123). Greenwich, CT: JAI.

Ted Putnam is currently a principal in the firm Mindful Solutions in Missoula, Montana. He worked for the United States Department of Agriculture Forest Service from 1963 to until 1998, first as a firefighter and smoke jumper and later as a specialist in the investigation of wild-land fire entrapments and in the design of fireline safety equipment. His publications and entrapment investigations are focused on human factors, psychology, and decision making. After the 1994 South Canyon fire, which claimed 14 lives, he launched an initiative to promote individual mental development as a means to reduce poor decisions, accidents, and fatalities. In 2005, he was presented with the National Wildfire Coordination Group’s Paul Gleason Lead By Example Award for “lifetime achievement in wildland fire leadership” and with the International Association of Wildland Fire’s Wildland Fire Safety Award for “a lifetime of contributions in fire safety.”

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III Interpretation 7. Making Sense of Blurred Images: Mindful Organizing in Mission STS-107 8. Organizing and the Process of Sensemaking 9. Impermanent Systems and Medical Errors: Variety Mitigates Adversity

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7 Making Sense of Blurred Images: Mindful Organizing in Mission STS-107 Setting the Scene A recurring theme in organizational analysis is that perceptions change and become more conventional when they are handed off from person to person (Patterson and Woods, 2001). Such handoffs are common in distributed systems such as those discussed in Chapter 4. The uncertainty absorption that is associated with handoffs has been around for some time (e.g. Campbell, 1958). For example, the steady loss of detail is visible in Sir Frederic Bartlett’s (1932) experiments with serial reproduction involving tasks that resemble the children’s game ‘Telephone.’ As a message is handed from person to person, it becomes simplified to the point where it bears little resemblance to the original communiqué. Chapter 7 explores this phenomenon of serial editing in the organizational setting of NASA. We take a close look at an instance of compounded abstraction where misspecification and misunderstanding are magnified by mindless organizing, with tragic results. Concepts that are central to many analyses in this book are illustrated. These include compounded abstraction, shareability constraint, and mindful organizing in high reliability organizations. NASA’s attention during the launch of the Columbia shuttle mission STS-107 on January 16, 2003 was distributed among several groups. Some of those groups were more worried than others about what happened 82 seconds into the flight. At that moment there was a puff of smoke at the root of the left wing of the shuttle, but the only photo of the event was blurred and susceptible to different interpretations. While some groups were worried and lobbied for clearer images of the puff, others who had a stake in minimizing disruptions of the shuttle schedule discounted the need for further images. Since those who lobbied for discounting were at higher levels in the NASA hierarchy, they dominated the debate. No further diagnosis of the debris strike was made . . . until after the shuttle disintegrated over Texas on February 1, 2003.

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The analysis in this chapter makes several points. First, while analyses of organizational behavior typically focus on choice and decision making, it is clear that those interpretations which precede decisions (e.g. this debris strike is essentially something we’ve seen before, the shuttle is ‘operational’ rather than ‘experimental’) constrain the choices that are made. Second, as people begin to attach labels to their raw impressions, details are lost. The key question is, ‘Are discriminatory, distinctive, unique details lost?’ If the answer is ‘yes,’ the attending is less mindful than if the answer is ‘no.’ These details are often weak signals that hint at more severe breakdowns. Swift imposition of abstractions on these signals can erase their informative distinctiveness and weaken them even further. Third, organizing for high reliability increases rich awareness of discriminatory details by shifting priorities away from efficiency and decision making toward effectiveness and sensemaking. Important resources for sensemaking (e.g. identity, cues, actions, plausible narratives) tend to be mobilized more readily when people ask ‘What’s the story?’ rather than ‘What’s the answer?’ Fourth, the complex effects of optimism in organizational life are evident in this case as they are in Chapter 10 on the Bristol Royal Infirmary. Optimism knits and motivates, but often at the expense of warnings, error detection, and updating. Fifth, this case is a vivid reminder that there is a subtle trap in discussions of ‘attending.’ The trap is that analysts will assume that the process refers to noticing events in the external environment. What gets missed is the fact that attending is just as much concerned with the functioning of the organization itself. As the Columbia Accident Investigation Board put it, ‘For all its cutting-edge technologies, “diving-catch” rescues and imaginative plans for the technology and the future of space exploration, NASA has shown very little understanding of the inner workings of its own organization’ (CAIB, 2003, p.202, and see p. 123 in the following reprinted article). Finally, the discussion of the shareability constraint – a notion that is central to several of our analyses – implies that initial perceptions lose potentially crucial details when they are transformed to make them more intelligible to others (this is the core of William James’ contrast between percept and concept). An interesting footnote to this pattern is that it assumes that a single observer views the ‘original’ scene. That assumption can be relaxed if we view the individual observer as ‘a parliament of selves’ (Mead, 1964). While knowledge is what exists ‘between’ heads, those heads could be represented within a single person where they provide diverse perspectives. When this happens, both nuance and intelligibility are preserved. The parliament, not the individual, scans the world. Therefore the editing that occurs as we move from perception to schema should not be as severe. The parliament, however, is dissolved when rank and pressures for closure silence the diverse voices.

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Making Sense of Blurred Images: Mindful Organizing in Mission STS-107 Karl E. Weick The following article was published as Chapter 9 in M. Farjoun and W. H. Starbuck (Eds), Organization at the Limit: Lessons from the Columbia Disaster, Blackwell, 2005, pp. 159–177. Reprinted with permission.

Chapter 6 in the final report of the Columbia Accident Investigation Board (CAIB) is titled “Decision-Making at NASA.” It is the longest chapter in the document, covering 53 pages or 23 percent of the report, which suggests that to understand the Columbia disaster one needs to understand the decision-making that produced it. But if you look at the section headings in chapter 6 they’re not what you would expect in a discussion of decisions. The four sections discuss: how debris losses came to be defined by NASA management as an acceptable aspect of the shuttle missions; how management goals “encouraged Shuttle managers to continue flying even after a significant bipod foam debris strike on STS-112”; how concerns about risk and safety by engineers conflicted with management beliefs that foam could not hurt the orbiter and that staying on schedule was more important; and the assumption that there was nothing that could have been done if foam strike damage had been discovered. These four concerns correlate to questions of how losses are defined, how goals frame choices, how higher-level beliefs dominate lower-level concerns, and how assumptions control search. None of these subtopics focuses on the actual act of making a decision. Instead, all of them are about meaning and about the processes of sensemaking that determined what was treated as a choice, what was seen as relevant to that choice, and what the choice came to mean once it was made. These subtopics make it clear that to analyze decision-making is to take a closer look at what people are doing at the time they single out portions of streaming inputs for closer attention, how they size up and label what they think they face, and how continuing activity shapes and is shaped by this sensemaking. This bracketing, labeling, and acting may create the sense that a choice is called for, but that is an outcome whose content is largely foreshadowed in its formulation. Stated in more general terms, “the decision-making process belongs to the flow of negotiations about meanings of action. Thus, a decision made by a manager in the course of organizing [i.e. sensemaking] is an interpretation of a problem in the light of past experience, and not a unique, totally ‘fresh’ act of choice” (Magala, 1997: 329). Decision-making is not so much a standalone one-off choice as it is an interpretation shaped by the abstractions and labels that are part of the ongoing negotiations about what a flow of events means. Thus, to understand “Decision-Making at NASA” we need to take a closer look at processes that produce the meanings that are ratified and reified in acts of choice. In this chapter we trace the fate of an equivocal perception of a blurred puff of smoke at the root of the left wing of the shuttle, 82 seconds after takeoff. Units and people within

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NASA made sense of this equivocal perception in ways that were more and less mindful. This variation in mindfulness led to processes of interpreting, abstracting, and negotiating that often preserved misunderstanding, misestimation, and misidentification rather than corrected it. Had mindfulness been distributed more widely, supported more consistently, and executed more competently, the outcome might well have been different. We propose that when people try to make sense of an equivocal display, they start with undifferentiated perception, and progress to differentiated perception privately and without any labeling of impressions. When these differentiated perceptions are made public and shared, they are named, dimensionalized, reified, and treated as facts (Irwin, 1977). This progressive compounding of abstraction can become more mindful if there is: (1) active differentiation and refinement of existing distinctions (Langer, 1989: 138); (2) creation of new discrete categories out of the continuous streams of events that flow through activities (1989: 157); and (3) a more nuanced appreciation of the context of events and of alternative ways to deal with that context (1989: 159). This combination of differentiation, creation, and appreciation captures more details, more evidence of small departures from expectations, and more awareness of one’s own ignorance. While mindfulness conceived in this way focuses on the individual, there are analogs of this individual mindfulness at the group and organizational level of analysis (e.g., Weick and Roberts, 1993). These analogs are especially visible in high-reliability organizations (HROs) that are the focus of High Reliability Theory (HRT). HRT is important because it is one of the three social science theories used in CAIB’s analyses (the other two are Diane Vaughan’s Normalization of Deviance and Charles Perrow’s Normal Accident Theory). HROs exhibit mindful processing when they pay more attention to failures than success, avoid simplicity rather than cultivate it, are just as sensitive to operations as they are to strategy, organize for resilience rather than anticipation, and allow decisions to migrate to experts wherever they are located (Weick and Sutcliffe, 2001). These may sound like odd ways to make good decisions, but decision-making is not what HROs are most worried about. Instead, they are more worried about making sense of the unexpected. In that context, their attempts to prepare for the unexpected through attention to failure, simplification, and operations, coupled with their attempts to respond adaptively through a commitment to resilience and migrating expertise make perfectly good sense. Those five processes of mindfulness are important because they preserve detail, refine distinctions, create new categories, draw attention to context, and guard against mis-specification, misestimation, and misunderstanding. When abstracting is done more mindfully, people are better able to see the significance of small, weak signals of danger and to do something about them before they have become unmanageable. As mindfulness decreases, there is a greater likelihood that misleading abstractions will develop and still be treated as legitimate, which increases the likelihood of error. The same story of decreased mindfulness can be written as its opposite, namely a story involving an increase in mindlessness. As attention to success, simplicity, strategy, anticipation, and hierarchy increases, there is greater reliance on past categories, more acting on “automatic pilot,” and greater adherence to a single perspective without awareness that things could be otherwise. These latter moves toward mindless functioning are associated with faster abstracting, retention of fewer details, more normalizing of deviant indicators, and more vulnerability to serious errors.

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Mindful Abstracting in STS-107 The focus of this chapter is the events surrounding the decision not to seek further images of possible damage to the shuttle that occurred shortly after it was launched on January 16, 2003. Blurred photographs taken during the launch showed that 81.7 seconds into the flight debris had struck the left wing with unknown damage. Requests for additional images from non-NASA sources to get a clearer picture of the damage were initiated by three different groups in NASA but were denied by the Mission Management Team on Day 7 of the 17-day flight (Wednesday January 22). Had better images been available, and had they shown the size and location of damage from bipod foam striking the wing, engineers might have been able to improvise a pattern of re-entry or a repair that would have increased the probability of a survivable landing. NASA personnel, with their heritage of the miraculous recovery of Apollo 13, never even had the chance to attempt a recovery of the Columbia crew. NASA’s conclusion that foam shedding was not a threat is seen by CAIB investigators to have been a “pivotal decision” (CAIB, 2003: 125). In CAIB’s words: NASA’s culture of bureaucratic accountability emphasized chain of command, procedure, following the rules, and going by the book. While rules and procedures were essential for coordination, they had an unintended negative effect. Allegiance to hierarchy and procedure had replaced deference to NASA engineers’ technical expertise . . . engineers initially presented concerns as well as possible solutions [in the form of] a request for images . . . Management did not listen to what their engineers were telling them. Instead, rules and procedures took priority. For Columbia, program managers turned off the Kennedy engineers’ initial request for Department of Defense imagery, with apologies to Defense Department representatives for not having followed “proper channels.” In addition, NASA Administrators asked for and promised corrective action to prevent such violation of protocol from recurring. Debris Assessment Team analysts at Johnson were asked by managers to demonstrate a “mandatory need” for their imagery request, but were not told how to do that . . . engineering teams were held to the usual quantitative standard of proof. But it was the reverse of the usual circumstance: instead of having to prove it was safe to fly, they were asked to prove that it was unsafe to fly. (CAIB, 2003: 200–1)

One way to understand what happened between the puff of smoke and the eventual disintegration of the shuttle is as the development and consequences of “compounded abstraction.” Robert Irwin (1977) coined this phrase to summarize the fate of initial perceptions as they are reworked in the interest of coordination and control. “As social beings, we organize and structure ourselves and our environment into an ‘objective’ order; we organize our perceptions of things into various pre-established abstract structures. Our minds direct our senses every bit as much as our senses inform our minds. Our reality in time is confined to our ideas about reality” (Irwin, 1977: 24). The essence of compounded abstraction is found in one of Irwin’s favorite maxims: “seeing is forgetting the name of the thing seen” (Weschler, 1982: 180). The naming and abstracting that transform originary seeing are done intentionally to introduce order into social life. But the conceptions that accomplish this soon “mean something wholly independent of their origins” (Irwin, 1977: 25). It is this potential for meanings to become

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wholly independent of their origins that worries HROs. The concern is that weak signals of danger often get transformed into something quite different in order to mobilize an eventual strong response. The problem is that these transformations take time, distort perceptions, and simplify, all of which allow problems to worsen. The trick is to get a strong response to weak signals with less transformation in the nature of the signal. To understand the fate of perceptions we need to remember that “we do not begin at the beginning, or in an empirical no-where. Instead we always begin somewhere in the middle of everything” (Irwin, 1977: 24). This means that we “begin” amidst prior labels and concepts. The question of how people make sense of equivocal events involves the extent to which they accept, question, and redefine the labeled world into which they are thrown. Acceptance tends to involve less mindfulness, whereas redefining and questioning tend to involve more mindfulness. For example, the original design requirements for Columbia precluded foam shedding by the external tank and also stipulated that the orbiter not be subjected to any significant debris hits. Nevertheless, “Columbia sustained damage from debris strikes on its inaugural 1981 flight. More than 300 tiles had to be replaced.” (CAIB, 2003: 122). Thus, people associated with STS-107 are in the middle of a stream of events where managers had previously chosen to accept the deviations from this design requirement rather than doubt them in order to eliminate them. Previous management had concluded that the design could tolerate debris strikes, even though the original design did not predict foam debris. Once that interpretation is made then foam debris is no longer treated as a signal of danger but rather as “evidence that the design is acting as predicted,” which therefore justified further flights (CAIB, 2003: 196). These prior compounded abstractions can be contested, doubted, or made the focus of curiosity by the managers of STS-107. But whether they will do so depends on whether abstracting is done mindfully. The STS-107 disaster can be viewed as a compounding of abstractions that occurred when the blurred image of a debris strike was transformed to mean something wholly independent of its origins. If this transformation is not mindful there are more opportunities for mis-specification, misestimation, and misunderstanding. Recall that NASA was concerned with all three of these mistakes. They defined “accepted risk” as a threat that was known (don’t mis-specify), tolerable (don’t misestimate), and understood (don’t misunderstand).

Coordination and Compounded Abstraction The basic progression involved in the compounding of abstraction can be described using a set of ideas proposed by Baron and Misovich (1999). Baron argues that sensemaking starts with knowledge by acquaintance that is acquired through active exploration. Active exploration involves bottoms-up, stimulus-driven, on-line cognitive processing in order to take action. As a result of continued direct perception, people tend to know more and more about less and less, which makes it easier for them to “forget the name of the thing seen.” Once people start working with names and concepts for the things that they see, they develop knowledge by description rather than knowledge by acquaintance, their cognitive processing is now schema-driven rather than stimulus-driven, and they go beyond the information given and elaborate their direct

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perceptions into types, categories, stereotypes, and schemas. Continued conceptual processing means that people now know less and less about more and more. The relevance of these shifts for organizational sensemaking becomes more apparent if we add a new phrase to the design vocabulary, “shareability constraint” (Baron and Misovich, 1999: 587). Informally, this constraint means that if people want to share their cognitive structures, those structures have to take on a particular form. More formally, as social complexity increases, people shift from perceptually based knowing to categorically based knowing in the interest of coordination. The potential cost of doing so is greater intellectual and emotional distance from the details picked up by direct perception. Thus, people who coordinate tend to remember the name of the thing seen, rather than the thing that was seen and felt. If significant events occur that are beyond the reach of these names, then coordinated people will be the last to know about those significant events. If a coordinated group updates its understanding infrequently and rarely challenges its labels, there is a higher probability that it eventually will be overwhelmed by troubles that have been incubating unnoticed. If perception-based knowing is crucial to spot errors, then designers need to enact processes that encourage mindful differentiation, creation, and appreciation of experience. One way to do this is by reducing the demands for coordination. But this is tough to do in specialized, differentiated, geographically separated yet interdependent systems where coordination is already uneven. Another way to heighten mindfulness is to institutionalize learning, resilience, and doubt by means of processes modeled after those used by HROs. This allows abstracting to be done with more discernment. The transition from perceptually based to categorically based knowing in STS-107 can be illustrated in several ways. A good example of this transition is the initial diagnosis of the blurred images of the debris strike. People labeled the site of the problem as the thermal protection system (CAIB, 2003: 149) which meant that it could be a problem with tiles or the reinforced carbon carbon (RCC) covering of the wing. These two sites of possible damage have quite different properties. Unfortunately, the ambiguity of the blurred images was resolved too quickly when it was labeled a tile problem. This labeling was reinforced by an informal organization that was insensitive to differences in expertise and that welcomed those experts who agreed with top management’s expectation (and hope) that the damage to Columbia was minimal. For example, Calvin Schomburg, “an engineer with close connections to Shuttle management” (CAIB, 2003: 149), was regarded by managers as an expert on the thermal protection system even though he was not an expert on RCC (Don Curry was the resident RCC expert: CAIB, 2003: 119). “Because neither Schomburg nor Shuttle management rigorously differentiated between tiles and RCC panels the bounds of Schomburg’s expertise were never properly qualified or questioned” (CAIB, 2003: 149). Thus, a tile expert told managers during frequent consultations that strike damage was only a maintenance-level concern and that on-orbit imaging of potential wing damage was not necessary. “Mission management welcomed this opinion and sought no others. This constant reinforcement of managers’ pre-existing beliefs added another block to the wall between decision makers and concerned engineers” (CAIB, 2003: 169). Earlier in the report we find this additional comment: As what the Board calls an “informal chain of command” began to shape STS-107’s outcome, location in the structure empowered some to speak and silenced others. For example,

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a Thermal Protection System tile expert, who was a member of the Debris Assessment Team but had an office in the more prestigious Shuttle Program, used his personal network to shape the Mission Management Team view and snuff out dissent. (CAIB, 2003: 201)

When people adopt labels for perceptions, it is crucial that they remain sensitive to weak early warning signals. When people enact new public abstractions it is crucial, in Paul Schulman’s (1993: 364) words, to remember that members of the organization have neither experienced all possible troubles nor have they deduced all possible troubles that could occur. It is this sense in which any label needs to be held lightly. This caution is built into mindful organizing, especially the first two processes involving preoccupation with failure and reluctance to simplify. Systems that are preoccupied with failure look at local failures as clues to system-wide vulnerability and treat failures as evidence that people have knowledge mixed with ignorance. Systems that are reluctant to simplify their experience adopt language that preserves these complexities. NASA was unable to envision the multiple perspectives that are possible on a problem (CAIB, 2003: 179). This inability tends to lock in formal abstractions. It also tends to render acts that differentiate and rework these abstractions as acts of insubordination. “Shuttle managers did not embrace safety-conscious attitudes. Instead their attitudes were shaped and reinforced by organization that, in this instance, was incapable of stepping back and gauging its biases. Bureaucracy and process trumped thoroughness and reason” (CAIB, 2003: 181). It takes acts of mindfulness to restore stepping back and the generation of options. The Mission Management Team did not meet on a regular schedule during the mission, which allowed informal influence and status differences to shape their decisions, and allowed unchallenged opinions and assumptions to prevail, all the while holding the engineers who were making risk assessments to higher standards. In highly uncertain circumstances, when lives were immediately at risk, management failed to defer to its engineers and failed to recognize that different data standards – qualitative, subjective, and intuitive – and different processes – democratic rather than protocol and chain of command – were more appropriate. (CAIB, 2003: 201)

“Managers’ claims that they didn’t hear the engineers’ concerns were due in part to their not asking or listening” (CAIB, 2003: 170). There was coordination within an organizational level but not between levels. As a result, abstractions that made sense within levels were senseless between levels. Abstractions favored within the top management level prevailed. Abstractions of the engineers were ignored. Had the system been more sensitive to the need for qualitative, intuitive data and democratic discussion of what was in hand and what categories fit it, then more vigorous efforts at recovery might have been enacted. These shortcomings can be pulled together and conceptualized as shortcomings in mindfulness, a suggestion that we now explore.

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Mindful Organizing in STS-107 When abstraction is compounded, the loss of crucial detail depends on the mindfulness with which the abstracting occurs. As people move from perceptually based knowledge to the more abstract schema-based knowledge, it is still possible for them to maintain a rich awareness of discriminatory detail. Possible, but difficult. Recall that mindfulness includes three characteristics: (1) active differentiation and refinement of existing distinctions, (2) creation of new discrete categories out of the continuous streams of events, and (3) a nuanced appreciation of context and of alternative ways to deal with it (Langer, 1989: 159). Rich awareness at the group level of analysis takes at least these same three forms. People lose awareness when they act less mindfully and rely on past categories, act on “automatic pilot,” and fixate on a single perspective without awareness that things could be otherwise. The likelihood that a rich awareness of discriminatory detail will be sustained when people compound their abstractions depends on the culturally induced mindset that is in place as sensemaking unfolds. In traditional organizations people tend to adopt a mindset in which they focus on their successes, simplify their assumptions, refine their strategies, pour resources into planning and anticipation, and defer to authorities at higher levels in the organizational hierarchy (Weick and Sutcliffe, 2001). These ways of acting are thought to produce good decisions, but they also allow unexpected events to accumulate unnoticed. By the time those events are noticed, interactions among them have become so complex that they are tough to deal with and have widespread unintended effects. In contrast to traditional organizations, HROs tend to pay more attention to failures than success, avoid simplicity rather than cultivate it, are just as sensitive to operations as they are to strategy, organize for resilience rather than anticipation, and allow decisions to migrate to experts wherever they are located. These five processes enable people to see the significance of small, weak signals of danger and to spot them earlier while it is still possible to do something about them. We turn now to a brief discussion of the five processes that comprise mindful processing (Weick and Sutcliffe, 2001) and illustrate each process using examples from the STS-107 mission. These examples show that the way people organize can undermine their struggle for alertness and encourage compounding that preserves remarkably little of the initial concerns.

Preoccupation with Failure Systems with higher reliability worry chronically that analytic errors are embedded in ongoing activities and that unexpected failure modes and limitations of foresight may amplify those analytic errors. The people who operate and manage high-reliability organizations are well aware of the diagnostic value of small failures. They “assume that each day will be a bad day and act accordingly, but this is not an easy state to sustain, particularly when the thing about which one is uneasy has either not happened, or has happened a long time ago, and perhaps to another organization” (Reason, 1997: 37). They treat any lapse as a symptom that something could be wrong with the larger system and could combine with other lapses to bring down the system. Rather than view

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failure as specific and an independent, local problem, HROs see small failures as symptoms of interdependent problems. In practice, “HROs encourage reporting of errors, they elaborate experiences of a near miss for what can be learned, and they are wary of the potential liabilities of success including complacency, the temptation to reduce margins of safety, and the drift into automatic processing” (Weick and Sutcliffe, 2001: 10–11). There are several indications that managers at NASA were not preoccupied with small local failures that could signify larger system problems. A good example is management’s acceptance of a rationale to launch the STS-107 mission despite continued foam shedding on prior missions. Foam had been shed on 65 of 79 missions (CAIB, 2003: 122) with the mean number of divots (holes left on surfaces from foam strikes) being 143 per mission (CAIB, 2003: 122). Against this background, and repeated resolves to act on the debris strikes, it is noteworthy that these struggles for alertness were short-lived. Once the debris strike on STS-107 was spotted, Linda Ham, a senior member of the Mission Management Team, took a closer look at the cumulative rationale that addressed foam strikes. She did so in the hope that it would argue that even if a large piece of foam broke off, there wouldn’t be enough kinetic energy to hurt the orbiter. When Ham read the rationale (summarized in CAIB 2003: fig. 6.1–5 (p. 125)) she found that this was not what the flight rationale said. Instead, in her words, the “rationale was lousy then and still is” (CAIB, 2003: 148). The point is, the rationale was inadequate long before STS-107 was launched, this inadequacy was a symptom that there were larger problems with the system, and it was an undetected early warning signal that a problem was present and getting larger. A different example of inattention to local failure is a curious replay in the Columbia disaster of the inversion of logic first seen in the Challenger disaster. As pressure mounted in both events, operations personnel were required to drop their usual standard of proof, “prove that it is safe to fly,” and to adopt the opposite standard, “prove that it is unsafe to fly.” A system that insists on proof that it is safe to fly is a system in which there is a preoccupation with failure. But a system in which people have to prove that it is unsafe to fly is a system preoccupied with success. When managers in the Shuttle Program denied the team’s request for imagery, the Debris Assessment Team was put in the untenable position of having to prove that a safety-of-flight issue existed without the very images that would permit such a determination. This is precisely the opposite of how an effective safety culture would act. Organizations that deal with high-risk operations must always have a healthy fear of failure – operations must be proved safe rather than the other way around. NASA inverted the burden of proof. (CAIB, 2003: 190)

It is not surprising that NASA was more preoccupied with success than failure since it had a cultural legacy of a can-do attitude stemming from the Apollo era (e.g. Starbuck and Milliken, 1988). The problem is that such a focus on success is “inappropriate in a Space Shuttle Program so strapped by schedule pressures and shortages that spare parts had to be cannibalized from one vehicle launch to another” (CAIB, 2003: 199). There was, in Landau and Chisholm’s (1995) phrase, an “arrogance of optimism” backed up with overconfidence that made it hard to look at failure or even acknowledge that it was a possibility (failure is not an option). Management tended to

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wait for dissent rather than seek it, which is likely to shut off reports of failure and other tendencies to speak up (Langewiesche, 2003: 25). An intriguing question asked of NASA personnel during the NASA press conference on July 23, 2003 was, “If other people feared for their job if they bring things forward during a mission, how would you know that?” The question, while not answered, is a perfect example of a diagnostic small failure that is a clue to larger issues. In a culture that is less mindful and less preoccupied with failure, early warning signals are unreported and abstracting proceeds swiftly since there is nothing to halt it or force a second look, all of which means that empty conceptions are formalized rapidly and put beyond the reach of dissent. Furthermore, in a “culture of invincibility” (CAIB, 2003: 199) there is no need to be preoccupied with failure since presumably there is none. To summarize, in a culture that is less mindful and more preoccupied with success, abstracting rarely registers and preserves small deviations that signify the possibility of larger system problems. Doubt about the substance that underlies abstractions is removed. If the “can-do” bureaucracy is preoccupied with success, it is even more difficult for people to appreciate that success is a complex accomplishment in need of continuous reaccomplishment. A preoccupation with failure implements that message.

Reluctance to Simplify All organizations have to focus on a mere handful of key indicators and key issues in order to coordinate diverse employees. Said differently, organizations have to ignore most of what they see in order to get work done (Turner, 1978). If people focus on information that supports expected or desired results, then this is simpler than focusing on anomalies, surprises, and the unexpected, especially when pressures involving cost, schedule, and efficiency are substantial. Thus, if managers believe the mission is not at risk from a debris strike, then this means that there will be no delays in the schedule. And it also means that it makes no sense to acquire additional images of the shuttle. People who engage in mindful organizing regard simplification as a threat to effectiveness. They pay attention to information that disconfirms their expectations and thwarts their desires. To do this they make a deliberate effort to maintain a more complex, nuanced perception of unfolding events. Labels and categories are continually reworked, received wisdom is treated with skepticism, checks and balances are monitored, and multiple perspectives are valued. The question that is uppermost in mindful organizing is whether simplified diagnoses force people to ignore key sources of unexpected difficulties. Recurrent simplification with a corresponding loss of information is visible in several events associated with STS-107. For example, there is the simple distinction between problems that are “in-family” and those that are “out-of-family” (CAIB, 2003: 146). An in-family event is “a reportable problem that was previously experienced, analyzed, and understood” (CAIB, 2003: 122). For something to even qualify as “reportable” there must be words already on hand to do the reporting. And those same words can limit what is seen and what is reported. Whatever labels a group has available will color what it perceives, which means there is a tendency to overestimate the number of in-family events that people feel they face. Labels derived from earlier experiences shape later experiences,

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which means that the perception of family resemblance should be common. The world is thereby rendered more stable and certain, but that rendering overlooks unnamed experience that could be symptomatic of larger trouble. The issue of simplification gets even more complicated because people treated the debris strike as “almost in-family” (CAIB, 2003: 146). That had a serious consequence because the strike was treated as in the family of tile events, not in the larger family of events involving the thermal protection system (CAIB, 2003: 149). Managers knew more about tile issues than they knew about the RCC covering, or at least the most vocal tile expert knew tile better. He kept telling the Mission Management Team that there was nothing to worry about. Thus, the “almost” in-family event of a debris strike that might involve tile or RCC or both became an “in-family” event involving tile. Tile events had been troublesome in the past but not disastrous. A mere tile incident meant less immediate danger and a faster turnaround when the shuttle eventually landed since the shuttle would now need only normal maintenance. Once this interpretation was adopted at the top, it was easier to treat the insistent requests for further images as merely reflecting the engineers’ professional desires rather than any imperative for mission success. Had there been a more mindful reluctance to simplify, there might have been more questions in higher places, such as “What would have to happen for this to be out-of-family?”, “What else might this be?”, “What ‘family’ do you have in mind when you think of this as ‘in’ family, and where have you seen this before?” A second example of a willingness to simplify and the problems which this creates is the use of the Crater computer model to assess possible damage to the shuttle in lieu of clearer images (CAIB, 2003: 38). Crater is a math model that predicts how deeply into the thermal protection system a debris strike from something like ice, foam, or metal will penetrate. Crater was handy and could be used quickly, but the problems in doing so were considerable. NASA didn’t know how to use Crater and had to rely on Boeing for interpretation (CAIB, 2003: 202). Crater was not intended for analysis of large unknown projectiles but for analysis of small, well-understood, in-family events (CAIB, 2003: 168). By drawing inferences from photos and video of the debris strike, engineers had estimated that the debris which struck the orbiter was an object whose dimensions ranged between 20" ⫻ 20" ⫻ 2" to 20" ⫻ 16" ⫻ 6", traveling at 750 feet per second or 511 m.p.h. when it struck. These estimates proved to be remarkably accurate (CAIB, 2003: 143). The problem is this debris estimate was 640 times larger than the debris used to calibrate and validate the Crater model (CAIB, 2003: 143). Furthermore, in these calibration runs with small objects, Crater predicted more severe damage than had been observed. Thus, the test was labeled “conservative” when initially run. Unfortunately, that label stuck when Crater was used to estimate damage to Columbia. Even though the estimates of damage were meaningless, they were labeled “conservative,” meaning that damage would be less than predicted, whatever the prediction. The engineer who ran the Crater simulation had only run it twice and he had reservations about whether it should be used for Columbia, but he did not consult with more experienced engineers at Huntington Beach who had written the Crater model (CAIB, 2003: 145). All of these factors reinforce the simplification that “there’s not much to worry about” (CAIB, 2003: 168). In a way, NASA was victimized by its simplifications almost from the start of the shuttle program. The phrase “reusable shuttle” was used in early requests for Congressional funding in order to persuade legislators that NASA was mindful of costs and efficiencies.

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But once this label was adopted, it became harder to justify subsequent requests for more funds since supposedly it shouldn’t cost much to “reuse” technology. Likewise, the word “shuttle” implies a simple vehicle that transports stuff, which makes it that much harder to argue for increased funding of research and development efforts on the transporter. Perhaps the most costly simplification both internally and externally was designation of the shuttle as “operational” rather than “developmental” (CAIB, 2003: 177). An operational vehicle can be managed by means of mindless routines, whereas one that is developmental requires mindful routines that promote attention to the need for improvisation and learning and humility. CAIB investigators were aware of NASA’s tendency toward mindless oversimplification, and in their discussion titled “Avoiding Oversimplification” (CAIB, 2003: 181), they concluded that NASA’s “optimistic organizational thinking undermined its decision-making.” In the case of STS-107 NASA simplified 22 years of foam strikes into a maintenance issue that did not threaten mission success. The simplification was not reviewed or questioned, even when it was perpetuated by a “lousy rationale” and even when, in the case of Atlantis launched as STS-27R in December 1988 (CAIB, 2003: 127), there had been serious efforts to revisit the foam strikes and understand them more fully. Much closer in time to the STS-107 launch, STS-112 was the sixth known instance of left bipod foam loss, yet that loss was not classified as an “in-flight anomaly” (CAIB, 2003: 125). Instead, people including Linda Ham who attended the Program Requirements Control Board meeting to determine the flight readiness of STS-113 (the next flight after 112 and the flight just before 107) accepted a flight rationale that said it was safe to fly with foam losses (CAIB, 2003: 125) and Mission 113 was launched. It was decided to treat the foam loss as an “action,” meaning that its causes needed to be understood. But the due date for reporting the analysis of causes kept getting delayed until finally the report was due after the planned launch and return of STS-107. Thus, NASA flew two missions, 113 and 107, with the causes of the loss of bipod foam still unresolved. To summarize, in a culture that is less mindful and more willing to simplify, abstracting is done superficially in a more coarse-grained manner that confirms expectations, suppresses detail, overstates familiarity, and postpones the recognition of persistent anomalies.

Sensitivity to Operations People in systems with higher reliability tend to pay just as much attention to the tactical big picture in the moment as they do to the strategic big picture that will materialize in the future. Given the complexity of the context and the task in most high-reliability systems, it is important to have ongoing situational awareness which enables people to see what is happening, interpret what it means, and extrapolate what those interpretations suggest will happen (Endsley, 1995). In naval operations, for example, this ongoing realtime awareness is called “having the bubble“: “Those who man the combat operations centers of US Navy ships use the term ‘having the bubble’ to indicate that they have been able to construct and maintain the cognitive map that allows them to integrate such diverse inputs as combat status, information sensors and remote observation, and the

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real-time status and performance of the various weapons and systems into a single picture of the ship’s overall situation and operation status” (Rochlin, 1997: 109). Ongoing action occurs simultaneously with thinking. People act in order to think and this allows them to generate situational assessments as well as small adjustments that forestall the accumulation of errors. fThe intent is to notice anomalies while they are still isolated and tractable and even ‘before they have become failures. An example of the loss of sensitivity to operations was the subtle shift of attention among members of the Mission Management Team away from the ongoing STS-107 mission toward the meaning of the debris strike for the next mission, STS-114. They were more concerned with how much time it would take to repair the damage and whether that delay might seriously jeopardize an already unrealistic launch schedule. Notice that officially the task of “mission management” means managing the current mission here and now, not the “next mission.” But Linda Ham was in an awkward position. Not only was she in charge of STS-107, but she was also designated as the manager of launch integration for the next mission after STS-107, mission STS-114. This additional responsibility meant that she was worried that added time used to reposition STS-107 for new imaging would affect the STS-114 mission schedule (CAIB, 2003: 153). Furthermore, if the STS-107 foam strike were to be classed as an in-flight anomaly, that would mean that the problem had to be solved before STS-114 could be launched (CAIB, 2003: 138). The “lousy rationale” that paved the way for STS-107 would finally have to be replaced by a more solid rationale which would require an unknown amount of analytic time. All of these concerns drew attention away from the present mission. Part of the insensitivity to operations that is visible in the Columbia disaster is insensitivity to the effects of schedule pressure on performance (CAIB, 2003: 131). NASA had set a hard goal of having the space station core completed on February 19, 2004 with the launch of STS-120. This February 19 launch was to carry Node 2 of the space station which would complete the core for which the United States was responsible (CAIB, 2003: 131). Failure to meet this goal meant that NASA would undoubtedly lose support from the White House and Congress for subsequent space station missions. To meet the February 19 goal, NASA had to launch 10 flights in less than 16 months (the calendar for this calculation starts in late summer 2002) and four of those 10 missions had to be launched in the five months from October 2003 to Node 2 launch on February 2004 (CAIB, 2003: 136). This February 19, 2004 date was seen as a “line in the sand,” made all the more real and binding for managers by a Screensaver that counted off days, hours, minutes, seconds until this date. The sample screensaver included in the CAIB report shows 477 days or 41,255,585 seconds to go until the Node 2 launch (CAIB, 2003: fig. 6.2-3 (p. 133)). A major operation associated with STS-107 was analysis of just how bad the damage was from the foam strike. A debris assessment team was formed to make this assessment, but it was not given the formal designation that NASA usually assigns to such a central team and activity. Normally, such a group is called a problem resolution team, or a “tiger team.” The Debris Assessment Team was called neither, meaning that its role was unclear to its members and also to the rest of the organization. People knew how to treat a “problem resolution team” but not a debris assessment team. CAIB put the problem this way: “The Debris Assessment Team, working in an

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essentially decentralized format, was well-led and had the right expertise to work the problem, but their charter was ‘fuzzy’ and the team had little direct connection to the Mission Management Team. This lack of connection . . . is the single most compelling reason why communications were so poor during the debris assessment” (CAIB, 2003: 180). Even the operations of managing itself were handled without much sensitivity. As we saw earlier, the Mission Management Team allowed unchallenged opinions and assumptions to prevail at their level but held engineers to higher standards even though this pattern was ill suited to manage with unknown risks. When management said “No” to the requests for additional images of the debris strike, this action left frontline people confused about what “No” meant. It makes a huge difference to ongoing operations whether you interpret “No” to mean “We did get the images and they show no damage,” or “We got the images and they show that there is no hope for recovery,” or “We got the images and they are no better than the ones we already have.” With more sensitivity to operations, the meaning of “No” would have been clearer (Langewiesche, 2003). It is hard to overemphasize the importance of sensitivity to operations since its effects ramify so widely and quickly. Insensitivity often takes the form of a poor understanding of the organization and its organizing, a fault that is especially visible in NASA. “An organization system failure calls for corrective measures that address all relevant levels of the organization, but the Board’s investigation shows that for all its cutting-edge technologies, ‘diving-catch’ rescues and imaginative plans for the technology and the future of space exploration, NASA has shown very little understanding of the inner workings of its own organization” (CAIB, 2003: 202). This inadequate understanding was evident in the initial efforts to get additional images of the debris strike. Not knowing the official procedures for requesting images, lower-level personnel made direct contact with those who could mobilize the imaging capabilities of non-NASA agents. But their failure to go through formal NASA channels was used as the basis to shut down efforts that were already under way to provide these additional images (CAIB, 2003: 150). For example, Lambert Austin did not know the approved procedure to request imagery so he telephoned liaison personnel directly for help. He was criticized for not getting approval first and for the fact that he didn’t have the authority to request photos (Cabbage and Harwood, 2004: 110). There was a cursory check to see who needed the images, but the team officially charged to analyze the foam strike was never contacted (CAIB, 2003: 153). When engineers tried to get action on their request for further images they used an institutional channel through the engineering directorate rather than a mission-related channel through the Mission Management Team (CAIB, 2003: 172). This attempt to get action backfired. Management inferred that because the request for images went through the engineering directorate the request was a noncritical engineering desire rather than a critical operational need (CAIB, 2003: 152). To summarize, in a culture that is less mindful and more insensitive to operations, abstraction is loosely tied to details of the present situation as well as to activities currently under way and their potential consequences. These loose ties impair the situational awareness that can often detect and correct issues that soon turn into problems and finally into crises.

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Resilience/Anticipation Most systems try to anticipate trouble spots, but the higher-reliability systems also pay close attention to their capability to improvise, to act without knowing in advance what will happen, to contain unfolding trouble, and to bounce back after dangers materialize. Reliable systems spend time improving their capacity to do a quick study, to develop swift trust, to engage in just-in-time learning, to mentally simulate lines of action, and to work with fragments of potentially relevant past experience. As Wildavsky (1991: 70) put it, “Improvement in overall capability, i.e., a generalized capacity to investigate, to learn, and to act, without knowing in advance what one will be called to act upon, is vital protection against unexpected hazards.” In the eyes of many NASA employees, resilience was the core issue in STS-107. They might have been able to do something to bring back Columbia’s crew, but they were never given the chance. They were never given the chance because top management never believed that there was anything that necessitated resilience. Management thought the blurred puff was a maintenance-turnaround issue, and also wondered why clearer images were needed if there was nothing that could be done anyway. It might appear that efforts to estimate damage using the Crater simulation (mentioned earlier) were an example of resilience. For all the reasons mentioned earlier, Crater was ill chosen and handled poorly when run, which means it represents mindless resilience at best. It was mindless because it was left in the hands of an inexperienced person, more experienced people were not consulted on its appropriateness, it was treated as the evaluation tool, and when its “conservative” results were presented the limitations of the model were buried in small print on an already wordy PowerPoint slide. To bounce back from the ambiguity of blurred images, NASA could, for example, have expanded data collection to include asking astronauts to download all of their film of the launch and to see if they could improvise some means to get an in-flight view of the damaged area. Although both actions were suggested, neither was done. Furthermore, there was little understanding of what it takes to build and maintain a commitment to resilience. NASA was unwilling to drop its bureaucratic structure and adopt a more suitable one: NASA’s bureaucratic structure kept important information ffom reaching engineers and managers alike. The same NASA whose engineers showed initiative and a solid working knowledge of how to get things done fast had a managerial culture with an allegiance to bureaucracy and cost-efficiency that squelched the engineers’ effort. When it came to managers’ own actions, however, a different set of rules prevailed. The Board found that Mission Management Team decision-making operated outside the rules even as it held its engineers to a stifling protocol. Management was not able to recognize that in unprecedented conditions [non-routine, equivocal], when lives are on the line, flexibility and democratic process should take priority over bureaucratic response. (CAIB, 2003: 202–3)

Mindful organizing requires different structures for different tempos of events. This means that people need to learn to recognize when they are in unprecedented situations where continued compliance with protocol can be disastrous. A commitment to resilience means a continued willingness to drop one’s tools in the interest of greater agility.

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Westrum (1993) has argued that, if a system wants to detect problems, it has to have the capabilities to deal with those problems. What is crucial is that the causal arrow runs from response repertoire to perception. We can afford to see what we can handle and we can’t afford to see what we can’t handle. So a system with a small response repertoire or a system that is misinformed about its response repertoire will miss a lot. What is interesting in the context of a commitment to resilience is the discovery that, while size and richness of the response repertoire are crucial as Westrum argued, NASA shows us that knowledge of and trust in that response repertoire are equally important. The lower levels of NASA, with its better-developed knowledge of response capabilities, could afford to see the possibility of serious damage. But the top, with its more restricted view of the “same” capabilities, could not. You can’t have resilience if half the system, and the authoritative half at that, wants to believe that there is nothing to bounce back from and nothing to bounce back with. Thus, the ability of a response repertoire to improve or hinder seeing depends on the distribution of knowledge about that repertoire. If those in authority are uninformed about capability, then they may see fewer trouble spots since they know of no way those could be handled if they did see them. To summarize, in a culture that is less mindful and more attentive to anticipation than to resilience, abstracting is shallow due to limited action repertoires and imperfect knowledge about the variety of actions that could actually be activated by units within the organization. A limited action repertoire coupled with limited knowledge of the situation predisposes people to rely heavily on old undifferentiated categories and to see little need to create new ones. A weak commitment to resilience reinforces reliance on past success, simplification, and strategy, all of which make it easier to lose anomalous details and harder to doubt one’s grasp of a situation.

Channeling Decisions to Experts Roberts et al. (1994) identified what has come to be perhaps the most cited property of HROs, migrating decisions. The idea of migration, first developed to make sense of flight operations on carriers, is that “decisions are pushed down to the lowest levels in the carriers as a result of the need for quick decision-making. Men who can immediately sense the potential problem can indeed make a quick decision to alleviate the problem or effectively decouple some of the technology, reducing the consequences of errors in decision-making . . . decisions migrate around these organizations in search of a person who has specific knowledge of the event” (1994: 622). Expertise is not necessarily matched with hierarchical position, which means that an organization that lives or dies by its hierarchy is seldom in a position to know all it could about a problem. When people say, for example, that NASA is not a badgeless culture, they mean rank matters and that rank and expertise do not necessarily coincide (Langewiesche, 2003: 25). We see this when Linda Ham asks who is requesting the additional images of Columbia, rather than what are the merits of the request (CAIB, 2003: 172). A more mindful organization lets decisions “migrate” to those with the expertise to make them. What makes this migration work is that the abstractions imposed on the problem incorporate meanings that are grounded more fully in

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experience and expertise. Whether the subsequent decision is then made by the expert or the authority is less important, since deeper reflection has already been built into the options. The continuing debate over whether or not to secure more images was noteworthy for the ways in which expertise was neglected. For example, “no individuals in the STS107 operational chain of command had the security clearance necessary to know about National imaging capabilities . . . Members of the Mission Management team were making critical decisions about imagery capabilities based on little or no knowledge” (CAIB, 2003: 154). Managers thought, for example, that the orbiter would have to make a timeconsuming change from its scheduled path to move it over Hawaii, where a new image could be made. What no one knew was that Hawaii was not the only facility that was available (CAIB, 2003: 158). No one knew, no one asked, no one listened. The Columbia Accident Investigation Board fingered the issue of a lack of deference to expertise as a key contributor to the Columbia accident. “NASA’s culture of bureaucratic accountability emphasized chain of command, procedure, following the rules, and going by the book. While rules and procedures were essential for coordination, they had an unintended negative effect. Allegiance to hierarchy and procedure had replaced deference to NASA engineer’s technical expertise” (CAIB, 2003: 200). To summarize, in a culture that is less mindful and more deferential to hierarchy, abstracting is less informed by frontline experience and expertise and more informed by inputs that are colored by hierarchical dynamics such as uncertainty absorption, withholding bad news, and the fallacy of centrality (Westrum, 1982).

Conclusion I have argued that the Columbia accident can be understood partly as the effects of organizing on perception, categorization, and sensemaking. Specifically, it has been argued that the transition from perceptual-based knowing to schema-based knowing can be done more or less mindfully, depending on how organizations handle failure, simplification, operations, resilience, and expertise. Organizations that are preoccupied with success, simplification, strategy, anticipation, and hierarchy tend to encode fewer perceptual details, miss more early warning signs of danger, and are more vulnerable to significant adverse events that go undetected until it is too late. Organizations that are preoccupied with failure, complication, operations, resilience, and expertise are in a better position to detect adverse events earlier in their development, and to correct them. This chapter represents an attempt to add the ideas of compounded abstraction and mindful organizing to those portions of High Reliability Theory that were mentioned in the CAIB report. These additions allow us to suggest more specific sites for intervention in NASA’s ways of working that could mitigate errors and improve learning. The CAIB report emphasized that High Reliability Theory is about the importance of commitment to a safety culture, operating in both a centralized and decentralized manner, communication, and the significance of redundancy (CAIB, 2003: 180–1), but the report did not go into detail about just how such properties work. In the present chapter I have tried to highlight cognitive and social processes that operationalize and provide the mechanisms for those four general properties mentioned by the CAIB.

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To examine sensemaking is to take a closer look at the context within which decisionmaking occurs. In the case of STS-107, the decision not to seek further images of possible damage while Columbia was in flight was plausible given the way top management envisioned the problem. Their decision to live with blurred images, tenuous optimism, and continuing concerns from the larger community of engineers, made sense to them. But that sense was sealed off from reworking by its formal and formalized stature. It was also sealed off from reworking because of management’s inattention to such things as signals of failure, misleading labels, misunderstood operations, and capabilities for resilience, and because of the overly narrow range of expertise that was heeded. Columbia’s mission was endangered by rapid compounding of abstractions made possible by less mindful organizing. To prevent similar outcomes in the future we need to get a better understanding of how sense develops under conditions of high pressure, with special attention paid to the editing and simplification that occur when early impressions are pooled for collective action. It is mechanisms associated with coordinating, abstracting, and sensemaking that enact the moment-to-moment reliable organizing that produces a high-reliability organization. Attention to similar mechanisms in all organizations can mitigate adverse events. Inattention to these same mechanisms by NASA contributed to Columbia’s last flight.

Acknowledgments I am grateful to Moshe Farjoun, Bill Starbuck, and Kyle Weick for their efforts to help me make this a better chapter. Bill’s help comes exactly 40 years after he first helped me with my writing when we were both in Stanley Coulter Annex at Purdue University. That persistent help and my persistent benefiting from it deserve mention.

References Baron, R.M., and Misovich, S.J. 1999. On the relationship between social and cognitive modes of organization. In S. Chaiken and Y. Trope (eds.), Dual-Process Theories in Social Psychology. Guilford, New York, pp. 586–605. Cabbage, M., and Harwood, W. 2004. Comm Check: The Final Flight of Shuttle Columbia. Free Press, New York. CAIB (Columbia Accident Investigation Board). 2003. Report, 6 vols.: vol. 1. Government Printing Office, Washington, DC. www.caib.us/news/report/default.html. Endsley, M.R. 1995. Toward a theory of situation awareness in dynamic systems. Human Factors 37, 32–64. Irwin, R. 1977. Notes toward a model. In Exhibition Catalog for the Robert Irwin Exhibition, Whitney Museum of American Art, April 16-May 29, 1977 Whitney Museum of American Art, New York, pp. 23–31. Landau, M., and Chisholm, D. 1995. The arrogance of optimism: notes on failure avoidance management. Journal of Contingencies and Crisis Management 3, 67–80. Langer, E. 1989. Minding matters: the consequences of mindlessness-mindfulness. In L. Berkowitz (ed.), Advances in Experimental Social Psychology, vol. 22. Academic, San Diego, pp. 137–73.

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Langewiesche, W. 2003. Columbia’s last flight. Atlantic Monthly 292(4), 58–87. Magala, S.J. 1997. The making and unmaking of sense. Organization Studies 18(2), 317–38. Perrow, C. 1984. Normal Accidents: Living with High-Risk Technologies. Basic Books, New York. Reason, J. 1997. Managing the Risks of Organizational Accidents. Ashgate, Brookfield, VT. Roberts, K.H. 1990. Some characteristics of high reliability organizations. Organization Science 1, 160–77. Roberts, K.H., Stout, S.K., and Halpern, J.J. 1994. Decision dynamics in two high reliability military organizations. Management Science 40, 614–24. Rochlin, G.I. 1997. Trapped in the Net. Princeton University Press, Princeton, NJ. Schein, E. 1996. The three cultures of management: implications for organizational learning. Sloan Management Review 38, 9–20. Schulman, P.R. 1993. The negotiated order of organizational reliability. Administration and Society 25(3), 353–72. Starbuck, W.H., and Milliken, F.J. 1988. Challenger, fine-tuning the odds until something breaks. Journal of Management Studies 25, 319–40. Turner, B. 1978. Man-Made Disasters. Wykeham, London. Weick, K.E. 1987. Organizational culture as a source of high reliability. California Management Review 29, 112–27. Weick, K.E., and Roberts, K.H. 1993. Collective mind in organizations: heedful interrelating on flight decks. Administrative Science Quarterly 38, 357–381. Weick, K.E., and Sutcliffe, K.M. 2001. Managing the Unexpected. Jossey-Bass, San Francisco. Weick, K.E., Sutcliffe, K.M., and Obstfeld, D. 1999. Organizing for high reliability: processes of collective mindfulness. In Research in Organizational Behavior, ed. B. Staw and R. Sutton, 21, pp. 81–123. Weschler, L. 1982. Seeing Is Forgetting the Name of the Thing One Sees: A Life of Contemporary Artist Robert Irwin. University of California, Berkeley. Westrum, R. 1982. Social intelligence about hidden events. Knowledge 3(3), 381–400. Westrum, R. 1993. Thinking by groups, organizations, and networks: a sociologist’s view of the social psychology of science and technology. In W. Shadish, and S. Fuller (eds.), The Social Psychology of Science. Guilford, New York, pp. 329–42. Wildavsky, A. 1991. Searching for Safety. Transaction, New Brunswick, NJ.

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8 Organizing and the Process of Sensemaking Setting the Scene When it comes to puzzles in sensemaking it is hard to improve on what people must have thought the first time they observed the carcass of a platypus. This happened at the British Museum in 1798 when naturalists on the staff received an ‘animal’ specimen from Australia. The ‘animal’ had a mole-like body, duck’s beak, otter-like feet, and a spur on the rear leg that was venomous. Given this odd combination the most plausible story was that scientists were probably examining a hoax, a hybrid creature that had been stitched together by Chinese sailors or a mischievous taxidermist. Probe as they did, however, they could find no stitches (Eco, 1997). In Chapter 8 we propose that several conditions were present when these naturalists struggled to make sense of the heap of brown fur in front of them. Our proposal is that ‘people concerned with identity in the social context of other actors engage ongoing circumstances from which they extract cues and make plausible sense retrospectively while enacting more or less order into these ongoing circumstances (p. 131 in the following reprinted article). The naturalists didn’t want to look stupid or unscientific so they fixated on certain features (e.g. beaver-like tail), constructed a plausible rendering of what they saw (e.g. this is a fake object that has been sewn together from parts), and probed the carcass to find evidence that supported their story. It was not until they received additional specimens that the story of a hoax became less plausible and the story of a crucial evolutionary shift more plausible. In a nutshell, this is a possible infrastructure for the organizing that precedes decision making. As we say in this chapter, organizing is ‘the experience of being thrown into an ongoing, unknowable, unpredictable streaming of experience in search of answers to the question, “what’s the story?” (p. 133 of the reprinted article). As Erving Goffman (1974, p. 30) put it, we can tolerate the unexplained, but not the inexplicable. The taxonomic mischief caused by the platypus was close to inexplicable. Some would call such circumstances a ‘cosmology episode’ similar to what may have been experienced by trapped wildland firefighters at Mann Gulch (see Weick, 2001, pp. 104–110). Images of the unknowable, the inexplicable, and the cosmological are dramatic and may seem overblown. However, we would argue that discrepant moments in everyday life at work are no less unsettling despite being scaled down. We illustrate this point by focusing on

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the example of a premature infant whose physical condition is deteriorating. As nurses try to talk a story and a diagnosis into existence, they demonstrate additional qualities of sensemaking that add to those attributed to the naturalists. Nevertheless, whether people start with a large discrepancy (the naturalists) or watch small discrepancies get bigger and bigger (the nurses), both groups cope in ways that combine social relations, identity, retrospect, cues, ongoing change, plausibility, and enactment. Their goal is to move away from the inexplicable, toward the unexplained, then through the plausible, and ending with the more plausible, which they continue to update and refine. There are several ways in which this chapter enlarges ideas that keep cropping up in this book. For example, in Chapter 2 we discussed the assumption of evolution and here in Chapter 8 (pp. 138–140 of the reprinted article) that assumption generates a framework to depict the process of sensemaking. There is a recurring emphasis in these chapters on the linkage between action and cognition. Here we see that linkage in the form of arguments that people act their way into sense, that sense gets acted back into the world (pp. 133, 135 and 136), and that when one focuses on action, interpretation rather than choice is the central issue (p. 132). Finally, this is one of the few places where the sense of pathos that sometimes accompanies sensemaking is mentioned (p. 135). Actions don’t start out as mistakes but sometimes they do become mistaken and are recognized as such too late. True, mistakes are the occasion for learning. True also, they are complex cognitions. As Paget puts it, ‘the now of mistakes collides with the then of acting with uncertain knowledge. Now represents the more exact science of hindsight, then the unknown future coming into being’ (Paget, 1988, p. 48, cited on p. 135 here). In streaming experience composed of impermanence and continuous change, the ‘suffering’ that is one of the hallmarks of Buddhism’s ‘Three characteristics of existence’ (impermanence, suffering, impersonality; see p. 93 in the reprinted article in Chapter 6) may well be regrets clarified in retrospect, the inevitable rise and fall of affect, and craving and clinging that prove fruitless. Important recent work on sensemaking is found in Balogun and Johnson (2005), Blatt et al. (2006), Dervin, Foreman-Wernet, and Lauterbach (2003), Fiss and Hirsch (2005), Klein, Moon, and Hoffman (2006a, 2006b), Maitlis (2005), Mills and Weatherbee (2006), and Rouleau (2005). The following article by Karl E. Weick, Kathleen M. Sutcliffe, and David Obstfeld was published in Organization Science, 2005, 16(4), 409–421.

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Organizing and the Process of Sensemaking Karl E. Weick, Kathleen M. Sutcliffe Department of Management and Organizations, Ross School of Business, University of Michigan, 701 Tappan, Ann Arbor, Michigan 48109-1234 {[email protected], [email protected]}

David Obstfeld Organization and Strategy, University of California, Irvine, Irvine, California 92697, [email protected] Organization Science Vol. 16. No. 4, July–August 2005, pp. 409–421 ISSN 1047-7039 EISSN 1526-5455 05 1604 0409 © 2005 the Institute for operations Research and the Management Sciences, 7240 Parkway Drive, Suite 300, Hanover, MD21076. USA. Reprinted with permission.

Sensemaking involves the ongoing retrospective development of plausible images that rationalize what people are doing. Viewed as a significant process of organizing, sensemaking unfolds as a sequence in which people concerned with identity in the social context of other actors engage ongoing circumstances from which they extract cues and make plausible sense retrospectively, while enacting more or less order into those ongoing circumstances. Stated more compactly and more colorfully, “[S]ensemaking is a way station on the road to a consensually constructed, coordinated system of action” (Taylor and Van Every 2000, p. 275). At that way station, circumstances are “turned into a situation that is comprehended explicitly in words and that serves as a springboard to action” (p. 40). These images imply three important points about the quest for meaning in organizational life. First, sensemaking occurs when a flow of organizational circumstances is turned into words and salient categories. Second, organizing itself is embodied in written and spoken texts. Third, reading, writing, conversing, and editing are crucial actions that serve as the media through which the invisible hand of institutions shapes conduct (Gioia et al. 1994, p. 365). The emerging picture is one of sensemaking as a process that is ongoing, instrumental, subtle, swift, social, and easily taken for granted. The seemingly transient nature of sensemaking (“a way station”) belies its central role in the determination of human behavior. Sensemaking is central because it is the primary site where meanings materialize that inform and constrain identity and action (Mills 2003, p. 35). When we say that meanings materialize, we mean that sensemaking is, importantly, an issue of language, talk, and communication. Situations, organizations, and environments are talked into existence. Explicit efforts at sensemaking tend to occur when the current state of the world is perceived to be different from the expected state of the world, or when there is no obvious way to engage the world. In such circumstances there is a shift from the experience of immersion in projects to a sense that the flow of action has become unintelligible in some way. To make sense of the disruption, people look first for reasons that will enable them to resume the interrupted activity and stay in action. These “reasons” are pulled from frameworks such as institutional constraints, organizational premises,

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plans, expectations, acceptable justifications, and traditions inherited from predecessors. If resumption of the project is problematic, sensemaking is biased either toward identifying substitute action or toward further deliberation. Sensemaking is about the interplay of action and interpretation rather than the influence of evaluation on choice. When action is the central focus, interpretation, not choice, is the core phenomenon (Laroche 1995, p. 66; Lant 2002; Weick 1993, pp. 644–646). Scott Snook (2001) makes this clear in his analysis of a friendly fire incident over Iraq in April 1994 when two F-15 pilots shot down two friendly helicopters, killing 26 people. As Snook says, this is not an incident where F-15 pilots “decided” to pull the trigger. I could have asked, “Why did they decide to shoot?” However, such a framing puts us squarely on a path that leads straight back to the individual decision maker, away from potentially powerful contextual features and right back into the jaws of the fundamental attribution error. “Why did they decide to shoot?” quickly becomes “Why did they make the wrong decision?” Hence, the attribution falls squarely onto the shoulders of the decision maker and away from potent situation factors that influence action. Framing the individual-level puzzle as a question of meaning rather than deciding shifts the emphasis away from individual decision makers toward a point somewhere “out there” where context and individual action overlap . . . . Such a reframing—from decision making to sensemaking—opened my eyes to the possibility that, given the circumstances, even I could have made the same “dumb mistake.” This disturbing revelation, one that I was in no way looking for, underscores the importance of initially framing such senseless tragedies as “good people struggling to make sense,” rather than as “bad ones making poor decisions” (pp. 206–207).

To focus on sensemaking is to portray organizing as the experience of being thrown into an ongoing, unknowable, unpredictable streaming of experience in search of answers to the question, “what’s the story?” Plausible stories animate and gain their validity from subsequent activity. The language of sensemaking captures the realities of agency, flow, equivocality, transience, reaccomplishment, unfolding, and emergence, realities that are often obscured by the language of variables, nouns, quantities, and structures. Students of sensemaking understand that the order in organizational life comes just as much from the subtle, the small, the relational, the oral, the particular, and the momentary as it does from the conspicuous, the large, the substantive, the written, the general, and the sustained. To work with the idea of sensemaking is to appreciate that smallness does not equate with insignificance. Small structures and short moments can have large consequences. We take the position that the concept of sensemaking fills important gaps in organizational theory. We reaffirm this idea and take stock of the sensemaking concept first by highlighting its distinctive features descriptively, using an extended example of pediatric nursing. Next we summarize the distinctive features of sensemaking conceptually and discuss intraorganizational evolution, instigations, plausibility, and identity. Finally, we summarize the distinctive features of sensemaking prospectively and examine future lines of work that may develop from ideas about institutions, distributed sensemaking, power, and emotion. We conclude with a brief description of gaps in organizational theory that the concept of sensemaking fills.

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The Nature of Organized Sensemaking: Viewed Descriptively Organizational sensemaking is first and foremost about the question: How does something come to be an event for organizational members? Second, sensemaking is about the question: What does an event mean? In the context of everyday life, when people confront something unintelligible and ask “what’s the story here?” their question has the force of bringing an event into existence. When people then ask “now what should I do?” this added question has the force of bringing meaning into existence, meaning that they hope is stable enough for them to act into the future, continue to act, and to have the sense that they remain in touch with the continuing flow of experience. While these descriptions may help delimit sensemaking, they say little about what is organizational in all of this. The answer is that sensemaking and organization constitute one another: “Organization is an attempt to order the intrinsic flux of human action, to channel it toward certain ends, to give it a particular shape, through generalizing and institutionalizing particular meanings and rules” (Tsoukas and Chia 2002, p. 570). We need to grasp each to understand the other. The operative image of organization is one in which organization emerges through sensemaking, not one in which organization precedes sensemaking or one in which sensemaking is produced by organization. A central theme in both organizing and sensemaking is that people organize to make sense of equivocal inputs and enact this sense back into the world to make that world more orderly. Basic moments in the process of sensemaking are illustrated in the following account, where a nurse describes what she did while caring for a baby whose condition began to deteriorate (Benner 1994, pp. 139–140)1: Nurse: I took care of a 900-gram baby who was about 26 or 27 weeks many years ago who had been doing well for about two weeks. He had an open ductus that day. The difference between the way he looked at 9 a.m. and the way he looked at 11 a.m. was very dramatic. I was at that point really concerned about what was going to happen next. There are a lot of complications of the patent ductus, not just in itself, but the fact that it causes a lot of other things. I was really concerned that the baby was starting to show symptoms of all of them. Interviewer: Just in that two hours? Nurse: You look at this kid because you know this kid, and you know what he looked like two hours ago. It is a dramatic difference to you, but it’s hard to describe that to someone in words. You go to the resident and say: “Look, I’m really worried about X, Y, Z,” and they go: “OK.” Then you wait one half hour to 40 minutes, then you go to the Fellow (the teaching physician supervising the resident) and say: “You know, I am really worried about X, Y, Z.” They say: “We’ll talk about it on rounds.” Interviewer: What is the X, Y, Z you are worried about? Nurse: The fact that the kid is more lethargic, paler, his stomach is bigger, that he is not tolerating his feedings, that his chem strip (blood test) might be a little strange. All these kinds of things. I can’t remember the exact details of this case; there are clusters of things that go wrong. The baby’s urine output goes down. They sound like they are in failure. This kind of stuff. Their pulses go bad, their blood pressure changes. There are a million things that go on. At this time, I had been in the unit a couple or three years.

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Sensemaking Organizes Flux Sensemaking starts with chaos. This nurse encounters “a million things that go on” and the ongoing potential for “clusters of things that go wrong”—part of an almost infinite stream of events and inputs that surround any organizational actor. As Chia (2000, p. 517) puts it, we start with “an undifferentiated flux of fleeting sense-impressions and it is out of this brute aboriginal flux of lived experience that attention carves out and conception names.” As the case illustrates, the nurse’s sensemaking does not begin de novo, but like all organizing occurs amidst a stream of potential antecedents and consequences. Presumably within the 24-hour period surrounding the critical noticing, the nurse slept, awoke, prepared for work, observed and tended to other babies, completed paper work and charts, drank coffee, spoke with doctors and fellow nurses, stared at an elevator door as she moved between hospital floors, and performed a variety of formal and impromptu observations. All of these activities furnish a raw flow of activity from which she may or may not extract certain cues for closer attention.

Sensemaking Starts with Noticing and Bracketing During her routine activities, the nurse becomes aware of vital signs that are at variance with the “normal” demeanor of a recovering baby. In response to the interruption, the nurse orients to the child and notices and brackets possible signs of trouble for closer attention. This noticing and bracketing is an incipient state of sensemaking. In this context sensemaking means basically “inventing a new meaning (interpretation) for something that has already occurred during the organizing process, but does not yet have a name (italics in original), has never been recognized as a separate autonomous process, object, event” (Magala 1997, p. 324). The nurse’s noticing and bracketing is guided by mental models she has acquired during her work, training, and life experience. Those mental models may help her recognize and guide a response to an open ductus condition or sickness more generally. Such mental models might be primed by the patient’s conditions or a priori permit her to notice and make sense of those conditions (Klein et al, in press). Some combination of mental models and salient cues calls her attention to this particular baby between the hours of 9 to 11 with respect to a bounded set of symptoms. The more general point is that in the early stages of sensemaking, phenomena “have to be forcibly carved out of the undifferentiated flux of raw experience and conceptually fixed and labeled so that they can become the common currency for communicational exchanges” (Chia 2000, p. 517). Notice that once bracketing occurs, the world is simplified.

Sensemaking Is About Labeling Sensemaking is about labeling and categorizing to stabilize the streaming of experience. Labeling works through a strategy of “differentiation and simple-location, identification and classification, regularizing and routinization [to translate] the intractable or obdurate

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into a form that is more amenable to functional deployment” (Chia 2000, p. 517). The key phrase here is “functional deployment.” In medicine, functional deployment means imposing diagnostic labels that suggest a plausible treatment. In organizing in general, functional deployment means imposing labels on interdependent events in ways that suggest plausible acts of managing, coordinating, and distributing. Thus, the ways in which events are first envisioned immediately begins the work of organizing because events are bracketed and labeled in ways that predispose people to find common ground. To generate common ground, labeling ignores differences among actors and deploys cognitive representations that are able to generate recurring behaviors: “For an activity to be said to be organized, it implies that types of behavior in types of situation are systematically connected to types of actors. . . . An organized activity provides actors with a given set of cognitive categories and a typology of actions” (Tsoukas and Chia 2002, p. 573). A crucial feature of these types and categories is that they have considerable plasticity. Categories have plasticity because they are socially defined, because they have to be adapted to local circumstances, and because they have a radial structure. By radial structure we mean that there a few central instances of the category that have all the features associated with the category, but mostly the category contains peripheral instances that have only a few of these features. This difference is potentially crucial because if people act on the basis of central prototypic cases within a category, then their action is stable; but if they act on the basis of peripheral cases that are more equivocal in meaning, their action is more variable, more indeterminate, more likely to alter organizing, and more consequential for adapting (Tsoukas and Chia 2002, p. 574).

Sensemaking Is Retrospective The nurse uses retrospect to make sense of the puzzles she observes at 11:00. She recalls “what he looked like two hours ago. It’s a dramatic difference.” Symptoms are not discovered at 11:00. Instead, symptoms are created at 11:00 by looking back over earlier observations and seeing a pattern. The nurse alters the generic sensemaking recipe, “how can I know what I think until I see what I say,” into the medically more useful variant, “how can I know what I’m seeing until I see what it was.” Marianne Paget (1988, p. 56) has been especially sensitive to the retrospective quality of medical work as is evident in her description of mistakes in diagnosis: “A mistake follows an act. It identifies the character of an act in its aftermath. It names it. An act, however, is not mistaken; it becomes mistaken. There is a paradox here, for seen from the inside of action, that is from the point of view of an actor, an act becomes mistaken only after it has already gone wrong. As it is unfolding, it is not becoming mistaken at all; it is becoming.” When people bracket a portion of streaming circumstances and label them as a concern, a bad sign, a mistake, or an opportunity, the event is at an advanced stage; the label follows after and names a completed act, but the labeling itself fails to capture the dynamics of what is happening. Because mistakes and diagnoses are known in the aftermath of activity, they are fruitfully described as “complex cognitions of the experience of now and then. They identify the too-lateness of human understanding” (Paget 1988, pp. 96–97). So, “the now of mistakes collides with the

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then of acting with uncertain knowledge. Now represents the more exact science of hindsight, then the unknown future coming into being” (Paget 1988, p. 48).

Sensemaking Is About Presumption To make sense is to connect the abstract with the concrete. In the case of medical action, “instances of illness are concrete, idiosyncratic, and personal in their expression, and the stock of knowledge is abstract and encyclopedic. Interpretation and experimentation engage the concrete, idiosyncratic, and personal with the abstract and impersonal” (Paget 1988, p. 51). It is easy to miss this linkage and to portray sensemaking as more cerebral, more passive, more abstract than it typically is. Sensemaking starts with immediate actions, local context, and concrete cues, as is true for the worried nurse. She says to the resident, “Look, I’m really worried about X, Y, Z.” What is interesting about her concerns is that she is acting as if something is the case, which means any further action tests that hunch but may run a risk for the baby. To test a hunch is to presume the character of the illness and to update that presumptive understanding through progressive approximations: “The [medical] work process unfolds as a series of approximations and attempts to discover an appropriate response. And because it unfolds this way, as an error-ridden activity, it requires continuous attention to the patient’s condition and to reparation” (Paget 1988, p. 143).

Sensemaking Is Social and Systemic The nurse’s sensemaking is influenced by a variety of social factors. These social factors might include previous discussions with the other nurses on duty, an off hand remark about the infant that might have been made by a parent, interaction with physicians— some of whom encourage nurses to take initiative and some who do not—or the mentoring she received yesterday. However, it is not just the concerned nurse and her contacts that matter in this unfolding incident. Medical sensemaking is distributed across the healthcare system, and converges on the tiny patient as much through scheduling that involves crosscovering of one nurse’s patients by another nurse (and through multiple brands of infusion pumps with conflicting setup protocols) as it does through the occasional appearance of the attending physician at the bedside. If knowledge about the correctness of treatment unfolds gradually, then knowledge of this unfolding sense is not located just inside the head of the nurse or physician. Instead, the locus is systemwide and is realized in stronger or weaker coordination and information distribution among interdependent healthcare workers.

Sensemaking Is About Action If the first question of sensemaking is “what’s going on here?,” the second, equally important question is “what do I do next?” This second question is directly about action, as is illustrated in this case, where the nurse’s emerging hunch is intertwined with the

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essential task of enlisting a physician to take action on the case. The talk that leads to a continual, iteratively developed, shared understanding of the diagnosis and the persuasive talk that leads to enlistment in action both illustrate the “saying” that is so central to organizational action. In sensemaking, action and talk are treated as cycles rather than as a linear sequence. Talk occurs both early and late, as does action, and either one can be designated as the “starting point to the destination.” Because acting is an indistinguishable part of the swarm of flux until talk brackets it and gives it some meaning, action is not inherently any more significant than talk, but it factors centrally into any understanding of sensemaking. Medical sensemaking is as much a matter of thinking that is acted out conversationally in the world as it is a matter of knowledge and technique applied to the world. Nurses (and physicians), like everyone else, make sense by acting thinkingly, which means that they simultaneously interpret their knowledge with trusted frameworks, yet mistrust those very same frameworks by testing new frameworks and new interpretations. The underlying assumption in each case is that ignorance and knowledge coexist, which means that adaptive sensemaking both honors and rejects the past. What this means is that in medical work, as in all work, people face evolving disorder. There are truths of the moment that change, develop, and take shape through time. It is these changes through time that progressively reveal that a seemingly correct action “back then” is becoming an incorrect action “now.” These changes also may signal a progression from worse to better.

Sensemaking Is About Organizing Through Communication Communication is a central component of sensemaking and organizing: “We see communication as an ongoing process of making sense of the circumstances in which people collectively find ourselves and of the events that affect them. The sensemaking, to the extent that it involves communication, takes place in interactive talk and draws on the resources of language in order to formulate and exchange through talk . . . symbolically encoded representations of these circumstances. As this occurs, a situation is talked into existence and the basis is laid for action to deal with it” (Taylor and Van Every 2000, p. 58). The image of sensemaking as activity that talks events and organizations into existence suggests that patterns of organizing are located in the actions and conversations that occur on behalf of the presumed organization and in the texts of those activities that are preserved in social structures. We see this in the present example. As the case illustrates, the nurse’s bracketed set of noticings coalesce into an impression of the baby as urgently in need of physician attention, but the nurse’s choice to articulate her concerns first to a resident and then to a Fellow produces little immediate result. Her individual sensemaking has little influence on the organizing of care around this patient as this passage shows (Benner 1994, p. 140): . . . At this time, I had been in the unit a couple or three years. I was really starting to feel like I knew what was going on but I wasn’t as good at throwing my weight in a situation like that. And I talked to a nurse who had more experience and I said, “Look at this kid,” and I told her my story, and she goes: “OK.” Rounds started shortly after that and she walks up to the Attending [Physician in charge of patient] very quietly, sidles

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up and says: “You know, this kid, Jane is really worried about this kid.” She told him the story, and said: “He reminds me about this kid, Jimmie, we had three weeks ago,” and he said: “Oh.” Everything stops. He gets out the stethoscope and listens to the kid, examines the kid and he says: “Call the surgeons.” (Laughter) It’s that kind of thing where we knew also what had to be done. There was no time to be waiting around. He is the only one that can make that decision. It was a case we had presented to other physicians who should have made the case, but didn’t. We are able in just two sentences to make that case to the Attending because we knew exactly what we were talking about. . . . this particular nurse really knew exactly what she was doing. [The Attending] knew she knew what she was doing . . . . She knew exactly what button to push with him and how to do it.

What we see here is articulation (Benner 1994, Winter 1987), which is defined as “the social process by which tacit knowledge is made more explicit or usable.” To share understanding means to lift equivocal knowledge out of the tacit, private, complex, random, and past to make it explicit, public, simpler, ordered, and relevant to the situation at hand (Obstfeld 2004). Taylor and Van Every (2000, pp. 33–34) describe a process similar to articulation: “A situation is talked into being through the interactive exchanges of organizational members to produce a view of circumstances including the people, their objects, their institutions and history, and their siting [i.e., location as a site] in a finite time and place.” This is what happens successively as the first nurse translates her concerns for the second more powerful nurse, who then rearticulates the case using terms relevant to the Attending. The second nurse absorbs the complexity of the situation (Boisot and Child 1999) by holding both a nurse’s and doctor’s perspectives of the situation while identifying an account of the situation that would align the two. What is especially interesting is that she tries to make sense of how other people make sense of things, a complex determination that is routine in organizational life.

Summary To summarize, this sequence highlights several distinguishing features of sensemaking, including its genesis in disruptive ambiguity, its beginnings in acts of noticing and bracketing, its mixture of retrospect and prospect, its reliance on presumptions to guide action, its embedding in interdependence, and its culmination in articulation that shades into acting thinkingly. Answers to the question “what’s the story?” emerge from retrospect, connections with past experience, and dialogue among people who act on behalf of larger social units. Answers to the question “now what?” emerge from presumptions about the future, articulation concurrent with action, and projects that become increasingly clear as they unfold.

The Nature of Organized Sensemaking: Viewed Conceptually Sensemaking as Intraorganizational Evolution The preceding overview of early activities of sensemaking and organizing that mobilize around moments of flux needs to be compressed if it is to guide research and practice.

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One way to do that is to assume that “a system can respond adaptively to its environment by mimicking inside itself the basic dynamics of evolutionary processes” (Warglien 2002, p. 110). The basic evolutionary process assumed by sensemaking is one in which retrospective interpretations are built during interdependent interaction. This framework is a variant of Donald Campbell’s application of evolutionary epistemology to social life (1965, 1997). It proposes that sensemaking can be treated as reciprocal exchanges between actors (Enactment) and their environments (Ecological Change) that are made meaningful (Selection) and preserved (Retention). However, these exchanges will continue only if the preserved content is both believed (positive causal linkage) and doubted (negative causal linkage) in future enacting and selecting. Only with ambivalent use of previous knowledge are systems able both to benefit from lessons learned and to update either their actions or meanings in ways that adapt to changes in the system and its context. For shorthand we will call this model “enactment theory,” as has become the convention in organizational work (e.g., Jennings and Greenwood 2003). Graphically, the ESR sequence looks like Figure 1. If we conceptualize organizing as a sequence of ecological change-enactment-selectionretention with the results of retention feeding back to all three prior processes, then the specific activities of sensemaking fit neatly into this more general progression of organizing. The reciprocal relationship between ecological change and enactment includes sensemaking activities of sensing anomalies, enacting order into flux, and being shaped by externalities. The organizing process of enactment incorporates the sensemaking activities of noticing and bracketing. These activities of noticing and bracketing, triggered by discrepancies and equivocality in ongoing projects, begin to change the flux of circumstances into the orderliness of situations. We emphasize “begin” because noticing and bracketing are relatively crude acts of categorization and the resulting data can mean several different things. The number of possible meanings gets reduced in the organizing process of selection. Here a combination of retrospective attention, mental models, and articulation

Ongoing updating

Ecological change

Enactment

Identity plausibility

Retrospect extracted cues

Selection

Retention

Feedback of identity on selection and enactment

Figure 1 The Relationship Among Enactment, Organizing, and Sensemaking Source. Jennings and Greenwood (2003; adapted from Weick 1979, p. 132).

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perform a narrative reduction of the bracketed material and generate a locally plausible story. Though plausible, the story that is selected is also tentative and provisional. It gains further solidity in the organizing process of retention. When a plausible story is retained, it tends to become more substantial because it is related to past experience, connected to significant identities, and used as a source of guidance for further action and interpretation. The close fit between processes of organizing and processes of sensemaking illustrates the recurring argument (e.g., Weick 1969, pp. 40–42) that people organize to make sense of equivocal inputs and enact this sense back into the world to make that world more orderly. The beauty of making ESR the microfoundation of organizing and sensemaking is that it makes it easier to work with other meso- and macro-level formulations that are grounded in Campbell’s work (e.g., Aldrich 1999, Baum and Singh 1994, Ocasio 2001).

Instigations to Sensemaking The idea that sensemaking is focused on equivocality gives primacy to the search for meaning as a way to deal with uncertainty (e.g., Mills 2003, p. 44). Thus, we expect to find explicit efforts at sensemaking whenever the current state of the world is perceived to be different from the expected state of the world. This means that sensemaking is activated by the question, “same or different?” When the situation feels “different,” this circumstance is experienced as a situation of discrepancy (Orlikowski and Gash 1994), breakdown (Patriotta 2003), surprise (Louis 1980), disconfirmation (Weick and Sutcliffe 2001), opportunity (Dutton 1993), or interruption (Mandler 1984, pp. 180–189). Diverse as these situations may seem, they share the properties that in every case an expectation of continuity is breached, ongoing organized collective action becomes disorganized, efforts are made to construct a plausible sense of what is happening, and this sense of plausibility normalizes the breach, restores the expectation, and enables projects to continue. Questions of “same or different” tend to occur under one of three conditions: situations involving the dramatic loss of sense (e.g., Lanir 1989), situations where the loss of sense is more mundane but no less troublesome (e.g., Westley 1990), and unfamiliar contexts where sense is elusive (e.g., Orton 2000). Methodologically, it is hard to find people in the act of coping with disconfirmations that catch them unawares (see Westrum 1982 for a clear exception). Such outcroppings can be found, however, if we examine how everyday situations sometimes present us with either too many meanings or too few. For example, managing any kind of process (e.g., a production routine) with its interconnected processes of anticipation and retrospection (Patriotta 2003) creates equivocality of time (e.g., is this a fresh defect, or has it happened for some time?) and equivocality of action (e.g., do I have the resources to correct this defect?). Regardless of whether there are too many meanings or too few, the result is the same. Actors are faced with fleeting sense impressions that instigate sensemaking. While scholars have a strong interest in conscious sensemaking and in making the sensemaking process more visible, they also agree with Gioia and Mehra (1996, p. 1228), who suggest that much of organizational life is routine and made up of situations that do not demand our full attention. As they note, people’s sense can be “modified in intricate ways out of awareness via assimilation of subtle cues over time”

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(p. 1229). Acknowledgement of this facet of sensemaking is important if only to avoid the impression that “routine organizational life is devoid of sense” (Gioia and Mehra 1996, p. 1229).

Plausibility and Sensemaking Sensemaking is not about truth and getting it right. Instead, it is about continued redrafting of an emerging story so that it becomes more comprehensive, incorporates more of the observed data, and is more resilient in the face of criticism. As the search for meanings continues, people may describe their activities as the pursuit of accuracy to get it right. However, that description is important mostly because it sustains motivation. People may get better stories, but they will never get the story. Furthermore, what is plausible for one group, such as managers, often proves implausible for another group, such as employees. In an important study of culture change, Mills (2003, pp. 169–173) found that stories tend to be seen as plausible when they tap into an ongoing sense of current climate, are consistent with other data, facilitate ongoing projects, reduce equivocality, provide an aura of accuracy (e.g., reflect the views of a consultant with a strong track record), and offer a potentially exciting future. The idea that sensemaking is driven by plausibility rather than accuracy (Weick 1995, p. 55) conflicts with academic theories and managerial practices that assume that the accuracy of managers’ perceptions determine the effectiveness of outcomes. The assumption that accuracy begets effectiveness builds on a long stream of research on environmental scanning, strategic planning, rational choice, and organizational adaptation (e.g., Duncan 1972, Pfeffer and Salancik 1978) and persists, for example, in current theorizing on search and adaptive learning (e.g., Gavetti and Levinthal 2000) and strategic decision making (e.g., Bukszar 1999). However, studies assessing the accuracy of manager’s perceptions are rare (see Sutcliffe 1994, Starbuck and Mezias 1996 for exceptions), and those studies that have been done suggest that managers’ perceptions are highly inaccurate (Mezias and Starbuck 2003). This may explain why some scholars propose that the key problem for an organization is not to accurately assess scarce data, but to interpret an abundance of data into “actionable knowledge” (Bettis and Prahalad 1995). These critiques have raised the question of the relative importance and role of executives’ perceptual inputs relative to their interpretations of these inputs. Kruglanski (1989) argues, for example, that perceptual accuracy should be treated as pragmatic utility, judged only by its usefulness for beneficial action. A focus on perceptual accuracy is grounded in models of rational decision making: A given problem is evaluated in relation to stable goals and a course of action chosen from a set of alternatives. In this model, accurate information is important in evaluating the feasibility and utility of alternative actions, and accurate perceptions increase decision quality. However, actual organizations do not fit this conception. Problems must be bracketed from an amorphous stream of experience and be labeled as relevant before ongoing action can be focused on them. Furthermore, managers with limited attention face many such issues at the same time, often evaluating several situations, interpretations, choices, and actions simultaneously. Thus, inaccurate perceptions are not necessarily a bad thing,

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as Mezias and Starbuck (2003) conclude. People do not need to perceive the current situation or problems accurately to solve them; they can act effectively simply by making sense of circumstances in ways that appear to move toward general long-term goals. Managerial misperceptions may not curtail effective performance if agents have learning mechanisms and operate in a context where there are incentives to improve performance (Mezias and Starbuck 2003, p. 15; Winter 2003, p. 42). The important message is that if plausible stories keep things moving, they are salutary. Action-taking generates new data and creates opportunities for dialogue, bargaining, negotiation, and persuasion that enriches the sense of what is going on (Sutcliffe 2000). Actions enable people to assess causal beliefs that subsequently lead to new actions undertaken to test the newly asserted relationships. Over time, as supporting evidence mounts, significant changes in beliefs and actions evolve.

Identity and Sensemaking Identity construction is seen by many to be one of the two basic properties that differentiate sensemaking from basic cognitive psychology (Gililand and Day 2000, p. 334). The other property is the use of plausibility as the fundamental criterion of sensemaking. Mills (2003) made a similar point when she organized her study of culture change at Nova Scotia Power around identity construction, which “is at the root of sensemaking and influences how other aspects, or properties of the sensemaking process are understood” (Mills 2003, p. 55). Discussions of organizational identity tend to be anchored by Albert and Whetten’s (1985) description of identity as that which is core, distinctive, and enduring about the character of the organization. From the perspective of sensemaking, who we think we are (identity) as organizational actors shapes what we enact and how we interpret, which affects what outsiders think we are (image) and how they treat us, which stabilizes or destabilizes our identity. Who we are lies importantly in the hands of others, which means our categories for sensemaking lie in their hands. If their images of us change, our identities may be destabilized and our receptiveness to new meanings increase. Sensemaking, filtered through issues of identity, is shaped by the recipe “how can I know who we are becoming until I see what they say and do with our actions?” The pathway from image change to identity change is demonstrated in Gioia and Thomas (1996). Their work suggests that if managers can change the images that outsiders send back to the organization, and if insiders use those images to make sense of what their actions mean, then these changes in image will serve as a catalyst for reflection and redrafting of how the organization defines itself. The controversy implicit in Gioia and Thomas’s findings is the suggestion that identity may not be nearly as enduring as first thought, and may be more usefully conceptualized as a variable, mutable continuity (Gioia et al. 2000). If this were found to be the case, then identity would turn out to be an issue of plausibility rather than accuracy, just as is the case for many issues that involve organizing and sensemaking. Gioia and Chittipeddi (1991) set the stage for many of the current concerns with identity and image in their early finding that sensemaking is incomplete unless there is sensegiving, a sensemaking variant undertaken to create meanings for a target audience. The

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refinement of this demonstration is the finding that the content of sensegiving (present versus future image) and the target (insider versus outsider) affect how people interpret the actions they confront. Yet to be examined is the effect of efforts at sensegiving on the sensemakers. In the sensemaking recipe “how can I know what I think until I see what I say?” sensegiving corresponds to the saying. However, notice that the saying is problematic, you do not really know what you think until you do say it. When you hear yourself talk, you see more clearly what matters and what you had hoped to say. Sensegiving therefore may affect the sensemaker as well as the target. For example, in Gioia and Chittipeddi’s study, those administrators trying to move a university’s identity and image into the category “top 10 university” may themselves have thought differently about this issue as they articulated their campaign to improve the university’s reputation. It is clear that the stakes in sensemaking are high when issues of identity are involved. When people face an unsettling difference, that difference often translates into questions such as who are we, what are we doing, what matters, and why does it matter? These are not trivial questions. As Coopey et al. (1997, p. 312, cited in Brown 2000) note, Faced with events that disrupt normal expectations and, hence, the efficacy of established patterns of meaning and associated behavior, individuals attempt to make sense of ambiguous stimuli in ways that respond to their own identity needs. They are able to draw creatively on their memory—especially their personal experience—in composing a story that begins to make sense of what is happening while potentially enhancing their feelings of self-esteem and self-efficacy. The story is a sufficiently plausible account of “what is happening out there?” that it can serve as a landscape within which they and others might be able to make commitments and to act in ways that serve to establish new meanings and new patterns of behavior.

The outcomes of such processes, however, are not always sanguine. This was the case in Bristol Royal Infirmary’s (BRI) continuation of a pediatric cardiac surgery program for almost 14 years in the face of data showing a mortality rate roughly double the rate of any other center in England (Weick and Sutcliffe 2003, p. 76). The board of inquiry that investigated this incident concluded that there was a prevailing mindset among people at BRI that enabled them to “wish away their poor results” as a “run of bad luck” even though “there was evidence sufficient to put the Unit on notice that there were questions to be answered as regards the adequacy of the service” (Kennedy 2001, pp. 247–248). That mindset prevailed partly because surgeons constructed their identity as that of people learning complex surgical procedures in the context of unusually challenging cases. The dangerous omission in this identity was that the resources they used for learning were minimal. They did not collect detailed data about their own prior performance, solicit input from other members of the surgical team, or observe the work of other surgeons who were more skilled at this procedure until formal complaints were filed against pediatric surgeons.

The Nature of Organized Sensemaking: Viewed Prospectively Considering the modest amount of empirical work on sensemaking that has accumulated so far, the question of “future directions” pretty much takes care of itself. Almost

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any kind of work is likely to enhance our understanding of a largely invisible, takenfor-granted social process that is woven into communication and activity in ways that seem to mimic Darwinian evolution. We briefly discuss institutionalization, distributed sensemaking, power, and emotion to illustrate a few of the many ways in which present thinking about sensemaking might be enhanced.

Sensemaking and Institutional Theory We have treated organizing as activity that provides a more ordered social reality by reducing equivocality. A crucial question is whether that reality gets renegotiated in every social interaction or whether, as Zucker (1983) puts it, “institutionalization simply constructs the way things are: alternatives may be literally unthinkable” (p. 5). The tension inherent in these otherwise “cool” positions is evident when Czarniawska (2003, p. 134) observes that “Intentional action never leads to intended results, simply because there is a lot of intentional action directed at different aims in each time and place. Institutionalization, like power, is a post factum description of the resultant of all those efforts combined with the random events that accompanied them.” Discussions of sensemaking often include words like “construct,” “enact,” “generate,” “create,” “invent,” “imagine,” “originate,” and “devise.” Less often do we find words like “react,” “discover,” “detect,” “become aware of,” or “comply with.” This asymmetry suggests that people who talk about sensemaking may exaggerate agency and may be reluctant to assume that people internalize and adopt whatever is handed to them, as Zucker suggests. An example of such exaggeration might be the statement, “sensemaking is the feedstock for institutionalization” (Weick 1995, p. 36). Institutionalists might well argue that the causal arrow in this assertion points in the wrong direction. The causal arrow neglects evidence showing that organizational members are socialized (indoctrinated) into expected sensemaking activities and that firm behavior is shaped by broad cognitive, normative, and regulatory forces that derive from and are enforced by powerful actors such as mass media, governmental agencies, professions, and interest groups (Lounsbury and Glynn 2001). In other words, “no organization can properly be understood apart from its wider social and cultural context” (Scott 1995, p. 151). These diverse positions can begin to be reconciled if we focus on mechanisms that link micro-macro levels of analysis and if we pay as much attention to structuring and conversing as we do to structures and texts. One way to further such reconciliation is to follow the lead of Hedstrom and Swedberg (1998), who argue that when we want to explain change and variation at the macrolevel of analysis, we need to show “how macro states at one point in time influence the behavior of individual actors, and how these actions generate new macro states at a later time” (p. 21). Sensemaking can provide micromechanisms that link macrostates across time through explication of cognitive structures associated with mimetic processes, agency, the mobilization of resistance, alternatives to conformity such as independence, anticonformity, and uniformity (Weick 1979, p. 115), and ways in which ongoing interaction generates the taken for granted. Examples of such mechanisms are found in Elsbach’s (2002) description of institutions within organizations and in descriptions of “conventions” in the French Convention School of institutionalists’ thought (Storpor and Salais 1997, pp. 15–43).

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The juxtaposition of sensemaking and institutionalism has been rare, but there are recent efforts to correct this (see the important integration proposed by Jennings and Greenwood 2003). For example, Klaus Weber’s (2003) study of globalization and convergence specifically connects the sensemaking and macroinstitutional perspectives. Weber focuses on the content rather than the process of sensemaking. He argued that the media provides corporate vocabularies, and that corporate social structures direct the distribution of these vocabularies among actors. His findings suggest that while institutions in the form of public discourse define and impose the problems to which corporate actors respond, those public institutions do not appear to direct the solutions. Thus, public discourse appears to direct corporate attention, set agendas, and frame issues, but it is less critical for supplying response repertoires. Weber concludes that the relationship between institutions and corporate sensemaking is not linear; the use of corporate sensemaking vocabularies tends to be triggered by institutions, but institutions have less influence over what happens subsequent to triggering.

Distributed Sensemaking The rhetoric of “shared understanding,” “common sense,” and “consensus,” is commonplace in discussions of organized sensemaking. However, the haunting questions remain: Are shared beliefs a necessary condition for organized action (Lant 2002, p. 355), and is the construct of collective belief theoretically meaningful (Porac et al. 2002, p. 593)? The drama associated with such questions is demonstrated by Hughes et al. (1992) in their study of reliability in the UK air traffic control system: If one looks to see what constitutes this reliability, it cannot be found in any single element of the system. It is certainly not to be found in the equipment . . . for a period of several months during our field work it was failing regularly . . . . Nor is it to be found in the rules and procedures, which are a resource for safe operation but which can never cover every circumstance and condition. Nor is it to be found in the personnel who, though very highly skilled, motivated and dedicated, are as prone as people everywhere to human error. Rather we believe it is to be found in the cooperative activities of controllers across the “totality” of the system, and in particular in the way that it enforces the active engagement of controllers, chiefs, and assistants with the material they are using and with each other (cited in Woods and Cook 2000, p. 164).

Promising lines of development would seem to occur if work on distributed cognition (Hutchins 1995), heedful interrelating (Weick and Roberts 1993), and variable disjunction of information2 (Turner 1978, p. 50) were focused less on the assembling and diffusing of preexisting meaning and more on collective induction of new meaning (see Laughlin and Hollingshead 1995 for laboratory investigations of this issue). When information is distributed among numerous parties, each with a different impression of what is happening, the cost of reconciling these disparate views is high, so discrepancies and ambiguities in outlook persist. Thus, multiple theories develop about what is happening and what needs to be done, people learn to work interdependently despite couplings loosened by the pursuit of diverse theories, and inductions may be more clearly associated with effectiveness when they provide equivalent rather than shared meanings.

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Sensemaking and Power Sensemaking strikes some people as naïve with regard to the red meat of power, politics, and critical theory. People who are powerful, rich, and advantaged seem to have unequal access to roles and positions that give them an unequally strong position to influence the construction of social reality (Mills 2003, p. 153). Sensemaking discussions do tend to assume that meanings survive as a result of voting (e.g., Weick 1995, p. 6), with the proviso that sometimes the votes are weighted equally and sometimes they are not. Enhancements of sensemaking that pay more attention to power will tend to tackle questions such as how does power get expressed, increase, decrease, and influence others? Preliminary answers are that power is expressed in acts that shape what people accept, take for granted, and reject (Pfeffer 1981). How does such shaping occur? Through things like control over cues, who talks to whom, proffered identities, criteria for plausible stories, actions permitted and disallowed, and histories and retrospect that are singled out. To shape hearts and minds is to influence at least seven dimensions of sensemaking: the social relations that are encouraged and discouraged, the identities that are valued or derogated, the retrospective meanings that are accepted or discredited, the cues that are highlighted or suppressed, the updating that is encouraged or discouraged, the standard of accuracy or plausibility to which conjectures are held, and the approval of proactive or reactive action as the preferred mode of coping.

Sensemaking and Emotion Magala (1997, p. 324) argued that perhaps the most important lost opportunity in the 1995 book Sensemaking in Organizations was fuller development of a theory of organizational sentiments. Such a theory was “hinted at but ignored.” The opening for further development of emotional sensemaking was the property that projects are ongoing, and when interrupted generate either negative emotions when resumption is thwarted or positive emotions when resumption is facilitated. If emotion is restricted to events that are accompanied by autonomic nervous system arousal (Berscheid and Ammazzalorso 2003, p. 312; Schachter and Singer 1962), if the detection of discrepancy provides the occasion for arousal (Mandler 1997), and if arousal combines with a positive or negative valenced cognitive evaluation of a situation (e.g., a threat to well-being or an opportunity to enhance well-being), then sensemaking in organizations will often occur amidst intense emotional experience. Consider the case of high task interdependence. As the interdependent partners “learn more about each other and move toward closeness by becoming increasingly dependent on each other’s activities for the performance of their daily behavioral routines and the fulfillment of their plans and goals, the number and strength of their expectancies about each other increase. As a result, their opportunities for expectancy violation, and for emotional experience also increase” (Berscheid and Ammazzalorso 2003, p. 317). When an important expectancy is violated, the partner becomes less familiar, less safe, and more of a stranger. In the face of an emotional outburst, people often ask in disbelief “what did I do?!” That is the wrong question. The better question is “what did you expect” (Berscheid and Ammazzalorso

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2003, p. 318)? Expectations hold people hostage to their relationships in the sense that each expectancy can be violated, and generates a discrepancy, an emotion, and a valenced interpretation. If I expect little, there is little chance for discrepancy and little chance for emotion. However, when “an outside event produces negative emotion for an individual in a close relationship, the individual’s partner may be less likely to remain tranquil and supportive than a superficial partner might be because the partner is likely to be experiencing emotion him or herself; the partner’s emotional state, in turn, may interfere with the partner’s ability to perform as the individual expects” (Berscheid and Ammazzalorso 2003, p. 324). Further exploration of emotion and sensemaking is crucial to clear up questions such as whether intraorganizational institutions are better portrayed as cold cognitive scripts built around rules or as hot emotional attitudes built around values (Elsbach 2002, p. 52).

Conclusions To deal with ambiguity, interdependent people search for meaning, settle for plausibility, and move on. These are moments of sensemaking, and scholars stretch those moments, scrutinize them, and name them in the belief that they affect how action gets routinized, flux gets tamed, objects get enacted, and precedents get set. Work to date suggests that the study of sensemaking is useful for organizational studies because it fills several gaps. Analyses of sensemaking provide (1) a micro-mechanism that produces macro-change over time; (2) a reminder that action is always just a tiny bit ahead of cognition, meaning that we act our way into belated understanding; (3) explication of predecisional activities; (4) description of one means by which agency alters institutions and environments (enactment); (5) opportunities to incorporate meaning and mind into organizational theory; (6) counterpoint to the sharp split between thinking and action that often gets invoked in explanations of organizational life (e.g., planners versus doers); (7)background for an attention-based view of the firm; (8)a balance between prospect in the form of anticipation and retrospect in the form of resilience; (9) reinterpretation of breakdowns as occasions for learning rather than as threats to efficiency; and (10) grounds to treat plausibility, incrementalism, improvisation, and bounded rationality as sufficient to guide goal-directed behavior. Analyses of sensemaking also suggest important capabilities and skills that warrant attention and development. For example, the concept of enacted environments suggests that constraints are partly of one’s own making and not simply objects to which one reacts; the concept of sensemaking suggests that plausibility rather than accuracy is the ongoing standard that guides learning; the concept of action suggests that it is more important to keep going than to pause, because the flow of experience in which action is embedded does not pause; and, the concept of retrospect suggests that so-called stimuli for action such as diagnoses, plans for implementation, and strategies are as much the products of action as they are prods to action. Taken together, these properties suggest that increased skill at sensemaking should occur when people are socialized to make do, be resilient, treat constraints as

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self-imposed, strive for plausibility, keep showing up, use retrospect to get a sense of direction, and articulate descriptions that energize. These are micro-level actions. They are small actions, but they are small actions with large consequences.

Acknowledgments The authors thank two anonymous reviewers, Senior Editor Alan Meyer, and Gary Klein for constructive comments on previous versions of this paper.

Endnotes 1 The terms “open ductus” and “complications of the patent ductus” referenced by the nurse in her description refer to a condition formally known as patent ductus arteriosus. Patent ductus arteriosus is a condition where the ductus arteriosus, a blood vessel that allows blood to bypass the baby’s lungs before birth, fails to close after birth. The word “patent” means open. If the patent ductus is not closed, the infant is at risk of developing heart failure or a heart infection. 2 “. . . a complex situation in which a number of parties handling a problem are unable to obtain precisely the same information about the problem so that many differing interpretations of the problem exist” (Turner 1978, p. 50).

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9 Impermanent Systems and Medical Errors: Variety Mitigates Adversity Setting the Scene One byproduct of impermanence is variety. In a hospital emergency department, for example, one is never quite sure what will come through the doors next. All one can be sure of is that it will be some combination of ambiguity and clarity that will be met with some mixture of doubt and certainty that is turned into some combination of action, updating, and diagnosing. Routines and protocols impose some short-term certainties that momentarily silence some doubts, but other doubts remain. Further removal of doubt is influenced by the extent to which variety in the possibilities entertained by the medical treatment team is sufficient to sense and comprehend the differences that they face. This is the issue of requisite variety, and this is the issue that is explored here in the context of medical practice. Requisite variety is a relationship between the variety in one system relative to the variety in another system. The shorthand version of this relationship is that ‘only variety can destroy variety’ (Ashby, 1956, p. 207). Haberstroh (1965) describes the main idea in this way: ‘If the environment can disturb a system in a wide variety of ways, then effective control requires a regulator that can sense these disturbances and intervene with a commensurately large repertory of responses’ (p. 1176). The amount of variety that can be controlled in any situation is determined by the system with the least variety. Variety that goes unnoticed remains free to be expressed in unintended outcomes. The lesser variety typically is on the side of practitioners since it is these people whose conversations and texts use concepts that break a continuing flow into discrete, incomplete, stable fragments and leave out whatever lies between the breaks (e.g. James, 1911/1996, p. 88). There are several variants of the idea of requisite variety in the organizational literature (e.g. Daft and Wiginton, 1979; Miller, 1993; Nonaka and Takeuchi, 1995, pp. 80–94; Weick, 1987). Paul Schulman’s (1993) work is representative. He summarizes an in-depth analysis of reliability at the Diablo Canyon nuclear power station by means of his own version of requisite variety, which he calls ‘conceptual slack.’ Schulman argues

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that the many procedures, meetings, and negotiations at Diablo Canyon initially seemed confusing but turned out to be expressions of divergent analytical perspectives, all of which were focused on maintaining operational reliability in the face of unexpected disturbances. These diverse perspectives on production processes represent conceptual slack that serves as a hedge against surprise, analytic error, and hubris. At Diablo Canyon, there is a widespread recognition that all of the potential failure modes into which highly complex technological systems could resolve themselves have yet to be experienced. Nor have they been exhaustively deduced. In this respect the technology is still capable of surprises (Schulman, 1993, p. 364).

What is worrisome about medical systems is that conceptual slack, expression of divergent perspectives, and acceptance of limits on previous experience can be organized out of existence when dyads are incapable of respectful interaction, groups are incapable of heedful interrelating, and hospitals are incapable of mindful organizing (see Chapter 12 where these three forms of organizing are described in greater detail). As we mentioned earlier, the idea of a ’system’ is tricky when one uses interpretation rather than computation as a frame of reference. A system is both structure and process. Most important, flows of experience are not monoliths. There are different rates of change within flows, slower rates afford structures that shape processes with faster rates of change. Not only do rates of change vary but so do such things as likelihood of recurrence, complexity of emergent complications, success of self-organizing, and conversion of deviation-amplifying feedback into deviation-counteracting feedback. Slower rates of change, recurrent sequences, linear development, successful self-organization, and stable deviation-counteracting feedback all support the idea that there are relatively stable islands of interconnected events within flux. For pragmatic purposes we label each island of connected events, a system. We often retain that same label when we comprehend collections of islands. The common feature among the collections is interdependence made possible by recurrence. The uncommon feature is that each island has unique variety in its repertory of responses and in its sensing capabilities. I know how abstract this all sounds, but it is not a simple task to reconcile properties of interconnection and feedback with properties of impermanence and interpretation. Labored though the explanation may be, it has concrete implications. Within a hospital or within an emergency department, there are both recurrent practices and nonrecurrent improvisations. As patients flow from medical specialty to medical specialty, hierarchical relationships plus range of skills vary and the result is matching and mismatching of the variety in the patient’s condition. Mismatches are hypothesized to produce more adverse conditions than are matches. Mismatches can be corrected if conceptual slack is preserved and if people with higher status listen to partisans of plausible but neglected perspectives. Systems are impermanent, but not all of them to the same extent. It could be predicted that micro-systems built on respect are more permanent than meso-level systems built on heeding, and both are more permanent than macro-systems built on mindful organizing. Mindful organizing is more transient because it tends to be more complex, more counterintuitive, more difficult to execute, and it is harder to institutionalize.

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Under pressure complex systems revert to simpler configurations. Mindful organizing is harder to pull off even though it could lead to a more dramatic reduction in medical adverse events. That promise notwithstanding, micro-systems such as respectful interaction seem to be the place to start. Small, short, respectful interactions built on trust, trustworthy reporting, and higher self-regard generate considerable variety and can sense and manage considerable variety. Respectful interactions may also be easier to create: easier, not easy. The following article was first published in this volume.

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Impermanent Systems and Medical Errors: Variety Mitigates Adversity Karl E. Weick

Medical errors are increasingly portrayed as a complex compounding of latent and active slipups, all of which get tied together, often by chance, and produce adverse events. Here is a representative description of such compounding: Adverse events result from the interaction of the patient, the patient’s disease, and a complicated, highly technical system of medical care provided not only by a diverse group of doctors, other care givers, and support personnel, but also by a medical–industrial system that supplies drugs and equipment. To reduce the risk of adverse events, people connected with the medical community need to examine all of these factors as well as their relation with each other (Leape et al., 1991).

Here is a representative example of the compounding of adversity: A man in his late 50s suffered severe chest pain at home; he suspected a heart attack but did not go to the hospital. Thirty-six hours later, short of breath from congestive heart failure and pulmonary edema, he felt bad enough to call an ambulance. He arrived at the emergency department in respiratory failure and was intubated and immediately admitted to intensive care. The cardiologist initiated a heparin drip and a lidocaine drip, routine measures for myocardial infarction. The patient had arrhythmia, and so the cardiologist added a Pronestyl drip. Because of the patient’s pulmonary edema, the respiratory internist was concerned about bronchospasm and added a theophylloine drip. The second day in the intensive care unit, the stress of the crisis and the heparin had affected the patient’s digestive tract. The gastroenterologist scoped him, saw stress gastritis, and ordered a Pepcid drip. The patient got worse and worse and lost consciousness. His primary physician called a nephrology consultant, who looked at the system, and surmised that the patient had a dilution hyponatremia. Each of the 5 drips was in the standard D5W solution, and together they were diluting the blood sodium beyond the patient’s capacity to compensate, because of pain, congestive heart failure, and renal failure. Laboratory tests showed that the serum sodium was down to 90 from the normal value of 130. The patient died before the doctors could totally fix the hemodynamic balance (Abernathy and Hamm, 1995, p. 234).

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The separate bags, each of which was hung to address a declining condition, made sense in the context of a specific subsystem such as myocardial infarction, arrhythmia, bronchospasm, gastritis. Collectively, however, the drips were compounding in an adverse manner, something that is seen most clearly by the last person in the chain, the nephrology consultant. He looked ‘at the system’ not just the subsystems, spotted the compounding, saw that the patient had too few resources to counteract the disturbance, tried to intervene but had too few resources to fix the imbalance, and the patient died. This is an event with many system storylines that go unnoticed. For example, physicians actually create a more complicated patient than their specialty can handle, but they do so in the mistaken belief that they are merely reacting to his condition, not enacting it. They are mindful of a narrow band of symptoms of interest to their specialty, but mindless toward a wider set of connections and consequences. Said differently, the boundaries around each specialty subsystem are drawn too narrowly, and there is too little outside consultation to catch this narrowness. There is no apparent protocol for multiple drips, even though there seems to be a protocol for each individual drip. Each new drip adds complexity to the patient’s condition, but that condition soon becomes more complex than any individual treatment system can sense or correct. There is too much variety in the patient, and too little variety in the system that tries to control patient outcomes. There is too little communication across people initiating treatment. The patient, who is handed along from specialist to specialist, is represented in each handoff in an oversimplified manner that conceals potential interdependencies among treatments (Wachter, 2008, pp. 85–98). Whatever charts may have been kept throughout proved to be inadequate as documents that could direct efforts at control. This incident illustrates a basic tension within medical systems. ‘As the doctors say of a wasting disease, to start with it is easy to cure but difficult to diagnose. After a time, unless it has been diagnosed and treated at the outset, it becomes easy to diagnose but difficult to cure’ (Machiavelli cited in Hock, 1999, p. 116). That trajectory fits the case of dilution hyponatremia. When the third bag was hung, it was hard to diagnose that the condition was turning sour, but easy to cure it by rebalancing sodium levels. By the fifth bag it was easy to spot the sodium imbalance but hard to correct it. The remedy for a compound error like this is not obvious or easy. Charles Bosk points to the challenge: ‘Just how efficient can we expect an error-ridden, difficult, cognitively complex, manually complicated, interdependent system like health care to be? (Wiener, 2000, pp. xii–xiii). One answer to Bosk’s question of ‘how much efficiency can we expect’ is that it all depends on the degree to which temporary systems register the complexity of the environmental states that they attempt to control. This property has been called ‘requisite variety,’ and it operates according to the principle that ‘the larger the variety of action available to a control system, the larger the variety of perturbations it is able to compensate’ (Heylighen, 1992). Applied to medical work, the idea of requisite variety implies that it takes a complex coordinated medical system to register diseases in their early stages and control them in their more advanced stages. It is argued that increased requisite variety can be created in medical care through greater attention to respectful interaction between individuals, heedful interrelating within groups, and mindful organizing among groups. Each of these three ways of orchestrating a system

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represents high variety coordination, a subtle mix of sufficient diversity to spot the unexpected, and sufficient unity to construct and enact a meaningful response. Finally, I briefly discuss how to set requisite variety in motion.

Variety as a Property of Systems When people try to treat medical errors as systemic, they may become less fixated on operator error and individual blame, but they may now become fixated on a new object, interdependence as a proxy for systems. If they swap one fixation for another then a new problem appears. Once you begin to uncover a string of dependent events, it’s hard to stop. In the five bags incident, for example, why didn’t the respiratory therapist see the consequences of adding a fourth drip? Because he didn’t anticipate sodium dilution. Why? Because the bags he used in the past had varying amounts of stock solution. Why? Because he worked both pediatric and adult services. Why? Because the size of the respiratory staff had been cut. Why? Because the CEO was cutting costs in order to impress the Board with his command of fiscal controls. Why? Because the CEO’s contract was up for renewal. Why? . . . . You get the point. Sooner or later it seems like everything is connected to everything else. While that may be true, the connection of everything to everything is no more helpful in managing error than is the equally vacuous attribution that individuals are to blame for errors. Part of the problem when we espouse a systemic perspective is that we have no easy way to link concepts of systems with concepts of adverse events. Typically a systemic perspective asserts that systems exist and systems fail and failed systems generate adverse events. There’s nothing wrong with such an explanation except that it doesn’t say much. One way to be more explicit about the error mechanism in systems is to reanimate an idea from earlier discussions of systems theory, Ross Ashby’s ‘Law of Requisite Variety’ (1956). This idea was previewed in the introduction, where it was summarized as ‘the larger the variety of action available to a control system, the larger the variety of perturbations it is able to compensate.’ Systems with higher requisite variety should catch the development of adverse events more quickly and should recover from those events with less damage than is true for systems with lower requisite variety. What have we gained by this modest proposal? Actually quite a bit. There are at least three properties of systems that affect variety and the tendency to produce adverse events: disturbance, regulator, output system. Environmental disturbances affect both a regulator and some system that generates output. The idea of ‘disturbance’ is found in the medical literature as, for example, in the situation where there is mounting evidence that a patient’s situation is changing and does not meet medical expectations. At such moments, ‘the change in patient status is experienced as a time of ambiguity, disturbance, or active problem solving (Benner, Hooper-Kyriakidis, and Stannard, 1999, p. 414). Regulators sense some portion of the disturbance, attempt to counteract what is sensed, and try to render the treatment system more resilient in the face of disturbances. The treatment (output) system transforms inputs from disturbances and regulators into outputs, but is at the mercy of disturbances unless the regulator destroys them. Thus, only variety in the regulator can destroy variety in the disturbed system and insure reliability in system outputs.

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Think back to the case of the battered child syndrome (see p. 31). Pediatricians were hesitant to ‘see’ that parents were battering their own children because they weren’t sure what to do if they did see this. This pattern changed in Colorado when a social worker was added to the pediatric treatment team of a pediatrician and radiologist (Westrum, 1993). Social workers were knowledgeable about protective services and knew what physicians didn’t know, namely how to deal with abusive parents and protect their children. The addition of that capability to the medical treatment team increased its variety. Physicians could now afford to see more variety in the dark side of their patients because now they had a way to cope with what they saw. When the team’s repertoire of actions got larger, its capability to sense and regulate variety also got larger. As a result, previously unchecked disturbances to the functioning of children were interrupted earlier in their development and resulted in less trauma. In the case of the battered child, requisite variety was achieved by increasing the variety of the sensing regulator. However, requisite variety can also be achieved by decreasing the variety in the disturbing environment. This strategy is illustrated by the situation of a traditional school classroom where one teacher faces 30 students (Glanville, 1998). Suppose for the sake of argument that the teacher’s brain can assume any one of 1 billion different states and that each of the 30 student brains can do the same. If you do the math, the total number of brain states of the students in combination is 10 to the 270th. The variety of the class is vastly larger than that of the teacher. Since the teacher’s variety can’t get larger, control lies in her ability to shut down the variety she faces. How does she do that? The teacher assumes an authoritative position at the front of the class, often on an elevated platform, suggesting superiority, with all 30 ‘brains’ facing her. This makes side conversations and combinations of brains difficult. Variety may be further reduced by requiring that uniforms be worn in a single sex classroom by people who are the same age. Students are not allowed to talk until told to do so, and when they do talk they talk in response to a question whose content and timing are under the control of the teacher. When one student answers a teacher-controlled question, that answer is treated as if the student speaks on behalf of the 30 people in the class. Variety is further restricted because students work on the same task in the same way. Taken together, these and other devices essentially reduce the variety of 30 people to the variety of one person. This is accomplished by removing interactions that enact combinations and excess variety. It is instructive to draw parallels between the teaching example and medical treatment. At the bedside, the senior resident or the attending physician is the equivalent of the teacher in authority while the other staff are in the more ambiguous position of being partially students and partially co-instructors. Staff gain or lose variety depending on how the attending treats them. The patient is also in the odd position of being both the system whose outcomes physicians are trying to improve and the source of disturbances whose variety may or may not be registered and counteracted by treatment personnel. Treatment interventions themselves may add disturbances, as was the case in the five bag example. Several things are noteworthy when we set up these parallels. Conceptions of boundaries are crucial. When people make decisions regarding what is inside the system and outside the system, they determine which variety is treated as a threatening disturbance and which variety is treated as an asset for coping. These decisions are not as straightforward as they may seem. Consider the treatment team. The treatment team can be

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part of the disturbance or part of the coping. They become part of the problem and add to the variety of the disturbance if they register information about the patient’s condition but this information is not mentioned, or if they mention it but it is ignored. In either case, the disturbance that confronts the team remains more varied than does the mediator that filters it. More effects of the disturbance persist and adverse consequences may not be far behind. The treatment team becomes part of the solution, however, if they sense and report variation, suggest remedies, and these suggestions are heard, discussed, and treated as legitimate. People who report variations can be viewed as ‘partisans of neglected perspectives’ (Schulman, 1993). What is crucial is not just that neglected perspectives are represented. Partisans also have to speak up and be heard. When vocal partisans are heard, this increases the variety of a treatment team. When they are not, adversity follows. Benner, Hooper-Kyriakidis, and Stannard (1999) describe a typical incident in which a critical care nurse tries repeatedly to convince a ‘gum-chewing third year resident’ that the high blood pressure of a patient threatens to blow out her recent graft from bypass surgery. The resident ignores the concern, the graft blows, the patient dies, and the nurse berates herself for not fighting harder (pp. 222–223). The resident lacks variety twice over. He both lacks sufficient variety to sense the disturbance and he shuts down the variety in the person trying to speak on behalf of the disturbance. Both moves present the resident with what looks like a low variety problem that he has under control. What he actually controls, however, is a caricature of the problem, and the disturbances that he fails to sense and counteract have a devastating outcome. Requisite variety is a compact way to engage additional properties of medical systems associated with error, properties such as power, coordination, and interpretation. Consider power. Systems contain people and roles with differing amounts of power, which is significant for requisite variety because ‘power makes people stupid’ (Flyvbjerg, 1998, pp. 37, 229). In situations with large power differentials, people with more power have the freedom to define reality, which means they need to spend less time trying to understand how reality is constructed. Mind, intellect, and alertness tend to be marginalized by powerful people. The result is a loss of variety. Fewer justifications may be formulated for interventions, which leaves associates in the dark as to what is being attempted and why. Less documentation may be prepared which makes for less continuity of care. Modifications in the direction of power equalization have the opposite effects and increase variety. While the language of ‘empowerment’ has come to sound contrived and manipulative, the move toward self-management and a more equal distribution of power, however one chooses to label it, is a change toward enacting more variety into teams that now face sicker patients. Consider coordination. Elsewhere (see pp. 34) we noted that Baron and Misovich (1999) draw a distinction between perceptual and conceptual cognitive processing. Perceptual processing involves direct perception where people develop knowledge of acquaintance through active, hands-on exploration. By contrast, when people work in the conceptual mode, they develop knowledge by description, their cognitive processing is now schema-driven rather than stimulus-driven, and they translate direct perceptions into types, categories, stereotypes, and schemas. As demands for coordination increase, people shift from perceptual to conceptual modes sooner, more sharply, in the interest of sharing what they see. However, in doing

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so details get lost. Highly coordinated medical teams may be more effective because they are able to forestall expected disturbances by controlling them at the source, much like the stern teacher in the traditional classroom. If they fail to contain the disturbances then highly coordinated teams could become less effective because the common labels that bind them also blind them to idiosyncratic details that warn of actions that are becoming mistakes. Consider interpretation. Two important activities in medical systems are sensing disturbances and making sense of what is sensed. Both are central to requisite variety. People see that they have the categories to discriminate, which suggests that believing is seeing. Assuming that to be the case, conceptual slack, understood as complex shared language, is crucial because it lets people believe more and see more. Themes such as these come to the forefront if we treat medical systems as interpretation systems. ‘Organizational interpretation is formally defined as the process of translating events and developing shared understanding and conceptual schemes among members (Daft and Weick, 1984, p. 286). Clinical interpretation in medical settings involves: . . . the ability to name subtle (italics added) changes that point to transitions in the patient’s condition. Clinical reasoning calls for reasoning-in-transition based on perceptual acuity about particular manifestations of the disease and on knowing the particular patient, all of which is interpretive. Interpretation is necessarily social. . . . Clinicians would lose their grasp and their ways to act (if they did not tell) coherent and plausible stories and communicate to others (Benner, Hooper-Kyriakidis, and Stannard, 1999, p. 414).

Interpretation systems are assumed to vary in at least two ways: (1) their assumptions about the analyzability of the environment and (2) the intensity with which they intrude into the environment to see what it means. First, organizations tend to assume that the environment is either analyzable with discoverable features or unanalyzable with constructed features. The assumption that the environment is analyzable leads systems to focus on ‘intelligence gathering, rational analysis, vigilance, and accurate measurement. This organization will utilize linear thinking and logic and will seek clear data and solutions’ (Daft and Weick, 1984, p. 287). By contrast, the assumption that the environment is unanalyzable leads to systems that ‘are more personal, less linear, more ad hoc and improvisational. . . . The outcome of this process may include the ability to deal with equivocality, to coerce an answer useful to the organization, to invent an environment and be part of the invention (p. 287). Second, organizations tend to intrude more or less forcefully into their environments to see what they face and what it means. Active systems are more likely to allocate resources to experimenting and to learn by doing. Passive systems, by contrast, accept the data that the environment gives them and deliberate about whatever they receive. They devote more resources to forecasting, planning, and surveying. The contrast drawn here between active and passive intrusion resembles a contrast that Brunsson (1982) makes between action rationality and decision rationality. The contrast between active and passive intrusion maps on to the earlier example of the traditional but active teacher who wades into 30 connected brains and disconnects them from one another, and the less active pediatric treatment team that sees injuries consistent with parental abuse but

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resolves this darker possibility by inventing odd diagnoses (e.g. brittle bones) to justify ignoring these darker possibilities. The way in which systems are organized for interpretation can affect requisite variety. The assumption of unanalyzability favors intuitive labeling, which should lead to more diversity in shared language than the assumption of analyzability, which is more likely to favor a search for the correct label. Likewise, active search with its hands-on specificity should lead to more diversity in shared language than does passive search with its a priori categories that blur and lump diverse inputs. An active medical system that accepts both the reality of its own ignorance and the reality of an unknowable world should have richer conceptual cognitive processing, looser coordination, greater requisite variety, and fewer adverse events than does a more passive, rational medical system that waits for the knowable world to deliver the correct answer.

Sources of Interconnected Variety in Medical Systems It is easy to get caught up in the image of requisite variety, assume that greater variety is the answer to error, and lose sight of the fact that in order for variety to destroy variety, it must be tied together. Disturbances are not counteracted simply by random bursts of variety. There must be ‘orchestration’ (Benner, Hooper-Kyriakidis, and Stannard, 1999, pp. 204–211) of the variety that is directed at a crisis. The task here is not straightforward. A durable stream of organization theory argues that integration and differentiation create opposing demands, integration favors formalized rational systems, and differentiation favors less formalized systems (Scott, 1998, pp. 103–104). Differentiation promotes adaptation in diverse changing environments while integration is a better fit for homogeneous stable environments (Lawrence and Lorsch, 1967). This chapter has focused on settings of critical care that involve surprise, transitions in patients, and unexpected and unknowable disturbances. Thus, it is not surprising that the thrust of the argument seems to be that errors persist because of too little systemic variety and too little differentiation, which implies that too much integration is the villain. The design challenge, however, is to enact recurrent interdependencies that are simultaneously differentiated and integrated at the dyadic, group, and organizational levels of analysis. Resources that are differentiated in the interest of variety can be integrated in dyads through interactions that are respectful, in groups through heedful contributions that incorporate task interdependencies, and in organizations through mindful processes that preserve system resilience in the face of change (see pp. 215–219 where these are discussed in greater detail). Each of these three variants is a loose system that favors variety and conceptual slack, but each is also a coupled system that preserves intention, consensual validation, and a coordinated division of labor. Respectful interaction (Campbell, 1990) integrates variety by combining trust, trustworthiness, and self-respect. The combination is part of what holds a high variety medical system together. If any one of these three is weakened, then it is still possible that someone registers the variety that is present in the disturbance (e.g. an advanced care nurse registers that excessive blood pressure can threaten an arterial graft). However, the singular sensing is not integrated with other observations, which means the system loses variety and gains adversity.

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Heedful interrelating (Weick and Roberts, 1993) is a meso-level pattern of integration and differentiation first described in the context of flight operations on aircraft carriers that had fewer serious accidents. The pattern was a threefold combination of contributions (people see their work as a contribution to a system, not as a standalone activity), representations (people visualize the meshing of mutually dependent contributions), and subordination (people focus on mutually dependent contributions and defer to the requirements of that pattern). When people represent and adjust the joint situation of their contributions, those representations and adjustments vary in their detail and differentiation. Extrapolated to medical work, high variety disturbances tend to be handled more effectively by high variety representations. However, medical systems tend to be tied together by routines that are often better suited to situations of lower variety. Crucial variety may be sacrificed when people reach for protocols in the belief that their activities are interrelated in a simple manner when in fact their situations are more complex and require rich reciprocal interaction (Daft and Lengel, 1986). Mindful organizing is a macro-level pattern that is focused on how organizations deal with failure, simplification, operations, resilience, and expertise. Organizations that direct more attention to these five tend to be more reliable, partly because they are able to mobilize more variety in the face of disturbances (Weick and Sutcliffe, 2007). This pattern is labeled ‘mindful organizing’ because it slows the speed with which perceptions are converted into conceptions, thereby enriching the awareness of discriminatory detail. Mindful organizing makes it is easier for groups to interrelate heedfully and individuals to interact respectfully, which means that all three of these variety-preserving integrations are mutually supportive.

Requisite Variety in Practice Systemic medical errors become more visible and more tractable when viewed as problems of requisite variety. Just as there are pathogens lying around everywhere to trip up medical systems, there are variations lying around everywhere to counteract those pathogens, and just as pathogens can line up like holes in Swiss cheese (Reason, 1997) to trigger adversity, variety can line up to contain it. The problem is one of mobilization. Medical systems can be organized in ways that activate less variety than is requisite to deal with higher variety disturbances. This imbalance allows variation to remain meaningless and amplify into adverse consequences. To reduce adversity, practitioners need to focus on ways in which variety is imbalanced and strive for greater balance. Some unexpected and relatively minor changes can rebalance variety. To rebalance variety, people need to talk differently. If people don’t know what they think until they see what they say (Weick, 1995), then altering what they say can alter what they see and think and do. Systemic requisite variety becomes more salient and more attainable when people begin to talk about transient systems, orchestrating diverse experience, redoing the system rather than assuming its permanence, trying too hard to confirm hunches, loosening the connections and norms that stifle speaking up, appreciating the ways in which diversity enlarges a response repertoire, treating handoffs as sites where sensemaking can be oversimplified, bringing in neglected perspectives, and

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strengthening nonclinical skills such as respectful interaction and heedful interrelating. All of these tap systemic sources of variety. These are ways of talking differently that can affect practice. However, this is not simply about empty talk. The words we have introduced are new ways to envision the systems that people have been seeing all along. The new words highlight activities and skills whose importance had not been seen before. The new words have referents that become clearer when the terms are discussed with relevant parties. The new words suggest new leverage points for increased effectiveness and reliability. To rebalance variety also means to ask for help, give help, accept ignorance, seek improvement rather than perfection, and punish hubris. This cluster of changes is responsive to the fact that medicine works in an environment that is often unknowable and unpredictable (McDaniel and Driebe, 2001). The dominant issue under such conditions is not decision making with its distracting rational system overlay. The dominant issue, instead, is one of sensemaking, interpretation, and the resumption of treatment after an unexpected interruption. The variety necessary for meaningful interpretation lies between people who are candid about what they do and don’t know and what it might mean. It does not lie in an all-purpose algorithm for decision making. As Sutcliffe (2001) notes in her synthesis of the literature on environments and organizational information processing, ‘better information processing may not so much be characterized by an ability to choose between accurate images and misperceptions, but rather the ability to enhance plausibility and choose between different potential misperceptions’ (p. 211). Interpretations that enhance plausibility tend to be those that help to get an interrupted activity or a disturbed system back underway. This means that information processing is as much about repair and resumption as it is about accurate representation (Blattner, 2000). Unsettling as that feels, it is consistent with the idea that actions gradually become adverse rather than appear adverse from the very beginning (Paget, 1988). This is consistent with the idea that the complex mind necessary to cope with such a world lies in relationships between people rather than inside a single head. To rebalance variety is to take seriously the idea that a little structure goes a long way. ‘Moderate’ coordination, ’moderate’ being read both as an adjective and a verb, is the byword. Moderate coordination in the descriptive sense of modest coordination allows for more internal differentiation, imposes fewer categories on perception, enables a greater variety of connections and recombinations of experience, and slows the development of incomprehensible interactive complexity (Perrow, 1984; Cook and Woods, 1994, p. 290). To moderate coordination means to monitor variety, preserve conceptual slack, dispel the idea that a good team is synonymous with people all of one homogeneous mind, protect minority perspectives, and make your own sensemaking public by stating what you see as the situation, the task, the goal, the concerns, and asking others to do same (Weick, 1995, p. 55). The theme here, as it has been throughout, is that looser coordination enables richer dialogue, which fosters earlier detection of smaller anomalies and quicker containment with fewer adverse consequences. In clinical medicine, where acts often become identified as mistaken only after they have already gone wrong (e.g. Paget, 1988, pp. 45, 48, 56), requisite variety plays a unique role. Something that is an error now often wasn’t an error back then. The conclusion that an error has been made is a product of hindsight. The fascinating quality of

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requisite variety in a treatment team is that hindsight is multiple and varied. Different people, with different experiences and different responsibilities, track different outcomes in an unfolding patient history. When people who track early outcomes look back in hindsight from those early vantage points, they see clearer sequences that produced those outcomes. These perceptions are an invaluable source of updating for people who are tracking outcomes farther downstream that have not yet materialized and triggered hindsight. An act that is still ‘becoming’ for someone waiting for delayed outcomes has already ‘become’ a finished act complete with outcome and antecedents for people who are tracking more immediate outcomes. Even though early hindsight produces a biased history, it nevertheless preserves some truths about how and what the act is becoming. These truths are invaluable to those who will engage in their own hindsight from a later point in time. The emerging picture is one in which a system with high requisite variety has the capability for nested hindsight. There are several different anomalous ‘nows’ that single out several different earlier ‘thens’ that were not errors back then but were veering in unanticipated directions. Collectively, the nested moments of hindsight catch the acts that comprise the act of becoming that Paget found so elusive (Paget, 1988, p. 56). Caregivers at the bedside tend to see acts gone wrong sooner than caregivers farther removed from the bedside, who monitor outcomes that are spaced out over longer periods. If systems are designed to be more respectful, heedful, and mindful, then fewer acts, whether they are near term or long term, should become adversely wrong.

Informal System Theories: Simplifications and Refinements The insistence that there would be fewer adverse medical events if people were more sensitive to the systemic nature of medical care is true as stated but false as practiced. It is true in the sense that adverse medical outcomes are often embedded in complex, lengthy, and overdetermined sequences of events that seem interconnected and systemic. It is false in the sense that awareness of these complex interdependencies is blunted by frameworks and assumptions that lack sufficient nuance and context to register how complexity is converted into adversity and how such conversion can be contained. The result is that people talk a lot about systems, but the talk has little effect on errors. Cook and Woods (1994) show that this disjunction between the complex genesis of adversity and the adoption of a simple remedy (e.g. operator error) creates a repetitive error cycle (p. 221). Why would this happen? One possibility is that prevailing ideas about medical systems generate primitive storylines that impede error mitigation. The following are some possible misunderstandings about systems that might produce such an outcome. Misunderstandings of medical systems may arise when people mistakenly believe that no system exists when in fact one does (false negatives). Such misperceptions are likely in medical care where people want to be in control, go to great lengths to preserve the illusion that they are in control, and assess situations in terms of their controllability. Given these preferences, to ‘see’ systems is to see dependency and a loss of control. The stubborn persistence of a tendency to blame individuals rather than systems for medical errors may stem in part from an equally stubborn tendency to see the world in such a

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way that the illusion of control is preserved. False negatives are also likely if people look for stereotypical systems (i.e. those that are tight and mechanical, and closed) and, finding few such entities, conclude that few systems exist. False negatives are likely when people are unaware of the extensive preparations made to ‘set up the environment’ for medical care in such settings as an operating room (e.g. Benner, Hooper-Kyriakidis, and Stannard, 1999, p. 191). When help and systems are invisible, we tend to overestimate our own importance in the determination of outcomes and minimize the contributions of others. That oversight often leads those who normally set up the environment to withdraw commitment, work to rule, and withhold information. Those actions dissolve what little system there was and produce the very nonsystemic setting that was prophesized to begin with. False positives, the belief that there is a system when in fact there is none, often occur because people infer that their connections to similar others are evidence of a system and further evidence that they are sensitive to the systemic nature of medical care. Anesthetists talk to other anesthetists not to surgeons, but tend to see their homogeneous anesthesia group as a more diverse, large-scale system than it is. We saw hints of such ethnocentrism in the five bags case. Other examples are common. The battered child syndrome (see Chapter 3, pp. 31, where this is discussed in greater detail) was not publicized nationally until the early 1960s because the pediatric radiologists who spotted signs of it in X-rays in the 1940s talked among themselves, not to pediatricians. Pediatricians who heard about these findings essentially said, ‘If parents were beating their children I would know about it. Since I don’t know about it, it isn’t happening.’ This egocentric tendency, labeled by Ron Westrum (1993) as the ‘fallacy of centrality,’ both shrinks the size of perceived systems and makes it easier to feel in control. During the inquiry into pediatric deaths at the Bristol Royal Infirmary (Kennedy, 2001, p. 216), there was a lively disagreement about how often pediatric surgical patients were delivered to the ICU unit without any warning or any advance contact to smooth the transfer. The scrawled notation ‘Transferred from Ward 5. Arrived unannounced as usual’ on the record of a patient who had a difficult recovery (MR 722/63) suggests that the staff at Bristol thought that a system existed in theory for patient transfer, but not in practice. Very young unstable patients were put in jeopardy by the false positive belief that a functioning system did exist (see Chapter 10 for an elaboration of this example and also Weick and Sutcliffe, 2007, Chapter 6).

Informal Systems as Rational Systems Limited understanding of systems may occur because systems are described using a salient but limited set of dimensions. Medical systems are often described as rational, closed, and mechanical. While these descriptions are complementary, they also tend to conceal several leverage points for error mitigation that become more apparent if systems are portrayed as open and natural. When medical personnel refer to ‘systems’ and ‘systemic error,’ they usually have in mind a rational system comprised of explicit roles, rules, routines, and relationships intentionally created to achieve well-defined objectives efficiently. Control, formal structures, specified responsibilities, and predictable performance are hallmarks of such systems.

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Rational systems are purposely designed and continue on even though there is turnover of staff. Rational systems often seem to operate in a ‘computational’ manner in which they scan and search the environment for relevant data, code those data into information, and convert the information into decisions (Lant, 2002, p. 344). What sometimes gets lost in such depictions is that search is costly, ambiguity is just as much of a problem as is ignorance, decision makers try to act rationally but have limited success doing so, coding is limited by the categories that are sanctioned within the organization, and decision situations do not come ready-made but instead are defined into existence. Each of those points of slippage within a tidy computational view represents an opening where error might be generated, but also where errors might be detected and contained. The concept of rational systems undoubtedly makes sense in a medical context where people favor evidence-based medicine, an analytic mindset, the presumption that technology is a source of precision and reliability, and where there is pressure to justify decisions and design omniscient protocols. The problem is that rational system models miss much of what happens when people try to act in a rational manner or hold others to idiosyncratic definitions of what constitutes rational action. For example, when people try to reconstruct the root cause of a medical error, they often tend to stop their search backward for a cause once they find an error that they can do something about (Rasmussen, 2000, p. 32). When this happens people are dealing with putative reasons, not root causes (Senders, 1994, p. 175). If a person had known that such a reason was plausible beforehand, that knowledge alone would not have predicted the adverse event (e.g. she was tired and misread the label, except that tired people often read labels correctly, rested people read labels incorrectly, and misread labels seldom kill people). If you alter a system to remove a reason for error, that action may have little impact since you never fingered a cause to begin with. To see the limits of a rational perspective we take a closer look at the contrasts between closed and open and mechanical and natural systems.

Informal Systems as Closed Systems The easiest way to make sense of recurrent interdependence and improve its efficiency is to see it as a determinate system, and the easiest way to perceive a determinate system is to limit it to a small enough set of variables and connections so that you can comprehend, control, and predict all of them. James Thompson (1967) described a typical closed system model that did this: ‘Scientific management achieves conceptual closure of the organization by assuming that goals are known, tasks are repetitive, output of the production process somehow disappears, and resources in uniform qualities are available (Thompson, 1967, p. 5). Closed systems are preoccupied with socialization, preservation of a given form, attrition of dissimilar elements, simplification, control, and categorizing and depersonalizing clients, all of which renders them ill-suited to span boundaries and handle high variety disturbances. A richer rendition is the open system. An open system is conceptualized in relation to the environments it faces, not as sealed off from those environments. The image is one of organizations as ‘adaptive interdependent systems, comprised of various interrelated – possibly conflicting subsystems – attempting to meet and influence the dynamic demands of the environment’

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(Baum and Rowley, 2002, p. 6). Systems are not simply open to the environment; they are dependent on inputs from the environment and soon run down without continued inputs (Katz and Kahn, 1978). Transactions across boundaries are crucial and the contingent nature of these transactions means that system functioning itself is in continual flux as environmental uncertainty varies. Groups within open systems tend to be loosely connected and there is an emphasis on processes. People who work with open systems are insistent that social organization does not consist of an anatomical structure analogous to physical or biological systems. Instead, one treats the structure of an open system as recurrent patterns among events that are enacted into existence. Katz and Kahn put it this way: The fact that organizational structure is created and maintained only as the members of the organization interact in an ordered way suggests a high degree of openness, a persistent and inherent vulnerability to forces in the organizational environment. It suggests also a continuing necessity to maintain the organizational structure against such forces or adapt to them. Much of the theorizing and empirical work about organizations has assumed explicitly or implicitly a closed system, in which the inputs to the system are regarded as constants. The open-system approach reminds us that organizational inputs are neither constant nor guaranteed (Katz and Kahn, 1978, p. 754).

When people view medical systems as closed they miss the fact that much medical treatment is delivered by transient, temporary systems (Goodman, 1981) assembled at the bedside, often with new players (e.g. floating nurses, temporary interns). A transient system must be enacted, orchestrated, and reaccomplished. If one views medical systems as open systems then error mitigation means keeping up with dynamic environmental demands, focusing attention on adaptation as well as efficiency, accepting the reality of dependence, living with looser connections in the interest of greater internal diversity, protecting processes as well as structures, redoing the structure that keeps unraveling, and expecting the unexpected.

Informal Systems as Mechanical Systems The easiest way to depict a system is in the form of a flow chart or a series of boxes and arrows, the result being an image that looks like a plumbing diagram for an old Scottish castle (Weick, 1987a, p. 97). The problem is that such depictions disguise mechanisms of systemic error. A mechanistic system implies interrelated means designed to achieve a single end, and conceals means conflict, goal conflict, and evolving forms as factors in medical error. There is the implication that the parts mean nothing apart from the system within which they function, which conceals the fact that parts themselves are systems capable of generating and forestalling error. A mechanical system tends to be regarded as an instrument to attain goals, which means it becomes the dominant way in which a field of action is rationalized. Efficiency, the one best way, and foresightful design replace learning, flexibility, and improvisation as means of error mitigation. A mechanical system is a depersonalized system. When people label connected activity a ‘system’ it is easy for them to forget that what is crucial about such activity is that

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it is interpersonal, tied together by communication and built of task relationships that involve interdependence and dependence. To enrich the idea of a rational system we can blend it with what Scott (1998) calls a ‘natural’ system. The adjective ‘natural’ captures the idea that when people come together to work on complex tasks, they do so, not as mere fragments with purported skills (this fragmentation is sometimes referred to as ‘partial inclusion’; see Katz and Kahn, 1978, p. 7) but as complex personalities, created by their location in relationships, desirous of acting their way into a meaningful existence. What is ‘natural’ in natural systems are human social tendencies such as social comparison (people judge the correctness of their opinions by comparison with similar others), social facilitation (the mere presence of others enhances performance of welllearned behaviors), and threat-rigidity (people tend to centralize when threatened). To focus on natural systems is to pay more attention to adaptation than to efficiency, more attention to informal relationships than formal structure, and more attention to emergent purposes than to imposed purposes. To focus on systemic error in natural medical systems means to take a closer look at the ways in which human interaction, sentiments, responsiveness to expectations, making do within constraints, and creation of meaningful work predispose to error or error mitigation. To adopt a natural system perspective is to pay less attention to normative structures of rules, plans, and prescriptions and more attention to behavioral structures of interpersonal influence, improvisation, and social support. In natural systems, participants shape structure, whereas structure is thought to shape participants in a rational system (Scott, 1998, p. 58). If rational systems dominate medical care, then we should expect to find that people act as if structures shape participants and as if remedies for medical error are structural. However, if we pay more attention to natural systems then we should also see how people enact many of their own structures and, in doing so, increase or reduce error.

Note 1 I am deeply grateful to Dr Reuben McDaniel Jr for his help with this discussion and for his continuing inspiration.

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IV Action 10. Hospitals as Cultures of Entrapment: A Re-analysis of the Bristol Royal Infirmary 11. Enacting and Environment: The Infrastructure of Organizing 12. Positive Organizing and Organizational Tragedy

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10 Hospitals as Cultures of Entrapment: A Re-analysis of the Bristol Royal Infirmary Setting the Scene One reason why organizational life is punctuated by a steady stream of interruptions and recoveries is that mistakes are common. Human fallibility is ‘like gravity, weather, and terrain, just another foreseeable hazard’ (Reason, 1997, p. 25). The issue with evolving mistakes is not just why they occurred, but why they were not detected earlier and corrected. The visibility of errors was seen as an important issue earlier in this book when we discussed the tendency of high reliability organizations to be ‘preoccupied with failure.’ When people organize a flow of experience into expectations and thick observation, moments of disorganization become more apparent, earlier. Chapter 10 describes a powerful mechanism for sensemaking that, in this case of pediatric surgery, conceals human fallibility, reduces the visibility of error, and leads to excess deaths. Surgeons don’t ‘see’ errors in their procedures because they don’t have to. They explain the excess deaths on their units as the result of unusually complex cases rather than of their flawed skills, both interpersonal and technical. Rather than see their work as ‘less than adequate’ (p. 180 in the following reprinted article), they see their problems as more than complicated. In many situations, deficiencies such as these would be corrected. That doesn’t happen at the British Royal Infirmary (BRI) and one reason is a powerful mechanism of sensemaking. When surgeons diagnose, cut, repair, restore, follow-up, and give accounts of their work to other surgeons, administrators, and families, these actions tend to be public, irrevocable, and volitional. Since these actions are already over by the time people make retrospective sense of them, it is easier to customize the reasons why things turned out the way they did than it is to change the outcomes themselves. Actions are in effect already ‘frozen.’ All that is left to vary are the ways in which people justify what they did, and some justifications are more culturally appropriate than others. Thus, at the BRI, the prevailing justification was that

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excess deaths were due to excess complexity of cases. There are three reasons why this explanation was so binding for so long. First, the culture was one in which actions were public (not private), irrevocable (not reversible), and based on professional choices (not forced). Second, the appropriate justifications within the BRI culture included ‘we make do with the resources we have (p. 185 ),’ ‘our cases are severe,’ and ‘we know what we’re doing, but our nurses sometimes don’t.’ Third, records of the surgical procedures, complications, and outcomes were kept in log books written by the surgeons themselves with only limited additional measures collected by less involved parties. The mechanism that is posited to underlie the tragedy of the BRI was explored theoretically by Weick (2001), pp. 5–31. The large consequences in the present chapter are the excess deaths that are the progressive result of small but airtight justifications. What is striking is the way in which these small justifications affect subsequent actions and perceptions. Once the justification becomes prominent, then the world is transformed into a field of threats that call forth stronger and larger blind spots. These blind spots were the very things that worried firefighter Paul Gleason (see pp. 265–266) when he feared that making decisions would tempt him to polish and defend them. His preference to see himself as making sense (interpretation rather than a choice) for some indefinite period (revocable) to his team (public) reduces the threats and increases flexibility. However, revocability does have costs. It substitutes impermanence and insecurity for stability and certainty. Revocability moves the world of the firefighting team from crystal toward smoke. While the ideas of commitment and self-justification have been around for some time (e.g. Brehm and Cohen, 1962; Kiesler, 1971; Salancik, 1977) they have not lost their robustness or their value as a starting point in any account of sensemaking (e.g. Tavris and Aronson, 2007). Ideas about commitment instantly combine cognition and action and forestall the more labored effort to explain which comes first. Choice, irrevocability, and publicity are features that are present in almost any setting, which means that the observer can get a quick preview of the extent to which actions will be defended in depth and a hint of how those actions may be justified. As a final note, much of the work on justification is often referred to as ‘self-justification’. People tend to explain their actions so as to present those actions and themselves in a favorable light. Now, with that frame in mind think back to the discussion in Chapter 6 of the cardinal Buddhist meditation: impermanence, suffering, selflessness. It is conceivable that as organizing becomes more mindful and more accepting of impermanence, there will be less self-justification because there is less persistence of a singular self. Justification is replaced with attentiveness. Just such a shift seems important in the context of the adverse events recounted in Chapter 10. The disturbing lesson that flows from the BRI is that there are conditions where it is easier to justify adverse events than to correct them (p. 182 in the reprinted article). Selflessness might change that. The following article by Karl E. Weick and Kathleen M. Sutcliffe was published in California Management Review, 2003, 45(2), 73–84.

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Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary Karl E. Weick Kathleen M. Sutcliffe California Management Review, Vol 45, No 2, Winter 2003, 45 (2), 73–84. Copyright © The Regents of the University of California, Reprinted with permission.

Organizational culture is often used to explain extraordinary organizational performance. In fact, the term “safety culture” has recently emerged in the healthcare literature to describe the set of assumptions and practices necessary for healthcare organizations to provide optimal care.1 Culture enables sustained collective action by providing people with a similarity of approach, outlook, and priorities.2 Yet these same shared values, norms, and assumptions can also be a source of danger if they blind the collective to vital issues or factors important to performance that lie outside the bounds of organizational perception.3 Cultural blind spots can lead an organization down the wrong path, sometimes with dire performance consequences. This was the case at the Bristol Royal Infirmary (BRI). The example of BRI represents a sustained period of blindness associated with organizational culture. Culture can entrap hospitals into actions from which they cannot disengage and which subsequently lead to repeated cycles of poor performance. The working definition of culture used in the BRI inquiry was “those attitudes, assumptions, and values which condition the way in which individuals and the organization work.”4 While Schein provides a more detailed definition,5 a more compact definition is used here to treat culture as “what we expect around here.”6 Cultural entrapment means the process by which people get locked into lines of action, subsequently justify those lines of action, and search for confirmation that they are doing what they should be doing. When people are caught up in this sequence, they overlook important cues that things are not as they think they are. The Bristol Royal Infirmary pediatric cardiac surgery program had significantly higher mortality rates than other centers in England and failed to follow the overall downward trend in mortality rates seen in the other cardiac surgery programs.7 The case shows how small actions can enact a social structure that keeps the organization entrapped in cycles of behavior that preclude improvement. The question is why did Bristol Royal Infirmary continue to perforin pediatric cardiac surgeries for almost fourteen years (1981–1995) in the face of poor performance? This persistence was the result of a A preliminary set of ideas about Bristol were presented at a conference funded by the Agency for Healthcare Research and Quality held at the University of Michigan Business School November 16–18, 2001, titled “Creating an Organizational Infrastructure for Patient Safety.” We are indebted to Kyle Weick for his comments on a preliminary version of this article.

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cultural mindset about risk, danger, and safety that was anchored by a process of behavioral commitment that shaped interpretation, action, and communication.

Description of Events at Bristol Royal Infirmary Pediatric Cardiac Surgery8 The Bristol Royal Infirmary (BRI) and the Bristol Royal Hospital for Sick Children, also known as Bristol Children’s Hospital (BCH), are teaching hospitals associated with Bristol University’s Medical School located in southwest England.9 In 1984, the BRI and BCH were designated by the National Health Service as one of nine Supra Regional Service (SRS) centers to provide pediatric cardiac surgical care for infants and neonates under 1 year old. (To put things into perspective, this involves surgery to correct anomalies on hearts no bigger than a peach pit.) BRI was designated to provide open-heart surgery, while the BCH was designated to provide closed-heart surgery. The decision to centrally fund specialized services and establish the SRS center system was made by the National Health Service to control and concentrate resources and to assure that clinicians would encounter a sufficient number of rare cases to acquire necessary experience and expertise. As noted in the BRI Inquiry final report, the assumption was that “[a] unit should undertake a certain volume of cases to ensure good results in this very exacting field.”10 The idea was that the more practice, the better a center would become, and the more likely it would be to experience over time a complete range of rare conditions and complications. Very few open-heart surgeries on children under 1 had been performed at BRI when it was initially designated. In contrast to other units in the UK that had developed special expertise in pediatric cardiac surgery, Bristol did not stand out in this area. In fact, government officials admitted that the case for making Bristol an SRS was weak because it was unlikely to have sufficient volume to maintain the proficiency of its participants.11 Still a decision to designate it as an SRS was made primarily on geographic grounds— there were no other locations in southwest England nearly as capable as Bristol, and to have no program in southwest England at all would have led to quite long transfer distances. As noted in the report, “the Advisory Group was concerned to see that part [southwest England] covered . . . if you are designating a service for the first time and you are endeavoring to cover the country, you may well have to identify a unit which at that moment in time is not performing as well as some of the other centers which may have been established for many years, the intention is to develop that service, nurture that service.”12 The physical setting at Bristol is worth noting since it figures prominently in the inquiry report. BRI is located two-blocks away from the BCH. Open-heart surgery is done at Bristol Infirmary and closed heart is done at Children’s Hospital. Cardiologists are located at Children’s Hospital, there are none at the BRI, and surgeons are based at BRI. Most of the children are kept in wards at BRI after they are operated on with an open-heart procedure. At BRI, open-heart surgery is done on the fourth floor, while the ICU unit is on the sixth floor. The ICU unit can only be reached by a non-dedicated elevator, so it is necessary to have somebody moving out of surgery waiting for an elevator, with the possibility of getting on an elevator that has several other people on it. Once

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children are moved up to the sixth floor, they are taken care of for a short period of time until they are stabilized. Then they are taken back down in the elevator, transferred to an ambulance that moves them to the BCH where they are cared for on a ward. These transfers and handoffs all have the potential to magnify small problems that linger after surgery. The problems with the split site and split service were noted in the early 1980s by hospital officials and the regional health authority and the aim was to unify the care of children on one site and to recruit a surgeon who specialized in pediatric cardiac surgery. Several other features need mentioning. First, the regional health authority and hospital board relied on the CEO, Dr. John Roylance, for direction. Dr. Roylance in turn relied on Dr. James Wisheart, one of the two pediatric surgeons who did the work. Wisheart was a man of many trades, holding other positions in BRI such as associate director of cardiac surgery and the chairman of the hospital’s medical committee. Wisheart is described in the report in rather negative terms; he arrives late to surgery, his patients typically are on bypass before he shows up (not highly recommended), and when he gets into complicated problems he is faulted for not being able to step back and see what is developing. Moreover, he’s intimidating and autocratic enough that the rest of the team is reluctant to tell him what they see unfolding in front of them. The other surgeon is Dr. Janardan Dhasmana, who is described as being more deferential. He is seen to have adequate skills with the exception of the neonatal switch procedure. He is also described as self critical, disengaged from his surgical team, and unaware of their importance as a “whole team.”13 Dr. Wisheart and Dr. Dhasmana operated both on children and adults. However, pediatric cardiac surgery was only a small part of the overall cardiac surgery activity. Experts agreed that the minimum caseload necessary for a center to maintain sufficient expertise was approximately 80–100 open-heart operations annually for two surgeons (40–50 per surgeon).14 As noted, the Bristol open-heart pediatric caseload for children under 1 year of age was low, averaging about 46 between the two surgeons per year. When the pediatric cardiac surgical program began, its performance was roughly commensurate with the other programs. However, over the next seven years, while all other centers improved their performance, Bristol did not. Between 1988 and 1994, the mortality rate at Bristol for open-heart surgery in children under one was roughly double the rate of any other center in England in five of the seven years. The mortality rate (defined as deaths within 30 days of surgery) between 1984 and 1989 for open-heart surgery under 1 at Bristol was 32.2% and the average rate for the other centers for the same period was 21.2%.15 For the year 1989–1990, the mortality rate for Bristol was 37.5% and the comparable figure for other UK centers was 18.8%.16 For the period 1991 to 1995, data analyses showed that Bristol had between 30 and 35 excess deaths over what would have been expected if the unit had been “typical” based on the performance of the other eleven centers around the UK. The mortality rate for closed-heart procedures in children under 1 year at BCH did not differ significantly from those of the other centers around the UK.17 Although some clinicians explained the differences in mortality rates on the ground that Bristol was seeing a more complex mix of cases, clear evidence indicated “divergent performance in Bristol.”18 Bristol simply had failed “to progress.”19

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Clues that things were not going as well as they seemed were abundant. In fact, concerns about pediatric performance began to surface as early as October 1986 when a professor at the University of Wales wrote to the Regional Health Authority to report: “It is no secret that their [BRI pediatric cardiac] surgical service is regarded as being at the bottom of the UK league for quality.”20 Government officials investigated the issue, but in the absence of supporting evidence, they concluded that the problem was related to the volume of cases, not the quality of care.21 As events unfolded there were at least 100 formal concerns raised about the quality of care being delivered, including those raised by Dr. Stephen Bolsin, a consultant anesthetist who joined BRI in 1988.22 Bolsin immediately noted differences between his previous experience at Brompton hospital and his experience at BRI. In contrast to Brompton, operations at BRI were longer, which meant that the babies were being kept on the by-pass machines much longer with consequent adverse outcomes. In addition to Bolsin’s explicit and repeated complaints to colleagues, he complained to the hospital’s CEO John Roylance, who dismissed him by saying the issue was a clinical matter, one that was the domain of the pediatric cardiac surgeons. While Bolsin wasn’t shy about expressing his concerns to the CEO and colleagues within his specialty, he never directly confronted either of the surgeons with his concerns. Concerns surfaced in other places as well. An article written by the Pediatric Pathologist at Bristol reporting on postmortem examinations of seventy-six Bristol children who had under gone surgery for congenital heart disease was published in the Journal of Clinical Pathology in 1989. Among the findings reported in that article are 29 cases of cardiac anomalies and surgical flaws that contributed to death.23 In January 1991, the Royal College of Physicians refused to accredit the BRHSC as an institution to train pediatric cardiology because of the split site and split services.24 A series of six exposé articles criticizing pediatric care at BRI, written by Dr. Phillip Hammond, were published in Private Eye (Bolsin was the source of the information for these articles).25 Events reached a climax in early 1995 after the death during surgery of a child, Joshua Loveday, whose operation had been resisted by everyone except the two surgeons. An external review by two people selected by Dr. Wisheart described “confusion” at Bristol and pediatric cardiac surgeries were essentially halted. Parents called for an inquiry in 1996. The inquiry itself started June 18, 1998 and ended with the publication of the report in July 2001.

What Happened? There is no disagreement that the pediatric cardiac service provided at Bristol was less than adequate and continued as such for many years in the face of growing evidence of the poor quality of care. Although there are many plausible interpretations of what went wrong, one of the most striking findings of the Bristol inquiry is the conclusion by investigators that “while the pediatric cardiac service was less than adequate, it would have taken a different mindset from the one that prevailed on the part of the clinicians at the center of the service, and senior management, to come to this view. It would have required abandoning the principles which then prevailed: of optimism, of ‘learning curves,’ and of gradual improvements over time. It would have required

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them to adopt a more cautious approach rather than ‘muddling through.’ That this did not occur to them is one of the tragedies of Bristol.”26 How did the mindset originate and why was it impervious to change? A single organizational process of behavioral commitment explains the origins of the BRI mindset and its persistence. While this mindset may look like “muddling through” from the outside, it has a different standing inside. The mindset at BRI was sufficiently workable and reasonable that it explained away both poor performance and the need to learn. The basic ideas of behavioral commitment are summarized by Salancik and Pfeffer.27 “Commitment binds an individual to his or her behavior. The behavior becomes an undeniable and unchangeable aspect of the person’s world, and when he makes sense of the environment, behavior is the point on which constructions or interpretations are based. This process can be described as a rationalizing process, in which behavior is rationalized by referring to features of the environment which support it. Such sensemaking also occurs in a social context in which norms and expectations affect the rationalizations developed for behavior, and this can be described as a process of legitimating behavior. People develop acceptable justifications for their behavior as a way of making such behavior meaningful and explainable.”28 That description is noteworthy for its connections between micro and macro levels of analysis. At the macro level of hospitals and their environments, the description links micro rationalizing processes such as justification to the larger setting when it refers to: features of the environment that offer support to the justification; the social context whose norms and expectations supply the content of justification; legitimacy of actions and justification in the eyes of key stakeholders; and justifications that are explainable and meaningful to people outside the circle of action at the sharp end of the error chain. At the micro level, the description links justification to specific details in day-to-day medical work. When people take important actions that are visible and hard to undo, it is hard for them to deny that the actions actually occurred. If those clear actions are also seen as volitional, then those actions are also harder to disown and the actor is held responsible for them. Public, irrevocable, chosen actions put reputations on the line and compel some kind of explanation and justification. The content of those justifications is not chosen casually because so much is at stake. Only a limited number of justifications are socially acceptable, and people have to live with the justifications they adopt. Thus, whatever justifications people voice tend to have considerable tenacity, they tend to influence subsequent perceptions and action, and they locus disproportionately on information that confirms their validity rather than disconfirms it. Behavioral commitment, therefore, has three components: an elapsed action, socially acceptable justification for that action, and potential for subsequent activities to validate or threaten the justification. It is important to understand that the idea of justification as used here is not synonymous with mere individual self-justification or defensiveness. Justification is “rationalizing done within socially acceptable bounds.”29 Rationalization will not work unless it is culturally appropriate. These ideas help us make sense of what happened at BRI. Bristol is described as a collection of fragmented, loosely coupled, self-contained subcultures (the inquiry board calls them “tribes“),30 managed by a CEO whose idea of leadership and oversight

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was to say, “You fix it.” The BRI culture is one in which people share the practice “of explaining or justifying . . . mediocre or poor results on the basis of case severity rather than directing attention to producing better results.”31 The prevailing explanation for bad results at BRI is not “we are doing something wrong and need to improve,” but rather that these are “bad patients . . . and we are doing our best.”32 If this pattern at BRI is translated into the language of behavioral commitment, then there is high autonomy and choice within each sub-culture of professionals. There is high irrevocability since surgical interventions on tiny patients are hard to reverse. In addition, there is high visibility for the actions and outcomes among people within the same specialty, surgical teams and ICU personnel, and among referring cardiologists, the families of patients, and regional and National Health Service monitors. BRI, as is true of many hospitals, enacted a context of choice, irrevocability, publicity, and rationales within which adversity was an outcome that was easier to justify than to remedy. The initial justifications that focused on unusual case complexity had a surprising tenacity that is explained by the fact that they served to reduce uncertainty, they were supported when “tested” against records maintained by the affected personnel, and they were plausible in the sense that a case can be complex either because of the patient’s presenting condition or because of the physician’s inadequate treatment of that condition. Moreover, right when the justification seemed most endangered, there was an anomalous year in 1990 where mortality rates at BRI came back into line with those of the other centers.33 Rather than question why there was this change, people treated it as evidence that the justifications were correct (i.e., we’re learning and gradually improving). The BRI board of inquiry summarized the essentials of what we call a culture of entrapment, this way: “The surgeons were working in a relatively new and developing field of highly complex surgery. They were dealing with small numbers of disparate congenital cardiac anomalies. Perhaps unsurprisingly, they tended to turn to their own logs of operations as the most detailed, relevant and reliable sources of data. In these logs they saw a pattern of complex cases. In this hard-pressed service, which was attempting to offer the full range of specialist care to these children, as well as meeting all the other needs of a cardiac surgical unit, the poor results achieved were believed then, and are still believed, by Mr. Wisheart to be the result of this pattern of complex cases, the result of caring for an unusually high proportion of unusually difficult cases.”34 Tenacious justifications make it harder to learn, harder to discontinue the justified action, and easier to spot information that confirms their validity. Carried to the extreme, this is one mechanism by which people developed “professional hubris.”35 This basic social process for constructing reality is common to organizations of all kinds, both those experiencing adversity and those experiencing success.36 Even though this social process is fundamental, it gets ignored because people tend to blame adversity on operators at the sharp end of the accident chain and fail to look at earlier moments when commitments are hardening. The analytic error is compounded when people are then removed from their organizational contexts (which favor some justifications and discourage others) and are then judged one at a time, in isolation, as if they alone intended to err. Static renderings of organizational structure can mask ongoing interpretations, expectations, and learning that enable action to continue. Medical work turns either toward adversity or away from it because of the content of culture. However, content

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alone is not sufficient to produce adversity or to protect against it. Content needs to matter. When it is selectively mobilized to justify actions that might otherwise raise doubts about legitimacy, then content matters a lot. Content that matters can either open current practices to closer inspection and improvement, or it can seal them off— as was the case at BRI.

Discussion “Medicine used to be simple and ineffective and relatively safe, but now it is complex, effective, and potentially dangerous.”37 Surgeons at BRI did not expect that their learning would be so gradual, or that other centers would outperform them, or that their own management would inadvertently undermine possibilities for improvement. When the unexpected occurs, sensemaking intensifies. As Diane Vaughan made clear in her analysis of the Challenger disaster: “When an unexpected event occurs, we need to explain it not only to others, but to ourselves. So we imbue it with meaning in order to make sense of it. We correct history, reconstructing the past so that it will be consistent with the present, reaffirming our sense of self and place in the world. We reconstruct history every day, not to fool others but to fool ourselves, because it is integral to the process of going on. . . . People attempt to rescue order from disorder.”38 BRI reconstructed a history of excess deaths and transformed it into a history of excess complexity. That reconstruction rescued order from disorder and imbued the past with meaning, all of which is perfectly understandable. What is harder to accept is the persistence of a rationale that precludes learning, reduces openness to information, and minimizes cross-specialty communication. The reconstructed rationale persists because layers of bureaucrats above the surgical unit, people who had some say in the original choice to designate BRI as a center of excellence, find their own judgments in jeopardy. The unintended consequence is that the whole chain of decision makers comes to support an explanation that makes it difficult for an underperforming unit to improve or to stop altogether. To analyze BRI as a setting that entraps people in behavioral commitments does provide a compact synopsis of a sprawling, complex lapse in patient safety. However, there is always the danger that such an analysis seems like little more than an exercise in re-labeling. That is not the case here. There are some unusual implications that follow from the analysis, three in particular. One unexpected twist is that those who are in a better position to learn from adversity are those who have low choice to become involved in adverse events. If high choice sets justification in motion, then low choice reduces the pressure to justify and reduces the necessity to engage in a biased search for the sources of adversity. Choice is higher at the top of hierarchies than at the bottom (e.g., surgeons are higher than anesthetists who are higher than nurses). People at the bottom of hierarchies also tend to be closer to the patient’s bedside, for longer periods, with richer data. They see adversity as it unfolds; and their reduced sense of volition reduces pressure on them to justify and construct acceptable reasons for errant actions. However, there is a catch. Their actions are visible to everyone above them in the hierarchy and they are also at the sharp end of the chain of events leading to adversity

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where the last irrevocable act occurs. This increases pressure on them to justify adverse outcomes. People at the bottom are torn between justification and candor. Their public irrevocable acts tempt them to justify, but their forced compliance with directives from above tempts them toward candor. The tensions created by these opposing temptations may mean that frontline medical workers are people at a tipping point. That possibility is important because it means that they may welcome surprisingly small interventions of support, security, and psychological safety39 that could tip the balance toward candor and learning and away from concealment and justification. The point here is that fear of punishment may not be the only dynamic that leads people to cover up error. Errors may look like they are being covered up when in fact they are being explained away in order to justify public, irrevocable, volitional actions that have turned into mistakes.40 If attempts to improve patient safety focus on justification rather than on fear of punishment, then the targets for change are quite different. Interventions would tend to focus on perceived choice with the intent to show that earlier choices were less voluntary than first thought (e.g., you really had no choice but to go in), and/or focus on perceived irrevocability with the intent to show that treatment can be started over (e.g., let’s stop all medications and see where we are), and/or focus on perceived visibility with the intent to demonstrate that observers forgot what they saw, were unimportant to begin with, or understood how the system conspired to make things worse (e.g., they have rotated onto a different service and are seeing a different set of problems). The central and simple idea is that people with less of a stake in what they can afford to see and what they must ignore, will see more, spot the development of adversity at earlier stages, and contain adversity more effectively. A second unexpected twist is that the much-discussed “autonomy” of professionals such as surgeons and hospital CEOs takes on a different meaning. Hospitals are contexts in which autonomy works against learning. When physicians contract with hospitals, call their own shots, and, as in the case of BRI,“report to” a CEO who says “you work it out, the quality of clinical care is your exclusive preserve,”41 then they experience relatively high levels of choice. If you add in the fact that when physicians are concerned about accountability and liability, these are proxies for visibility and irrevocability, then it is clear that hospitals are sites where professional action is exceedingly binding and where justifications are consequential. The net result is that change is next to impossible, even when no one is satisfied with current performance levels. Through repeated cycles of justification, people enact a sensible world that matches their beliefs, a world that is not clearly in need of change. Increasingly shrill insistence that change is mandatory changes nothing, since neither the rationales nor the binding to action change. Inadequate performance persists. Finally, the idea of a “safety culture” is applicable in medical settings, but not for the reasons people usually think. Discussions of culture typically focus on content and refer to shared beliefs, shared norms, and shared assumptions. The BRI board of inquiry variously referred to BRI as a provider-oriented culture,42 a culture of blame,43 a club culture where your career depends on whether you fit into the inner circle44 and not on your performance,45 a culture of fear,46 an oral culture,47 a culture of justification,48 a culture of paternalism (professionals know best so don’t ask questions),49 and a culture of uncertainty.50 As investigators combed through the BRI data with the benefit of

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hindsight, they sought some kind of “invisible hand” that preserved the same interpretation of the same inadequate performance for several years. People at BRI persistently believed that things were anomalous rather than unacceptably poor.51 It was the combination of choice, irrevocability, and publicity that preceded this interpretation and not the content of the interpretation per se that precluded learning. Accelerated learning, in this view, is more likely when the committing context itself is weakened and not when the content of justifications dwells more on maxims of safety. If there is a maxim implied in this analysis, it reads “challenge easy explanations.” An “easy” explanation is one that that has shallow plausibility, meaning that it can explain away any outcome, is not readily refuted, and the best that can be done to disarm it is to doubt it. Easy explanations for the poor outcomes at BRI included: “our poor outcomes will improve over time with experience,” “outcomes will improve once we get a hoped-for new surgeon,”52 and “our poor outcomes are an artifact of small numbers that look worse when converted into percentages, and they are inevitable because we are treating sicker children.”53 As the board of inquiry said, “All of these arguments had sufficient plausibility at the time that they could be believed, and they could not be readily refuted, though they might be doubted.”54 Justification turns a conspicuous action into a meaningful action. The resulting meaning can promote or impede improvement. Culture plays at least two roles in this transformation. First, culture supplies the meaning. Second, culture supplies the conspicuousness that influences the intensity with which the meaning is defended. The lesson for hospitals is also twofold. First, be certain that the socially acceptable reasons that are available as content for justifications center on a learning orientation that values communication, openness, mutual aid, and mindful attention to patient care. As Marc de Laval put it, “physicians must become more open and comfortable with their fallibility and the patients must accept their own vulnerability.”55 Second, hospitals should try to weaken the committing context that surrounds adverse events so that people are not forced to justify inadequate performance. This is the tougher assignment of the two. The BRI inquiry board said that the better professional mindset at BRI would have been “to abandon the principles which then prevailed of optimism, of learning curves, and of gradual improvement over time, and adopting what may be called the precautionary principle.”56 However, that is as far as the board went. One way to give substance to their precautionary principle is to translate it into the image of tempered commitment. To temper a committing context is to create moderate levels of choice, publicity, and revocability. One means to do this is to make the interdependencies that are involved in medical work more explicit. The unwillingness and inability to see and improve interdependence at BRI was the feature most often criticized.57 This feature is the one that makes the biggest difference in performance improvement. When people understand interdependence, behavioral commitment can be moderated. Thus, choice is reframed as a collective responsibility such that the buck stops everywhere. Publicity is reframed as a collective commitment to provide constructive feedback to one another in order to improve performance. Irrevocability is reframed as a collective responsibility to identify escape routes, contingency plans, and to mentally simulate potential interventions in order to spot potential traps. When choice, publicity, and irrevocability are treated as collective responsibilities necessitated by task interdependence, this spreads responsibility but it does not diffuse it.

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The dangerous person in a scenario of behavioral commitment is an exposed individual, in search of perfection, who is reluctant to admit fallibility, but who also feels momentarily vulnerable in the face of adverse behavioral commitments. Vulnerability continues until he or she finds a plausible justification that explains the adversity away. What began as merely a plausible justification is likely to harden into dogma because it performs such an important function. Dogma precludes learning, and it precludes improvement. This is what happened at BRI and it need not happen again.

Notes 1 L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, D.C.: National Academy Press, 2000). 2 B.A. Turner and N.R Pidgeon, Man-Made Disasters, 2nd edition (Oxford: ButterworthHeine-mann, 1997: 47). 3 Ibid. 4 Learning from Bristol (Crown Copyright 2002), p. 266. 5 See Chapter 1 in E.H. Schein, Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 1985). 6 K.E. Weick and K.M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity (San Francisco, CA: Jossey-Bass, 2001), pp. 121–122. 7 Learning from Bristol [see note 8], p. 4. 8 All details concerning the Bristol Royal Infirmary are taken from the Bristol Royal Infirmary Inquiry Final Report. The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995, Learning from Bristol, Presented to Parliament by the Secretary of State for Health by Command of Her Majesty, July 2001, Crown Copyright 2001. The inquiry was conducted between October 1998 through July 2001. The magnitude of the inquiry is daunting. The final printed version of the report is 530 pages and includes two CDs of raw data. The investigators received written evidence from five hundred and seventy-seven witnesses (two hundred and thirty-eight of those witnesses were parents). They also received and reviewed over nine hundred thousand pages of documents, eighteen hundred medical records, and took oral evidence for ninety-six days. They commissioned a hundred and eighty papers that were presented at seven different seminars. There are no restrictions on quoting or using the report. See www.bristoi-inquiry.org.uk. 9 Learning from Bristol, op. cit., p. 23. 10 ibid., p. 25. 11 Ibid,, p. 105. 12 Ibid., p. 105. 13 Ibid., p. 175. 14 Ibid., p. 104. 15 Ibid., p. 139. 16 Ibid., p. 136. 17 Ibid., pp. 4–5.

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18 Ibid., p. 4. 19 Ibid., p. 4. 20 Ibid., p. 134. 21 Ibid., p. 134. 22 Ibid., pp. 134–151. 23 Ibid., p. 136. 24 Ibid., pp. 138, 210. 25 Ibid., p. 141. 26 Ibid., p. 4. 27 G.R. Salancik and J. Pfeffer, “A Social Information Processing Approach to Job Attitude and Task Design,” Administrative Science Quarterly, 23/2 (June 1978): 224–253. 28 Ibid., p. 231. 29 Ibid., p. 235, footnote 3. 30 Learning from Bristol, op. cit., p. 266. 31 Ibid., p. 161. 32 Ibid., p. 161. 33 Ibid., p. 4. 34 Ibid., pp. 239–240. 35 Ibid., p. 164. 36 For examples, see MX. Tushman and C.A. O'Reilly III, Winning through Innovation: A Practical Guide to Leading Organizational Change and Renewal (Boston, MA: Harvard Business School Press, 1997), pp. 132–141; J. Ross and B.M. Staw, “Expo 86: An Escalation Prototype,” Administrative Science Quarterly, 31/2 (June 1986): 274–298. 37 Sir Cyril Chantler, former Dean, Guy’s, King’s and St. Thomas’s Medical and Dental School, cited in Learning from Bristol, op. cit., p. 355. 38 D. Vanghan, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA (Chicago, IL: University of Chicago Press, 1996), p. 281. 39 A.C. Edmondson, “Psychological Safety and Learning Behavior in Work Teams,” Administrative Science Quarterly, 44/2 (June 1999): 350–383. 40 M. Paget, The Unity of Mistakes: A Phenomenological Interpretation of Medical Work (Philadelphia, PA: Temple University Press, 1988). 41 Learning from Bristol, op. cit., p. 74. 42 Ibid., p. 257. 43 Ibid., p. 16. 44 Ibid., p. 302. 45 Ibid., pp. 68, 201. 46 Ibid., p. 201. 47 Ibid., p. 202. 48 Ibid., p. 161.

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49 Ibid., p. 268. 50 Ibid., p. 273. 51 Ibid., p. 163. 52 Ibid., p. 148. 53 Ibid., p. 247. 54 Ibid., p. 247. 55 Ibid., p. 272. 56 Ibid., p. 248. 57 Ibid., p. 4.

Kathleen Sutcliffe is associate professor of organizational behavior and human resource management at the University of Michigan

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11 Enacting an Environment: The Infrastructure of Organizing Setting the Scene Two assumptions associated with American pragmatism are incorporated into the concept of enactment, which is discussed in Chapter 11. These are: (1) The world people inhabit is one they had a hand in making. And it, in turn shapes their behavior. They then remake it. (2) Meaning and consciousness emerge from behavior. An object’s meaning resides not in the object itself but in the behavior directed toward it (Reynolds, 2003, p. 45).

The pragmatist William James lends substance to these assumptions: I, for my part, cannot escape the consideration, forced upon me at every turn, that the knower is not simply a mirror floating with no foot-hold anywhere, and passively reflecting an order that he comes upon and finds simply existing. The knower is an actor, and co-efficient of the truth on one side, whilst on the other he registers the truth which he helps to create. Mental interests, hypotheses, postulates, so far as they are bases for human action – action which to a great extent transforms the world – help to make the truth which they declare (James, 1992, p. 908).

In the language of this book, cognition and order lie in the path of the action. Organizations have been portrayed as action generators (Starbuck, 1983) and action has been in the forefront of discussions of organizing and sensemaking (Czarniawska, 2008). The concept of enactment folds together cognition, action, and order. Introduced in 1969 (Weick, 1969, pp. 63–71), the concept of an ‘enacted environment’ combined discussions by a diverse set of researchers (e.g. Mead, Skinner, Garfinkel, and Schachter) with Alfred Schutz’s discussions of retrospect, future perfect thinking, and the act of attention, to modify the idea that organizations adapted to ‘the’ environment. If you re-read those pages, you’ll see that the outlines of sensemaking are already there. In 1979,

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enactment (Weick, 1979, pp. 147–169) as a process was separated from its product, an enacted environment, to make the point that people are shaped by their own shaping of circumstances. The idea that creations create the creator in organizational life was elaborated by Weick (2001, pp. 176–236). A typical assertion reads, ‘People act their way into clearer identities by learning from retrospective interpretations of the improvisations necessary to handle discontinuous work assignments’ (Weick, 2001, p. 177). That summary sentence includes several properties of organizations that are affected by organizational designs: prescriptions for action, identities deemed legitimate, climate for learning, clarity and acceptability of retrospective interpretations, latitude for improvisation, and continuity in work assignments. Under conditions of impermanence all of these properties assume some form, which then shapes what organized people confront. In 1995 enactment was repositioned as one of seven properties of sensemaking (social, identity, retrospect, cues, ongoing, plausibility, enactment) in order to underscore that sensemaking is not simply a matter of idle thought (Weick, 1995). The insightful work of Mary Parker Follett was added to the growing number of scholars who described the complexity of enactment. She noted, for example, that: . . . the activity of the individual is only in a certain sense caused by the stimulus of the situation because that activity is itself helping to produce the situation which causes the activity of the individual. . . . My farmer neighbors know this: we prune and graft and fertilize certain trees, and as our behavior becomes increasingly that of behavior towards apple-bearing trees, these become increasingly apple-bearing trees. The tree releases energy in me and I in it; it makes me think and plan and work, and I make it bear edible fruit. It is a process of freeing on both sides. And this is a creating process (Follett, 1924, pp. 118–119, cited in Weick, 1995, p. 60).

Chapter 11 continues the elaboration of enactment, this time as part of a point– counterpoint debate with institutional theorists P. Devereaux Jennings and Royston Greenwood (2003). If one assumes that cognition lies in the path of the action, then the question arises as to which cognitions and which actions are salient, legitimate, and permissible when people organize. The answer from enactment seems to be that any old cognitions and actions are permissible. That’s nonsense say institutional theorists and they are right. In Westwood and Clegg’s (2003) words, ‘What institutional theory is said to add is a rich consideration of context, agency, structure, and mediated causality’ (p. 184). In addition, ‘enactment theory appears to provide a more complete explanation of the internal worlds and cognitive understandings of the intraorganizational members of interorganizational systems. Rich ethnography can thus be the appropriate if restricted role for enactment theory’ (Westwood and Clegg, 2003, p. 184). The notion of enactment implies more than action. It connotes the creation of structure as in the enactment of regulative legislation. Enactment is about agency ⫹ consequences. We do something and the situation is forever changed, and those changes affect us. There is no ducking the point that there are times when enactment sounds motivational as well as coolly cognitive. Enactment implies a sort of David and Goliath narrative. Small wins (Weick, 2001, pp. 426–443) can make a large difference, and sometimes the

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underdog wins. This can sound like naïve whistling in the dark. However, organizational life, in some of its more gritty moments, is a little like being thrown into someone else’s mess and then, through enactments, making it your own more orderly mess (p. 197 in the following reprinted article). In a world connected by weak ties, order writ small need not stay small.

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Enacting an Environment: The Infrastructure of Organizing Karl E. Weick The following article was published as Chapter 6(a) in R. Westwood and S. Clegg (Eds), Point/Counterpoint: Central Debates in Organisation Theory, London, Blackwell, 2003, pp. 184–194. Reprinted with permission.

The idea of an enacted environment is a roomy framework in which it is easy to get tripped up by nouns. For the sake of a point-counterpoint format I want to describe not so much an “official” version of what enactment might mean, but rather a depiction of what themes it stands for, how it serves to remedy blind spots in organizational theory, and how it creates its own blind spots. The idea of enactment seems to be useful shorthand, which theorists ignore at their own peril. That claim is the sense in which the following discussion has a debative quality. But there is more than enough ignorance to go around, and to act as if anyone formulation has the truth is to drown in hubris. Chapter 6(a) unfolds in the following manner. First, I will present a roomy initial version of what enactment is about, using Nigel Nicholson’s description as the point of departure. Second, I discuss briefly the context within which the idea of an enacted environment evolved in order to illustrate that, historically, it synthesized several salient themes of die 1960s and 1970s. Third, I ground the concept and history of enactment with a handful of examples. Fourth, I discuss several aspects of the idea that seem to have staying power because they correct blind spots in theories currently treated as mainstream. And I conclude by discussing shortcomings in the idea of enactment.

A Conceptual Delimiting of Enactment Nigel Nicholson’s (1995) informative entry on enactment in the Encyclopedic Dictionary of Organizational Behavior provides a solid base from which to begin. He describes enactment as a concept developed: to connote an organism’s adjustment to its environment by directly acting upon the environment to change it. Enactment thus has the capacity to create ecological change to which the organism may have subsequently to adjust . . . [The enactment process is discussed] in the context of active sensemaking by the individual manager or employee . . . Enactment is thus often a species of self-fulfilling prophecy . . . [Enactment is also about] the reification of experience and environment through action . . . [The idea] has found most use in strategic management to capture the dynamics of relations between organization and environment. . . One can expect enactment processes to be most visible in large and powerful organizations which have market-making capacity, but they are no less relevant to the way smaller enterprises conceive their contexts and make choices about how they will act in relation to them. (p. 155)

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Having touched on most of the key properties of enactment, Nicholson concludes: As an operational concept, enactment lacks precision and therefore cannot be expected to be much further elaborated in organizational analysis. However, it embodies an important recognition of how agency and constructive cognitive processes are essential elements in our understanding of the behavior of individuals and organizations, (pp. 155–6)

Nicholson catches a number of nuances that are often missed. Enactment is about both direct and indirect adjustment. Adjustment occurs directly through changing that which is confronted, and indirectly through changing oneself. Enactment is about direct action on an environment. Enactment occurs in the context of both organizing (it is action that induces and is shaped by ecological change) and active sensemaking, and in both instances resembles the mechanism associated with self-fulfilling prophecies. It is the resemblance to self-fulfilling prophecies that explains why enactment, which may begin as an expectation embedded in a reification, often has material consequences. The concept seems best suited for strategic management as expressed in large-scale initiatives deployed by powerful actors. Nevertheless, the idea remains useful to describe activities on a smaller scale as well. Enactment makes it legitimate to talk about issues of agency and construction in organizational theory, but apparently at an individual level analysis, as suggested by Nicholson’s reference to enactment by “an organism,” “the organism,” and “the individual manager and employee.” Nicholson’s judgment that the concept lacks the precision that would make for further elaboration is partially weakened by his own evidence that several different properties of organizing are encoded as a configuration by the word “enactment.” “Precision” may be less tightly coupled with “susceptibility to elaboration” than is suggested. But there is an important sense in which Nicholson is right. Some of the “lack of precision” that concerns him is attributable to the fact that there is an unclear figureground relationship among at least the terms “organizing,” “sensemaking,” and “enactment.” We see this in Jennings and Greenwood, who, like others, tend to use these words interchangeably but with some hesitance. I separate these three terms and treat “organizing” as the modified evolutionary process of ecological change—enactmentselection—retention. These amendments to evolution are spelled out abstractly in 1969 and more organizationally in 1979. Sensemaking, as described in 1995, is not unrelated to organizing, but it makes a very different point. The seven properties of sensemaking align with the processes of organizing in a straightforward fashion: ecological change and enactment in organizing ⫽ ongoing updating and enactment in sensemaking; selection ⫽ retrospect, extracted cues; retention ⫽ identity, plausibility; feedback from retention to subsequent enactment and selection ⫽ feedback of identity and plausibility to subsequent enactment and selection. And all of these organizing and sensemaking events are presumed to be social. The concept of sensemaking differs, however, from organizing in the sense that it is intended to break the stranglehold that decision making and rational models have had on organizational theory. Sensemaking implies that key organizational events happen long before people even suspect that there may be some kind of decision they have to make. Decision making is incidental, sensemaking is paramount. To focus on decisions is to miss most of what it means to reduce uncertainty and most of the ways emergent organizing attempts this reduction. Finally, the third concept,

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“enactment,” is the “glue” that joins organizing with sensemaking. Enactment is the stubborn insistence that people act in order to develop a sense of what they should do next. Enactment is about two questions: What’s the story? Now what? When people act in order to answer these questions, their acting typically codetermines the answer. Thus action alters what people face. It enacts part of their world, even if all that amounts to is an alteration of themselves. Enactment, at a minimum, changes the actor from inactive to active and, in doing so, deepens the actor’s stake in what is being done and in its outcome. These are collective, social phenomena between people, not isolated individual phenomena inside a single head. Complicated as all of this may appear, it boils down to a straightforward theme: people are in a complex reciprocal relationship with their environments. The italicized words emphasize that the referent is collective rather than individual, that causality is mutual rather than unilateral, and that the circumstances people confront are malleable and multiple, rather than monolithic and singular.

A Historical Delimiting of Enactment A deeper understanding of what enactment means may be possible if the idea is situated in the Zeitgeist of the late 1960s, when it was first articulated. The juxtaposition of the first book-length statement of ethnomethodology (Garfinkel, 1967), an attempt to synthesize social psychological research on consistency among attitudes and behavior (e.g. Abelson et al., 1968), a surge of interest in existentialism (e.g., Maclntyre, 1967), and disenchantment with the passive actor in stimulus-response psychology, all converged on common themes such as action defines cognition, existence precedes essence, attitudes are draped supportively around prior actions that are tough to undo. Those themes were heretical in the context of organizational theories that presumed that top management personified rationality with their enlightened decision making, flawless forecasting, and omniscient planning. The convergence in social science around the idea that cognition lies in the path of the action was not just heretical. It was also prophetic. These ideas coincided with a growing societal realization that administrators in Washington were trying to justify committing more resources to a war in Vietnam that the United States was clearly losing. One could not escape the feeling that rationality had a demonstrable retrospective core, that people looked forward with anxiety and put the best face on it after the fact, and that the vaunted prospective skills of McNamara’s “whiz kids” in the Pentagon were a chimera. It was easy to put words to this mess. People create their own fate. Organizations enact their own environments. The point seemed obvious. What wasn’t so obvious was the complications this picture created. People resonated to the idea that they were in control and could have an effect on the world. What they resisted was the further suggestion that, having changed the world, they had then become the authors of their own problems. Blaming came full circle, and people now confronted perils of their own making. Enactment made sense in and of the 1960s and 1970s when it first appeared. The debating point is, does enactment still make sense in the circumstances of the new millennium? I think it does, because the basics of organizing, as well as the realities of pervasive

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uncertainty, unknowable and unpredictable futures, learning by trial and error, and the inevitable lag of sensing behind motor actions (I see only what I’ve already done) haven’t changed that much. The content is different. But the forms through which the content flows remain pretty much the same.

An Illustrative Delimiting of Enactment To ground these initial descriptions of enactment, I want to describe some examples. These examples provide a feel for the phenomenon, suggest scenarios that are tough for mainstream positions to explain, and serve as templates to spot enactment in other settings. Iatrogenics, physician-induced disease, occurs when diagnostic tests, lines of questioning, or faulty procedures create sickness that was not present when the patient first consulted with a physician. The physician enacts a sicker and more complicated environment than first confronted him or her. Efforts to lessen the severity of wildland fires through preventative controlled burns usually (but not always) enact a safer wilderness for both firefighters and visitors by removing flammable underbrush that can produce hotter, taller, more explosive fires. An air traffic controller creates a holding pattern by stacking several aircraft in a small area of air space near a busy airport and, in doing so, enacts a cluttered display on the radarscope that is more difficult to monitor. Rumors that a stock trader has an unusually high hit rate often draw attention to that person’s trading, which leads others to duplicate the trader’s pattern of buying, which increases the action around a stock, which often raises its value, which seems to confirm that the trader is “hot,” which attracts more buyers and purchases and temporary upticks. The fact that a bandwagon effect drove up the share price, and not the quality of the stock, suggests a powerful pathway for enactment in the investment community. Abolafia and Kilduff ’s (1988) fascinating reconstruction of attempts to corner the silver market show in detail the ways in which enactment in financial markets can build on itself. NASA enacts a lean, mean environment in which overworked employees fail to convert metric units into the same units of measurement used in the rest of the project. As a result, an entire mission fails in public view, credibility is questioned, and whatever “savings” were gained through lean operation are lost in irretrievable hardware and the addition of time-consuming damage control. When Mercedes-Benz merges with Chrysler, and Travelers merges with Citibank, these so-called “mergers of equals” administered by coCEOs enact an acquisition of unequals in which the stronger CEO consolidates his (all four CEOs were male) initial advantage and soon ends on top. Hospitals refuse to report medical mistakes for fear of losing business and in their refusals enact new suspicions that keep away the very people they feared they would lose by disclosure. Proctor & Gamble initiate merger talks that enact shareholder flight from the stock, which drives down both share price and P&G’s attractiveness as a merger partner. Organizations that encourage closeness to the client enact a permissive world that encourages outrageous customer demands that can be remedied only by firing the client they tried so hard to recruit. An arrogant management team from the Union Pacific Railroad fires personnel from the newly acquired Southern Pacific Railroad and in doing so loses expertise needed to run the tricky railyard in Houston, manage to gridlock not only the yard but the southwest region, paralyze infuriated shippers, and create a lingering suspicion

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of the entire railroad industry. Campaign contributions enact a more selective administration of regulative environments. Successful lobbying of Congress to start daylight saving time earlier in the year increases hours of daylight in the spring and sales of garden supplies climb, but sales of candy at Hallowe’en plummet because people are unwilling to go trick-or-treating in the dark. So what do physicians, firefighters, air traffic controllers, traders, aerospace engineers, CEOs, hospital administrators, and lobbyists demonstrate? They show that discretion and strategic choice, implemented in ongoing work, can change the conditions of that work. They show that individual work can enact conditions that other people and other systems have to cope with. For example, iatrogenic disease does not stop at the physician’s door as the newly troubled patient walks out. Instead, the altered patient walks into the medical care system, where the consequences of the initial treatment spread and where the patient’s problems with the physician become other people’s problems as well. Enactment creates contingencies as well as events. The initiating conditions seem small in comparison to macro events only because these examples articulate the local turning point, the point of bifurcation, the moment of initiation. These triggering moments often serve to implant small but uncontained outcomes in larger systems. These embedded, uncontained outcomes continue to grow undetected until they spawn unanticipated consequences that threaten legitimacy, competence, and control. In each of the examples it is also important to note that the actors are not passive. They do not simply scan or notice or detect or perceive or sense the environment. Instead, they probe the circumstances into which they have been thrown. These probes are not blind, since experience, socialization, job descriptions, and culture influence them. These influences are relative, however, in the sense that they still leave considerable latitude. People still act with discretion, often with only a vague idea of what they are doing and what effect it will have. Their discretionary acting is intertwined with what they sense, although it is rare for busy actors to sort out the relative contributions. But whether actors reflect on their creations or not, analysts need to be mindful that organizational environments are not just an occasion for selective perception. They are also an occasion for selective intervention and shaping. Thus to change an organization is not simply to change what people notice, but how they notice. Active noticing leaves traces. Those enacted traces are drawn up into systems as problems for others. Thus any attempt to increase effectiveness will fail if all it tries to affect is what people notice, and not what they do as well.

Presumptions of an Enactment Perspective But what does an enactment perspective enable people to see and say about organizations that they miss when they invoke the modern trinity of transaction costs, institutional theory, and population ecology (TIP)? One thing enactment does is that it buys conceptual flexibility. (One man’s “imprecision” is another man’s “roominess.”) All three of the current mainstream positions make sense only so long as we presume that stasis rather than dynamics are what we need to explain, that reification of an invisible hand is a legitimate conceptual move, that everyday interacting and conversing are inconsequential, that there is an ontological difference between macro and micro

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levels of analysis, that people tell the truth when they fill out survey instruments or make entries in archival records, and that people are not distracted, preoccupied, or careless when they evaluate their options, try to follow precedent, or get thrown into the middle of someone else’s mess. Enactment helps people see constructive activity as well as maintenance and routine, because it is about verbs. Enactment is about operants, acts that operate on the world. It is about a set of words such as efferent, impose, project, shape, proact, control, manage, and establish, all of which imply agency or acting one’s intentions into the world. Enacting is visible in emerging organizational structures, redesign, and reorganizing. The conversation analyst Deirdre Boden (1994) illustrates this emphasis nicely in her description of the foundational nature of turn taking as a structure in organizing. For her, the organization becomes a real and practical place: only as the consequence of a recurrently generated ongoing conversation, multiply laminated, a world of telephone calls, meetings, planning sessions, sales talks and corridor conversations by means of which people inform, amuse, update, gossip, review, reassess, reason, instruct, revise, argue, debate, contest and actually constitute the moments, myths and through time, the very structuring of the organization . . . [T]he structuring properties of turn-taking provide the fine, flexible interactional system out of which institutional relations and institutions themselves are conjured turn by turn . . . The business of talk in the technical sense, is thereby transformed into business that gets done through talk. (Excerpted from Taylor and Van Every, 2000: 220)

To enact a conversational environment, close in, is to breach or bend the orderliness of turn taking. To enact opportunities and constraints into organizing is to interrupt a partner who is talking, to stay silent, to ignore, to affirm without warning, to attend, to mitigate, to reconcile, to cancel, or to close. Acts like these transform social circumstances into novel conversational texts, and these texts then provide an enacted platform for further action. Enactment helps people see the environment as something other than resources, institutional precedents, promises, uninterpreted information, niches, models to mimic, markets, liabilities, and costs. The “something other” is that all of those preceding features are names, punctuations, and interpretations imposed in the interest of meaning. If one is puzzled, then “finding” an organization to mimic, an institutional guideline to follow, a resource to be hoarded, a market to be saturated, or a liability to be skirted are ways to make sense and allocate effort. What makes any one of these quite diverse punctuations plausible is that they are imposed on circumstances that amount to a pun. People in organizations notice circumstances precisely because something unexpected occurs or something expected fails to occur (Mandler, 1982; Heidegger, 1962; Louis and Sutton, 1991). How one acts in the face of puns influences what will have been seen and done. For example, the bridge crew on a ship running at night, who are unable to agree whether another ship ahead of them is moving toward them or away from them, by their own actions enact the traffic they face. By positioning their own ship based on the erroneous assumption that the ship in front is moving away from them, that they are overtaking it, and that they should pass it on its port side, they change the relationship between the two ships. This change now enacts a pun for the

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oncoming other ship. (That ship looks like it is passing us both on our starboard and on our port.) As the ships, which are actually coming toward each other, close faster and take “evasive” action based on opposite views of what is unfolding, they steer into one another (Perrow, 1984). What began as an equivocal pun for one party – a ship ahead with an equivocal pattern of running lights that could mean either that it is coming or going and that we should meet it by passing either right or left – becomes a pun for the other party, and ends with the clarity of a collision. The issue is not decision making. The issue is what people thought they faced, a perception that was clarified by the actions they took, what those actions made salient, and the repertoire of interpretations available to them as a result of past experience and their current conversations. The point here is simply that more than perception is involved. Perceptually, the crew faced an equivoque. Their actions to resolve the indeterminacy produced a more determinate environment. The fact that the determinate environment led to bad outcomes is not the only issue. Equally important is the issue of what happened on the input side. How did people develop a sense of what they faced, what prevented their updating of that initial sense, how did their own actions affect their sense of certainty, how much of the data remained outside their explanation, and what were they doing while all of this happened? Questions like these are common when the world is treated as an indeterminate place that people make more sensible by acting their way into it. An indeterminate world is not a random world. Instead, it is loosely coupled, amenable to multiple interpretations, malleable to action, and contingent. Indeterminacy means differentially determinant, an “obvious” partition being that technology and other material artifacts are more determinant than are social resources. I put quotation marks around “obvious” because the world does not often sort itself neatly into those two categories. Latour (1988) has made this clear in his insistence that the pairing of tools with people does not create an aggregate. Instead, it creates a fused hybrid that is unified through action, a hybrid similar to what Heidegger seems to have in mind when he describes readyto-hand being. The discussion up to this point is noteworthy in the sense that it illustrates a third way in which enactment captures what the big three miss. The typical referent in most discussions of enactment tends to be small: the dyad, the small group, the double interact, the conversation, the principal-agent relationship, the imagined other, the individual, the team, face-to-face interaction, the partner, the confidant, and the co-leader. Units of this size tend to be lumped together as a micro level of analysis and then dismissed as inconsequential in a world of large organizations, substantial power distance, tall hierarchies, top management teams, interlocking directorates, scripts and routines, outsourced work, organizational fields, alliances, webs, and cultures. Regardless of the imagery, it is common to separate the organization as entity from individuals as its components. Having done so, investigators then argue that communication occurs in the container of an organization, or that the organization is produced by communication, and therefore can stand alone once communication stops. It is less common to read that organizations emerge in communication and are shaped momentarily by the nature of the relationship and the forms in the language that are realized when organizing is talked and acted into existence. This is a long-standing issue that keeps getting lost on people who reify large arbitrary assortments of people into acting entities. The issue is whether macro and micro are

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distinct entities. The answer from enactment is that there is no ontological difference between micro and macro, a position that is also articulated by Giddens and Latour (Taylor and Van Every, 2000: 141–72). Organization is realized in moments of conversation and joint action that are embedded in day-to-day interactions. Conversation is the site of organizational emergence, and the text generated during the conversation, its surface (Taylor and Van Every, 2000). Thus what an organization will have become is a property of communication and is read from the conversing. Said differently, organization is talked into existence again and again through conversations that overlap in time and space. Plausible summaries of these conversations that give conversants an identity, and their conversations some coherence, are fed back to participants by macro-actors. These moments of enunciation, which enable people to see what they have said and what it might amount to, occur when macro-actors (people who act on behalf of distributed conversations) are doing such things as writing an annual report, holding a press conference, issuing an order to employees, arguing for a position in the senior management committee, writing an internal report, talking employees into a strike, writing a column for an influential business publication, and so on (Taylor, personal communication, May 21, 2000). There are constraints on enactment just as there are constraints on the big three. But the constraints on enactment are lodged in quite different places. There are constraints in the grammar of the language that is used to convert interaction into text, constraints in the discipline of interaction, and constraints in the texts that are reflexively treated as evidence that shared images are being produced, accepted, and elaborated. To take the big three seriously is to translate their mechanisms into language, interaction, and shared images, and to pinpoint where and how they get talked into existence. Enactment thrives quite well without a macro/micro split. It does not waste time trying to, first, separate the organization as entity from the individual as component, and then, second, reconnect them. The economy of enactment lies in its treatment of organization as a form of social life that is: invariably situated, circumstantial, and locally realized in a finite time and place involving real people . . . [M]anagerial interventions are not exogenous at all, but merely another locally realized, personally communicated act expressed in language (a speech act), with this special characteristic, that they are meant to be, and are treated as being, declarative [declarative = communication that causes a state of affairs to exist, e.g. a priest saying, “I declare you man and wife,” marries the couple]. (Taylor and Van Every, 2000, p. 143)

Portraits of organization that posit autonomous structures, interorganizational relationships, and populations as containers filled with reactive individuals are convenient fictions behind which the containing gets worked out and changed through acting, conversing, and textualizing. Continuities in framing, in action, and in language from conversation to conversation, coupled with adjustments on the spot to the vagaries of interaction, produce distributed understanding that is more intelligent than is evident in any one conversation (Weick and Roberts, 1993). When macro-actors feed portions of this understanding back to the conversationalists, the feedback enables the conversationalists to talk organization into existence more readily and more prominently. The idea that organizations as well as environments are enacted is missing from many discussions of enactment, although not from those of Giddens and Latour. If conversation

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is treated as the site of organizational emergence, and if the text of the conversing is treated as the surface from which objects, agents, attitudes, and intentions are read, then reciprocal enactment of organization as a social form and an environment as the context of for this form, then this missing piece can fill out the picture. A fourth quality that is invoked routinely in an enactment perspective, but less often in other perspectives, is what I will call a hermeneutic mind set. By hermeneutic mind set I mean the expectation that it takes two things to know one thing. While hermeneutics is typically equated with interpretation, I want to use the word to highlight the even more general themes of mutual determination, simultaneity, and joint realization. Consider two of Eco’s (1999) wonderfully stimulating questions. (1) What did Marco Polo think he was seeing when he first saw a rhinoceros on Java (pp. 57–9)? (2) What did curators at the British Museum think they were looking at in 1798 when they first looked at a stuffed “water mole” (a platypus) sent by colonialists from Australia? In both cases the puzzled viewers took something specific and tried to tie it to something categorical, so that they could use the linkage to probe the specific more closely, and to refine the categorical more sharply. Marco Polo’s best guess was that he had found an ugly, smelly, dark unicorn, and the curators’ best guess was that they had been duped by the same people who had sewn fishtails on to monkeys and tried to pass them off as mermaids. Enactment is about knowing and learning, which means it is about issues of epistemology. But the form of knowing that is involved in enactment, active probing that both shapes and meets resistance, means that it is also about issues of ontology. In fact, in Barbara Czarniawska’s wonderful phrase, enactment is about ontologizing one’s epistemology (private communication). Enactment is about probing that determines the nature and reality of what is probed. There are numerous relationships in which two elements are linked and, by successive approximations, specify one another more clearly, reduce uncertainty, and heighten understanding. Some of the more obvious pairings include the reciprocal specification that occurs when parts are linked with wholes, particulars with types, sentences with narratives, objects with schemas, situations with accounts, maps with territories, and specifics with generics. All of these pairings involve enactment. In each case there is an active placement of something specific into a more general context, which clarifies both the specific and the context. It is crucial that the pairing not be treated simply as the linkage of a less clear element (the specific) with a clearer element (the context). There is ambiguity and clarity on both sides. The act of generalizing a particular stretches the general. And the act of particularizing the general alters the figure-ground structure of the particular. Linkage, in other words, produces mutual specification. The map suggests what is important in the territory, the territory is altered to fit the map, and the map is altered to fit the altered territory, all of which actually occurred when Britain tried to control the American colonies it had never seen (Taylor and Van Every, 2000: 278–80). Territory is not territory without a map. And there is no map apart from some territory. It is a chicken-and-egg nightmare all the way down. Which comes first? Who knows? But then, does it matter if cycles, cause loops, mutual causation, and simultaneity are treated as the basics? Notice how quickly we move into the domain of organization theory and into some of its impasses. Enactment is faulted for positing culture-free action that unfolds with

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almost no constraints on what is done or what it means. Institutionalists are faulted for positing free-floating reified social facts that mysteriously constrain what people do and mean. If you look back at the paired terms in the previous paragraph, enactment ⫽ parts, particulars, sentences, objects, situations, territories, and specifics; institutions ⫽ wholes, types, narratives, schemas, accounts, maps, and generics. Each position has part of the answer. Or none of the answer! The answer is in the relating, the relations, the cycling. Action unattached to a narrative is senseless. But a narrative without a reader is equally senseless. Each without the other is nonsense. But the solution is not simply to take two elements and link them with two connections. Instead, the solution is to adopt the embedded act as a foundational structure. An embedded act is one whose very character is defined by and defining of context. The question for organizational theory is, what are the mechanisms by which social order shapes and is shaped by the hermeneutics of action? Any old starting place will do if, and only if, it is neither privileged nor treated as self-sufficient. I think that the concept of enactment, by combining ontology and epistemology, makes people more sensitive to the hermeneutic quality of organizational life. And by hermeneutic quality I do not mean that the idea of interpretation or interpretation systems is closer to the truth than are the ideas of principal-agent contracts or differential survival within populations. I mean instead that reciprocal defining is the infrastructure of organizing, and that we see this root act more clearly in enactment than we do anywhere else. But surely the least productive way to see and say anything important about organizations is to partition the world arbitrarily into separate macro and micro domains, and then plead with so-called meso theorists to save us from the folly of our ways and reunite us.

Blind Spots in Enactment While enactment addresses several themes that are elided in mainstream theories, it suffers from its own elisions. Remediation of these shortcomings constitutes an agenda for further elaboration. The concept of enactment provides a suitable vocabulary to discuss agency in the sense of acting. But enactment is silent on the more organizationally crucial meaning of agency as acting for or acting on behalf of. It is the very fact of enacting on behalf of or for, or in the name of that lends sufficient force to action that it is able to reshape circumstances. Pure agency, at least in organizing, may not be forceful enough to enact much of anything. The concept of enactment, although collective in spirit, tends to be individualistic in execution. For example, frequent references to self-justification, self-fulfilling prophecies, and identity rather than reputation do not preclude collective referents, but they certainly do not encourage them, either. Attempts to work out behaviorally informed mechanisms for collective intelligence (e.g. Weick and Roberts, 1993; Hutchins, 1995; Klimoski and Mohammed, 1994; Klein, 1998; Taylor and Van Every, 2000) decouple the concept of enactment from its more individualistic origins and show how groups and teams act their way into shared meaning. These are moves in the right direction.

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The concept of enactment is incomplete because there is almost no discussion of mediation or of chains of enactment. Instead, the standard scenario is one in which there is an actor, an action, an ecological change, and an unanticipated consequence for the actor. It is less typical to find enactment described as a series of actions, spread across time and space and conversations, that gradually transform something relatively safe into something quite dangerous (e.g. Vaughan, 1996, on the continued normalization of deviations that foreshadowed the Challenger disaster). This imbalance, however, seems to be undergoing a change. The increasingly influential body of work on the antecedents of organizational accidents (e.g. Perrow, 1984; Reason, 1997; Turner and Pidgeon, 1997; Weick et al., 1999) has, as its signature, tales of distributed, cumulative enactment of increasingly unsafe conditions that eventually claim the reputations, if not the bodies, of the enactors. Recent analysis of latent and active systemic causes for adverse medical events (Kohn et al, 1999) seem to illustrate a serious attempt to understand mediated enactments rather than the more simplistic direct enactments that seem to be the last and most proximal and most visible actions that alter circumstances. Many discussions of enactment have little to say about the stuff of organization, by which I mean the technology, artifacts, and other material forms that are so important to people like Latour and Czarniawska. That omission is surprising, because the notion of enactment frequently draws its inspiration from the sensemaking recipe “How can I know what I think until I see what I say?” The only way one can see what one says, taken literally, is to read what one has written. Writing and editing and reading are major pastimes in organizational life that enact prominent environments. And yet they are invisible in many discussions of enactment. This omission is potentially serious. It is possible that the main reason environments seem so amenable to enactment is that they have been stripped clean of any technology that would impede it. The problem is not so much that the environment is loosely coupled. The problem is that it is empty. If the environment is empty then it is not surprising that people are able to enact the conditions that in turn enact them. What could interfere with the process? Or deflect it? A subtle blind spot in discussions of enactment is the implication that when one person enacts an environment there are no competing enactors or enactments. Conflict is nonexistent in many treatments of enactment. This makes it tough to use the concept to make sense of politicized organizations. In a world of politics, the power to make an enactment stick is often the goal that people strive for rather than the means they employ to reach some less self-centered outcome. And in a world of politics, hybrid enactments comprised of compromise should be the rule. And compromised enactments should produce fragmented environments that produce new puzzles for sensemaking. Taylor and Van Every (2000: 245), in their important communication-centered theory of organization, criticize the enactment formulation for its singular focus on the environment. They argue that “the enactment of the environment is merely incidental to the most fundamental enactment of all, that of the organization itself ” (p. 245). There have been fleeting references to enacted organizations throughout this chapter and articulation of assumptions that make it easier to incorporate it (e.g. discussion of the hermeneutics of enactment, viewing discourse as agency). Nevertheless, if enactment consists of some form of seeing what one says in order to know what one thinks,

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then it remains focused on the thinking rather than the thinker. Seeing what one has said and is capable of saying, and inferring what one must have thought, are defining acts. They attract others or repulse them. They are easy or difficult to share. They resonate and organize or prove to be senseless and disorganize. Social life is the ground from which enactments emerge. How can we know who we are until we see what we do and what we face? Imprecise or not, that seems like an elaboration worth attempting. Finally, while the problem is not unique to the enactment formulation, it is still tough to be precise about what is meant by “action.” Part of the problem is that people are seldom in the state of not acting. This means that enactment may be more about redirection of a unit that is already acting than about getting the unit in motion in the first place. The theoretical problem then shifts to the specification of relationships, conversations, and contexts that interrupt, override, and redirect. Enactment, in this view, occurs concurrent with breaches, surprises, the unexpected, and events that interrupt routine responding (Weick, 1995: chapter 4). Enactment may force the breaching. Or it may respond to breaching. In either case enactment would be guided by goals and intentions associated with the breach. And yet most of the examples of enactment cited earlier seem to have consisted of routine actions such as diagnosing, ordering, merging, downsizing that gradually breached the system routines of others and produced unanticipated consequences that eventually interrupted the original actors and became their environment. Acts spread across time and space and teams and hierarchical levels were the rule in the examples of enactment. At this point in time, enactment may derive its value from its stubborn nudging of theorists to be clearer about what circumstances people are thrown into and clearer about what people do when these circumstances are uncertain. People turn to one another in such conditions, which means that their intelligence lies between them in relationships and what those relationships will allow and not in individual heads. Enactment argues that people act in order to replace uncertainty with meaning. These actions in search of meaning spin off unanticipated consequences, and we are reminded yet again that such consequences are a constant in organizational life. Enactment directs attention earlier in time to the “innocent” acts of sensemaking that set in motion constraints that have the potential to enlarge and consume system resources and attention. Enactment serves as a reminder that detecting and managing these latent conditions, and the consequences that are flowing from them, is a recurrent task. Because the task recurs, the organization that performs the task must itself be reaccomplished. And, in the reaccomplishing, people relate in ways that are more or less effective for updating their sense of what is occurring and for spotting and managing the unexpected. Hence the centrality of organizing as a focus for organizational theory. Hence the centrality of sensemaking as the activity that smoothes over or singles out unexpected events. And, hence, the suspicion of formulations in organizational theory that talk mostly about permanent structures, routine responding, passive sensing, clear-cut options, focused strategies, munificent environments, and decisive action. There are better vocabularies available and they tend to be dominated by verbs. There are four verbs in the sensemaking recipe: to know, to think, to see, and to say. Organizing around those four verbs surely has at least as much impact as does the fluttering of the wings of a butterfly in the Amazon.

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References Abelson, R. P., Aronson, E., McGuire, W. J., Newcomb, T. M., Rosenberg, M. J., and Tannenbaum, P. H. (1968) Theories of Cognitive Consistency: A Sourcebook. Chicago: Rand McNally. Abolafia, M. Y., and Kilduff, M. (1988) “Enacting market crisis: the social construction of a speculative bubble,” Administrative Science Quarterly, 33: 177–93. Boden, D. (1994) The Business of Talk. Cambridge: Polity Press. Eco, U. (1999) Kant and the Platypus: Essays on Language and Cognition. New York: Harcourt Brace. Garfinkel, H. (1967) Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall. Heidegger, M. (1962) Being and Time. New York: Harper & Row. Hutchins, E. (1995) Cognition in the Wild. Cambridge, MA: MIT Press. Klein, G. (1998) Sources of Power. Cambridge, MA: MIT Press. Klimoski, R., and Mohammed, S. (1994) “Team mental model: construct or metaphor?” Journal of Management, 20: 403–37. Kohn, L. T., Corrigan, J. M., and Donaldson, M. S., eds (1999) To err is Human: Building a safer Health System. Washington, DC: National Academy of Science. Latour, B. (1988) Science in Action. Cambridge, MA: Harvard University Press. Louis, M. R., and Sutton, R. I. (1991) “Switching cognitive gears: from habits of mind to active thinking,” Human Relations, 44: 55–76. Maclntyre, A. (1967) “Existentialism,” in P. Edwards (ed.) The Encyclopedia of Philosophy III–IV, pp. 147–54. New York: Macmillan. Mandler, G. (1982) “Stress and thought processes,” in L. Goldenberger and S. Breznitz (eds) Handbook of Stress, pp. 88–104. New York: Free Press. Nicholson, N. (1995) “Enactment,” in N. Nicholson (ed.) Blackwell Encyclopedic Dictionary of Organizational Behavior, pp. 155–6. Cambridge, MA: Blackwell. Perrow, C. (1984) Normal Accidents. New York: Basic Books. Reason, J. (1997) Managing the Risks of Organizational Accidents. Aldershot: Ashgate. Taylor, J. R., and Van Every, E. J. (2000) The Emergent Organization: Communication as its Site and Surface. Mahwah, NJ: Erlbaum. Turner, B. A., and Pidgeon, N. F. (1997) Man-made Disasters, second edition. Oxford: Butterworth-Heinemann. Vaughan, D. (1996) The Challenger Launch Decision. Chicago: University of Chicago Press. Weick, K. E. (1995) Sensemaking in Organizations. Thousand Oaks, CA: Sage. Weick, K. E., and Roberts, K. H. (1993) “Collective mind in organizations: heedful interrelating on flight decks,” Administrative Science Quarterly, 38: 357–81. Weick, K. E., Sutcliffe, K. M., and Obstfeld, D. (1999) “Organizing for high reliability: processes of collective mindfulness,” in B. Staw and R. Sutton (eds) Research in Organizational Behavior XXI, pp. 81–123. Greenwich, CT: JAI Press.

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12 Positive Organizing and Organizational Tragedy Setting the Scene Throughout this book, we generalize from smaller scale processes to larger scale processes and from events on the darker side to those on the brighter side. These generalizations are built from a combination of similarities in process and the assumption of continuity across levels of analysis. We examine presumptive organizational tragedies and find patterns that influence whether an unfolding event will have positive or negative outcomes. The patterns we find in tragedies are of interest in the context of the burgeoning field of positive organizational scholarship (POS). For example, a section in the document titled ‘The Essence of Positive Organizational Scholarship’ published by the Center for Positive Organizational Scholarship at the University of Michigan states: The positive approach does not ignore, deny, or denigrate the negative phenomena and problems found in organizations. It seeks, instead, to study organizations and organizational contexts typified by appreciation, collaboration, vitality, and fulfillment, where creating abundance and human well-being are key indicators of success. It seeks to understand what represents the best of the human condition.1

In this chapter we take a closer look at the construction of contexts where excellence can be observed despite conditions that are ominous and consequential. Again, we anchor the discussion in impermanence, ceaseless change, sensemaking, and action. Actions, as Paget (1988) suggests, are moving, evolving, and becoming as time passes. As the evolving gets farther along, it often becomes easier to see the extent to which the action is succeeding or failing. Late in the evolution it is easy to say, as one looks back, ‘if I knew back then what I know now, I would have acted differently, but I didn’t know this back then and therefore I didn’t act differently.’ Thus, even though actions start neutral, they generate positive or negative chains of events depending on the ways in which turning points are managed. In this chapter, I argue that there are at least three patterns of organizing that affect what happens at these turning points. These three include respectful interaction at the micro level, heedful interrelating at the meso level, and mindful organizing at the macro level. Breakdowns within each pattern predispose toward negative outcomes whereas consolidation within each pattern

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predisposes toward positive outcomes. In addition, practices associated with each level also steer events toward a positive or negative outcome. Two practices in particular, one structural and one processual, seem especially important, judging from studies of wildland firefighting teams. First, the practice of creating a structure that consists of lookouts, communication, escape routes, and safety zones (LCES) aids early detection of the unexpected and safe retreat when the unexpected escalates violently. Second, the practice of making sense in public by addressing the situation, task, intent, concerns, and by calibrating that sense (STICC), shapes both what people expect when they engage a volatile event and what cues they use to alert them that their expectations need to be revised. Together, these three forms of interaction and two practices provide a foundation, grounded in anticipations of collapse, that increase the odds of resilient continuation and high performance. The argument in Chapter 12 expands both the set of contexts in which vitality and fulfillment occur and the variety of actions that indicate abundance, well-being, and success. No matter how much any positive moment reflects vitality, thriving, flourishing, and fulfillment, that same moment of accomplishment is also a moment of complication. As John Dewey’s puts it, each achievement creates: . . . a new distribution of energies which have henceforth to be employed in ways for which past experience gives no exact instruction. . . . From the side of what has gone before achievement settles something. From the side of what comes after, it complicates, introducing new problems and unsettling factors. There is something pitifully juvenile in the idea that ‘evolution,’ progress, means a definite amount of accomplishment which will forever stay done, and which by an exact amount lessens the amount still to be done, disposing once and for all of just so many perplexities and advancing us just that much closer to a final stable and unperplexed goal (Dewey, 1922, p. 285).

Accomplishments are transient, and impermanence complicates. It is this emerging complication, consisting of both the positive and the negative, that creates a crucial moment of interpretation. Moments of thriving and flourishing are invariably associated with problems. Again John Dewey states: ‘(I)nstruction in what to do next can never come from an infinite goal, which for us is bound to be empty. It can be derived only from study of the deficiencies, irregularities and possibilities of the actual situation.’ When we see that the mark of a positive outcome is an increase in complexity, then ‘failure loses some of its fatality and suffering yields fruit of instruction not of bitterness’ (Dewey, 1922, pp. 288–289).

Note 1 http://www.bus.umich.edu/Positive/PDF/POS%20Essence.pdf

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Positive Organizing and Organizational Tragedy Karl E. Weick The following article was published as Chapter 5 in Kim S. Cameron, Jane E. Dutton, and Robert E .Quinn (Eds), Positive Organizational Scholarship: Foundations of a New Discipline, Berrett-Koehler, 2003, pp. 66–80. Reprinted with permission.

Organizational disasters such as Tenerife (Weick, 1993), Challenger (Vaughan, 1996), Bhopal (Shrivastava, 1987), Exxon Valdez (Roberts & Moore, 1993), and Mann Gulch (Weick, 1993) are tragic because they destroy lives, reputations, firms, resources, legitimacy, jobs, trust, confidence, and illusions of control. This dark picture is sometimes relieved by small pockets of positivity that take the form of heroes who rise to the occasion in a disaster or of lessons learned so that people don’t die in vain. But are there larger implications for positive organizing in these events? If organizational life is a million accidents waiting to happen, do we credit positive organizing for the fact that 999,999 of those accidents don’t happen? If issues can turn into problems, which can then turn into crises, does positive organizing occur when issues are kept from enlarging into problems and crises? If systems tend toward disorder and entropy, and if entropy and disorder are dangerous, then do we credit positive organizing when order is preserved, chaos is reversed, and near misses get no worse? If any disaster could have been worse, does that mean that whatever kept it from being worse is an instance of positive organizing? Questions such as these lie behind the following discussion and animate it.

A Perspective on Positivity Initial Assumptions The arguments developed in this chapter are based on the assumptions that mistakes and errors are inevitable in organized life, that actions become mistaken but don’t start out mistaken, and that positivity in organizations occurs relative to mistakes that could have been made rather than relative to healthy functioning. Exceptional action in the context of fragile organizing consists of efforts that keep the action going in the face of breakdown as well as efforts that allow the journey to continue when maps are lost. In the eyes of some, assumptions like this exemplify a rhetoric of deficit. But I want to suggest a different interpretation. I want to propose that what may look like a rhetoric of deficit is actually something quite different if you pay closer attention to just how complex and fragile and entropic and unknowable the organizing of people and technology can be. When people organize, they enact vulnerability as well as social support (Weick, 1990) and they trigger social loafing as well as collective energy (Snook, 2000). Positive organizational scholarship (POS) often assumes the existence

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of a stable, continuing organization as the platform on which and against which and with which positive moments are built. That assumption of a stable platform may bear rethinking. Studies of organizational failure suggest that when people organize, they enact a platform that is more vulnerable than it looks and is often audited more rudilessly by unexpected events than anyone anticipated. “The ability to deal with a crisis situation is largely dependent on the structures that have been developed before the chaos arrives. The event can in some ways be considered as an abrupt and brutal audit: at a moment’s notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront” (Lagadec, 1993: 54). If organizing is vulnerable, then positivity tends to be expressed in acts that contain and repair that vulnerability as well as in acts that transcend that vulnerability.

Positive Organizing If we adopt this alternative set of assumptions about vulnerable organizing, then notice what that does to a continuum of positivity anchord by “effective” and “ineffective”. It shifts the definition of “normal” away from labels such as “effective,” “efficient,” “reliable,” “ethical,” “helpful,” and “coping,” toward the left-hand set of labels that include “errorprone,” “ineffective,” “harmful,” and “threat-rigidity.” If the baseline for normal organizing shifts toward the left, then prevention of accidents, reliable performance, recovery from a near miss, and managing the unexpected now become meaningful outcroppings of positive organizing. While those actions are seldom labeled with words such as “virtuous,” “generous,” “abundant,” “flourishing,” and “empowering,” that does not mean that they are any less extraordinary or fulfilling if we pay closer attention to the context within which they unfold. Part of that context consists of latent errors that are being incubated (Reason, 1997), as well as subcultures focused on issues other than safety, people with diverse experience regarding fallibility, and problems that compete for scarce attention from overloaded workers.

The Juxtaposition of Positivity and Tragedy The purpose of this chapter, then, is to reexamine patterns of organizing that have become visible in studies of organizational failure and to rethink their meaning when those patterns are viewed through the lens of emerging perspectives gathered under the rubric of positive organizational studies. This reexamination is tougher than it looks, since many observers react to organizational failures such as “excess fatalities” in open heart surgery on infants (Weick & Sutcliffe, 2001) with a mixture of despair, anger, blame, suspicion, disbelief, and the resolve to reform. Noticeably lacking, at least at first, is nuanced perception, and especially any comprehension that there might be positive implications buried somewhere in the tragedies. Nevertheless, nuance and differentiation and learning are possible. The trick is to overcome hindsight bias, and to prevent a negative evaluation of the outcomes (or a positive evaluation) from coloring the search backward for conditions that are consistent with that outcome (Starbuck & Milliken, 1988). For example, it is easy to move backward analytically from the

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outcome of thirteen fatalities in the Mann Gulch wildland fire, and spot earlier negative conditions of miscommunication, inexperience, and contested leadership. It is harder to break that mental set and notice as well that the leader updated his strategy three separate times to fit changing conditions, that a life-saving solution was enacted at the last possible moment, and that having a close friend near at hand saved two lives. POS is about seeing differently. The value of seeing differently is put to a test in the context of tragedy. Rethinking failures in organizing is also tougher than it looks because of the limits of language. Scholars of POS struggle to find compelling words that capture positive deviance. Scholars of reliability and failure struggle to find compelling words that capture the complex experience of unintended consequences that develop and unfold unpredictably in an unknowable world. To call this unfolding either “negative” or “positive” is to miss much of its deep structure. Marianne Paget (1988) made a similar point in the context of medical mistakes: “The language of mistakes is a limited language, for a mistake contains always the implicit structure of right and wrong. Such a structure of meaning fails to capture the many possible rights and wrongs, the many efficacious and inefficacious turns in human experience that sediment out in time as neither right nor wrong, or as both right and wrong” (p. 81). “The chasm into which discourse stumbles, then, when the language of mistakes is used, suggests the denial of moments of randomness, unguidedness, and accidentalness in human conduct” (p. 149). Paget’s observations are interesting in their implication that when we argue over the relative usefulness of positive versus negative perspectives, and over the meaning of illness, health, and fitness, we may miss entirely that portion of organizational life that is attributable to chance, luck, randomness, accidents, and fortuitous timing

Chapter Overview In the remainder of this chapter I juxtapose positivity and tragedy in two ways. First, I suggest that nonobvious outcroppings of positivity occur in the context of mistakes, contradictions, disorganization, and defenses. Second, I examine core values and designs at multiple levels of analysis that enable people to transcend vulnerable organizing. These designs are described as respectful interaction, heedful interrelating, and mindful organizing. Together they constitute the vision of positive organizing that emerges when one starts from descriptions of organizational tragedy rather than from descriptions of organizational health.

Organizing in an Unknowable World When people organize, they often create a context where people are thrown into equivocal streams of events that can be interrupted by unexpected events. Actions of recovery, bricolage, repair, updating, making do, and improvisation tend to dominate in such settings. Positive organizing, therefore, occurs concurrent with wading into uncertain citcumstances and dealing with whatever unexpected events occur using tools that themselves were unexpected recombinations of existing repertoires. The interface

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between positivity and tragedy is especially visible in the phenomena of mistakes, contradictory adaptive tendencies, the threat of disorganization, and organizational defenses. We examine these four interfaces briefly to illustrate commonplace features of organizing that shape positive and negative outcomes.

Mistakes Mistakes are inevitable in organizing, which means that freedom from mistakes is not the signature of positive organizing. As Paget (1993) said in her work on medical error, “Physicians are ‘expert’ in a work that proceeds by trial and error” (p. 15). Positive organizing in this context is partly a matter of accepting the existence of error and fallibility, and partly a matter of being sensitive to mistakes that must be avoided and working to contain those that do occur. This wariness extends even to conspicuous positive moments such as optimism, hope, and encouragement. In the context of work that proceeds by trial and error, hope and optimism are seen as desirable but also as a potential source of Type 1 errors (optimists accept the null hypothesis that nothing dangerous is happening when the true state of nature is that something dangerous is developing). Concern over Type 1 errors of optimism is evident in Landau and Chisholm’s discussion (1995) of “the arrogance of optimism” and in March, Sproull, and Tamuz’s concern (1991) that a near miss interpreted positively as safety in the guise of danger may well reflect just the opposite, danger in the guise of safety. To understand mistakes is to understand potential common ground between positivity and tragedy. A plausible common assumption is that people act their way into meaning. This means that in their early stages, and for some stretch of time, actions are becoming meaningful rather than unfolding with clear-cut meaning right from the start. In these moments of uncertainty about what the acting will have become, there is the possibility that the action can become either positive or negative. Ernst Mach saw this in 1905 when he wrote, “Knowledge and error flow from the same mental sources, only success can tell the one from the other” (Rasmussen, 2000: 32). David Hume saw the same thing earlier when he said, “tis impossible to separate the chance of good from the risk of ill” (Sharpe & Faden, 1998: 1). This open-ended quality of unfolding action is at the heart of Marianne Paget’s analysis (1988) of medical mistakes: Mistakes are known only after they are made; that is to say, they are known now rather than then “Then” is a fulcrum of meaning. . . . (as in the phrase) “1 didn’t think it was a mistake then.” . . . In these phrases “then” does not just mean then as opposed to now. It means then when an act or sequence of acts was becoming, emerging in time. . . . A mistake follows an act. It identifies an act in its completion. It names it. An act, however, is not a mistake; it becomes mistaken. . . . As it is unfolding, it is not becoming a mistake at all. It is moving and evolving in time. We take the wrong path as a cognition only after already having taken the wrong path in fact. Reflection returns to the act of becoming mistaken and embraces it with hindsight, (pp. 44–45)

As an action unfolds it may turn out to be either positive or negative since either outcome emerges from a common pathway. Jens Rasmussen, reflecting on the issue of a common pathway, argued that “rather than studying errors we ought to focus on

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strategies to recover from unsuccessful explorations” (2000: 33). If unfolding action remains equivocal for some period, and if it could eventually be more or less successful, then what does this mean for positive organizing? One possibility is that if unfolding actions are equivocal, then the likelihood of positive outcomes should increase for those actors who are able to project the unfolding act in imagination and use future perfect thinking (Weick, 1979: 194–200) to anticipate what it will have produced, and make corrections here and now. Other possibilities implied by equivocal unfolding are that positive organizing means persisting in anticipation that a positive self-fulfilling prophecy will have been triggered. It may mean publicizing one’s intentions so that others can spot early warning signs of failure, signs that the committed actor might miss. It may mean building capability for recovery as well as directing a greater proportion of mindful attention to near-term details and the health of the process rather than solely to positive outcomes that are anticipated.

Wisdom Tragedies have an intimate relationship to the otherwise positive property of wisdom and to its expression in the form of an attitude of wisdom (Weick 1998). The concept of wisdom that seems to work best in discussions of organizing to meet the unexpected is John Meacham’s suggestion (1990) that “the essence of wisdom . . . lies not in what is known but rather in the manner in which that knowledge is held and in how that knowledge is put to use. To be wise is not to know particular facts but to know without excessive confidence or excessive cautiousness. . . . [T]o both accumulate knowledge while remaining suspicious of it, and recognizing that much remains unknown, is to be wise” (pp. 185, 187). Thus, “the essence of wisdom is in knowing that one does not know, in the appreciation that knowledge is fallible, in the balance between knowing and doubting” (p. 210). Wisdom is a quality of thought that is animated by a dialectic in which the more one knows, the more one realizes the extent of what one does not know. Negative organizing can undermine wisdom in at least two ways. First, negative organizing occurs when ignorance is discounted. The discounting of ignorance is associated with acts of hubris and arrogance, with structures that encourage the fallacy of centrality (Westrum, 1982), and with perceptions of infallibility. To act with wisdom is to accept ignorance, to be wary of simplification (Weick & Sutcliffe, 2001: 11–12, 59–62), and to be more attentive to operations in the here and now (Weick & Sutcliffe, 2001: 13–14,62–65). Second, negative organizing also undermines wisdom when knowledge rather than ignorance is discounted, as when people withhold key information and fail to speak up. To restore wisdom and to reconcile knowledge and ignorance, people need to take seriously a nonobvious maxim for positivity: “ambivalence is the optimal compromise.” Although this formulation originated with William James, it has been elaborated by Donald Campbell (1990): The presence in moral codes, proverb sets, and motivational systems of opposing values is often interpreted as discrediting the value system by showing its logical inconsistency. This is a misapplication of logic, and in multiple-contingency environments, the

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joint presence of opposing tendencies has a functional survival value. Where each of two opposing tendencies has survival relevance, the biological solution seems to be an ambivalent alternation of expressions of each rather than the consistent expression of an intermediate motivational state. Ambivalence, rather than averaging, seems the optimal compromise, (p, 45)

Ambivalence as a virtue can be illustrated in the context of medical care. In medicine, responses such as risk and caution, intimacy and detachment, aggressiveness and surrender, repetition and improvisation, intuition and deliberation, and curiosity and timidity are opposing tendencies, each of which at some time may be valuable given slight alterations in the conditions of the individual medical case (e.g., Benner, HooperKyriakidis, & Stannard, 1999). A system that is able to preserve opposing actions rather than intermediate actions retains more adaptability.

Entropy Entropy is an older term used in the earlier theories of organization (e.g., Katz & Kahn, 1978) to generalize the second law of thermodynamics to human social systems. It was argued that systems run down and become disorganized unless they import energy, creativity, and complexity. Originally it was suspected that a system had to be open to offset entropy, but later it was suggested that a well-functioning organization might overcome entropy without importing energy (Kuhn & Beam, 1982: 24). Notice the missing combination in all of this. The literature describes mostly systems that are closed/entropic, closed/nonentropic, and open/nonentropic, but largely neglects systems that are open/entropic. That oversight is due largely to the prevailing idea that entropy is a liability specific to systems closed off from the environment (Scott, 1998: 90). Open systems supposedly are protected from this liability by their continuous infusion of new resources and new complexity that stimulate reorganization. In light of newer work on organizing for high reliability, we now see that open systems can degrade. Specifically, studies of tragedy and reliability have begun to show that order is dear, chaos is cheap, coordination is precarious, reciprocal interdependence is tough, pooled interdependence is easy, mutuality is shaky, and maintenance and caring are imperative. Furthermore, open systems are just as susceptible to spontaneous disorganizing as are closed systems. Thus, coordination and communication are fragile whether they are embedded in open or closed systems. There is a clear POS twist in all of this. Discussions of organizational reliability turn out to be discussions of the foundations of organizing. To be reliable is to maintain order and organization in the face of tendencies toward disorder. In that sense reliability is organization. And it is an accomplishment as well. People fail to see the “miracle” in all of this because they assume that organized action is natural, disorganized action is not. If we reverse that assumption and pay more attention to chaos, then POS becomes synonymous with actions that hold systems together. Reliable organizing is positive organizing because it enables events such as caregiving (Gordon, Benner, & Noddings, 1996) to happen again and again through continuous adjustment to changing circumstances (Weick 1987).

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Defenses Perhaps the most influential formulation within the literature of organizational accidents is James Reason’s “swiss cheese model” (1997). The basic idea is that there are hazards that threaten organizations, defenses that separate damaging hazards from vulnerable people and assets, and losses that are produced when the defenses are breached by the hazards. Defenses take a variety of forms including awareness of hazards, routines for safe operations, warnings of danger, recovery from deviant functioning, barriers that block hazards, containment of hazards that escape barriers, and escape routes if containment fails (p. 7). Each defense is represented as a slice of swiss cheese and the weaknesses in each defense are represented by the holes in each slice. The holes represent latent errors in the defense due to things like poor design, gaps in supervision, and training shortfalls. “The necessary condition for an organizational accident is the rare conjunction of a set of holes in successive defences, allowing hazards to come into damaging contact with people and assets” (p. 11). Holes may line up either when people on the front line commit an active error of disabling some defenses, as happened at Chernobyl (Meshkati, 1991), or when they make an active error in the form of a wrong diagnosis, as happened at Bhopal (Shrivastava, 1987). The crucial point is that accidents are systemic. They are often blamed on operators, which all too often merely conceals the incompetence at the top that produced the latent conditions in the first place. Now comes the twist that involves positive organizing. First, positive organizing could create stronger defenses with fewer holes, through activities that strengthen governance, establish informed cultures, equalize power, encourage the detection of vulnerability, and so on. Second, positive organizing could support frontline operators more fully so that they make fewer active errors that allow gaps in defenses to line up. And third, positive organizing could encourage some of the more positive defenses such as understanding, awareness, guidance, discretion, transparency, and resilience, and discourage some of the more negative defenses such as control, authority favored over expertise, dense rules, inflexible routines, increased surveillance, and automated safety features.

Macrocosms of Wisdom Positive organizing is about enabling people collectively to wade into a rich unknowable world and build rich experience. Such an intention is more likely to be realized if people are organized in ways that enhance attention, resilience, wisdom, and reliability. Studies of organizational tragedy suggest possible organizational designs that further these intentions. If we take account of levels of analysis, then positive organizing takes the form of respectful interaction at the micro level, heedful interrelating at the intergroup level, and mindful organizing at the organizational level. These designs are often operationalized in daily activity by wise structures that hold people together (summarized by the acronym LCES—lookouts, communication links, escape routes, and safety zones) and by wise guidance that helps people make sense of what is happening (summarized by the acronym STICC—situation, task, intent, concerns, and calibration). These three patterns are reviewed briefly.

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Respectful Interaction Campbell (1990) argued that when people face the common dilemma where their private views are in conflict with a majority view, this threatens social life. If individuals defer to the majority, they withhold potentially important information. If they oppose the majority, they withhold commitment and threaten group viability. And either choice, taken to the extreme, endangers the self-respect of the person caught in the middle, who winds up being either a spineless conformist or an arrogant deviant. Campbell suggests that this microcosm of social life, recapitulated in the Asch (1952) conformity experiment, requires a complex ongoing resolution composed of three elements: People need to trust the reports of others and be willing to base their beliefs and actions on them. People have to be trustworthy observers and report honestly so that others can use their observations in coming to valid beliefs. People have to maintain self-respect, which means they have to respect their own perceptions and beliefs, and seek to integrate them with the reports of others without belittling either the others or themselves. Whenever one or more of these three components are missing, an adverse event is more likely. Consider wildland firefighting (Weick, 1993), an activity with many features found in most organizational settings. In firefighting, as in much of collective life, people confront surprise, high stakes, the need to do something fast while the problem is small, variable experience, reactive choices, strong expectations, and authorities who often lack expertise and data. Wildland fire disasters illustrate the collapse of respectful interaction. The Mann Gulch disaster (Maclean, 1992) in 1949 was mainly a breakdown in trust. People failed to believe that foreman Wagner Dodge’s escape fire would save them, they tried to outrun the fire on their own, and perished. The South Canyon disaster (Maclean, 1999) in 1994, which killed fourteen, was mainly a breakdown in honesty and trustworthy reporting. People had serious doubts about who was in charge, where the escape routes were located, and why they were clearing brush downhill, which is a dangerous operation. None of these doubts were voiced publicly, which meant that crew members who were worried individually assumed that their own concerns were unshared and unfounded. The Battlement fire (Maclean, 1999: 179–183) in 1976 was a breakdown in self-respect. A four-man crew disregarded their own doubts about moving down into a gulch to fight fire late in the afternoon, they accepted their supervisor’s assessment that it was safe to do so, and three of the four men perished when the fire exploded shortly after they entered the gulch. Respectful interaction at the micro level tends to be expressed in structures that encourage wise action and wise sensemaking. Positive outcomes are more likely if people take a clue from effective wildland firefighting crews, and enact a minimal structure that consists of lookouts, communication links, escape routes (at least two), and safety zones that are known to everyone (Gleason, 1991). What’s interesting about an LCES design is that it encourages wise action by blending knowledge and doubt. Deployment of lookouts and communication implies that a group knows what is happening and how the local conditions are related to the big picture. Attention to escape routes and safety

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zones, however, implies that what the group knows may be incomplete and that this potential ignorance needs to be translated into contingency plans. The net result is that the group is simultaneously confident and cautious. Escape routes and safety zones preclude hubris. Lookouts and communication links preclude timidity. Taken together, these four conditions enact high-variety ambivalence that is better suited to deal with highvariety disturbances. Positive outcomes are also more likely if leaders engage in a process of public sensemaking that covers five issues: here’s the situation we face; here’s what I think we should do; here’s why we should do that; here’s what we should keep our eyes on because if that changes we’re in a new situation; now talk to me. The leader who explains the situation, the task, the intent, the concerns, and then asks for calibration, gives people a common frame that they can update and amend, a framework that fosters resiliency and points the way to recovery. This format is increasingly being used to brief teams who face crisis conditions. Generalized to other settings, people are more likely to experience well-being at work when that work occurs in a wise LCES structure that accepts both knowledge and ignorance, and when that knowledge is made public by a STICC protocol that makes the knowledge available for discussion and updating.

Heedful Interrelating In the first Institute of Medicine report on medical errors, titled “To Err Is Human” (Kohn, Corrigan, & Donaldson, 2000), medical care was described as having some resemblance to flight operations on nuclear aircraft carriers: People are quick to point out that health care is very different from a manufacturing process, mostly because of the huge variability in patients and circumstances, the need to adapt processes quickly, the rapidly changing knowledge base, and the importance of highly trained professionals who must use expert judgment in dynamic settings. Though not a biological system, the performance of crews and flight personnel on aircraft carriers provides an example that has features that are closer to those in health care environments than manufacturing . . .. [P]eacetime flight operations on aircraft carriers [are] an example of organizational performance requiring nearly continuous operational reliability despite complex patterns of interrelated activates among many people. These activities cannot be fully mapped out beforehand because of changes in weather (e.g. wind direction and strength), sea conditions, time of day and visibility, returning aircraft arrivals, and so forth. Yet, surprisingly, generally mapped out sequences can be carried out with very high reliability in novel situations using improvisation and adaptation and personnel who are highly trained but not highly educated, (pp. 160–161)

In both healthcare and flight operations there is high interdependence in a situation of continuous change. Positive organizing that is capable of handling unexpected disturbances comes from “generally mapped out sequences” enacted by “highly trained” people who are jointly capable of “improvisation” and “adaptation.” One way to describe this joint capability is the concept of “heedful interrelating.” Weick and Roberts (1993) found that flight operations on carriers with fewer serious accidents were tied together by a pattern of contributions, representations, and

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subordination that were enacted with care, alertness, and wariness. Interrelated contributions functioned something like a mind, and flight operations handled disturbances with more or less intelligence depending on how heedfully each of the three properties were interrelated. The first property of heedful interrelating is that people see their work as a contribution to a system, not as a stand-alone activity. People act as if they are “under the direction of a single organizing center” (Asch, 1952: 251) even though no such center exists. When people act as if their action contributes to the creation and functioning of something, then this “something” begins to materialize. This is the sense in which positive organizing functions like a self-fulfilling prophecy. The second property of heedful interrelating is representation and involves visualizing the meshed contributions. Asch describes representation this way: “There are group actions that are possible only when each participant has a representation that includes the action of others and their relations. The respective actions converge relevantly, assist and supplement each other only when the joint situation is represented in each and when the representations are structurally similar” (1952: 251–252). If people produce contributions that enact a system, then they need to see what they have produced in order to protect it and improve it. That is the role of representation. And finally, having enacted and represented a system, people need to take it seriously. That’s what is accomplished by the third property of heedful interrelating, subordination. Subordination refers to the fact that once contributions and representations “bring group facts into existence and produce the phenomenal solidity of group process” (Asch, 1952: 252), people treat the system as their referent, ask what it needs, and act in ways intended to meet those needs. Subordination points to the referent that people have in mind when they interrelate. Low subordination occurs when people work to rule, partition the world into “my job” and “not my job,” withhold tacit knowledge that might suggest novel interpretations, act solely on the basis of self-interest, and prefer talking over listening. The referent under such conditions is solo action, not mutual action, and if things go wrong, repairs are designed more to save face than to save the situation.

Mindful Organizing At the organizational level of analysis, susceptibility to tragedy seems to be determined in part by how organizations deal with failure, simplification, operations, resilience, and expertise. Those organizations that spend more time examining failure as a window on the health of the system, more time resisting the urge to simplify assumptions about the world, more time observing operations and their effects, more time developing resilience to manage unexpected events, and more time locating local expertise and creating a climate of deference to those experts, tend to be more reliable (Weick & Sutcliffe, 2001). Collectively these five processes enact rich awareness of discriminatory detail, wisdom, and continuing adjustments in the service of reliability. What is distinctive about mindful organizing is that there is a consistent effort to recapture detail. This organizational priority is much like an equivalent priority in many of the wisdom traditions that emphasize living in the here and now, being present, focusing on the moment,

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and being aware (Hadot, 1995; Morita, 1998; Suzuki, 2002). Positive organizing that facilitates being present in the moment enriches experience and pragmatically improves perception, alertness, and adaptation through efforts to refine and differentiate existing categories, create new categories, and detect subtle ways in which contexts vary and call for contingent responding. The five processes of mindful organizing are also important because they mobilize resources for sensemaking (Weick, 1995: 17–62), resources such as interaction and conversation (social), clear frames of reference (identity), relevant past experience (retrospect), neglected details in the current environment (cues), updating of impressions that have changed (ongoing), plausible stories of what could be happening (plausibility), and actions that clarify thinking (enactment). When these sensemaking resources are mobilized, people are better able to spot the significance of small, weak signals of danger implicit in the unexpected and to spot them earlier while it is still possible to do something about them.

Conclusion Throughout this chapter I have focused on the question of what positive organizing might consist of given the contexts of vulnerability that get quietly laid down when people organize. Repeatedly in these discussions, positivity and failing were juxtaposed. Those juxtapositions had at least two effects. First, previous actions that looked neutral or negative were seen as nonobvious outcroppings of positivity. Second, there was the implied suggestion that many of the most conspicuous examples of positive organizing are relatively rare and appear mostly after organizing breaks down. That being the case, pre-breakdown positivity, a form that is much more common and much less visible, may be a more crucial empirical site to develop POS than people realize. Throughout the chapter has been the implicit theme that failed organizing begins with an infrastructure that is initially neutral and can subsequently turn either positive or negative. While scholars of organizational failure show how these beginning stages can turn sour, scholars of positive organizing could show how these same initial stages can turn toward other outcomes. Throughout this chapter it has also been assumed that reliability is an accomplishment. To go through a day filled with a million accidents waiting to happen, and to find at the end of the day that they are still waiting to happen, is amazing. To produce a dull normal day in settings of high interactive complexity is a skilled achievement. To be able to claim that “things are pretty quiet” may mean that one has just accomplished an incredible piece of work. And finally, these studies of tragedy suggest that positive organizing consists in part of structures that encourage people to update and disengage when there is danger of entrapment, and of processes that encourage vigilant sensemaking. Both wisdom and humility are at the heart of these organizing devices. People who deploy a LCES structure basically acknowledge that they are both knowledgeable and ignorant of an unfolding event, and they underscore their ignorance by implementing lookouts, communication links, and escape routes to protect people against the limits of their understanding. People who make sense of a dynamic situation publicly by means of a STICC format, and

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then ask people to correct what they have heard, reaffirm that the group collectively may know more than they do, that the group will think better if it gets into motion and thinks while doing, and that strength in dynamic environments comes from an assurance that wariness and alertness are deployed reliably. If individual safety remains the one uncontested element in Maslow’s otherwise much criticized hierarchy of needs (1970), then it seems reasonable to argue that collective safety, both psychological and physical, is just as crucial for groups if they are to strive for virtue, extraordinary performance, and lives that are worth living. Enacting that safety is virtuous organizing.

Acknowledgment I am grateful to Kim Cameron, Kathleen Sutcliffe, Jane Dutton, and Tim Vogus for discussions that were helpful in the formulation of this chapter.

References Abernathy, C. M., and Hamm, R. M. (1995). Surgical Intuition. Philadelphia: Hanley and Belfus. Asch, S. E. (1952). Social Psychology. Englewood Cliffs, NJ: Prentice-Hall. Campbell, D. T. (1990). Asch’s moral epistemology for socially shared knowledge. In I. Rock (Ed.), The Legacy of Solomon Asch: Essays in Cognition and Social Psychology (pp. 39–52). Hillsdale, NJ: Erlbaum. Comte, A. (1983). Auguste Comte and Positivism: The Essential Writings. Chicago, IL: University of Chicago Press. Glass, D. C., and Singer, J. E. (1972). Urban Stress. New York: Academic. Gleason, P. (1991). LCES: a key to safety in the wildland fire environment. Fire Management Notes, 52(4), 9. Gordon, S., Benner, P., and Noddings, N. (Eds) (1996). Caregiving. Philadelphia, PA: University of Pennsylvania Press. Hadot, P. (1995). Philosophy as a Way of Life. Oxford, UK: Blackwell. Katz, D., and Kahn, R. L. (1978). The Social Psychology of Organizations (2nd ed.). New York: John Wiley & Sons, Inc. Kennedy, I. (2001). Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at Bristol Royal Infirmary 1984–1995. London: Her Majesty’s Stationer. Kohn, L. T., Corrigan, J. M., and Donaldson, M. S. (Eds) (2000). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy of Science. Landau, M., and Chisholm, D. (1995). The arrogance of optimism: notes on failure avoidance management. Journal of Contingencies and Crisis Management, 3, 67–80. Maclean, J. N. (1999). Fire on the Mountain. New York: William Morrow. Maclean, N. (1992). Young Men and Fire. Chicago, IL: University of Chicago Press. March, J. G., Sproull, L. S., and Tamuz, M. (1991). Learning from samples of one or fewer. Organization Science, 2, 1–13. Maslow, A. (1970). Motivation and Personality. New York: Harper & Row. Mintzberg, H. (1973). The Nature of Managerial Work. New York: Harper & Row. Morita, S. (1998). Morita Therapy and the True Nature of Anxiety-Based Disorders (shinkeishitsu). Albany: State University of New York.

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Paget, M. (1988). The Unity of Mistakes: A Phenomenological Interpretation of Medical Work. Philadelphia, PA: Temple University Press. Paget, M. A. (1993). A Complex Sorrow. Philadelphia: Temple University Press. Peters, T. J., and Waterman Jr, R. H. (1982). In Search of Excellence. New York: Harper & Row. Rasmussen, J. (2000). The concept of human error: is it useful for the design of safe systems in healthcare? In C. Vincent and B. De Mol (Eds), Safety in Medicine (pp. 31–48). Amsterdam: Pergamon. Reason, J. (1997). Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate. Roethlisberger, F. J. (1977). The Elusive Phenomena. Cambridge, MA: Harvard University Press. Roethlisberger, F. J. (1968). Man-In-Organization. Cambridge, MA: Belknap. Sharpe, V. A., and Faden, A. I. (1998). Medical Harm. Cambridge, UK: Cambridge University Press. Suzuki, S. (2002). Not Always So. New York: Harper Collins. Useem, M. (1998). The Leadership Moment. New York: Random. Weick, K. E. (1976). Educational organizations as loosely coupled systems. Administrative Science Quarterly, 21, 1–19. Weick, K. E. (1987). Organizational culture as a source of high reliability. California Management Review, 29, 112–127. Weick, K. E. (1993). The collapse of sensemaking in organizations: the Mann Gulch disaster. Administrative Science Quarterly, 38, 628–652. Weick, K. E. (1995). Sensemaking in Organizations. Thousand Oaks, CA: Sage. Weick, K. E., and Roberts, K. H. (1993). Collective mind in organizations: heedful interrelating on flight decks. Administrative Science Quarterly, 38, 357–381. Weick, K. E., and Sutcliffe, K. M. (2001). Managing the Uunexpected. San Francisco, CA: Jossey-Bass.

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V Learning and Change 13. Emergent Change as a Universal in Organizations 14. Drop your Tools: An Allegory for Organizational Studies 15. Leadership as the Legitimation of Doubt

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13 Emergent Change as a Universal in Organizations Setting the Scene The very first image that appeared in this book described experience as a ’sea of ceaseless change.’ I argued that organizing is about creating some patterned recurrence into that ceaseless change. Organizing itself was seen to consist of continuing efforts to reaccomplish the impermanent patterns that had been created. If we begin with these primitive notions of continuous change, then the question arises, ‘Why does the extensive literature on organizational change focus on how to create change rather than on how to cease change?’ Typically we read about conditions (e.g. crises) and interventions (e.g. planned change) that unfreeze inertial systems, modify them, and then refreeze the modified system. However, aren’t systems already unfrozen? Isn’t modification already underway? And what does refreezing mean in an unfrozen flow? Such questions are an obvious simplification, but they preserve a grain of truth. Scratch any account of creating and managing change and the idea that change is a three-stage process which necessarily begins with a process of unfreezing will not be far below the surface. Indeed it has been said that the whole theory of change is reducible to this one idea of Kurt Lewin’s (Hendry, 1996, p. 624).

To change flux is to bracket portions of it, slow or accelerate those bracketed portions, and close the loop on the bracketed events so that feedback enables recurrence. Recall a similar proposal from Chia (p. 4) when he said that organizing could be more productively thought of as ‘a generic existential strategy for subjugating the immanent forces of change.’ To subjugate the forces of change is to slow them, recycle them, freeze them, and that shift from unfreezing to freezing is what this chapter begins to explore. Chapter 13 is a follow-on to Weick and Quinn (1999), where Bob Quinn and I reorganized the change literature into themes of episodic change and themes of continuous change. Chapter 13 is an initial attempt to retain the concept of impermanence and blend in some of what has been written about organizational change. The central

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argument is that recurrence, even though it is patterned, is still subject to continuous alteration. These alterations often call forth efforts to reaccomplish the pattern. Each reaccomplishment alters the earlier pattern. The result is change within change, albeit on a smaller scale. When people recognize and preserve these smaller scale changes, the results often resemble planned change. The difference is that changes embedded in emerging reaccomplishments adapt to local quirks more quickly and often more fully. The continuing adaptation that is associated with emergent change seems to occur when people stay in motion, have a direction, look closely, update often, and converse candidly. The content of a program of planned change may be less important than is the mechanism it triggers. Any old change program will do as long as that program (1) animates people and gets them moving and experimenting; (2) provides a direction; (3) encourages updating through closer attention to what is happening; and (4) facilitates respectful interaction that enables people to build a stable rendition of what they face. The question for any planned changed program is the extent to which it engages or blocks these four. It is the thrust of my argument that there is nothing special about the content of specific change programs that explains their success or failure. Instead, what matters is the extent to which the program triggers sustained animation, direction, attention, and respectful interaction. It is these four practices that make it easier or harder for people to make sense collectively of what they currently face and to then deal with it. Consider what happens to these four in a conventional change intervention. When a new program is imposed on people, they have to keep the business going in the old way while they become accustomed to running it in the new way. When they try to do this their work often becomes more equivocal. Working in the old way is simultaneously good (it maintains continuity) and bad (it resists new practices). Resolving the equivocality is tough because people find it harder to act in order to test hunches, harder to identify a general direction that allows local adaptation, and harder to converse candidly in ways that build a consensual picture of what is happening. If the equivocality persists, this becomes increasingly stressful, which has the unfortunate effect of forcing people back on to overlearned earlier routines that are the very tendencies the change initiative was supposed to abolish. To fine-tune this argument, we need to remember that impermanence and ‘ceaseless change’ are synonymous with animation and motion. Thus, change is already underway and therefore unfreezing is not the central issue in organizational change. What does become central in the determination of outcomes are practices that incorporate direction, attention, and respectful interaction. Thus we come full circle back to where we started, namely text, conversation, bracketing, sensemaking, and mindfulness as the core of organizing. We also come full circle back to the problem of how to depict all of this. The ‘solution’ to the problem lies in language that evolves. Wallace Stevens summarizes the nature of the quest: A language, considered semantically, evolves through a series of conflicts between the denotative and connotative forces in words; between an asceticism tending to kill language by stripping words of all association and a hedonism tending to kill language by dissipating their sense in a multiplicity of associations. These conflicts are nothing more than changes in the relation between imagination and reality (Stevens, 1965, p. 13).

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Chapter 13 mixes direct denotation with suggestive connotation and tacks between them with an arrangement of ideas that invites further conflicts. To call this an ‘existential strategy’ is fitting. The following article was published as Chapter 11 in M. Beer and N. Nohria (Eds), Breaking the Code of Change, Boston, MA: Harvard Business School Press, 2000, pp. 223–241.

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Emergent Change as a Universal in Organizations Karl E. Weick The following article was published as Chapter 11 in M. Beer and N. Nohria (Eds), Breaking the Code of Change, Boston, MA: Harvard Business School Press, 2000, pp. 223–241. Copyright © Harvard Business School Press. Reprinted with permission.

The breathless rhetoric of planned transformational change, complete with talk of revolution, discontinuity, and upheaval, presents a distorted view of how successful change works. The hyperbole of transformation has led people to overestimate the liabilities of inertia, the centrality of managerial planning, and the promise of fresh starts, and to underestimate the value of innovative sensemaking on the front line, the ability of small experiments to travel, and the extent to which change is continuous. To create a richer picture of organizational change, this chapter makes the case that emergent, continuous change forms the infrastructure that determines whether planned, episodic change will succeed or fail. I will begin by describing emergent continuous change and contrasting it with planned, episodic change. I will then argue that preferences for either style of change are affected by assumptions about inertia, programmatic change, and unfreezing. Emergent change tends to be valued more highly when inertia is seen as a peripheral rather than as a central issue in organizational effectiveness; when the foundations of change are seen to consist of animation, direction, updating, and dialogue rather than of programmatic directives; and when sensitivity to ongoing processes of change leads people to favor intervention strategies of rebalancing rather than strategies of unfreezing.

The Nature of Emergent Change To understand the nature of emergent change in organizations, consider a few realworld examples and a few theoretical conceptualizations.

Emergent Change in Practice Here’s what emergent change looks like in everyday life. An executive at Macquarie Bank in Australia describes an emergent style of change when he says, “We never stay still, but we don’t change in quantum leaps—our corporate culture would preclude that; running a business on partnership concepts means that policy decisions are not too dramatic, they evolve” (Stace and Dunphy 1994, p. 98). A manager of the chemical division of a major oil company reviews his unit’s ongoing initiatives that anticipate corporate-sponsored transformation: “When [the CEO] began to focus on how he wanted to run the corporation, mission-vision-values came along. I drew

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a picture for my troops. One box portrayed the company-wide mission-vision-values, and an overlapping box contained our mission and guiding principles. I said, ‘Isn’t seventy percent of it the same?’ ‘Yeah.’ ‘And isn’t this different stuff better?’ ‘Yeah.’ ‘So what’s the big deal?’ ‘Nothing.’ Actually I think that most of us at Chemical are proud that the company sort of adopted the path that we were on” (Kleiner and Rodi 1998, p. 6). Kentucky Fried Chicken (KFC), in the early (1970s) stages of its internationalization, encouraged entrepreneurial frontline operations that created continuing change; this produced innovations such as chicken nugget experiments and new kitchen designs. However, all of these innovations were dropped when, in the 1980s, formal analytic management processes were installed at corporate headquarters to produce planned change. Much of the planned change amounted to reinvention of changes that had previously been accomplished and then abandoned. In the words of the KFC-Japan president, “We kept thinking there were lots of ways they (corporate) could have learned from us. We felt our twelve-piece minibarrel could be a success elsewhere. And our small store layouts with their flexible kitchen design seemed ideal for U.S. shopping malls. We were even experimenting with chicken nuggets in 1981—well before McDonald’s introduced them—but were told to stop” (Ghoshal and Bartlett 1997, p. 72). Allan Leighton and Archie Norman, in their attempts to revitalize the Asda supermarket chain, set a direction in which they wanted the firm to move; but the changes themselves were a mixture of local deviations, open-ended experiments, and formalization of informal tactics that worked. In a description that has as much figurative value as it has literal accuracy, Leighton characterized the message this way: “We told people to pile produce up, see how much sells, and not worry about waste” (speech at the August 1998 Harvard Business School conference).

Examples much like these are found in Waterman’s (1987) discussion of “informed opportunism” (pp. 24–70) and “tiny steps” (pp. 225— 228); in Brown and Eisenhardt’s (1998) discussion of “growing the strategy” (pp. 191–215); in Kouzes and Posner’s (1987) discussion of “small wins” (pp. 217–238); in Collins and Porras’s (1994) discussion of “opportunistic experimentation” (pp. 140–168); and in Peters’s (1997) discussion titled “You Can’t Live without an Eraser” (pp. 75–121). The recurring story is one of autonomous initiatives that bubble up internally; continuous emergent change; steady learning from both failure and success; strategy implementation that is replaced by strategy making; the appearance of innovations that are unplanned, unforeseen, and unexpected; and small actions that have surprisingly large consequences.

Emergent Change in Theory What is interesting theoretically about the preceding examples is the emergent quality of change in each description plus the fact that change is ongoing, continuous, and cumulative. Orlikowski (1996) provides a rich summary of the qualities these examples share: Each variation of a given form is not an abrupt or discrete event; neither is it, by itself discontinuous. Rather, through a series of ongoing and situated accommodations, adaptations, and

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alterations (that draw on previous variations and mediate future ones), sufficient modifications may be enacted over time that fundamental changes are achieved. There is no deliberate orchestration of change here, no technological inevitability, no dramatic discontinuity, just recurrent and reciprocal variations in practice over time. Each shift in practice creates the conditions for further breakdowns, unanticipated outcomes, and innovations, which in turn are met with more variations. Such variations are ongoing; there is no beginning or end point in this change process, (p. 66)

As people experiment with “the everyday contingencies, breakdowns, exceptions, opportunities, and unintended consequences” of work (p. 65), they improvise, produce ongoing variations, and enact micro-level changes. Emergent, continuous change, when contrasted with planned change, can be defined as “the realization of a new pattern of organizing in the absence of explicit a priori intentions” (Orlikowski 1996, p. 65). The basic argument is that as accommodations and experiments “are repeated, shared, amplified, and sustained, they can, over time, produce perceptible and striking organizational changes” (p. 89). These “striking organizational changes” are often equated with emergent strategy, and the processes that led up to them with emergent strategizing. Examples of such analyses are found in Eden and Ackermann’s (1998) work on strategy maps; Mintzberg, Ahlstrand, and Lampel’s (1998) discussion of “strategy formation as emergent process” (pp. 175–232); Czarniawska and Joerges’s (1996) discussion of “the travel of ideas” (pp. 13–48); and Sayles’s (1993) discussion of “strategy from below” (pp. 130–153).

Comparison of Planned Change and Emergent Change The power of emergent change to enhance adaptability in changing environments derives from the liabilities of planned change plus the advantages of emergent change. Stated in synoptic form, the liabilities of planned change include a high probability of relapse; uneven diffusion among units; large short-term losses that are difficult to recover; less suitability for opportunity-driven than for threat-driven alterations; unanticipated consequences due to limited foresight; temptations toward hypocrisy (when people talk the talk of revolution but walk the talk of resistance); adoption of best practices that work best elsewhere because of a different context; ignorance among top management regarding key contingencies and capabilities at the front line; and lags in implementation that make the change outdated before it is even finished. The advantages of emergent change include its capability to increase readiness for and receptiveness to planned change and to institutionalize whatever sticks from the planned change; sensitivity to local contingencies; suitability for on-line real-time experimentation, learning, and sensemaking; comprehensibility and manageability; likelihood of satisfying needs for autonomy, control, and expression; proneness to swift implementation; resistance to unraveling; ability to exploit existing tacit knowledge; and tightened and shortened feedback loops from results to action. The preceding mirror-image lists suggest conditions under which emergent changes are less effective and planned changes more so. Thus, emergent changes can be slow to cumulate; too small to affect outputs or outcomes; less well suited for responding to threats than for exploiting opportunities; limited by preexisting culture and technology;

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deficient when competitors are wedded to transformation; better suited to implementation in operations, plants, and stores than to strategy, firm-level, or corporate change; diffuse rather than focused; insufficiently bold or visionary; wedded to a teleological view of change (“intent” drives change), which means that other “engines” such as dialectical, life-cycle, or evolutionary change may be overlooked (Van de Ven and Poole 1995); and unlikely to generate a shift from one frame of reference to a totally different one. By contrast, planned change may be better able to capture attention and focus it on a single direction. Planned change affords a pretext and cover for changes that may be peripheral to the transformational vision but are seen as desirable to make anyway; it is usually aligned with the distribution of power in the organization; it conveys to key stakeholders the impression of being a rational program; it allows a more informed choice among options for implementation; and, because it consists of an explicit, compact mandate, it may be easier to diffuse, although this very solidity may also make it easier to attack and/ or avoid. The content of these lists is not news, although they are seldom assembled this way for the sake of comparison. What is news is that each list constitutes a reasonably coherent argument for a distinct style of change. These arguments constitute a mindset toward change that practitioners often share with researchers. Furthermore, the language of these mindsets may be embodied in organizational cultures as a dominant logic of change. Each set of arguments is supported by a deeper set of assumptions. I turn now to discussion of three of them: inertia, programmatic change, and unfreezing.

The Assumption of Inertia Pivotal in discussions of change are assumptions about inertia. I argue that an appreciation of the pervasive influence of emergent change fluctuates as a function of how one thinks about inertia. The greater the attachment to the idea that organizations build up inertial structures and are held in place by those structures, the greater will be the reliance on planned change rather than emergent change. According to this line of thinking, inertia is an “inability for organizations to change as rapidly as the environment” (Pfeffer 1997, p. 163). This inability to change rapidly has been attributed to a variety of factors, including dense interdependencies that are difficult to change (Gersick 1991), habitual routines (Gioia 1992), complacency induced by success (Miller 1993), top management who have been in place too long (Virany et al. 1992), and outdated technology (Tushman and Rosenkopf 1992). All of these attributions are basically variations on the idea that the seeds of inertia lie with “a system of interrelated organizational parts that is maintained by mutual dependencies among the parts and with competitive, regulatory, and technological systems outside the organization that reinforce the legitimacy of managerial choices that produced the parts” (Romanelli and Tushman 1994, p. 1144). These interdependencies tend to become tighter during a period of relative equilibrium. The problem is, this tightening often occurs at the expense of continued adaptation to environmental changes. As adaptation lags behind environmental change, effectiveness decreases, pressures for change increase, and the firm begins to enter a period of crisis. As pressures continue to increase, they may trigger an episode of planned change during

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which activity patterns, roles, responsibilities, and personnel are altered. These alterations then become the basis for a new equilibrium period. Representative descriptions of planned change efforts that are consistent with this scenario can be found in Miles’s (1997) insightful presentation of four major corporate transformations; Tushman and O’Reilly’s (1996) discussion of discontinuous changes in strategy, structure, and culture at Apple as it moved from the leadership of Steve Jobs through that of John Sculley, Michael Spindler, Gil Amelio, and back to Jobs; and Bate’s (1990) discussion of culture change at British Rail.

Images of Inertia Reflected in Images of Organization The basic images of organizations that people have in mind, when they argue that firms are susceptible to inertia and therefore require transformational interventions, are actually quite complex. Organizations that develop inertia and require planned change to undo it are viewed as entities that (1) move from one state to another in a forward direction through time, (2) move from a less developed state to a better-developed state, (3) move toward a specific end state often articulated in a vision, (4) move only when there is disruption and disequilibrium, and (5) move only in response to forces planned and managed by people apart from the system (Marshak 1993). The basic image is that of a solid structure, held together by tight interdependencies, whose direction is inertial and is subject to redirection only by the application of a substantial set of forces. It is possible, however, to portray organizations in a different manner, one that makes the role of inertia much less central in the determination of change. In this alternative portrait, more attention is paid to processes of organizing than to structures of organization. Coordination is viewed as a dynamic process that tends to unravel and therefore has to be reaccomplished continuously. The constant tension between unraveling and reaccomplishment is an ongoing prod to emergent, continuous change. When people reaccomplish the coordination that ties their activities together, they tend to alter it slightly so that it fits better with changing demands from internal and external sources. This continuous updating tends to produce units that change just as rapidly as their environments. Hence, inertia is no longer a problem. Which means it is no longer a determining factor in change. When inertia is less central, a different and more meaningful story of organization, organizing, and change can be told. This narrative depicts organizations as follows (Marshak 1993): (1) Organizations go through periods of ebb and flow that repeat themselves; in these periods processes unravel and then need to be reaccomplished. (2) Organizations move in an orderly sequence through cycles whose disruption creates a crisis. Typically, units try various strategies, identify strategies that seem to work, and remember and repeat those that work, all of which produces an orderly evolutionary cycle of variation/selection/ retention. (3) Organizations are preoccupied with journeys and directions rather than with destinations and end states. That is, top management provides the direction and leaves the front line to provide the sensemaking and experiments that move the unit in that general direction, in ways that are responsive to local contingencies. (4) Organizations view effective change as interventions that restore balance and orderly sequences. In other words, effective change does not replace one

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state with another but rather restores adaptive sequences that had been disrupted; for example, a mandate imposed from the top might preempt experimentation, which would produce the less balanced sequence selection/retention, which would then need to be restored to the more adaptive sequence of variation/selection/retention. And (5) organizations accept the reality that nothing remains the same forever. For example, people do not expect that they will be able to fix the organization once and for all and put design problems behind them.

Nuance in the Image of Inertia The picture of inertia that results when emergent change and organizing are conceptualized in terms of process, flow, and structuring (rather than structures) is quite different from that associated with planned change. For example, organizational routines are assumed to unfold in a repetitive manner by those who worry that this repetition blunts adaptation and can be reversed only by planned change. Routines are portrayed quite differently, however, by those who talk about emergent change. Investigators such as March and Olsen (1989, p. 38), Feldman (1989, p. 130), and Nelson and Winter (1982), have found that so-called routines actually consist of sequences that unfold in slightly different ways each time they are enacted. This variation tends to be responsive to subtle environmental changes, which means that adaptability is preserved rather than lost. Likewise, mechanisms of inertia are seen by those who advocate planned change to reside in patterns of dense, tight interdependence that can be altered only when attacked forcefully from the outside. Again, these dense patterns are viewed differently by those who talk about emergent change. The latter tend to see organizational interdependencies as more transient, temporary, and loose. This is because the organizational forms that are more salient for them include events in which alliances form and reform continuously (e.g., Browning, Beyer, and Shetler 1995), or in which innovations generated internally that go unsupported become the occasion for people to leave the firm and form their own company around those innovations (e.g., Martin 1997). The elaborate system of stable, mutual dependencies that Romanelli and Tushman describe is less characteristic of network organizations with their chronically salient large set of alternative partners. It is also true that views regarding the importance of inertia, and of the type of change that is necessary to deal with it, may covary with the standpoint of the observer. From a distance (the macro level of analysis composed of the big picture captured by upper management), when observers watch the flow of events that constitute organizing, they see what looks like repetitive action, routine, and inertia dotted with occasional episodes of revolutionary change. But a view from closer in (the micro level of analysis composed of particular details captured by the front line) suggests ongoing adaptation and continuous adjustment. Although these adjustments may be small, they also tend to be frequent across units, which means they add up swiftly and can alter structure and strategy. Some students of change (e.g., Orlikowski 1996) treat these ongoing adjustments as the essence of organizational change and argue that emergent change is the infrastructure of all change. Other students (e.g., Nadler et al. 1995)

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describe these ongoing adjustments as incremental variations on the same theme and lump them together as typical of epochs of convergence, during which interdependencies tighten. Convergence is interrupted sporadically by epochs of divergence— sometimes termed revolution, deep change, or transformation. From a middle standpoint halfway between near and distant, emergent and planned change begin to become indistinguishable. Thus, people in middle management who see fragments of frontline detail and fragments of a bigger picture are in the odd position of being the most savvy about what actually goes on in change, yet the least able to do anything about it.

The Assumption of Programmatic Change Planned change often takes the form of off-the-shelf standardized solutions that focus on one issue and are driven through the organization by directives from top management. As Beer and his colleagues (1990) demonstrate, these attempts at revitalization amount to false starts, because they fail to have simultaneous impact on three important drivers of effective change: coordination, commitment, and competence. My analysis here is in the spirit of Beer and colleagues’ search for fundamentals. But I differ in my list of fundamentals because I start from a different place. I assume that change engages efforts to make sense of events that don’t fit together (Weick 1995). Sensemaking involves “the meaningful linkaging of symbols and activity, that enables people to come to terms with the ongoing struggle for existence” (Prus 1996, p. 232). The four bare-bones conditions required for successful sensemaking are that people (1) stay in motion, (2) have a direction, (3) look closely and update often, and (4) converse candidly. My working hypothesis is that these conditions are activated more often by emergent change than by planned change, which is why I feel that emergent change is crucial in revitalization. This hypothesis derives from the basic requirements for sensemaking. If sensemaking is drastically simplified, this question captures it: How can we know what we think until we see what we say? People need to act in order to discover what they face, and they need to talk in order to discover what is on their mind. The “saying” involves action and animation; the “seeing” involves directed observation; the “thinking” involves the updating of previous thinking; and the “we” that makes all of this happen takes the form of candid dialogue that mixes together trust, trustworthiness, and self-respect. Sensemaking appears to be the root activity when people deal with an unknowable, unpredictable world. In these dealings, they produce continuous ongoing change. Thus, effective sensemaking and effective emergent change are tied together closely. The more fully sensemaking activities are activated, the more effective the change. The basic story in successful change seems to go like this. Faced with an important surprise (e.g., unexpected loss of market share), crisis (e.g., inability to meet loan covenants), or interruption (e.g., shutdown due to unsafe practices), people try to make sense of what is happening and adopt some program to remedy the trouble. It makes no difference what program they choose to implement, because any old program will do—as long as that program (1) animates people and gets them moving and generating experiments that uncover opportunities; (2) provide a direction; (3) encourages updating through

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improved situational awareness and closer attention to what is actually happening; and (4) facilitates respectful interaction in which trust, trustworthiness, and self-respect (Campbell 1990) all develop equally and allow people to build a stable rendition of what they face. Whether the chosen program involves economic value added, or total quality, or the creation of a learning organization, or transformation, or teachable points of view, or action learning or culture change or whatever, effectiveness will improve or decline depending on whether the program engages or blocks the four components of sensemaking. These components by themselves are sufficient to produce change. But they require a pretext for activation; there needs to be some kind of surprise and some kind of content to set them in motion. Both of these requirements, a surprise and a program, are met in virtually all of the cases described in this book. Nevertheless, it is the thrust of my argument that there is nothing special about the content of any one program per se that explains its success or failure in producing change. What matters is the extent to which the program triggers sustained animation, direction, attention/updating, and respectful interaction. It is these four activities that make it easier or harder for people collectively to make sense of what they currently face and to deal with it. The successful engagement of these four driving forces is not inevitable. Planned change often produces animation and some direction, but not necessarily closer attention and updating or interaction in which people listen, speak up, and maintain self-respect while dealing with differences in interpretations. Most change programs ignore one or more of these driving forces. Consider a run-of-the-mill change intervention. When a new program is imposed on people, they have to keep the business going—usually by continuing with the older way—while they get accustomed to running it the new way. When they attempt this juggling act, people typically implement rather than experiment, pay attention to compliance rather than to effects and outcomes, and listen rather than speak up. When interventions inhibit animation, direction, attention, and dialogue, ambiguity increases. As a result, the rate of change is slowed rather than accelerated, because people are distracted by their efforts to reduce ambiguity. The problem is, they don’t have access to the tools they need to manage ambiguity. People face ambiguity without action that tests hunches, without a general direction that allows local adaptation, without close attention to details and consequences, and without candid dialogue to build a consensual picture of what is happening. If the ambiguity persists, this situation becomes increasingly stressful. And stress has the unfortunate effect of forcing people back onto overlearned earlier routines that are the very tendencies the change initiative was supposed to abolish. In a change process that works, people tackle new tasks and discover new capabilities. They continue to move in the direction of greater alignment of personal and organizational values. They continue to notice, now in greater detail, just how much top management neglected and has left as their legacy for the units to clean up. And they become increasingly willing to speak up about what really needs to be remedied. All four of these activities—animation, direction, attention, respectful interaction— are crucial for adaptation, learning, and change in a turbulent world. But they are also the four activities most likely to be curbed severely in a hierarchical commandand-control system. Furthermore, there is no guarantee that highly touted planned change programs will necessarily recognize, restore, or legitimize animation, direction, attention, or

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respectful interaction. Thus, an important message of this essay is that if a change program leaves these elements untouched, it will fail. A further message is that emergent change is more likely than planned change to engage all four simultaneously.

The Assumption of Unfreezing If people want to change a system in which they feel inertia runs deep, then their best bet is to start with Kurt Lewin’s prescription for change: unfreeze-change-refreeze. As Hendry (1996) notes, “Scratch any account of creating and managing change and the idea that change is a three-stage process which necessarily begins with a process of unfreezing will not be far below the surface. Indeed it has been said that the whole theory of change is reducible to this one idea of Kurt Lewin’s” (p. 624). We sometimes forget that Lewin presumed that there was high resistance to change and that strong emotions are often needed to breach the resistance. “To break open the shell of complacency and self-righteousness it is sometimes necessary to bring about deliberately an emotional stir-up” (Lewin 1951, quoted in Marshak 1993, p. 400). But although strong emotions may provide “major sources of energy for revolutionary change” (Gersick 1991), they may also degrade cognition and performance in ways analogous to those of stress (Driskell and Salas 1996). Another message of this essay is that if you take emergent change more seriously and inertia less seriously, then you’ll discover a broader range of options for change than those associated with planned change. If a problem of declining organization performance is diagnosed as one of inertia, then it makes sense to design an intervention that unfreezes the inertia, makes a change, and finally refreezes and institutionalizes the change. But if change is continuous and emergent, then the system is already unfrozen. Further efforts at unfreezing could disrupt what is essentially a complex adaptive system that is already working. In a system where continuous emergent change is happening, ineffectiveness lies not in inertia but in processes whose steps have gotten out of sequence or are unevenly accomplished, or in which some steps have momentarily disappeared. Continuous change may have lost its continuity or run into blockages. If ineffectiveness is attributed to disruptions in continuous change, then a more plausible change sequence would be freeze, rebalance, unfreeze. To freeze continuous change means to make a disrupted sequence visible and to show patterns in what is happening—to uncover the causal sequence embodied in a process in order to spot vicious circles (Senge 1990). Freezing may also consist of a marginal gloss of real-time interaction in which people discover that their intentions and assumptions are at odds with what they produce (e.g., Argyris 1990). To rebalance means to reinterpret, relabel, and resequence steps so they unfold with fewer blockages. And finally, to unfreeze after rebalancing is to resume emergent change, complete with its improvisation and learning, in ways that are now more attentive to local changes, more resilient to anomalies, and more flexible in their execution. One reason it is tough to alter a pattern of emergent change is that this requires a demanding set of diagnostic and intervention skills. People find it difficult to “see” processes, sequences, and patterns in a flow of events (Pettigrew 1997). What they are

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looking for, basically, are small inputs that have large consequences. Conversations are a good example of small inputs that can enlarge. As Ford and Ford (1995) put it, “The macrocomplexity of organizations is generated, and changes emerge, through the diversity and interconnectedness of many microconversations, each of which follows relatively simple rules” (p. 560). It is harder for people to see the power of process dian it is for them to see the power of dungs, frequencies, stabilities, structures. Furthermore, for people to intervene meaningfully in emergent change, they need considerable linguistic skills to capture and label a flow of events, resequence and relabel that flow, and then release the revised flow. Skilled change agents recognize adaptive emergent changes, make them more salient, and reframe them (Bate 1990). As Rorty (1989) observed, “a talent for speaking differently rather than for arguing well, is the chief instrument of cultural change” (p. 7). For example, Wilkof and her colleagues (1995) report on their attempt to intervene in the relationship between two companies in a difficult partnership. Wilkof ’s initial attempts to improve cooperation focused on feeding back problems from a traditional data collection. This tactic failed and led to the discovery that although there were technical or structural solutions available, the actors could not agree on them, because of vastly different cultural lenses and diametrically opposed interpretations of meaning. The consultant, therefore, changed her strategy. She began meeting independently with the actors from each organization. In the meetings she would meet each condemnation not with data or argument but with an alternative interpretation from the cultural lens of the other company. She calls the process “cultural consciousness raising.” Wilkof and colleagues underscore the importance of helping people learn to interpret the actions of others not as technical incompetence but as behaviors that are consistent with a particular cultural purpose, meaning, and history. The power of this intervention can be understood in the context of Schein’s (1996) observation that “The most basic mechanism of acquiring new information that leads to cognitive restructuring is to discover in a conversational process that the interpretation that someone else puts on a concept is different from one’s own” (p. 31). Barrett and colleagues (1995) and Dixon (1997) have made similar arguments to the effect that the most powerful change interventions occur at the level of everyday conversation. The power of conversation, dialogue, and respectful interaction to reshape ongoing change has often been overlooked. We are in thrall to the story of dramatic interventions in which heroic figures turn around stubbornly inertial structures held in place by rigid people who are slow learners. This is a riveting story. It is also a deceptive story. It runs roughshod over capabilities already in place, over the basics of change, and over changes that are already under way.

Summary and Conclusions Emergent change consists of ongoing accommodations, adaptations, and alterations that produce fundamental change without a priori intentions to do so. Emergent change occurs when people reaccomplish routines and when they deal with contingencies, breakdowns, and opportunities in everyday work. Much of this change goes unnoticed, because small alterations are lumped together as noise in otherwise

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uneventful inertia and because small changes are neither heroic nor plausible ways to make strategy. If leaders take notice of emergent change and its effects, however, they can be more selective in their use of planned change. To take notice means to become more aware of personal assumptions about inertia, because these assumptions color not just one’s views of change but one’s views of what is an effective organization. It is hard to see the value of emergent change unless you also see the organization in terms of structuring rather than structure, flexible routines rather than rigid routines, and loosely coupled interdependencies rather than tightly coupled ones. The wise leader sees emergent change where others see only inertia and pretexts for planned change. The wise leader also sees that emergent change is most effective when people have the resources they need to produce it. One way to think about such resources is in terms of the question, What is valued in this firm? Emergent change, and its close relative sensemaking, are likely to be more effective when the culture of the corporation makes it clear that people are valued when they experiment with job descriptions (animation), implement a directive strategy in a novel manner (direction), rewrite requirements that no longer fit the environment (attention and updating), and speak up when things aren’t working (dialogue). In a traditional commandand-control system, it is hard for upper management to walk the talk of those four prerequisites. It is that very difficulty that leads top management to favor planned change. Planned change is more centralized and easier to control from the top, which means it is easier talk to walk. The problem is, when top management opts for planned change, it often discards some of its best innovators, some of its best innovations, and some of its most adaptive processes. Thus, a new “code of change” could be the recognition that organizational change is not management induced. Instead, organizational change is emergent change laid down by choices made on the front line. The job of management is to author interpretations and labels that capture the patterns in those adaptive choices. Within the framework of sensemaking, management sees what the front line says and tells the world what it means. In a newer code, management doesn’t create change. It certifies change. The moral of emergent change would seem to be that if something is not invented within the organization, it should be regarded as suspect. When consulting gurus sweep in with their promises of magical transformation through programs invented elsewhere, the wise manager thinks twice before allowing that show to unfold. The informed hesitancy springs from a deeper appreciation that mundane transformation may already be under way in the guise of unnoticed emergent change. Those emergent changes need to be noticed, labeled, and legitimized rather than displaced by the vendor-driven flavor of the month.

References Argyris, C. 1990. Overcoming Organizational Defenses: Facilitating Organizational Learning. Boston: Allyn and Bacon. Barrett, F. J., G. F. Thomas, and S. P. Hocevar. 1995. The Central Role of Discourse in Large-Scale Change: A Social Construction Perspective. Journal of Applied Behavioral Science 31: 352–372.

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Bate, P. 1990. Using the Culture Concept in an Organization Development Setting. Journal of Applied Behavioral Science 26: 83–106. Beer, M., R. A. Eisenstat, and B. Spector. 1990. The Critical Path to Corporate Renewal. Boston: Harvard Business School Press. Brown, S. L., and K. M. Eisenhardt. 1998. Competing on the Edge. Boston: Harvard Business School Press. Browning, L. D., J. M. Beyer, and J. C. Shetler. 1995. Building Cooperation in a Competitive Industry: Sematech and the Semiconductor Industry. Academy of Management Journal 38: 113–151. Campbell, D. T 1990. Asch’s Moral Epistemology for Socially Shared Knowledge. In The Legacy of Solomon Asch, ed. I. Rock, 39–52. Hillsdale, NJ: Erlbaum. Collins, J. C, and J. I. Porras. 1994. Built to Last. New York: Harper. Czarniawska, B., and B. Joerges. 1996. Travels of Ideas. In Translating Organizational Change, ed. B. Czarniawska and G. Sevon, 13–48. New York: Walter de Gruyter. Dixon, N. M. 1997. The Hallways of Learning. Organizational Dynamics (spring): 23–34. Driskell,J. E., and E. Salas, eds. 1996. Stress and Human Performance. Mahwah, NJ: Erlbaum. Eden, C, and F. Ackermann. 1998. Making Strategy. London: Sage. Feldman, M. S. 1989. Order without Design. Stanford: Stanford University Press. Ford, J. D., and L. W. Ford. 1995. The Role of Conversations in Producing Intentional Change in Organizations. Academy of Management Review 20, no. 3: 541–570. Gersick, C.J. G. 1991. Revolutionary Change Theories: A Multilevel Exploration of the Punctuated Equilibrium Paradigm. Academy of Management Review 16: 10–36. Ghoshal, S., and C. A. Bartlett. 1997. The Individualized Corporation. New York: Harper. Gioia, D. A. 1992. Pinto Fires and Personal Ethics: A Script Analysis of Missed Opportunities. Journal of Business Ethics 11: 379–389. Hendry, C. 1996. Understanding and Creating Whole Organizational Change through Learning Theory. Human Relations 49: 621–641. Kleiner, A., and G. Roth. 1998. Perspectives on Corporate Transformation: The OilCo Learning History. Society for Organizational Learning Working Paper 18.009. Cambridge, MA: MIT. Kouzes, J. M., and B. Z. Posner. 1987. The Leadership Challenge. San Francisco: Jossey-Bass. Lewin, K. 1951. Field Theory in Social Science. New York: Harper and Row. March, J. G., and J. P. Olsen. 1989. Rediscovering Institutions. New York: Free Press. Marshak, R. J. 1993. Lewin Meets Confucius: A Review of the OD Model of Change. Journal of Applied Behavioral Science 29: 393–415. Martin, R. 1997. Cascading Choices. Unpublished manuscript, University of Toronto. Miles, R. H. 1997. Leading Corporate Transformation. San Francisco: Jossey-Bass. Miller, D. 1993. The Architecture of Simplicity. Academy of Management Review 18: 116–138. Mintzberg, H., B. Ahlstrand, and J. Lampel. 1998. Strategy Safari. New York: Free Press. Nadler, D. A, R. B. Shaw, and A. E. Walton. 1995. Discontinuous Change. San Francisco: Jossey-Bass. Nelson, R., and S. Winter. 1982. An Evolutionary Theory of Economic Change. Cambridge, MA: Belknap Press. Orlikowski, W. J. 1996. Improvising Organizational Transformation Overtime: A Situated Change Perspective. Information Systems Research 7, no. 1: 63–92. Peters, T. 1997. The Circle of Innovation. New York: Knopf. Pettigrew, A. M. 1997. What Is Processual Analysis? Scandinavian Journal of Management 13, no. 4: 337–348.

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Pfeffer, J. 1997. New Directions for Organization Theory. New York: Oxford University Press. Prus, R. 1996. Symbolic Interaction and Ethnographic Research. Albany, NY: State University Press. Romanelli, E., and M. L. Tushman. 1994. Organizational Transformation as Punctuated Equilibrium: An Empirical Test. Academy of Management Journal 37: 1141–1166. Rorty, R. 1989. Contingency, Irony, and Solidarity. New York: Cambridge University Press. Sayles, L. R. 1993. The Working Leader. New York: Free Press. Schein, E. H. 1996. Kurt Lewin’s Change Theory in the Field and in the Classroom: Notes toward a Model of Managed Learning. Systems Practice 9: 27–47. Senge, P. 1990. The Fifth Discipline. New York: Doubleday. Stace, D., and D. Dunphy. 1994. Beyond the Boundaries. Sydney: McGraw-Hill. Tushman, M. L., and C. A. O’Reilly III. 1996. The Ambidextrous Organization: Managing Evolutionary and Revolutionary Change. California Management Review 38: 1–23. Tushman, M. L., and L. Rosenkopf. 1992. Organizational Determinants of Technological Change: Toward a Sociology of Technological Evolution. Research in Organizational Behavior 14: 311–347. Van de Ven, A. H., and M. S. Poole. 1995. Explaining Development and Change in Organizations. Academy of Management Review 20, no. 3: 510–540. Virany, B., M. L. Tushman, and E. Romanelli. 1992. Executive Succession and Organization Outcomes in Turbulent Environments: An Organization Learning Approach. Organization Science 3: 72–91. Waterman, R. H., Jr. 1987. The Renewal Factor. Toronto: Bantam. Weick, K. E. 1995. Sensemaking in Organizations. Thousand Oaks, CA: Sage. Wilkof, M. V., D. W Brown, and J. W. Selsky. 1995. When the Stories Are Different: The Influence of Corporate Culture Mismatches on Interorganizational Relations. Journal of Applied Behavioral Science 31: 373–388.

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14 Drop Your Tools: An Allegory for Organizational Studies Setting the Scene The following article was written as a framework for stock taking on the occasion of Administrative Science Quarterly’s 40th anniversary. It describes the analytic tools for organizational studies that were proposed by the first editor, James D. Thompson, and asks, do we need to keep, amend, or drop some of these tools? The form of this question was stimulated by a much earlier event in 1949 where 13 people were killed in Mann Gulch by an exploding wildland fire when many failed to drop their tools. The weight of tools they refused to drop slowed their retreat and allowed the fire to overtake them (see Weick, 2001). What does it mean to drop one’s tools? On February 26, 1995, near San Francisco, a blimp was practicing takeoffs and landings. As the blimp was circling to land, a warning light indicated that the battery was losing power rapidly. The pilot landed the blimp as soon as he could, but it came to rest short of the runway on an elevated knoll. The passenger and the pilot climbed out to hold down the blimp by the ground-handling rail. The passenger tripped as he got out and rolled down the hill. By the time he got back on his feet, the blimp was rising past 20 feet with the pilot holding on to the railing. The pilot fell at about 200 feet. The blimp continued to rise and disappeared into the overcast. With the help of a fixed-wing aircraft, the unmanned airship was tracked as it ascended to an altitude of about 10 000 ft and drifted slowly northeast over the eastern San Francisco Bay area. After several hours, the blimp gradually descended when helicopters hovered over it and forced the blimp to the ground in Orinda, California (NTSB File LAX95LA121). Whether you drop your blimp, your heavy firefighting tools, your misleading financial models (e.g. Lowenstein, 2001), your supposed skill at multitasking (Jackson, 2008), or whatever, the result can be an increase in agility and wisdom. That is what Chapter 14 explores as it ranges from firefighting to theory construction. The dramatic change in conditions that can come about when tools are dropped was first recognized by wildland firefighter Ted Putnam (see Putnam’s work in Chapter 6). In the 1970s, Putnam was

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a competitive runner as well as a wildland firefighter, his specialty being 50 to 100 mile runs. He designed his own packs to carry snacks and water on his long runs. Putnam reports that routinely, about 3 miles from the finish, he would throw off his pack and be astonished at the feelings of ‘exhilaration’ and increased speed when he did so. Later, when Putnam began investigating wildland fire fatalities, he started to measure how far people who died would have gone if they had dropped their packs and heavy tools. He found that, in most cases, they would have made it to safety. However, for reasons explained in Chapter 14, dropping one’s tools to gain speed in life-threatening conditions is tougher than it looks. Back in Chapter 6 we referred to the ‘cardinal meditation’ in Buddhism that involves impermanence, grasping/clinging, and egolessness’ (p. 93 of the reprinted article). Suffering occurs when people become attached to impermanent things that disappear in a changing world. In a world of ceaseless change, no tool, including the tool of an organized form, is indispensable. To take impermanence seriously is to recognize that, ‘In pursuit of knowledge, every day something is acquired; In pursuit of wisdom, every day something is dropped.’ (Lao Tzu, cited in Muller, 1999, p. 134). Wisdom is the acceptance that things of the world go away. If we do drop our tools, then what are we left with? Why is wisdom a possible byproduct of dropping? Consider the tools of traditional rationality as expressed in the rational actor model. Those tools presume that the world is stable, knowable, and predictable. To set aside some of those tools is not to give up complete reliance on the tools that are ill-suited to the impermanent, the unknowable, and the unpredictable. To drop some tools of rationality is to gain access to lightness and wisdom in the form of intuitions, feelings, stories, improvisation, experience, imagination, active listening, awareness in the moment, and empathy. As Lance Sandelands (personal communication, May 2005) has suggested, tools preclude ways of acting. If you preclude ways of acting, then you preclude ways of seeing. If you drop tools, then ideas have more free play. Just think of the maxim that when you have a hammer, the entire world turns into things that need to be nailed. Take that one step further. If you drop your hammer, then the world is no longer a world of mere nails. In a practical sense, to learn more about what happens when you drop your tools, compare performance with and without the tool. Learn how much of a difference a tool makes. In the case of firefighters, during their training they compare how fast they can move with their packs on and with their packs off. When firefighters drop their packs, this makes a big difference in speed if they are small people, but a smaller difference if they are big people. The fascinating question is what is the equivalent dimension for big and small size when we’re talking about people who benefit more and less from dropping their overused ideas? Part of the process associated with dropping one’s tools may include an audit of what tools you do have. It helps to date when tools were first acquired because older tools tend to be overlearned. These are the tools that people regress to when under pressure, and they are the tools that are harder to drop (see Tenerife in Weick, 2001). Notice that, if dropping one’s tools is a relatively new skill and not overlearned, stress will dissolve that skill and force regression back to much earlier, much more resistant skills. Dropping one’s tools is seldom a one-off process in the way that it is in a retreat from an exploding fire. However, if you take a closer look at firefighting practice, there

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was a learning curve for dropping one’s tools. Initially, people in the Forest Service were trained to drop their packs, but then it was discovered that the chances of survival were better if they dropped their packs but kept their water and their radios. Initially, people also learned to drop all their tools to pick up speed. However, this was later refined to the directive that they drop their heavy tools like chain saws, 5 gallon water containers, and sigg packs containing gasoline but keep light tools such as shovels, which might help them clear away brush and create a spot that wouldn’t burn. The following article was published in the 40th Anniversary Issue of Administrative Science Quarterly, 1996, 41(2), 301–313.

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Drop Your Tools: An Allegory for Organizational Studies Karl E. Weick University of Michigan The following article was published in 301/Administrative Science Quarterly, 41 (1996): 301–313 © 1996 by Cornell University. Reproduced with permission.

The failure of 27 wildland firefighters to follow orders to drop their heavy tools so they could move faster and outrun an exploding fire led to their death within sight of safe areas. Possible explanations for this puzzling behavior are developed using guidelines proposed by James D. Thompson, the first editor of the Administrative Science Quarterly. These explanations are then used to show that scholars of organizations are in analogous threatened positions, and they too seem to be keeping their heavy tools and falling behind. ASQ’s 40th anniversary provides a pretext to reexamine this potentially dysfunctional tendency and to modify it by reaffirming an updated version of Thompson’s original guidelines.* Anniversaries, such as ASQ’s 40th year of publication, are occasions to take stock. Taking stock is an activity that is often a complex mixture of appreciation, wariness, anticipation, regret, and pride, all fused into thoughts of renewal. Carlos Fuentes (1990: 49–50) talked about the complications of renewal when he described the modern dilemma as “how to accept the diversity and mutation of the world while retaining the mind’s power of analogy and unity so that this changing world shall not become meaningless. Being modern is not a question of sacrificing the past in favor of the new, but of monitoring, comparing, and remembering values we created, making them modern so as not to lose the value of the modern.” In this essay, I explore a set of remembered, founding values for organizational studies articulated by the first editor of ASQ, James D. Thompson (1956) in the first issue of the journal. The vehicle I use to explore these values is a story of organizing and death that played itself out in two separate disasters involving crews engaged in wildland firefighting. In 1949, 13 firefighters lost their lives at Mann Gulch, and in 1994, 14 more firefighters lost their lives under similar conditions at South Canyon. In both cases, these 23 men and four women were overrun by exploding fires when their retreat was slowed because they failed to drop the heavy tools they were carrying. By keeping their tools, they lost valuable distance they could have covered more quickly if they had been lighter (Putnam, 1994, 1995). All 27 perished within sight of safe areas. The question is, why did the firefighters keep their tools? The imperative, “drop your tools or you will die,” is the image that I want to examine more closely. * I am grateful to Ted Putnam, Mark Linane, Martha Grabowski, Lt. Col. Thomas Sawner, Kate O’Keefe, and especially to Kyle Weick for their help with the details of this argument.

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The reluctance to drop one’s tools when threat intensifies is not just a problem for firefighters. Navy seamen sometimes refuse orders to remove their heavy steel-toed shoes when they are forced to abandon a sinking ship, and they drown or punch holes in life rafts as a result. Fighter pilots in a disabled aircraft sometimes refuse orders to eject, preferring instead the “cocoon of oxygen” still present in the cockpit. Karl Wallenda, the world-renowned high-wire artist, fell to his death still clutching his balance pole, when his hands could have grabbed the wire below him. Dropping one’s tools is a proxy for unlearning, for adaptation, for flexibility, in short, for many of the dramas that engage organizational scholars. It is the very unwillingness of people to drop their tools that turns some of these dramas into tragedies. These dramas, however, are not confined simply to the people in organizations that scholars study. The scholars themselves are equally at risk. Kaplan’s (1964: 28) “law of the instrument” portrays part of the risk: “Give a small boy a hammer, and he will find that everything he encounters needs pounding. It comes as no particular surprise to discover that a scientist formulates problems in a way which requires for their solution just those techniques in which he himself is especially skilled.” What else is “the law of the instrument” but a pointed comment that social scientists refuse to drop their paradigms, parables, and propositions when their own personal survival is threatened. To drop one’s tools, then, is an allegory for all seasons that is capable of connecting the past with the present. To introduce the allegory as a vehicle for stocktaking, I develop the following argument. First, I briefly paraphrase Thompson’s four guidelines for inquiry in administrative science. Second, I analyze the puzzling reluctance of firefighters to drop their tools and craft this analysis using Thompson’s guidelines. Specifically, the analysis highlights the power of context, the complex relationships that determine organized behavior, and the power of abstract concepts to reflect the details of firefighting into systems of thought. Third, I exploit the allegorical quality of the story and suggest that organizational scholars are in a similar threatened position to that of the firefighters and face a similar imperative to drop their heavy tools or they will be overrun. To drop one’s tools is simultaneously to accept mutation and to modernize remembered values or to believe the past as well as doubt it. These complex simultaneities are the essence of renewal and, therefore, provide a suitable way to observe ASQ’s 40th anniversary.

Thompson’s Founding Values for ASQ In the first issue of ASQ, the founding editor, James D. Thompson, published his own vision of what the then-emerging field of administrative science might look like. The abstract for his essay, titled “On Building an Administrative Science” (Thompson, 1956: 102), reads as follows: The unique contribution of science lies in its combination of deductive and inductive methods for the development of reliable knowledge. The methodological problems of the basic sciences are shared by the applied fields. Administrative science will demand a focus on relationships, the use of abstract concepts, and the development of operational definitions. Applied sciences have the further need for criteria of measurement and evaluation. Present abstract concepts of administrative processes must be operationalized and new ones developed or borrowed from the basic social sciences. Available knowledge in scattered sources

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needs to be assembled and analyzed. Research must go beyond description and must be reflected against theory. It must study the obvious as well as the unknown. The pressure for immediately applicable results must be reduced.

At first this sounds like standard visionary boilerplate. On closer inspection, it foreshadows values that stand up well as a framework for renewal that both accepts mutation and creates analogy. Thompson’s first sentence in the essay hints at his approach: “The issue of science vs. art for administration seems to be vanishing with the realization that one approach does not rule out the other” (p. 102). Nevertheless, since Thompson is not launching the “Administrative Art Quarterly,” he makes clear that his concern with science does not mean that he is preoccupied with measurement, quantification, statistics, or laboratory experiments. Instead, he is interested in work that uses “both deductive and inductive techniques for the development of logical, abstract, tested systems of thought” (p. 104). Here’s where the remembered values surface, all four of which Thompson regards as vital if inductive and deductive approaches are to be “blended” (p. 104). First, administrative science should “focus on relationships” among phenomena under stated conditions. Straightforward as this sounds, Thompson goes on to note that relationships are often assumed rather than demonstrated. Configurations and contingencies are ignored in favor of simple relationships, and people settle for assertions that A and B lead to C without asking the further questions of what else do A and B bring about, and what else leads to C (p. 108)? The second value is “the use of abstract concepts” to permit generalization and to move beyond concrete events and research organized around “ad hoc hypotheses” (p. 106). Thompson is worried that organizational researchers expend too much effort compiling incidents that support rather than test particular points of view. He also worries that people will forego abstraction in favor of the immediately applicable and settle for “commonsense hypotheses framed at low levels of abstraction, without regard for general theory” (p. 110). In a statement that could have come right out of the ‘90s, he insists that “current ‘best practice’ must be examined critically” (p. 111, italics in original ). The third value involves “the development of operational definitions” that bridge concepts and raw experience. His interest in operational definitions is driven not by positivist dogma, but by a desire to avoid concepts that are sterile, forever debatable, and unable to be tested widely. Though Thompson labels his concern as being that of “definition,” in fact he is arguing for operational distinctions or delineations so that theories can be differentiated at the scientific level, as well as at the metaphysical level. Theories are tested only by imperfect exemplifications of their parameters, which means that definitional operationism is impossible, but multiple operationism using designations that are flawed in different ways, is not (Campbell, 1988). The key issue for Thompson is grounding and approximations to knowledge, not spurious hard-headedness. Thompson resorts to some unusual verbs to make his argument about bridging, noting, for example, that empirical observations need to be “reflected” against theoretical systems and that scientific progress requires “convertibility of symbolic currency” (p. 107). The fourth value discussed is that of the criterion problem: How do we judge that one relationship yields a more desirable net effect than another one? Values of achievement, utility, service, preservation, and maintenance are mentioned as examples, with the

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clear caveat that administrative science has yet to address this issue. The importance of doing so lies in trying to predict the consequences of various administrative actions. In the present essay, for example, I invoke literal death as the criterion against which the effectiveness or ineffectiveness of organizing can be judged. By doing so, I have implied that deaths of a different kind, such as those involving censored ideas, loss of face, depression, loss of spirit, withdrawal, and avoided tests, are also legitimate criteria. When we try to assess the effects of new organizational forms, examination of the effects on bottom-line financial performance is narrow and misses the larger issues of the unique qualities behavior assumes by virtue of its being organized. Forms of organizing may hasten or slow other forms of death than bankruptcy, divestiture, acquisition, merger, or dissolution. But we won’t know that if we restrict the criteria we examine. Thompson was uneasy about the criterion problem in 1956, and renewal in 1996 may well benefit from reinstatement of his unease. It is remembered values such as these four that need to be modernized rather than sacrificed if we in organizational studies are to accept current diversity and mutation without losing either a sense of unity or the power of analogy. To illustrate how these values can be deployed, I briefly analyze the relationship between tools and tragedy at two separate wildland fires.

Tool Dropping at Mann Gulch and South Canyon The first of the two disasters, Mann Gulch, was made famous in Norman Maclean’s (1992) book titled Young Men and Fire. This accident occurred on August 5, 1949 when 14 young smokejumpers, their foreman Wagner Dodge, and a forest ranger were trapped near the bottom of a 76-percent slope in western Montana by an exploding fire. Thirteen of these men were killed when they tried to outrun the fire, ignoring both an order to drop their heavy tools and an order to lie down in an area where fuel had been burned off by an escape fire Dodge lit. Of the three who survived, Dodge lived by lying down in the cooler area created by the escape fire, and two others, Bob Sallee and Walter Rumsey, lived by squeezing through a break in the rocks at the top of the slope. Maclean (1992: 73) describes the crucial episode of tool dropping this way: Dodge’s order was to throw away just their packs and heavy tools, but to his surprise some of them had already thrown away all their equipment. On the other hand, some of them wouldn’t abandon their heavy tools, even after Dodge’s order. Diettert, one of the most intelligent of the crew, continued carrying both his tools until Rumsey caught up with him, took his shovel, and leaned it against a pine tree. Just a little farther on, Rumsey and Sallee passed the recreation guard, Jim Harrison, who, having been on the fire all afternoon, was now exhausted. He was sitting with his heavy pack on and was making no effort to take it off.

At South Canyon, outside Glenwood Springs, Colorado, roughly the same thing happened 45 years later on July 6, 1994. Again, late on a hot, dry, windy afternoon, near 4:00 P.M., flames on the side of a gulch away from firefighters jumped across onto their side beneath them and, in the words of the inquiry board, “moved onto steep slopes and into dense, highly flammable Gambel oak. Within seconds a wall of flame raced up the

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hill toward the firefighters on the west flank fireline. Failing to outrun the flames, 12 firefighters perished. Two helitack crew members on the top of the ridge also died when they tried to outrun the fire to the northwest. The remaining 35 firefighters survived by escaping out the east drainage or seeking a safety area and deploying their fire shelters” (U.S. Forest Service, 1994: 2). The firefighters who perished did not drop their tools or packs while trying to escape. For example, a portion of the site and thermal analysis of the body of firefighter #10, written at the time the bodies were being recovered from the hillside on July 7, reads as follows: “was still wearing his back pack. . . . Victim has chain saw handle still in hand with chain saw immediately above right hand. Saw blade is parallel to firefighter #9’s left leg.” Dropping their tools or packs would have significantly increased the firefighters’ chance of escape. “Since this crew walked part of the way out, an analysis was made based on the assumption that they ran all the way out. Another analysis assumed that they dropped their packs and tools and could have moved quicker exerting the same amount of energy. Both analyses reveal that the firefighters would have reached the top of the ridge before the fire if they had perceived the threat from the start” (U.S. Forest Service, 1994: A3–5).

Explanations for the Failure to Drop Tools There are at least ten reasons why firefighters in both incidents may have failed to drop their tools: 1.

2.

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Listening. There is some evidence that the sheer roar of the fire precluded people from hearing the order to drop their tools and run. At Mann Gulch, Robert Sallee reported that he couldn’t understand foreman Dodge when he ordered people to move into an area cleared by his escape fire (Sallee, 1949: 79), and Rumsey agreed that he couldn’t hear instructions clearly (Rumsey, 1949: 104–107). This dynamic also cannot be ruled out at South Canyon, since the people shouting at the retreating crew to run were separated from them by several hundred feet, and the fire had begun to roll with flame heights reaching 300 feet. Justification. People persist when they are given no clear reasons to change. At Mann Gulch, foreman Dodge did little briefing of his crew throughout the incident. One of the few times he spoke to them was when he gave the order to drop their tools. When the accident investigation board asked Dodge to tell them what reason he gave for dropping tools (Dodge, 1949: 121), Dodge replied, “It wasn’t necessary. You could see the fire pretty close and we had to increase our rate of travel some way or another.” What was clear to Dodge may not have been as clear to the other 15, nine of whom were first-year smokejumpers and all of whom had more experience fighting fires in timber than in the dry grass where they now found themselves. At South Canyon, the firefighters who kept their tools were also not given a reason to drop them. No one told them that they were at the head of an onrushing fire, which is crucial information, because it was plausible for them to perceive that they were on the north flank of the fire.

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3. Trust. People persist when they don’t trust the person who tells them to change. Members of the firecrew at Mann Gulch did not know Dodge well (U.S. Forest Service, 1949: 112), which made it hard for them to know how credible his orders and actions were. At South Canyon, the Prineville firefighters did not know the five smokejumpers mixed in with their crew, all five of whom had told the crew either to run or to deploy their shelters. These instructions were not legitimate orders, nor were they mentioned by trusted people. 4. Control. A prominent definition of technology is that it consists of knowledge of cause-effect relations (e.g., Rogers and Chen, 1990: 17). In the case of firefighters, keeping one’s hand tools is consistent with a cause-effect relationship for survival. The odds of surviving in a fire shelter as a fire passes over it are increased if the area around the shelter is clear of material that might catch fire and melt the shelter or allow flame to move inside it. Thus people who keep a hand tool retain a cause that may help them escape a fire. If, however, they also keep chainsaws or gas cans, then escape is more difficult. Furthermore, the mere knowledge that one retains some capacity to alter the environment, even if it is not exercised, may serve as a sort of “panic button” (Glass and Singer, 1972) and improve the quality of problem solving. 5. Skill at dropping. People may keep their tools because they don’t know how to drop them. I know how absurd that sounds. But think again. At Mann Gulch, Rumsey mentioned that even though he was running for his life, he grabbed Diettert’s shovel and leaned it against a tree. At South Canyon, firefighter Clinton Rhoades’ testimony shows that while outrunning the fire, he spent valuable time trying to find where he could put down his saw so it wouldn’t get burned. In his words, “at some point, about 300 yards up the hill . . . I then realized I still had my saw over my shoulder! I irrationally started looking for a place to put it down where it wouldn’t get burned. I found a place I it [sic] didn’t, though the others’ saws did. I remember thinking I can’t believe I’m putting down my saw” (U.S. Forest Service, 1994: Appendix 5). People who have learned during training to carry out whatever equipment they carry into a fire and who hear over and over how much equipment costs (e.g., a fireshelter costs $23, a parachute $600) might be at a disadvantage when, without prior experience of what it feels like or how to do it, they are told to drop their tools and their packs. From what we know about the effects of stress on overlearned behavior (e.g., Weick, 1990), the safest prediction would be that firefighters under pressure would regress to what they know best, which in this case would be keeping their tools. If somehow they could override that tendency, they still might try to protect these expensive tools by putting them down carefully away from potential flames, which eats up precious time. 6. Skill with replacement activity. People may keep their familiar tools in a frightening situation because an unfamiliar alternative, such as deploying a fire shelter, is even more frightening. People at Mann Gulch found it hard to drop their tools, but they found it even harder to comprehend the function of Dodge’s escape fire. No one followed Dodge in, and some thought the fire was supposed to serve as a buffer between them and the oncoming blowup (Sallee, 1949: 77). It is equally strange to be told to deploy a fire shelter. Firefighters do not get much practice

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7.

8.

9.

10.

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deploying fire shelters. Furthermore, it is tough to open a shelter while running in turbulent winds, with gloves on, and while looking for a clear flat area in which to lie down. Failure. To drop one’s tools may be to admit failure. To retain one’s tools is to postpone this admission and to feel that one is still in it and still winning. The year just prior to both Mann Gulch (U.S. Forest Service, 1949: 116–122) and South Canyon had been a light fire season, and people were relatively rusty in sizing up fires and their explosive potential. Thus, faced with an ambiguously developing situation and with an aggressive crew that would prefer to handle things itself rather than turn over an escaped fire to a more experienced crew, leaders might well be reluctant to admit failure. Social dynamics. People in a line may hold onto their tools as a result of social dynamics such as pluralistic ignorance (O’Gorman, 1986). If the first firefighter walking up an escape route keeps his or her tools, then the second person in line, who feels more fear, may conclude that the first person is not scared. Having concluded that there appears to be no cause for worry, the second person also retains his or her tools and is observed to do so by the third person in line, who similarly infers less danger than may exist. Each person individually may be fearful but mistakenly concludes that everyone else is calm. Thus, the situation appears to be safe, except that no one actually believes that it is. The actions of the last person in line, the one who feels most intensely the heat of the blowup, are observed by no one, which means it is tough to convey the gravity of the situation back up to the front of the line. Consequences. People will not drop their tools if they believe that doing so won’t make much difference. Small changes in speed and distance, changes on the order of 8 more inches covered per second, can mean the difference between safety and death. At South Canyon, if firefighters had dropped their tools five minutes before the fire hit them, they would all have been able to cover another 228 feet at the rate they were already moving, which would have put all of them close to or over the top (Putnam, 1995). But the cumulative effects of a small change made possible by carrying fewer tools are not evident, nor do they feel plausible psychologically, given the intense environment of wind, sound, heat, flying debris, and smoke. Small changes seem like trivial changes, so nothing changes. Identity. Finally, implicit in the idea that people can drop their tools is the assumption that tools and people are distinct, separable, and dissimilar. But fires are not fought with bodies and bare hands, they are fought with tools that are often distinctive trademarks of firefighters and central to their identity. Firefighting tools define the firefighter’s group membership, they are the firefighter’s reason for being deployed in the first place, they create capability, they are given the same care that the firefighters themselves get (e.g., tools are collected and sharpened after every shift), and they are meaningful artifacts that define the culture. Given the central role of tools in defining the essence of a firefighter, it is not surprising that dropping one’s tools creates an existential crisis. Without my tools, who am I? A coward? A fool? The fusion of tools with identities means that under conditions of threat, it makes no more sense to drop one’s tools than to drop one’s pride. Tools and identities form a unity without seams or separable elements.

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Although these 10 reasons for persistence in the face of threat have been discussed using the concrete events of firefighting, the analysis builds on Thompson’s principles. First, the preceding list shows that the willingness of endangered firefighters to drop their tools is overdetermined. Overdetermination is simply another way of stating Thompson’s first point that people have multiple, interdependent, socially coherent reasons for doing what they do. These interconnected reasons constitute social systems that become visible only when we “focus on relationships.” Second, the multiple ways in which people relate to tools can be understood more fully if we interpret those actions using abstract concepts such as justification, trust, and identity. It is these abstractions that allow us to compare Mann Gulch with South Canyon, to infer the likelihood of future tragedies in firefighting, and to extrapolate to other settings in which analogous threats may arise. These abstractions also convert the ad hoc hypotheses that worried Thompson into more generic processes seen in other places. It is these connections that bring more resources to bear on the problem of fatalities in fire suppression and in turn provide vivid instances that enrich and deepen the concepts. Third, the preceding analysis of tool dropping retains some measure of plausibility because, following Thompson’s third guideline, abstract concepts are tied to concrete action: Justification ⫽ length and depth of briefing regarding suppression strategy; trust ⫽ willingness to follow unusual orders given by strangers; and identity ⫽ preoccupation with reputation as a can-do firefighter. These bridges encourage ongoing induction and deduction. More important, the bridges forestall endless debates because the arguments are grounded, focused, and corrigible. If crew foremen lengthen their briefings or increase crew members’ familiarity with each other or replace a can-do identity, and if endangered firefighters still refuse to drop their tools, then justification, trust, and identity, at least as defined here, are suspect explanations. What is more crucial, it is precisely because of the conceptual grounding that we are encouraged to move off these explanations to find better ones. This was not news, even back in 1956. But what made it worth saying then, and worth reaffirming now, is the tendency to pursue either abstractions or particulars by themselves, independently, as if they had a life of their own and self-contained meaning. Meaning lies in the connecting of particulars with abstractions, which is why Thompson worried about relationships, abstractions, and bridges. Fourth, the analysis of tool dropping gains some of its bite because it engages the criterion problem. The “obvious” criterion of survival becomes a good deal more complex when we begin to see that physical survival does not dominate everyone’s attention at the same moment, nor is it connected to other issues in a homogeneous manner, nor does it mean the same thing to everyone. Furthermore, other criteria, such as effectiveness of fire-line construction, efficiency and speed of line construction, and ability to overcome challenges, obstacles, and risks, all compete for attention. Survival is only one among many criteria that are operating when firefighters try to interpret a fire that intensifies in ambiguous ways. It is precisely because people persist in making complex tradeoffs among multiple criteria amidst ambiguous cues that they fail to realize they are in serious trouble. The criterion issue, in this case, “what constitutes safe fire suppression,” is at the heart of the 10 reasons people refuse to drop their tools, as Thompson said it should be.

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Tool Dropping in Organizational Studies What does all of this have to do with the anniversary of ASQ? That question itself invites a search for parallels between the situation of endangered firefighters who forego changes that would reduce danger and the situation of organizational researchers who may be vulnerable in analogous ways. Specifically, the occasion of ASQ’s anniversary provides a good pretext to ask questions like, Are organizational researchers in danger of being overrun by issues that threaten their survival?; What are the heavy tools that weigh researchers down and make them less agile?; What are the light tools researchers should keep in order to preserve options?; and What does it take to get people to drop the heavy tools that endanger them? These are questions of renewal to be discussed in the organizational community at large, not something to be answered in a single essay. These are questions on which serious scholars, working in a low-paradigm field, will differ. To illustrate how the allegory of dropping one’s tools might be used to stimulate reflective stock taking, I want to reinvoke Thompson’s founding emphasis on relationships, abstractions, bridging, and criteria. The question of what danger, if any, threatens to overrun organizational studies can be answered in several ways. There are growing concerns that the business sector will replace universities as seats of knowledge creation (Davis and Botkin, 1994), that economists will displace nuanced models of organized human behavior with their data-free simplifications (Pfeffer, 1994: 96–100), that business firms will increasingly ignore those components of change programs that provide good data about the worth of the intervention (Hackman and Wageman, 1995), that theory detached from practice will be dismissed (Schon, 1995), and that a preoccupation with traditional decision making tells us much about something that no one does (Langley et al., 1995). Readers undoubtedly know of more severe threats than these. Those are the very things we need to discuss. None of the threats listed here approaches the scale of the Mann Gulch blowup. Then again, when the smokejumpers landed at Mann Gulch, they saw nothing on the scale of a blowup either. What is interesting about the illustrative threats listed here is that taking Thompson seriously would reduce most of them. Consider just the first three I mentioned. Knowledge creation by business firms is apt to be firm-specific and problem-specific, meaning that the knowledge acquired is not preserved in abstractions and must be invented anew with each internal change. It is this very tinkering and customizing sans systematic evaluation that lies behind many of the failed quality interventions that Hackman and Wageman (1995) discussed. Continuous updating of what is known within the firm, coupled with continuous monitoring to determine if updating is necessary, is expensive, not to mention susceptible to political manipulation. Consequently, assessment is short-circuited, learning is superstitious and misleading, and what appears to be knowledge creation in fact becomes the enlargement of ignorance. Normally, that would mean a secure place for organizational studies conducted in universities. It doesn’t. Researchers often adopt atheoretical lay language that stays close to practice and simply recapitulates what organizations feel they already know and say. The explicit and general theories that Thompson wants to cultivate are replaced by implicit and specific theories that continually need to be reinvented by academics and practitioners alike. When two groups are found to be doing the same thing, one is probably dispensable.

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Potential threats from economists have a different set of dynamics. Economists typically employ fictions that ignore relationships, theory-data linkages, and values other than financial performance. For example, McCloskey (1988) noted that economists are united in their assumption that people are driven by self-interest. He illustrates this assumption by positing the axiom of modest greed—people pick up five-hundred-dollar bills left on the sidewalk. The problem is that economists who endorse the greed axiom are far less likely to notice the Five-Hundred-Dollar-Bill Theorem: “If the Axiom of Modest Greed applies, then there exists no sidewalk in the neighborhood of your house on which a five-hundred-dollar bill remains” (p. 394). The axiom, in other words, is meaningless because it asserts something that never happens. This spurious profundity points up what happens when investigators overlook relationships and bridges between induction and deduction. Organizational studies may also be overrun by growing indifference toward empirical findings that do exist. There is an irony in the fact that it was the very focus on relationships (e.g., p. 321), abstractions (e.g., p. 337), induction-deduction linkages (e.g., p. 330), and criteria (p. 332) that enabled Hackman and Wageman (1995) to discover that TQM intervention often didn’t work because firms failed to implement data collection, scientific methods, and statistical tools (p. 332). Without these data, firms implement TQM imperfectly. Potentially even more serious is the fact that firms also have a poor sense of who they are, what they are doing, and why they face the outcomes they do. Aside from the question of potential threats, there is the question of what are the heavy tools that make researchers move more slowly and with less agility and make them more susceptible to being overrun. A partial answer is implicit in the arguments between Pfeffer (1995) and Van Maanen (1995) about the future of organizational studies. Their debate is partly a difference of opinion about which tools we should keep and which ones we should drop, a difference typified in Kant’s rich assertion that “perception without conception is blind; conception without perception is empty” (Blumer, 1969: 168). Pfeffer is worried about blindness and wants better-developed paradigms to prevent it. Van Maanen seems more worried about conceptual emptiness and wants more particulars to fill it. Pfeffer’s plea for focused concepts to remedy blind precepts and Van Maanen’s plea for nuanced discourse to remedy empty concepts can both be read as admonitions to drop tools. Pfeffer sees people weighed down by too many half-formed paradigms, just as Van Maanen sees people weighed down by too many half-formed sentences whose words reinforce the conceit that phenomena are represented rather than created. We need go no further than Thompson to see what to do next. We need, first, to reaffirm and modernize the importance of relationships, abstract concepts, operational bridging, and criteria. One form of modernizing is to incorporate those four into a Kuhnian version of science. To take Thompson seriously would then mean “obeying the normal conventions of your discipline, not fudging the data too much, not letting your hopes and fears influence your conclusions unless those hopes and fears are shared by all those who are in the same line of work, being open to refutation by experience, not blocking the road of inquiry. . . . [These practices] are names for a suitable balance between respect for the opinions of one’s fellows and respect for the stubbornness of sensation” (Rorty, 1982: 194–195). With those modernized reaffirmations in place, we should then be able to select paradigms that enable us to see with richness—which may produce a short half-life

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for many paradigms of economics. Those reaffirmations should also allow us to choose those words and images that reflect perceptions back into systems of thought—which may produce a short half-life for much precious postmodern prose. Pfeffer and Van Maanen certainly have no monopoly on the question of which heavy tools should be dropped. Others who weigh in include those who advise us to drop our departures from naive lay explanations (Jones, 1993: 96), our non-Darwinian insights (Dennett, 1995), our obsession with time-series data (Starbuck, 1994), our axiomatic treatment of requisite variety (Walsh, 1995: 307), our assumption that organic processes resolve uncertainty (Eisenhardt and Tabrizi, 1995: 108), our assumption of permanent organizations (March, 1995), and our need to be seen as professionals rather than amateurs (Said, 1994). There is no shortage of candidates for tools that weigh us down and preclude lightness. Common to most of them, and of singular importance in making them hard to drop, is the last of the ten reasons discussed for firefighters, identity. Identity, the fusion of tools with group membership, makes it hard for firefighters to consider tools as something apart from themselves that can be discarded, just as it makes it hard for scholars to consider concepts as something apart from themselves. The lightness associated with “the play of ideas,” improvisation, and experimentation disappears when dropping ideas or keeping them becomes confused with dropping or keeping group ties. Research on groupthink (Janis, 1982; Tetlock et al., 1992) shows how easily group identity and thinking fuse, such that one cannot be evaluated apart from the other. Campbell (1979) has shown how the learning theory developed in the tight research group surrounding Kenneth Spence was less powerful than the learning theory developed within the much looser group surrounding Edward Tolman. These differences are explained in part by the relative ease people in Tolman’s group had evaluating and changing ideas without regard for the effect of these changes on their reputations and the relative difficulty people in Spence’s group had when they tried to do the same thing. As dualities within organizational studies (e.g., macro/micro) harden into positions with which people identify and that in turn identify them, the tools associated with these positions take on excess weight, which ironically makes it harder for them to be dropped. The result is that attention is deflected from ideas to people. And as attention is drawn toward the field’s internal issues, people lose the struggle that remains against outside threats. Firefighters worried about who they are if they drop heavy tools cannot pay close attention to unfolding dramas that could suddenly turn dangerous. The same distraction, albeit with smaller stakes, faces ASQ readers in the 40th year of the journal, just as it has in the preceding 39 years. What’s different this time is that there is a declared pretext, the 40th anniversary, that legitimates stock taking and invites renewal. There is no shortage of mutation and diversity to be accepted in this 40th year. The threat is one of being overwhelmed by mutations for which one is unable to find meaning, a situation analogous to Mann Gulch and South Canyon. But organizational scholars have an advantage. They have a set of remembered values from ASQ’s founding that infuse meaning into the present and provide a platform for renewal. When Thompson urged us to focus on relationships, use abstract concepts, bridge observations and abstractions, and articulate the values that matter, he did so to improve the field, not to have groups pair off with ideas and block inquiry. To remind ourselves of that is to restore lightness.

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References Blumer, Herbert 1969 Symbolic Interactionism. Englewood Cliffs, NJ: Prentice-Hall. Campbell, Donald T. 1979 “A tribal model of the social system vehicle carrying scientific knowledge.” Knowledge: Creation, Diffusion, Utilization, 1: 181–201. ——1988 “Definitional versus multiple operationism.” In E. Samuel Overman (ed.), Methodology and Epistemology for Social Science: 31–36. Chicago: University of Chicago Press. Davis, Stan, and Jim Botkin 1994 The Monster under the Bed.New York: Simon and Schuster. Dennett, Daniel C. 1995 Darwin’s Dangerous Idea.New York: Simon and Schuster. Dodge, Wagner 1949 Testimony. Mann Gulch Transcript: 117–125. Washington, DC: U.S. Forest Service. Eisenhardt, Kathleen M., and Behnam N. Tabrizi 1995 “Accelerating adaptive processes: Product innovation in the global computer industry.” Administrative Science Quarterly, 40: 84–110. Fuentes, Carlos 1990 Myself with Others. New York: Farrar, Straus, Giroux. Glass, David C, and Jerome E. Singer 1972 Urban Stress. New York: Academic Press. Hackman, J. Richard, and Ruth Wageman 1995 “Total quality management: Empirical, conceptual, and practical issues.” Administrative Science Quarterly, 40: 309–342. Janis, Irving L. 1982 Victims of Groupthink, 2nd ed. Boston: Houghton Mifflin. Jones, Edward E. 1993 “The social in cognition.” In G. Harman (ed.), Conceptions of the Human Mind: 85–98. Hillsdale, NJ: Erlbaum. Kaplan, Abraham 1964 The Logic of Inquiry. San Francisco: Chandler. Langley, Ann, Henry Mintzberg, Patricia Pitcher, Elizabeth Posada, and Jan Saint-Macary 1995 “Opening up decision making: The view from the black stool.” Organization Science, 6: 260–279. Maclean, Norman 1992 Young Men and Fire. Chicago: University of Chicago Press. March, James G. 1995 “The future, disposable organizations and the rigidities of imagination.” Organization, 2: 427–440. McCloskey, Donald N. 1988 “The limits of expertise.” American Scholar, 57 (3): 393–406. O’Gorman, Hubert J. 1986 “The discovery of pluralistic ignorance: An ironic lesson.” Journal of the History of the Behavioral Sciences, 22: 333–347. Pfeffer, Jeffrey 1994 Competitive Advantage through People. Boston: Harvard Business School Press. ——1995 “Mortality, reproducibility, and the persistence of styles of theory.” Organization Science, 6: 681–686. Putnam, Ted 1994 “Analysis of escape efforts and personal protection equipment on the South Canyon fire.” Unpublished manuscript. U.S. Forest Service, Missoula Technology and Development Center. ——1995 “Analysis of escape efforts and personal protective equipment on the South Canyon fire.” Wildfire, 4 (3): 42–47. Rogers, Everett M., and Y-C. A. Chen 1990 “Technology transfer and the technopolis.” In M. A. Von Glinow and S. A. Mohrman, (eds.), Managing Complexity in High Technology Organizations: 15–36. New York: Oxford University Press. Rorty, Richard 1982 Consequences of Pragmatism. Minneapolis: University of Minnesota Press. Rumsey, Walter 1949 Testimony. Mann Gulch Transcript: 97–109. Washington, DC: U.S. Forest Service. Said, Edward W. 1994 Representations of the Intellectual. New York: Pantheon.

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Sallee, Robert 1949 Testimony. Mann Gulch Transcript: 69–89. Washington, DC: U.S. Forest Service. Schön, Donald A. 1995 “The new scholarship requires a new epistemology.”Change, 27 (61): 27–34. Starbuck, William H. 1994 “On behalf of naïveté.” In Joel A. C. Baum and Jitendra V. Singh (eds.), Evolutionary Dynamics of Organizations: 205–220. New York: Oxford University Press. Tetlock, Philip E., Randall S. Peterson, Charles McGuire, Shi-jie Chang, and Peter Feld 1992 Assessing political group dynamics: A test of the groupthink model.” Journal of Personality and Social Psychology, 63: 403–425. Thompson, J. D. 1956 “On building an administrative science.” Administrative Science Quarterly, 1 (1): 102–111. U.S. Forest Service 1949 Mann Gulch Transcript. Washington, DC: U.S. Forest Service. 1994 Report of the South Canyon Fire Accident Investigation Team, August 17, 1994. Washington, DC: U.S. Forest Service. Van Maanen, John 1995 “Fear and loathing in organization studies.”Organization Science, 6:687–692. Walsh, James P. 1995 “Managerial and organizational cognition: Notes from a trip down memory lane.” Organization Science, 6: 280–321. Weick, Karl E. 1990 “The vulnerable system: An analysis of the Tenerife air disaster.” Journal of Management, 16: 571–593.

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15 Leadership as the Legitimation of Doubt Setting the Scene ‘Uncertainty hurts business. It annoys individuals. Why keep the whole country, including business and individuals, in uncertainty over the tax burdens to be placed on us?. . . . (Calvin) Coolidge and Congress should ease our minds and grease our activities by reforming and reducing taxation as soon as feasible’ (Goodman, 2007, p. 215). If uncertainty is unwelcome in organizations, equally unwelcome should be the admonition that members should doubt what they think they know. However, that is the very message of this chapter. In an impermanent world, events may be other than they seem and can abruptly turn otherwise. Doubt is adaptability writ large, but certainty is adaptation to current conditions that is written even larger. Certainty is insensitive to change, and doubt is one of the few means to restore that sensitivity. The legitimation of doubt has been a tacit theme in previous chapters. For example, the fifth guideline for people using the STICC format for public sensemaking urges them to ‘calibrate.’ To calibrate is to be attentive to the sensemaking process in ways that uncover doubts about what lies ahead and whether the task is do-able (see p. 215 for STICC). Firefighter Paul Gleason said that when he deliberately engaged in sensemaking, this made it easier for his firefighting crews to doubt an earlier sense of what they faced and easier to replace it with a newer sense. A basic assumption that we started with (Chapter 3) asserted that ambivalence is the optimal compromise. What any group ‘knows’ becomes dated when change is continuous. This is not apparent unless retained knowledge is discredited (Weick, 1969, p. 60) and doubted (Weick, 1979, pp. 224–228). Doubt has its complications (e.g. Hecht, 2004). Several of these are found in Kramer’s (2007) provocative discussion titled Organizing Doubt. He presents a detailed framework, grounded in rhetoric, evolution, and sensemaking, to understand the often senseless world of Dutch armed forces assigned to peacekeeping operations in the former Yugoslavia. These units faced the dual problems of not understanding the conflicts well beforehand (no one did) and not knowing what they would encounter on patrols (e.g. shootings, mines, aggressive local population, road blocks, witnessed atrocities, deplorable living conditions, everyday accidents, and people who did not seem to be in need

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at all). In these crisis operations, units were confronted with unfamiliar tasks, roles, and problems (p. 231). The two assumptions at the core of Kramer’s analysis mirror the themes of Chapter 15: 1.

2.

‘If the environment is dynamically complex it is impossible to know and understand everything in advance, therefore you need to be able to doubt your existing insights’ (p. 17). ‘If the ability to doubt is of crucial importance for organizations dealing with dynamic complexity, organizations need to organize their ability to doubt. . . . (A) spirit of contradiction should be organized’ (pp. 17–18).

To organize doubt is to engage in meaningful argumentation. Matters of controversy are deliberately sought and discussed (p. 134). The intent is to curb the topdown imposition of ‘vision without argumentation’ (p. 141). Kramer shows that doubt becomes organized when sense-discrediting balances sensemaking, but such balancing is fruitless without action since the real problem is being open to the unknown. Real openness implies that a system is open to information that it has never thought of before. For this reason, action is an important informer for systems. . . . If presented with the unknown, systems can be confronted with circumstances in which they need to act before they think. New experiences are therefore the source for discrediting (Kramer, 2007, pp. 74–75).

Action is crucial because doubt, by itself, is dangerous. William Shakespeare made this clear in Act 1, scene 4 of Measure for Measure: ‘Our doubts are traitors, and make us lose the good we oft might win, by fearing to attempt.’ Leaders who legitimize doubt need also to legitimize attempts. That means modulating feelings of fear about what might happen. As Harold Garfinkel (1967) made clear in his discussion of ‘avoided tests,’ once we expect that dire consequences might occur were we to violate a presumed rule, we never act to see if the rule exists or if the consequences are as dire as we imagine. Thus, the presumed negative consequences of action is to forestall taking it. As a result, untested presumptions and unexplored doubts become reality. The resulting pattern of organized relations becomes closed, retained knowledge becomes transformed into complete knowledge, and the current adaptation becomes the final adaptation to circumstances that outrun the pattern. Inserting doubt into an already impermanent organization seeking certainty is not for the faint of heart. However, if circumstances keep changing, and yesterday’s organizing is partially obsolete, simultaneous doubt and belief directed at current functioning is necessary. To legitimize doubt is to act as if ambivalence is the optimal compromise (Weick, 2001, pp. 368–371).

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Leadership as the Legitimation of Doubt Karl E. Weick The following article was published as Chapter 8 in W. Bennis, G. M. Spreitzer, and T. Cummings (Eds), The Future of Leadership: Today’s Top Thinkers on Leadership Speak to the Next Generation, San Francisco, CA: Jossey-Bass, 2001, pp. 91–102 Reprinted with permission.

The purpose of this chapter is to develop an allegory for leadership in the twenty-first century, an allegory built around a moment in Warren Bennis’s life. As he describes in his commentary at the end of this book, Bennis gave an evening lecture at the Harvard School of Education while he was president of the University of Cincinnati. Everything came together in a superb performance. During the upbeat Q and A session after the speech, Bennis was startled when the dean, Paul Ylvisaker, asked quietly, “Warren, do you really love being president of Cincinnati?” Bennis did not have a snappy answer. In fact, he didn’t have any answer. After an interminable silence, in a room that quieted dramatically, Bennis finally said, “I don’t know.” Shortly thereafter, he came to the realization that he loved being a college president but hated doing a college presidency, and left Cincinnati. Why do I flag this as a moment that can carry the message of leadership for an entire century? Notice what Bennis did not say. He did not say, I can’t choose between yes and no. The question of whether he loves being president is not a problem in decision making. It is deeper than that. It is an issue of meaning, direction, and sensemaking. Standing in front of that Harvard audience, Bennis was facing a job, a university, a calling, and his own leadership theories with a mixture of puzzlement, ambivalence, and honesty. Leaders who stand in front of the new millennium and resist the temptation to treat it glibly or breathlessly are in the same position. I want to argue that, given what Bennis faced, he called this one right. When he said, “I don’t know,” that was a strong act of leadership, not a weak one. It was strong because it positioned him for the sensemaking that he needed to do, not for the decision making that would come later as a minor by-product of sensemaking. To lead in the future is to be less in thrall of decision making—and more in thrall of sensemaking (Weick, 1995). That is the theme I want to develop. Think first of the world Bennis faces at the moment of Ylvisaker’s question. It is a world that is partly unknowable and unpredictable. It is a world into which people have been thrown. By thrown, I mean that people can’t avoid acting, can’t step back and reflect on their actions, can’t predict the effects of their actions, have no choice but to deal with interpretations whose correctness cannot be settled once and for all, and they can’t remain silent. Anything they say shapes both events and themselves. These are the givens that shape sensemaking. This feeling of thrown-ness, and the need to make sense of it, are just what we would expect if we took seriously the psychological implications of quantum theory and chaos theory. Both of these theories suggest that the world is less like a machine

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and more like shifting patterns of relationships. These patterns are unknowable because any effort to measure them changes them. These patterns are also unpredictable because very small differences in initial conditions can lead very quickly to very large differences in the future state of a system (McDaniel, 1997). In an unknowable, unpredictable world, sensemaking is all we have. Rueben McDaniel put the point this way: Because the nature of the world is unknowable (chaos theory and quantum theory) we are left with only sensemaking. Even if we had the capacity to do more, doing more would not help. Quantum theory helps us to understand that the present state of the world is, at best, a probability distribution. As we learn from chaos theory, the next state of the world is unknowable. And so we must pay attention to the world as it unfolds. Therefore, it is a good thing that we can’t do more than sensemaking . . . because then we would only be frustrated by our inability to know. But believing enables action, which leads to more sense (sometimes), and taking action leads to more sense (sometimes), and sensemaking connects actions to beliefs (sometimes) [private communication].

It is the combination of thrown-ness, unknowability, and unpredictability that makes having some direction, any direction, the central issue for human beings, and by implication, the central issue for leaders. Sensemaking is about navigating by means of a compass rather than a map. “Maps, by definition, can help only in known worlds— worlds that have been charted before. Compasses are helpful when you are not sure where you are and can get only a general sense of direction” (Hurst, 1995, p. 168). Maps may be the mainstay of performance, but the compass and the compass needle, which function much like human values, are the mainstays of learning and renewal. If people find themselves in a world that is only partially charted, and if leaders also admit that they too don’t know, then both are more likely to mobilize resources for direction making rather than for performance. If I had to convert this broad portrait of leadership challenges into a set of contrasts, they would include the following. As unknowability and unpredictability become more prominent hallmarks of the twenty-first century, we can expect to find conditions such as these: ●

● ●

●

●

●

● ●

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Uncertainty will be based less on insufficient facts and more on insufficient questions. There will be fewer experts and more novices. There will be more of a premium on staying in motion than on detaching and reflecting. There will be more migration of decisions to those with the expertise to handle them, and less convergence of decisions on people entitled by rank to make them. There will be fewer attempts to capture the big picture and more attempts to capture the big story, with its ongoing dynamic, plot. There will more focus on updating and plausibility and less on forecasting and accuracy. There will be more improvisation and fewer routines. There will be more humility and less hubris.

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The Value of Uncertainty If we compress this set of predictions into a singular speculative picture of the effective leader, we can see why that person begins with the assertion, “I don’t know.” The effective leader is someone who searches for the better question, accepts inexperience, stays in motion, channels decisions to those with the best knowledge of the matter at hand, crafts good stories, is obsessed with updating, encourages improvisation, and is deeply aware of personal ignorance. People who act this way help others make sense of what they are facing. Sensemaking is not about rules and options and decisions. Sensemaking does not presume that there are generic right answers about things like taking risks or following rules. Instead, sensemaking is about how to stay in touch with context. In the face of all the recent rhetoric about “new rules,” we are better off playing up the fact of “newness” and playing down the possibility that this newness will necessarily take the form of rules. What’s new is the context. What’s new is the need for direction. What’s new is a premium on updating. And what’s new is the need to fall back on the compass rather than the map. We often run into the image of maps when people reaffirm Count Korzybski’s famous caution, the map is not the territory. Even though the map never was the territory, and even though people still get confused when they forget this, it is conceivable that the image of maps and territories itself is dated, and the lowly compass may be the better image. Even though the compass is not any closer to the territory than is the map, it is much harder to mistake the compass for the territory. A compass makes it clearer that we are looking for a direction rather than a location. And a compass is a more reliable instrument of navigation if locations on the map are changing. Regardless of whether one has a map or a compass, it is less crucial that people have a specific destination, and more crucial for purposes of sensemaking that they have the capability to act their way into an understanding of where they are, who they are, and what they are doing. While the effective leader may sometimes be able to point to a specific destination that people find compelling, it is more likely that the effectiveness lies in the ability to set in motion a process for direction making. When bewildered people ask, “What’s the story?” the crucial thing is to get them moving, observing, updating, and arguing about feasibility and plausibility. A powerful means to do this is for the leader to answer the question by saying, “I don’t know what the story is, but let’s find out.” That reply is more subtle than it sounds. A plausible story is actually not something that one “finds.” When the leader says, “let’s find out,” what the leader really means is, let’s create the story. The good story is not simply lying out there waiting to be detected. Instead, the good story comes from experience that is reworked, enacted into the world, and rediscovered as though it were something external. Bennis and the other leaders know that the discovered story is an implanted story, a story whose origins are more internal than they appear. Let me give an example of what I’ve been talking about by describing a leader and a leadership style that embodies what I have said. This example comes from my research on the antecedents of wildland firefighting disasters. One of the five best wild-land firefighters in the world is Paul Gleason. Much of his fame comes from his work in over five hundred serious fires, as crew chief in charge of nineteen other firefighters from the Interagency Hotshot Crew (the Zig Zag crew). Gleason said that when fighting fires, he prefers to view his leadership efforts as sensemaking rather than decision making. In his words,

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“If I make a decision it is a possession, I take pride in it, I tend to defend it and not listen to those who question it. If I make sense, then this is more dynamic and I listen and I can change it. A decision is something you polish. Sensemaking is a direction for the next period.” When Gleason perceives his work as decision making, he feels that he postpones action so he can get the decision “right” and that after he makes the decision, he finds himself defending it rather than revising it to suit changing circumstances. Polishing and defending eat up valuable time and encourage blind spots. If, instead, Gleason treats an unfolding fire as a problem in sensemaking, then he gives his crew a direction for some indefinite period, a direction that by definition is dynamic, open to revision at any time, self-correcting, responsive, and with more of its rationale being transparent. Gleason’s commitment to sensemaking is striking. When crews fight fires, they post a lookout whose job is to monitor the relationship between the oncoming fire and the crew and to warn if the distance between the two gets too small. On some of Gleason’s especially hazardous fires, where there is danger of rolling rocks or windblown spot fires, he has assigned as many as sixteen people to be lookouts, leaving only four people to actually fight the fire. In the Dude fire near Payson, Arizona, which was an active, dangerous fire, Gleason worked part of the time without gloves so he could get a fuller sense of the weather conditions. He clothed himself as if he didn’t know for sure what his surroundings were. It paid off. The first day of fighting this fire, around 1:45 in the afternoon, he felt a few drops of rain on the back of his hands. He knew there were no thunderstorms in the area, inferred that he must be feeling virga—condensation from a huge column of smoke that had iced over on top and was about to collapse—and he now knew that it was time to act. He moved firefighters into a safety zone just before the column collapsed. When it did so, it pushed fire in all directions and six people who were some distance from his safety zone were killed.

Leading by the Compass Gleason’s example nudges us to think more carefully about what it means to lead when one is thrown into an unknowable, unpredictable context in which the most one can hope for is a plausible direction and plausible updating. Just such a situation is what may have confronted Bennis at Harvard and leaders at the millennium. The nature of leadership when sense is up for grabs has some distinctive properties. I want to suggest that, in the face of doubt, leaders are best served if they focus on animation, improvisation, lightness, authentication, and learning.

Animation Successful sensemaking is more likely when people stay in motion, have a direction, look closely, update often, and converse candidly. This logic derives from the basic process that is involved. That process is embodied in the rhetorical question, How can we know what we think until we see what we say? People need to act in order to discover what they face, they need to talk in order to discover what they think, and they need to

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feel in order to discover what it means. The “saying” involves action and animation, the “seeing” Involves directed observation, the “thinking” involves the updating of previous thinking, and the “we” that makes all of this happen takes the form of candid dialogue that mixes together trust, trustworthiness, and self-respect. What is subtle about all of this is that it is surprisingly indifferent to content. In a way, any old prescription, any old change program, any old mantra or guru or text will do, as long as that program animates people and gets them moving and generating experiments that uncover opportunities; provides a direction; encourages updating through improved situational awareness and closer attention to what is actually happening; arid facilitates respectful interaction in which trust, trustworthiness, and self-respect (Campbell, 1990) develop equally and allow people to build a stable rendition of what they face. Whether people become animated because of “new economic rules,” or total quality, or learning organization, or transformation, or teachable points of view, or action learning, or culture change, or whatever, they are more or less likely to survive depending on whether their program engages or blocks these components of sensemaking. It is the thrust of this argument that there is nothing special about the content of change programs per se that explains their success or failure. What matters is the extent to which the program triggers sustained animation, direction, attention, and respectful interaction. It is these four activities that make it easier or harder for people to collectively make sense of what they are facing and to deal with it.

Improvisation When people are thrown into an unknowable, unpredictable environment, there is also a premium on improvisation. Improvisation can be defined as reworking previously experienced material in relation to unanticipated ideas that are conceived, shaped, and transformed under the special conditions of a current performance (adapted from Berliner, 1994, p. 241). Improvisation involves the flexible treatment of preplanned material. It is not about “making something out of nothing.” Instead, it is about making something out of previous experience, practice, and knowledge during those moments when people uncover and test intuitive understandings while their ongoing action can still make a difference (Schon, 1987, pp. 26–27). What is noteworthy in improvised action is a certain ad hoc adroitness (Ryle, 1979, p. 129). Improvisation materializes around a simple melody, formula, or theme that provides the pretext for real-time composing and embellishment. Outside the field of music, these melodies are the directions that are so important for sensemaking. The role of the leader during improvisation is suggested by Dan Isenberg’s (1985) description of battlefield commanders. On battlefields, commanders often “fight empirically” in order to discover what kind of enemy they are up against. “Tactical maneuvers will be undertaken with the primary purpose of learning more about the enemy’s position, weaponry, and strength, as well as one’s own strength, mobility, and understanding of the battlefield situation. . . . Sometimes the officer will need to implement his or her solution with little or no problem definition and problem solving. Only after taking action and seeing the results will the officer be able to better define the problem that he or she may have already solved!” (pp. 178–179). Commanders essentially hold a

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diagnosis lightly and tie their understanding to activity. This is akin to a simple melody that is embellished until a more appropriate melody emerges from the embellishments. A hunch held lightly is a direction to be followed, not a decision to be defended. It is easier to change directions than to reverse decisions, simply because less is at stake. This is what both Gleason and Bennis have taught us.

Lightness A leader who says “I don’t know” is a lot like a foreman who yells “drop your tools” to wildland firefighters who are trying to outrun an exploding fire. Firefighters who ignore this order and continue to carry heavy tools like chainsaws retreat more slowly. All too often, they are overtaken by the fire and perish. There have been at least twenty-three fatalities just since 1990 where this happened. I think analogous crises occur when a leader says “I don’t know” and followers refuse to drop their heavy tools of logic and rationality. Those tools presume that the world is stable, knowable, and predictable, something the leader has disavowed. The leader who says “I don’t know” essentially says that the group is facing a new ballgame where the old tools of logic may be its undoing rather than its salvation. To drop these tools is not to give up on finding a workable answer. It is only to give up on one means of answering that is ill-suited to the unstable, the unknowable, the unpredictable. To drop the heavy tools of rationality is to gain access to lightness in the form of intuitions, feelings, stories, experience, active listening, shared humanity, awareness in the moment, capability for fascination, awe, novel words, and empathy. All these non-logical activities trigger interpretations that have some plausibility and feasibility. And all these activities are made more legitimate when a leader says “I don’t know.” That admission forces the leader to drop pretense, drop omniscience, drop expert authority, drop a macho posture, and drop monologues. The lightness of listening and exploring is the consequence. Dropping one’s tools to regain lightness and agility is old news. Nowhere is this better stated than in the ancient epigram (Lao Tzu, cited in Muller, 1999, p. 134) that reads, In pursuit of knowledge, every day something is acquired; In pursuit of wisdom, every day something is dropped.

But old as the ties among dropping and lightness and wisdom may be, they tend to be forgotten in an era where leaders and followers alike are preoccupied with knowledge management, acquisitions, and acquisitiveness. When Bennis says to Ylvisaker, “I don’t know,” this comment suggests that something more than a pursuit of knowledge is involved, and something more than acquiring the title of president is at stake. When Bennis says he doesn’t know, that is a polite way of saying, this isn’t about knowledge and acquisitions at all. It is about something different, something more elusive, something more like a quest where the directions are less clear. When any leader suggests that the issue ahead is more about wisdom than knowledge and more about dropping than acquiring, this has an important effect on followers. It makes it legitimate for them to contribute in kind. A leader who drops heavy tools candidly

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and publicly is more likely to encourage similar acts in others. Having dropped their heavy tools, people are in a better position to watch closely and interact respectfully to begin to form some idea of what they do face. The likelihood that this will happen at all depends on their capability for lightness.

Authentication One of the early pioneers in the study of organizational behavior, Harvard’s Fritz Roethlisberger (1977), adds yet another twist to the Bennis prototype for leadership in the future. Roethlisberger was struck by the fact that the vast majority of problems that executives complained about had the same form. He repeatedly heard that many people in organizations were not doing what they should be doing, in spite of numerous policies and standards designed to make sure that workers would do what they should. Accounting people weren’t providing the information they were supposed to, supervisors weren’t supervising, marketing people weren’t working with production people, and so on. In a fascinating conjecture, Roethlisberger said it was as if the organization were undoing all the things the manager did when that person planned, directed, and coordinated. He went on to speculate that the undoing seemed to exhibit the mathematical property of reciprocalness. Thus the relation between the manager and the organization was either like multiplication and division, leaving an identity number of one, or addition and subtraction leaving an identity number of zero. In either case, the executive’s contribution was nil. What Roethlisberger wanted to find out was what was responsible for the apparent undoing. At this point in his discussion, Roethlisberger describes two extended cases where people don’t do what they are supposed to be doing. One is the famous Harvard case called the Dashman Company and the other is a real-life experience of one of his students, a stubborn engineer named “Hal” who was appointed superintendent of maintenance shortly after being exposed to Roethlisberger’s teaching. In the Dashman case, a newly appointed VP of purchasing, Mr. Post, sends out a directive to twenty decentralized purchasing agents saying that from now on, any purchasing contracts over $10,000 should be cleared with the top office. All twenty agents say they will be pleased to cooperate. But nothing happens. Not a single contract crosses Mr. Post’s desk. The case stops with the new VP asking his assistant, Mr. Larson, a veteran of the firm, what he should do. Roethlisberger’s students fumble with diagnoses for most of the classroom hour. With thirty seconds left before the bell, Roethlisberger says the following: If you stop to think for a moment, none of us knows what the situations in the plants really are, because none of us has gone to the plants to find out. We have just been speculating about what the situations there might be. This applies to Mr. Larson in the case as well as to us in the class. Until these speculations are checked, we may be mistaken. Hence, whatever Mr. Larson can say that might help to move matters in this direction may be the first simple step needed. Perhaps Mr. Larson with one sentence can preview a simple logic for Mr. Post to take the first step. So, dear students, please reflect and ponder until we meet at the next hour about what such a simple one-sentence response to Mr. Post’s query, “What should I do now?” should be [pp. 176–177].

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The sentence Roethlisberger was reaching for was this one. Mr. Larson might say, in response to Mr. Post’s question of what he should do now, “I don’t know; but perhaps if you or I or both of us went to visit the plants, we might be able to find out” (p. 177; italics in original). Regrettably, even with days to think about it, few of the students came up with this answer. And those who did often deemed the visit a gimmick to get people to cooperate the way they were supposed to. One student, Hal, who thought it was a gimmick, went back to his plant, was promoted to supervisor of maintenance, and assumed his new position. No sooner had he begun the new assignment than the shop steward called and said, “What the hell is going on in your department?” Biting his tongue, and stifling his overwhelming desire to say, “Who the hell do you think you’re talking to?” Hal said, “I don’t know. Why don’t you come to my office and tell me.” The steward came, voiced the grievances, Hal listened, and they worked through their differences. While these cases may have a quaint 1950s ring to them, set that feeling aside for the moment and look at what is happening. When leaders say “I don’t know,” this is a nonstereotypical response—they are supposed to know—and the response is truthful; it is factual in the sense that it states what the situation is; it establishes leader credibility in an unknowable world; it invites rather than precludes finding out more; it takes advantage of an immediate point of entry into an ongoing, here-and-now situation; and it strengthens rather than weakens relationships. In terms of the seven conditions for sensemaking (social resources, clear identity, retrospect, cue utilization, update of ongoing impressions, plausibility, and enactment ⫽ SIR COPE) the statement “I don’t know” is exemplary because it activates all seven. In turn, that means that the relationship has been fully tuned for sensemaking. When a leader says, “I don’t know,” that seldom stops the conversation. Instead, it invites such follow-on sentences as, I don’t know, “but we might know,” “but you might know and we need to listen,” “but knowing is not the issue here,” “but I know how to find out,” “but let’s talk to see what we do know for sure.” Any of these follow-ons authenticate doubt, unknowability, and unpredictability as the point of departure.

Learning The final and most obvious outcome of leadership acts that begin with not knowing is that they often end with something learned. A particularly vivid example of this point is Winston Churchill’s reworking of one of the darkest moments in his life. During World War II Churchill made a colossal error when he failed to realize how vulnerable Singapore was to attack by a Japanese land invasion. This error led to Singapore’s downfall. After the collapse Churchill asked four questions: Why didn’t I know? Why wasn’t I told? Why didn’t I ask? Why didn’t I tell what I knew? (See Allinson, 1993, pp. 11–12.) Those four questions are questions of interdependence. They are questions of sensemaking. And they are questions that are grounded in doubt. Those four questions take seriously the idea that knowledge is not something people possess in their heads but rather something people do together. That seems to be the wisdom that lies behind Bennis’s answer at Harvard. It is a wisdom that future leaders should take seriously if they want to deal candidly with what they face. It is a wisdom stripped of hubris. The leader willing to say “I don’t know” is

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also a leader willing to admit, in Oscar Wilde’s wonderful phrase, “I’m not young enough to know everything” (Kellman, 1999, p. 113).

References Allinson, R. E. (1993). Global Disasters. New York: Prentice-Hall. Bennis, W. (1999). The Future Has No Shelf Life: An Intellectual Memoire. Unpublished Manuscript. University of Southern California, Marshall School of Business, 3670 Trousdale Parkway, Los Angeles, CA 90089-0808. Berliner, P. F. (1994). Thinking in Jazz: The Infinite Art of Improvisation. Chicago, IL: University of Chicago Press. Campbell, D. (1990). Asch’s moral epistemology for socially shared knowledge. In I. Rock (Ed.), The legacy of Solomon Asch: Essays in cognition and social psychology (pp. 39–52). Hillsdale, N.J.: Erlbaum. Hurst, D. K. (1995). Crisis and renewal. Boston, MA: Harvard Business School. Isenberg, D. (1985). Some hows and whats of managerial thinking: Implications for future army leaders. In J. G. Hunt & J. D. Blair (Eds), Leadership on the Future Battlefield (pp. 168–181). Dulles, Va: Pergamon-Brassey’s. Kellman, S. G. (1999). Swan Songs. The American Scholar, 68(4), 111–120. McDaniel Jr, R. R. (1997). Strategic leadership: a view from quantum and chaos theories. Health Care Management Review, 21–37. Muller, W. (1999). Sabbath: Restoring the Sacred Rhythm of Rest. New York: Bantam. Roethlisberger, F. J. (1977). The Elusive Phenomena. Cambridge, MA: Harvard University Press. Ryle, G. (1979). Improvisation. In On thinking (pp. 121–130). London: Blackwell. Schon, D. A. (1987). Educating the Reflective practitioner. San Francisco, Ca: Jossey-Bass. Weick, K. E. (1995). Sensemaking in Organizations. Thousand Oaks, Ca: Sage.

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Epilogue

The preceding essays are reflections on the fugitive quality of organizing. Concepts, routines, and texts momentarily impose some permanence on flux, but conversations, experiences of thrownness, and wary improvisation reinstate the flux. My intent was to demonstrate that something as seemingly monolithic as the organization is actually a site where social order is precarious and continually reaccomplished. This is all a lot less tidy than it appears from a distance, which is why these essays are grounded in what are referred to as ‘micro’ level concepts. My focus is on human struggles and getting closer to experience. I take my inspiration from the Australian historian, Greg Dening:1 To give back to the past its present is to slough off certainties and to imagine people looking at possibilities. We are comfortable in our view of the past. The past happened in a totally particular way in space and time. That is its realism. All the possibilities of what might have happened are reduced to one. The energies of historical enquirers are focused on discovering what that one possibility was. But by that we have not re-presented the past. To do that we have to enter into the experience of those actors in the past who, like us, experience a present as if all the possibilities are still there. If a historian’s ambition is to describe how people actually experienced their lives, then that historian has to slough off many certainties. To give back to the past its present, one has to be a little humble about what one can know (Dening, 1996, pp. xv–xvi).

The five ideas that are repeated most often in the preceding chapters are Marianne Paget’s insight that acts become mistaken; Ron Westrum’s ego-centered fallacy of centrality; Ellen Langer’s description of mindfulness as the refinement of distinctions; Hari Tsoukas’s argument that generalizing is the central move in organizing; and Reuben Baron and Stephen Misovich’s articulation of the tradeoffs involved in the shareability 1

In Dening’s obituary, Dipesh Chakrabarty writes, ‘As Dening said in his semi-autobiographical “Beach Crossings: Voyaging across times, cultures and self ” [2007], in life as in work “the gamble is being yourself.” Even that fragment of a sentence is very Dening. He believed in the gerund form over the plain noun, for life was in the living of it, not in the word “life.” Nouns froze things too much for this taste. History was always history making, caught up in human activity, of the past and the present’ (The Sydney Morning Herald, April 11, 2008).

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constraint. If we infer a line of argument from just these five ideas it would assert that organizing creates organization out of generalizations, hindsight, and the conversion of knowledge by acquaintance into shared knowledge by description. We generalize in the interest of cohesion, but that generalizing is costly. Selective perception and editing are inevitable and substantial. People, however, often remain unaware of just how much goes unnoticed because they presume that their central position (everyone is central in some hierarchy) gives them a comprehensive picture. This fallacy of centrality undercuts both the presumption that things could be otherwise and the curiosity to see just what that ‘otherwise’ might be. Unconstrained abstracting leads to a condition where people know less and less about more and more. To reverse this condition, people try to capture nuances, refine distinctions, pay closer attention to particulars, invent new categories; in short, they try to act more mindfully. Mindful action is accomplished by refining one’s stock of concepts, by enlarging one’s action repertoire, by more focus on relationships of respectful interaction and heedful interrelating, and by the implementation of principles for high reliability organizing. The preceding essays are informed by an interpretive framework that is grounded in sensemaking. To focus on sensemaking is to ‘portray organizing as the experience of being thrown into an ongoing, unknowable, unpredictable streaming of experience in search of answers to the question, “what’s the story?” Plausible stories animate and gain their validity from subsequent activity. . . . Small structures and short moments can have large consequences’ (Chapter 8, p. 132). Lying just below the surface in many of the previous discussions is the implication that imagination is an imperative for organizational life (Weick, 2005). Imagination assumes this role because organization is not a stable identifiable entity. Instead, what exists is organizing: . . . an ongoing process of mediation in which the objective world where we live and interact both frames what we do and supplies us with the material for our own reconstruction of it. What we think of as organization is what is left over as a trace or memory of yesterday’s organizing. . . . (B)y the time we recognize the organization it is no longer there. What is there is our transformation of it; what makes it recognizable – recognizable – is precisely its no longer existing (Taylor and Van Every, 2000, p. 163).

When I am quizzed about my life in organizations, my referent is yesterday’s organization and my experience of it. However, that organization no longer exists. Yesterday’s organizing, viewed in hindsight, is all the tangible social reality we have to live with and theorize about. There is good reason to be humble.

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Index

abductive reasoning 39–44 Abernathy, C.M. 157 Abhidhamma 86, 89, 94 Abolathia, M.Y. 196 absorbed coping, concepts 40–2, 73–5 ‘abstract concepts’, Thompson’s four guidelines for inquiry 248–50, 254–7 action rationality, decision rationality 162–3, 181–6, 244 actions see also enacting concepts 4–8, 10, 16, 27–44, 66–81, 122–7, 130–48, 153–70, 173–221, 273–4 doubt 262–71 enacted environments 6, 189–204 entrapment cultures 175–86 information overload 66–81 organized sensemaking 136–48 positive organizing 207–20 active systems 162–70 actors 22–3, 139, 144–8, 181–6, 189–90, 199–204, 257 adaptation/adaptability theme 18, 21, 32, 51, 59–60, 137, 141, 189–204, 217–20, 229–39, 248–57 see also changes; doubt; dropped tools adjustment types, enactment 194–204 Administrative Science Quarterly (ASQ) 243, 245, 247–57 advanced beginner stage of expertise 76–8, 100–1 adversity 153–86

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AES see Applied Energy Systems agents 4–8, 33, 51, 59–60, 131–48, 190–204 air traffic control systems 101, 145, 196–7 aircraft carriers 101, 164, 217–18 airline pilots 15–16, 58–9, 248 Albert, S. 142 alert state, mindfulness 92–3, 98–103 alertness concepts 31–44, 92–3, 98–103, 117–27 Allinson, R.E. 270 Allport, Floyd 12 ambivalence assumption concepts 10, 18–23, 55–61, 213–14 indecisiveness contrasts 20 analysis 8, 9–23, 117–27, 144–8, 211–20 anchors concepts 6–8, 12–13, 109–28, 129–48, 207–20 faith 6, 27–44 recurrence 6, 119–27, 140–8 animation 226–39, 266–71, 274 see also changes leadership focus area 266–7 anticipation 13–14, 124–7 Apple 233 Applied Energy Systems (AES) 57 approximations 58–9 see also retrospect ardent state, mindfulness 92–3, 99–103 argumentation levels, interdependencies 55–61

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282

INDEX

Argyris, C. 237 arrhythmia 157–8 arrogance of optimism 118–19, 212–20, 271 articulation, definition 138 Asch, S.E. 216, 218 Asda 230 Ashby, Ross 159 assumptions ambivalence assumption 10, 18–23, 55–61, 213–14 complexity assumption 10, 20–3, 47–61 concepts 10–23, 32–44, 117–27, 189–204 as context 15–21 continuity assumption 10, 15–23 entrapment cultures 177–86 evolution assumption 10, 17–23, 130, 138–48, 194–204 inertia 232–5 information overload 70–3 levels of analysis assumption 10, 21–3, 117–27, 144–8, 211–20 organizing 11–23 social order 10–23 unfreezing 237–9 Atlan, H. 4 attend activities see also distributed sensemaking; information overload; mindfulness concepts 8, 45–105, 110–27, 176, 189–90, 273–4 Austin, Lambert 123 authentication, leadership focus area 266, 269–70 ‘automatic pilot’ 112–13, 117–27 autonomy of professionals, medical care systems 184–5 awareness concepts 91–103, 117–27, 140–8 see also mindfulness Baron, R.M. 114–15, 161, 273–4 Barrett, F.J. 238 Bartlett, C.A. 230 Bartlett, Sir Frederic 109 Bate, P. 233, 238 Bateson, Gregory 12 battered child syndrome, background 8, 9, 28–44, 160–3, 167 battlefield commanders 267–8

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Battlement fire 216 ‘be where you are with all your mind’ 42, 89 becoming 14–15 Beer, M. 227, 235 behavioral commitment issues, sensemaking 176–86, 235–9 believing concepts 28–9, 32–5, 37–44 definitions 37–9 faith 37–9 seeing 34–5, 86–103, 113–16 Benner, P. 76–8, 101, 133–4, 137–8, 162, 167, 214 Bennis, W. 262, 263–71 Bhopal disaster 209, 215 bioterrorism 51–61 blame cultures 184–6 blind spots enacted environments 193–4, 202–4 entrapment cultures 176–86 blurred images 109–27 Boden, Deirdre 198 Bodhi, B. 86, 97 Boeing 120 Boettinger, Henry 9 Bolsin, Dr Stephen 180 Boschetti, C. 6 Bosk, Charles 158 boundary conditions 40–2, 73–5, 160–3, 167–70 bracketing, organized sensemaking 134–48, 225–7 brands 97 breakdowns 11–23, 28–44, 76–81, 100–1, 109–27, 140–8, 207–20 Breaking the Code of Change (Beer & Nohria) 227 Bristol Children’s Hospital (BCH) 178–9 Bristol Royal Infirmary 14, 110, 143, 167, 175–86 see also entrapment cultures background 175–6, 177–83 CEO (Dr John Roylance) 180–2 discussion 183–6 early complaints 179–80 inquiry 180–3 justification issues 176–86 optimism effects 110, 180–6 reconstructed history 183–6 small entrapment actions 175–6, 177–86 British Rail 233

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INDEX

bronchospasm 157–8 Brown, A. 143 Brown, K.W. 99 Brown, S.L. 230 Brunsson, N. 162–3 Buddhism 86, 89–103, 130, 176, 244–5 see also Eastern . . . ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 176, 244–5 concepts 90–1, 97, 130 core message 90–1 Butcher list, information overload 65 California Management Review 176–88 Cameron, Kim S. 208, 220 Campbell, Donald 12, 17, 18–19, 139, 163–4, 213–14, 216, 236 capabilities, linguistic categorizing capabilities 16 ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 176, 244–5 Cartesian anxiety 32 Center for Disease Control and Prevention (CDC) 6, 47–61 certainty, doubt 261–2 chains of errors 14 Challenger disaster 54, 118, 183, 203, 209 changes change within change 6, 226–39 codes of change 239 concepts 6, 7, 85–103, 223–71 continuous change 6–8, 101–3, 130–48, 225–39 definitions 229–32 doubt 261–71 dropped tools 6, 124–5, 243–57, 268–9 emergent change 225–39 episodic change 225–9, 231–9 impermanent organizations 3–8 inertia 232–5 legitimation of doubt 261–71 mindful attention 6, 189–90 planned change 225–9, 231–9 programmatic change assumption 235–7 programs 226–39 rates of change 154–5 recurrence 6, 225–39 rise and fall of patterns 6–8, 225–39

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283

sensing mechanisms 35 social order 3–8 unfreeze-change-refreeze 7, 225–9, 237–9 chaos 4, 8, 12–13, 32–3, 36–7, 60, 134–48, 204, 263–4 see also complexity theory Chernobyl 215 Chia, Robert 3–4, 8, 48–9, 90, 133, 134, 135, 225 child abuse 8, 9, 28–44, 160–3, 167 Chisholm, D. 118–19, 212 Chittipeddi, K. 142–3 Chrysler 196–7 Churchill, Winston 270 Citibank 196–7 Clegg, S. 190–1 clinical interpretation, concepts 162–3 closed systems see also systems system theories 167–70, 214 co-evolution theory 56, 59–60, 130, 138–48 codes of change 239 codification, abductive reasoning 39 cognitive dissonance 11, 13–14, 42, 119–21 cognitive interdependencies, concepts 54–61 cognitive processes 11, 12, 13–14, 28–44, 47–61, 69–70, 114–27, 130–48, 189–204 information overload 69–70 interdependencies 47–61 mindfulness 95–6 sensemaking 55–61, 114–16, 130–48, 273–4 cognitive psychology 142–3 Cohen, M.D. 6 collective cognition effects, sensemaking 55–61 collective mindfulness 16 collective sensemaking 6, 9, 16, 47–64, 145–8 Collins, J.C. 230 Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27 background 109–27 channeling decisions to experts 125–7 conclusions 126–7 Crater computer model 120–1, 124 foam shedding 109, 111, 113–14 in-family/out-of-family problems 119–21 labeling 120–1

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284 Columbia shuttle (continued ) mindful abstracting 113–16 mindful organizing 116–27 preoccupation with failure 117–27 reluctance to simplify 119–27 resilience/anticipation issues 124–7 sensitivity to operations 121–7 standards of proof 118–19 STS-114 mission 122 commitment issues, sensemaking 176–86, 235–9 communications, organized sensemaking 137–48, 183, 199–204 compasses/maps, sensemaking 264–8 competence change drivers 235–9 stage of expertise 76–8, 100–1 competitive advantages 97 complex adaptive systems 51, 59–60 complexity see also simplicity assumption 10, 20–3, 47–61 concepts 4, 10, 20–3, 32–3, 47–61, 262–71 doubt 262–71 sensemaking 56–60 complexity theory 22, 32–3, 36–7, 47, 51, 59–61 see also chaos substitutions 59–60 complication issues, information overload 72–3 compound abstractions 28–9, 34–44, 113–27 compounding of adversity 157–9 computational information processing perspectives, information overload 70–3, 75, 165 computer service centers 17 concentration concepts 91–103 see also mindfulness conceptions mindfulness 85–103 perceptions 34–44, 51, 110–27, 161–3, 273–4 conceptual slack 153–4 see also requisite variety confirmation bias 14, 177–86 confused complexity periods, learning 20–1 consciousness, mindfulness 90–103

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INDEX

consequences, explanations for the failure to drop tools 253–4 content, mindfulness 85–103 context assumptions as context 15–21 enactment 195–6 ideas as context 13–15 continuity assumption, concepts 10, 15–23 continuous change 6–8, 101–3, 130–48, 225–39 control factors, explanations for the failure to drop tools 252–4 conversations see also smoke concepts 4–8, 33, 39–42, 109–27, 131–2, 200–4, 219–20 Cook, R.I. 166 cooperation, independent persons 3 coordination by mutual adjustments 55–61, 114–16 changes 233–9 inertia 233–4 requisite variety 161–3 Corriado, R. 6 Crater computer model 120–1, 124 creation of viable realities 10 criterion problem, Thompson’s four guidelines for inquiry 248–50, 254–7 crucial assumptions 8, 9–23 crucible of the quotidian 9 crystal see also redundancy; regularity; repetition; texts smoke contrasts 4, 6, 32–3, 37, 42 cues 7, 35, 41, 49, 57–61, 95–103, 129–48, 190–1, 219–20, 270 cultural issues 31–44, 117–27, 175–86, 215–20, 238–9 see also entrapment cultures blame cultures 184–6 cultures of fear 184–5 definition 177 emergent change 225–39 ‘culture of invincibility’ 119 Cummings, T. 262 curiosity 18–19 Czarniawska, Barbara 3, 11–12, 144, 189, 203, 231

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INDEX

Daft, R.L. 8, 162 danger signals, sensemaking resources 7, 16, 127 Dashman case 269–70 decision making see also expertise Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27 conclusions 79–81 hierarchy issues 125–6, 183–4, 264–6 information overload 6, 65–81 migrating decisions 125–6, 264–6 rational decision making 141–2, 147, 162–3, 167–70, 181–6, 244 sensemaking contrasts 265–6 deliberation levels, interdependencies 55–61 Dening, Greg 273–4 determinate systems 168–70 see also systems Dewey, John 5–6, 14–15, 37, 39–40, 66, 72–3, 81, 208 Dhasmana, Dr Janardan 179–80 Diablo Canyon nuclear power station 153–4 diagnoses bizarre diagnoses 36 SLE 49–61 treatments 28–44, 157–70 West Nile virus 6, 9, 47–64 differentiated expectations 85–103, 112–27, 134–48, 273–4 see also labeling; mindfulness disasters 39–42 see also interruptions discarding concepts 28–9, 32, 35–44 definitions 35–6 disconfirmation 140–8 discontent 7–8 disruptions, mindfulness 85–6, 90, 95–103, 131–2 distinctions, mindfulness 85–103, 110–27, 273–4 distributed information processing, interdependencies 54–61 distributed organizations 5 distributed sensemaking, concepts 6, 47–61, 132, 145–8 distributed systems Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27

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285

perceptions 109–27, 161–3 disturbances, systems theory 159–70 divergent perspectives 153–70 diversity 59–60, 153–70 see also variety Dixon, N.M. 238 Dodge, Wagner 216, 250–4 dogma 186 double interacts 22–3 doubt actions 262–71 benefits 261–71 compasses/maps 264–8 complications 261–2 concepts 6, 15, 19–20, 38–9, 55–61, 85–103, 153–70, 216–20, 261–71 dynamic complexity 262 knowing balance 19–20, 38–9, 153–4, 216–20, 261–71 leadership challenges 261–71 legitimation of doubt 261–71 sensemaking 6, 15, 19–20, 38–9, 55–61, 153–4, 216–20, 261–71 Dreyfuss, H.L. 76–7, 100 Dreyfuss, S.E. 76–7, 100 Driebe, Dean J. 49 dropped tools 6, 124–5, 243–57, 268–9 concepts 243–57, 268–9 examples 247–8 explanations for the failure to drop tools 251–4, 257 identity 253–4, 257 ‘law of the instrument’ 248 Mann Gulch fire disaster 12, 23, 41, 129–30, 209, 211, 216, 243–57 preserved patterns 6, 243–57 South Canyon disaster 216, 247, 250–7 Thompson’s four guidelines for inquiry 248–50, 254–7 Dude fire, Arizona 266 Dutch troops 261–2 Dutton, Jane E. 208, 220 Eastern philosophy/psychology 6 Buddhism 86, 89–103, 130, 176, 244–5 concepts 6, 35, 85–103, 130, 176, 244–5 impermanence 6, 35, 85–103 mindfulness 6, 35, 85–103 ‘not wobbling’ capabilities 86–7, 89–103 Western connections 99–103

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286

INDEX

Eco, U. 201 ecological change 139–48, 194–204 see also evolution . . . economists, potential threats 256–7 Edmunds, A. 65 egolessness, ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 176, 244–5 Eisenberg, Eric 32, 57 Eisenhardt, K.M. 230, 257 electricity analogy, information overload 65, 74–5 emergence theory 51, 56, 59–60, 230–9 emergent change see also changes concepts 225–39 conclusions 238–9 definition 229–31 inertia 232–5 planned change 231–2 in practice 229–30 programs 226–39 theory 230–1 emotions 18–23, 41, 94–5, 132, 144–8 empirical studies, information overload 71–2, 80–1 enacted environments blind spots 193–4, 202–4 concepts 6, 189–204 definition 189–90, 193–4 illustrative delimiting examples 196–7 presumptions 197–204 shortcomings 193, 194, 202–4 enacting 6–7, 28–44, 49, 58–61, 66–81, 130–48, 189–204, 218–20, 270, 274 see also actions; agents; cognitive processes; order adjustment types 194–204 concepts 6, 28–9, 32–44, 58–61, 66–81, 139–48, 189–204, 218–20, 270, 274 context 195–6 critique 193, 194, 202–4 definitions 36–7, 58–9, 189–90, 193–5 environmental issues 6, 189–204 examples 58–9 faith ties 37 flux 6, 134, 189–204 historical background 189–90, 195–6 illustrative delimiting examples 196–7

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improvisation 37, 190–204 information overload 66–81 perceptions 198–204 precision concerns 194–5 presumptions 197–204 sensemaking 36–7, 49, 58–61, 139–48, 189–204, 218–20 shortcomings 193, 194, 202–4 enactment theory 139–48 entrapment cultures blind spots 176–86 concepts 14, 175–86 definition 177, 182 justification issues 176–86 entropy 32, 59–60, 209–10, 214–20 environmental issues complexity assumption 20–1 enacted environments 6, 189–204 inertia 232–5 intraorganizational evolution 130, 138–48 systems 12, 15, 22–3, 56, 59–60, 153–70 epilogue 273–4 episodic change 225–9, 231–9 see also changes epistemology 201–4 ESR 139–48 ethnocentrism 167, 190–1, 195–6 evidence 4, 27–44 evolution assumption concepts 10, 17–23, 130, 138–48, 194–204, 207–8 intraorganizational evolution 130, 138–48 experiences 4–8, 10, 12, 27–44, 57–9, 99–103, 122–7, 131–48, 189–204, 219–20, 267–8, 273–4 expert stage of expertise 76, 78 expertise see also decision making; listening Columbia shuttle (STS-107) tragedy 125–7 concepts 7–8, 12, 76–81, 98–103, 125–7, 164–70, 218–20, 264–6, 274 five stages 76–8, 100–1 hierarchy issues 125–6, 183–4, 264–6 HRO processes 7, 98, 101–3, 112–27, 164–70, 218–20, 274 information overload antidote 75–81 Exxon Valdez disaster 209 F-15 pilots 132 façade maintenance, productivity studies 13

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INDEX

fact, faith 3 faction 10 failures concepts 7–8, 16, 17, 28–44, 98–103, 109–27, 159–70, 209–20, 253–4, 274 explanations for the failure to drop tools 253–4 HRO processes 7, 98, 101–3, 112–27, 164, 175–6, 218–20, 274 systems 159–70 faith 3, 4, 23, 27–44 anchors 6, 27–44 believing 37–9 concepts 4, 6, 23, 27–44 definition 27–9, 38–9 enacting ties 37 ‘faith that we are right’ step 23, 38–9 fallacy of centrality 36, 167, 273–4 false negatives/positives, systems 166–7 Farjoun, M. 110, 127 fatality investigations 86–7, 98–103 FBI 67–9 fear 18–19, 184–6 fears of punishment 184–6 feedback loops 3–8, 38–9, 185–6, 194–204 feelings 18–23, 41, 94–5, 132, 144–8 Feldman, Martha 37, 234 Ferriani, S. 6 Festinger, Leon 12, 13–14 fictions see also permanence illusions concepts 6–7 fingerprints 67–9 firefighters 6, 9, 14, 19, 36, 56, 75, 86–103, 129–30, 196–7, 207–20, 243–57, 265–9 see also dropped tools five bags medical error 157–9 Five-Hundred-Dollar-Bill Theorem 256 Flin, Rhona 75 flow charts, system diagrams 169–70 flux enacting 6, 134, 189–204 organized sensemaking 134–48, 225–7, 273–4 foam shedding, Columbia shuttle (STS-107) tragedy 109, 111, 113–27 ‘focus on relationships’, Thompson’s four guidelines for inquiry 248–50, 254–7 focused state, mindfulness 92–103 Follett, Mary Parker 190

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287

Ford, J.D. 238 Ford, L.W. 238 ‘Four Foundations’, mindfulness 91–3, 99–100 frames of reference 7, 132–3, 154, 185–6, 219–20 see also identity freezing, unfreeze-change-refreeze 7, 225–9, 237–9 fugitive quality of organizing 273–4 fulfilment 208–20 functional deployment, labeling 134–5 The Future of Leadership . . . (Bennis, Spreitzer, Cummings) 262 garbage cans 6 Garfinkel, Harold 12, 189, 195, 262 gastritis 157–8 Geertz, Clifford 10 Gehman, H.W., Jr 22 generalizations 34–5, 96–7, 102–3, 273–4 see also simplicity generation of texts, concepts 5–8 generic existential strategy 4–5 Ghoshal, S. 230 Gioia, D.A. 131–2, 140–1, 142–3, 232 Gleason, Paul 19, 49, 56, 176, 216, 261–2, 265–8 globalization 145 Goffman, Erving 129 Goleman, D. 97 greed axiom 256–7 Greenwood, R. 145, 190, 194 groundlessness concepts 32 guesses in an unknowable world 27–9, 38–44 Gunaratana, B.H. 91, 94 Guttman scale 54 habits 37, 72–3 see also routines Hackman, Richard J. 255–6 Ham, Linda 118, 122, 125–6 Hamm, R.M. 157 Hammond, Dr Phllip 180 Handbook of Organizational Decision Making (Starbuck & Hodgkinson) 66 handoffs, Columbia shuttle (STS-107) tragedy 109–27 Harmon-Jones, C. 14 Harmon-Jones, E. 14 Harrowitz, N. 39

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288 ‘having the bubble’ 121–2 heart disease 157–8 heedful interrelations within groups concepts 154–5, 158–70, 207–20, 274 properties 218 Heidegger, M. 10, 14, 40, 73–5, 199 Hein, Piet 22 help requests, requisite variety 165, 167 Hendry, C. 225, 237 Henig, R.M. 56 heterogeneous agents 51, 59–60 hidden transformations in an author’s mind 12–13 hierarchy issues, expertise 125–6, 183–4, 264–6 high reliability organizations (HROs) see also expertise; failures; operations; resilience; simplicity concepts 7–8, 20–1, 98–9, 101–3, 109–27, 164–70, 175–6, 218–20, 274 high reliability theory (HRT) 112–27 hindsight 165–6, 210–11, 273–4 hindsight bias 210–11 Hodgkinson, G. 66 holding patterns 58–9 HROs see high reliability organizations HRT see high reliability theory Hughes, J. 145 human condition 12, 15–16, 195–204, 207–20 human errors 14, 28–44, 153–72, 175–86 humility 264–6, 270–1, 274 Hurst, D.K. 264 Hutchins, E. 47, 60, 202 ideas cognitive dissonance 11, 13–14 concepts 11–23 as context 13–15 generation concepts 11–23 truth 14–15 unanticipated consequences 13–14 wisdom 14–15 identity 7, 41, 49, 57–61, 129–48, 190–1, 194–204, 219–20, 253–7, 270 see also frames of reference construction issues 142–3 definition 142 explanations for the failure to drop tools 253–4, 257

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INDEX

sensemaking 129–30, 142–8, 190–1, 194–204, 219–20, 270 imagination 31, 41–2, 274 impermanence see also mindfulness ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 130, 176, 244–5 concepts 3–4, 6, 86, 91, 93–103, 130, 176, 225–39, 244–5 definition 3–4, 6, 93–5 extent of impermanence 154–5 feelings 94–5 qualities 94–5 selflessness quality 94–5, 101–3 truth 32–3 unsatisfactoriness quality 94–5, 101–3 variety 4, 33, 60, 153–70 impermanent collaborations 6 impermanent organizations see also permanence illusions concepts 3–8, 9–23, 48–61, 93–103 definition 3–4 infrastructures 27–44, 189–204 wisdom 10–23 impression management, concepts 13–14 improvisation 7, 28–44, 102–3, 124–7, 147–8, 190–204, 211–20, 266–8, 273–4 see also resilience concepts 37–44, 102–3, 124–7, 266–8, 273–4 definition 267 enacting 37, 190–204 leadership focus area 266–8 wary improvisation 37–8 in-family problems 119–21 inaccuracy findings, management perceptions 141–2 incident commanders 75 indecisiveness, ambivalence contrasts 20 independent persons, cooperation 3 individualistic cultures 202–3 inertia concepts 232–9 images of organization 233–4 inexplicable, unexplained 129–30 informal system theories see also systems concepts 166–70

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INDEX

information conflicts, variable disjunction of information 48–9 information overload actions 66–81 assumptions 70–3 Butcher list 65 cognitive processes 69–70 complication issues 72–3 concepts 6, 65–81, 141–2 conclusions 79–81 coping strategies 69–70 critique 72–81 definitions 65, 69–70 electricity analogy 65, 74–5 empirical studies 71–2, 80–1 enacting 66–81 expertise antidote 75–81 information processing perspectives 70–3, 75, 165 interpretation aspects 72–81 interruptions 70–5, 78–81 listening 71–81 meaning 72–3, 75–81 mechanisms of adjustment 69–70 perceptions 69–81, 141–2 reconceptualizing overload 76–81 rethinking the assumptions 72–5 sensemaking 6, 65, 73–81, 141–2 significance factors 66, 72–81 symptoms 68–70 thrownness 72–81 time pressures 70–81 transitory aspects 66–81 understanding 66–81 information processing perspectives, information overload 70–3, 75, 165 infrastructures, impermanent organizations 27–44, 189–204 inputs information overload 65–81 systems theory 159–70 inquiry impediments, levels of analysis assumption 10, 21–3 insights, mindfulness meditation 97–103 instigations to sensemaking 140–1 institutions, sensemaking 132, 144–8, 190–1, 198–9, 201–4 intellectual capital 65–81 intelligence, interconnectivity product 47–8, 57–61

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interactions 7, 12, 22–3, 154–70, 207–20 Interagency Hotshot (Zig Zag) Crew 265–6 interconnectivity product, intelligence 47–8, 57–61 interdependencies 22–3, 47–61, 146–7, 154–70, 185–6, 195–204, 270–1 cognitive processes 47–61 distributed information processing 54–61, 165 reciprocal interdependencies 55–61, 195–204 INTERPOL 67–9, 81 interpret activities Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27, 130–48 concepts 8, 12, 16, 17–18, 72–81, 107–72 information overload 72–81 process of organized sensemaking 129–48 requisite variety 153–70 variety mitigates adversity 153–70 interruptions see also sensemaking concepts 10, 12, 14–15, 39–40, 70–5, 78–81, 95–103, 131–48 definition 10, 39 information overload 70–5, 78–81 recovery 39–40, 102–3, 131–2 resilience 41–2 types 39–40 intraorganizational evolution 130, 138–48 Irwin, Robert 34–5, 87, 113–14 Isenberg, Dan 267–8 James, William 3, 5–6, 8, 12, 18–19, 23, 32–3, 36–8, 41, 74, 110, 189, 213–14 Jennings, P.D. 145, 190–1, 194 Jobs, Steve 233 Journal of Management Inquiry 87 just-in-time learning 124 justification issues definition 181 explanations for the failure to drop tools 251–4 sensemaking 176–86, 202–3, 251 Kabat-Zinn, J. 92, 100 Kahn, R.L. 32, 169–70 Kant, Immanuel 51 Kaplan, A. 248 Katz, D. 32, 169–70

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290 Kellman, S.G. 271 Kelman, Steve 41 Kempe, Henry 31–2 Kentucky Fried Chicken (KFC) 230 key ideas 7–8, 27–44, 273–4 Kierkegaard 40 Kilbourne, Edwin 56 Kilduff, M. 196 Klein, Gary 12, 134, 148 knowing doubt balance 19–20, 38–9, 153–4, 216–20, 261–71 enactment 201–4 knowledge by acquaintance 34–5, 114–16, 274 by description 34–5, 114–16, 274 creation 255–6 Kock, N. 66, 73, 81 Korzybski, Count 265 Kouzes, J.M. 230 Kramer, E.-H. 6, 261–2 Kuhnian version of science 256–7 labeling see also differentiated expectations; regularity; routines; streaming experiences Columbia shuttle (STS-107) tragedy 120–1 concepts 27–9, 32–44, 81, 87, 110–27, 134–48, 163–4, 273–4 definitions 33–4, 134–5 functional deployment 134–5 ‘seeing is forgetting the name of the thing seen’ 34–5, 87, 113–16 Landau, M. 118–19, 212 Langer, E. 35, 85–6, 90, 95–6, 99–100, 117, 273–4 Langton, Christopher 4 language, concepts 5–8, 131–48, 226–7 Lao Tzu 244 Latour, B. 199–200, 203 ‘law of the instrument’, dropped tools 248 Law of Requisite Variety 159–60 see also requisite variety LCES structure 19, 208, 215–20 leadership 8, 49, 90, 180–6, 261–71 animation focus area 266–7 authentication focus area 266, 269–70 challenges 264–71 compasses/maps 264–8

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exemplary leaders 265–6 focus areas 266–71 improvisation focus area 266–8 learning focus area 264–6, 270–1 legitimation of doubt 261–71 lightness focus area 266, 268–9 Paul Gleason 19, 49, 56, 176, 216, 261–2, 265–8 Leape, L. 157 learning concepts 8, 14, 18, 20–1, 32–3, 36, 80–1, 124–7, 130–48, 162–3, 183–6, 201–4, 223–71 confused complexity periods 20–1 curves 180–1 dropped tools 248–57 just-in-time learning 124 leadership focus area 264–6, 270–1 mistakes 130–48, 183–6, 212–13 unlearning 248–57, 268–9 legitimation of doubt 261–71 levels of analysis assumption 10, 21–3, 117–27, 144–8, 211–20 Lewin, Kurt 225, 237–8 liabilities, concepts 6, 9, 110, 175–86 lightness leadership focus area 266, 268–9 linguistic categorizing capabilities 16 listening see also expertise concepts 5–8, 21, 42, 71–81, 116–27, 251–4, 268–9 explanations for the failure to drop tools 251–4 information overload 71–81 living forwards, understanding backwards 40–2 long-term plans, permanence illusions 6–7, 56 loose/tight fits, organizational designs 35, 48, 53–61, 123–7, 163–70 loosely connected organizations 48, 53–61, 123–7, 163–70 McDaniel, Reuben 36–7, 49, 170, 264 Mach, Ernst 212 Maclean, Norman 12, 216, 250 McNamara, Tracey 52 macro–micro phenomena 21–3, 139, 144–8, 158–70, 181–7, 199–204, 207–20, 257, 273–4 macrocosms of wisdom 215–20

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INDEX

Madrid train bombings 67–9 Magala, S.J. 146 Maines, D.R. 5 management perceptions see also leadership inaccuracy findings 141–2 managing Bristol Royal Infirmary 180–6 Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27 definition 8, 90 the unexpected 47–61, 71–2, 117–27 Mandler, George 12 Mann Gulch fire disaster 12, 23, 41, 129–30, 209, 211, 216, 243–57 see also dropped tools background 250–1 explanations 251–4 maps/compasses, sensemaking 264–8 March, J. 6, 12, 212, 234, 257 Marshak, R.J. 233, 237 Maruyama, Magorah 12 Maslow’s hierarchy of needs 220 Mayfield, Brandon 67–8 Meacham, J.A. 19, 213 Mead, George Herbert 16, 110, 189 meaning concepts 72–3, 75–81, 131–48, 183, 189–204, 210–20 failure reexaminations 210–20 information overload 72–3, 75–81 Measure for Measure (Shakespeare) 262 mechanical systems see also systems informal system theories 169–70 mechanisms of adjustment, information overload 69–70 medical care systems 6, 28–44, 153–70, 175–86, 196–7, 217–18 medical errors 14, 28–44, 153–72, 175–86, 196–7, 217–18 see also requisite variety meditation, mindfulness meditation 86–103 Mehra, A. 140–1 Mercedez-Benz 196–7 Merton, Robert 13 meso level, heedful interrelations within groups 154–5, 158–70, 207–20, 274 messes 51, 59–60 Meyer, Alan 148

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Meyerson, D. 6 Mezias, J. 141–2 micro–macro phenomena 21–3, 139, 144–8, 158–70, 181–7, 199–204, 207–20, 257, 273–4 migrating decisions 125–6, 264–6 see also expertise Miles, R.H. 233 Miller, J.G. 22 Mills, G.H. 131, 140–2, 146 mindful abstracting, Columbia shuttle (STS-107) tragedy 113–16 mindful attention changes 6 concepts 6, 85–103, 189–90 mindful organizations see also expertise; failures; operations; resilience; simplicity Columbia shuttle (STS-107) tragedy 116–27 concepts 6–8, 20–1, 85–103, 109–27, 154, 164–70, 207–20 guidelines 6–8, 98–9 positive organizing 218–20 mindfulness 6–8, 20–1, 31–44, 85–103, 154, 273–4 see also impermanence; moment-tomoment experiences ‘be where you are with all your mind’ 42, 89 ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 130, 176, 244–5 cognitive processes 95–6 concepts 6–8, 20–1, 35, 85–103, 154, 273–4 conclusions 102–3 definitions 85, 89–93, 95–6, 99, 273–4 distinctions 85–103, 110–27, 273–4 Eastern philosophy/psychology 6, 35, 85–103, 130, 176, 244–5 fatality investigations 86–7, 98–103 ‘Four Foundations’ 91–3, 99–100 guidelines 6–8 movie analogy 92 ‘not wobbling’ capabilities 86–7, 89–103 organizational studies context 96–103 organizational theory 93–103 organizing 6–8, 85–103 process/content 85–103, 117–27

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292

INDEX

mindfulness (continued ) remembering-the-present aspects 86–7, 89, 91–103 ‘seeing is forgetting the name of the thing seen’ 34–5, 87, 113–16 three sets of internal mental objects 92–3 voids 95–103 Western philosophy/psychology 35, 85–7, 95–103 mindfulness meditation concentration starting point 97–8 concepts 86–103 definition 89, 97–8, 103 insights 97–103 methods 97–8 mindfulness starting point 97–8 misleading conceptual moves 97–8 mindlessness 35, 95–103, 112–27 mindsets 180–6 Mintzberg, H. 231 misleading abstractions 97–8, 112–27 Misovich, S.J. 114–15, 161, 273–4 mission 229–30 mistakes concepts 12–15, 32–3, 57–8, 130–48, 165–6, 175–86, 209–20, 273–4 learning 130–48, 183–6, 212–13 positive organizing 209–20 truth 32–3, 135–6, 165–6, 211–13, 273–4 misunderstandings of medical systems 166–70 moment-to-moment experiences 6, 85–103, 127, 137 see also mindful organizations Morris, A. 65 movie analogy, mindfulness 92 mundane poetics 9–23 myocardial infarction 157–8 names 34–5, 87, 113–16, 134–48 see also labeling ‘seeing is forgetting the name of the thing seen’ 34–5, 87, 113–16 NASA 6, 41, 109–27, 196–7 see also Columbia shuttle (STS-107) tragedy National Health Service 178, 182 natural systems 170 see also systems nature 18–19 navy

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dropped tools example 248 ‘having the bubble’ 121–2 negative emotions, sensemaking 146–7 negative organizing, wisdom 213–14 neglected current details 7, 219–20 see also cues Neisser, Dick 12 Nelson, R. 234 nested hindsight capabilities, requisite variety 165–6 networks of conversations 5 New York Central Railroad 89 Nicholson, Nigel 193–4 nihilism 41 Niskar, W. 92 Nohria, N. 227 non-linear dynamics 51, 59–61 Nord, Walter 41 normal accident theory 112–27 normalization tendencies, unexpected events 54–5, 60, 112–27, 183 ‘not wobbling’ capabilities, Eastern philosophy/psychology 86–7, 89–103 novice stage of expertise 76–8, 100–1 ‘now and then’ concepts 130, 135–6, 165–70 nuclear-powered aircraft carriers 101, 217–18 nurses 75–8, 101, 132–48 nursing scenario 75–7 NYC Health Dept. 51–61 Obstfeld, David 130–51, 274 Olsen, J.P. 234 ‘one contact with the real’ 42 ongoing concepts 7, 41, 49, 57–61, 121–7, 129–48, 190–1, 194–204, 219–20, 264–6, 270 see also updating of changed impressions ontology 202 open systems see also systems system theories 167–70, 214 ‘operational definitions’, Thompson’s four guidelines for inquiry 248–50, 254–7 operations Columbia shuttle (STS-107) tragedy 121–7 concepts 7–8, 98–103, 112–27, 164–70, 218–20, 248–50, 274

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INDEX

HRO processes 7, 98, 101–3, 112–27, 164–70, 218–20, 274 optimism effects arrogance of optimism 118–19, 212–20, 271 Bristol Royal Infirmary 110, 180–6 Columbia shuttle (STS-107) tragedy 110–27 organizational behavior 110–27, 180–6, 212–20 order see also enacting; sensemaking; social . . . concepts 32–44, 131–48, 189–204 Organization at the Limit: Lessons from the Columbia Disaster (Farjoun & Starbuck) 110 Organization Science 130 Organization Studies 10–23, 29–44 organizational behavior 6, 9, 14, 15–18, 22, 28–44, 54, 109–27, 153–72, 175–86, 233–9 Columbia shuttle (STS-107) tragedy 6, 9, 22, 109–27 optimism effects 110–27, 180–6, 212–20 organizational change see changes organizational designs 34–5, 48, 53–61, 70–2, 96–103, 163–70 see also high reliability organizations information overload 70–2 loose/tight fits 35, 48, 53–61, 123–7, 163–70 loosely connected organizations 48, 53–61, 123–7, 163–70 mindfulness studies 96–103 reactive quality of organizations 56–61 organizational processes see processes organizational studies, dropped tools 6, 243–57 organizational theory 4–8, 9–23, 51–61, 70–1, 93–103, 132–48, 233–9 ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 130, 176, 244–5 concepts 11–23, 70–1, 93–103, 132–48, 233–9 critique 4–8 mindfulness 93–103 mundane poetics 9–23 searches for wisdom 9–23 styles 11–12 organizational tragedies dropped tools 6, 243–57, 268–9 positive organizing 210–20

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293

organizations, organizing contrasts 7, 100–1 organized impermanence concepts 4–8, 9–23 definition 3–4 overview of the book 3–8 organizing assumptions 11–23 Columbia shuttle (STS-107) tragedy 116–27 communications 137–48, 183, 199–204 definition 7, 39–40, 96–7, 100–1, 129, 133–4, 225–6, 274 fugitive quality 273–4 imagination 31, 41–2, 274 infrastructures 27–44, 189–204 mindfulness 6–8, 85–103 organization contrasts 7, 100–1 positive organizing 207–20 resilience 39–42, 124–7, 164–70, 218–20 sensemaking process 6, 129–48, 194–204 unknowable world 211–15, 264–71 Orlikowski, Wanda 17, 140, 230–1, 234 out-of-family problems 119–21 outputs information overload 65–81 systems theory 159–70 overdetermination concepts 254–7 overview of the book 3–8 overview of key ideas, concepts 8, 27–44, 273–4 Paget, Marianne 12, 14, 32–3, 57–8, 130, 135–6, 165–6, 207, 211, 212, 273–4 parents, battered child syndrome 8, 9, 28–44, 160–3, 167 ‘parliament of selves’ 110 partisans of neglected perspectives, systems 161–3 passive systems, concepts 162–70 past experiences 7, 37, 57–9, 122–7, 131–48, 189–204, 219–20, 267–8, 270, 273–4 see also retrospect pediatricians 8, 9, 28–44, 110, 132–48, 160–3, 167, 175–86, 196–7 autonomy of professionals 184–5 battered child syndrome 8, 9, 28–44, 160–3, 167 Bristol Royal Infirmary 14, 110, 143, 167, 175–86 critique 36, 143, 160, 167, 175–86

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294

INDEX

perceptions compound abstractions 28–9, 34–44, 113–27 conceptions 34–44, 51, 110–27, 161–3, 273–4 distributed systems 109–27, 161–3 enacting 198–204 fallacy of centrality 36, 167, 273–4 inaccurate management perceptions 141–2 information overload 69–81, 141–2 mindfulness 91–103 selective perceptions 274 permanence illusions 6–7 see also fictions; impermanent organizations Perrow, Charles 14, 112, 203 Peters, T. 230 Pettigrew, A.M. 237–8 Pfeffer, J. 53, 146, 232, 255–7 Pierce, Charles S. 38–9 pilots 15–16, 58–9, 248 planned change see also changes concepts 225–9, 231–9 emergent change 231–2 plasticity of categories 135 platypus 129, 201 plausible stories 7, 41, 49, 57–61, 80–1, 130–48, 165–70, 190–1, 194–204, 219–20, 264–6, 270, 274 see also sensemaking concepts 141–8, 165–70, 190–1, 194–204, 219–20, 264–6, 270 truth 141–8, 165–70, 264–6 poetry, mundane poetics 9–23 Point/Counterpoint: Central Debates in Organisation Theory 190–1 politics, sensemaking 146, 203, 255–6 Polo, Marco 201 Porras, J. 230 positive emotions, sensemaking 146–7 Positive Organizational Scholarship . . . (Cameron, Dutton, Quinn) 208 positive organizational scholarship (POS) 207–20 positive organizing concepts 207–20 entropy 214–20 heedful interrelations within groups 154–5, 158–70, 207–20, 274

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LCES structure 19, 208, 215–20 macrocosms of wisdom 215–20 mindful organizations 218–20 mistakes 209–20 respectful interactions between individuals 154–70, 207–20, 226–39, 269, 274 STICC 208, 215–20, 261 tragedies 210–20 unknowable world 211–15, 264–71 wisdom 213–20 Posner, B.Z. 230 power requisite variety 161–3, 166–70 sensemaking 132, 144, 146–8, 161–3, 166–70, 203 PowerPoint slides 124 pragmatism, concepts 5–6, 13–23, 189–204 precision concerns, enactment 194–5 predecessors concepts 8, 9–23 identities 12–13 premature baby 133–48 present-at-hand theories 40–2, 73–5, 78–81 preserved patterns 6, 243–57 presumptions enacted environments 197–204 sensemaking 136–48, 197–204 Private Eye 180 problem resolution teams 122–3 processes 6, 9, 11–23, 85–103, 117–27, 129–48 Columbia shuttle (STS-107) tragedy 111–27 concepts 6, 9, 110, 175–86 liabilities 6 mindfulness 85–103, 117–27 sensemaking 6, 129–48 systems theory 159–70 Proctor & Gamble 196–7 productivity studies cognitive dissonance 13–14 façade maintenance 13 proficient stage of expertise 76–8, 100–1 profound simplicity, HRO processes 7, 20, 98, 101–3, 112–27 programmatic change assumption 235–7 Putnam, Ted 10, 86–105, 243–4, 247, 253 quantum theory 36–7, 263–4 Quinn, Robert E. 7, 208, 225 quotidian, crucible of the quotidian 9

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INDEX

radial structures 135 Rasmussen, J. 47, 168, 212–13 rates of change 154–5 rational decision making 141–2, 147, 162–3, 167–70, 181–6, 244 re-accomplished social order 3–8, 9, 28–9, 32–44, 183 reactive quality of organizations 56–61 ready-to-hand alertness 10, 14, 40–2, 72–5, 76–8, 100–1 realities 10, 15–21, 42, 96–7, 99–103 assumptions 15–21 ‘one contact with the real’ 42 viable realities 10 Reason, James 14, 117–18, 175, 203, 210, 215 reciprocal interdependencies 55–61, 195–204 reconceptualizing overload 76–81 reconstructed history 183–6, 273–4 recovery see also resilience; sensemaking concepts 10, 14–15, 16, 39–40, 102–3, 131–2, 211–20, 273–4 definition 10, 39–40 interruptions 39–40, 102–3, 131–2 recurrence anchors 6, 119–27, 140–8 change 6, 225–39 concepts 3–8, 23, 28–44, 109–27, 140–8, 154–70, 225–39 redoing, concepts 28, 32–44 redundancy 33 see also crystal Reeves, T.K. 48 references 275–8 refined expectations see also mindfulness concepts 85–103, 117–27, 166–70, 273–4 informal system theories 166–70 regularity see also crystal; labeling concepts 4, 5–8, 28–9, 32–44, 126–7, 134–48 regulators, systems 153–70, 190–1 relationships heedful interrelations within groups 154– 5, 158–70, 207–20, 274 respectful interactions between individuals 154–70, 207–20, 226–39, 269, 274 Thompson’s four guidelines for inquiry 248–50, 254–7 thrownness 263–4

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295

reliable performance 96, 98–9, 110–27, 164–70 reluctance to conceptualize label 102–3 see also high reliability organizations remembering-the-present aspects of mindfulness 86–7, 89, 91–103 repetition 4, 17–18, 33 see also crystal requisite variety 60, 153–70 see also systems . . . ; variety concepts 153–70 coordination 161–3 fascinating quality 165–6 help requests 165, 167 interpretation 161–3 methods 160–1 nested hindsight capabilities 165–6 power 161–3, 166–70 in practice 164–70 rebalancing methods 164–6 schoolteacher example 160 resilience see also improvisation; recovery Columbia shuttle (STS-107) tragedy 124–7 concepts 7–8, 39–42, 98–103, 112–27, 147–8, 164–70, 218–20, 274 HRO processes 7, 98, 101–3, 112–27, 164–70, 218–20, 274 interruptions 41–2 organizing 39–42, 124–7, 164–70, 218–20 resources for sensemaking 7, 109–27 respectful interactions between individuals 154–70, 207–20, 226–39, 269, 274 see also trust . . . ‘response repertoires control noticing’ assumption 16, 125, 134 restless searching, concepts 5–8 retention concepts, evolution assumption 17–18, 130, 138–48, 194–204 retrospect 7, 12, 41, 49, 57–61, 129–48, 189–204, 219–20, 270, 274 see also approximations; past experiences; sensemaking richer thinking 49, 117–27, 215–20 rise and fall of patterns 6–8, 225–39 Roberts, K.H. 125, 164, 200, 202–3, 217–18 Rochlin, G.I. 122

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296 Roethlisberger, Fritz 269–70 Romanelli, E. 232–4 Rorty, Richard 41, 238, 256 routines see also habits; labeling concepts 7–8, 10–23, 28–44, 134–48, 153–4, 273–4 sequences 7 Roylance, Dr John 179–80 Rumsey, Walter 250–2 Ryan, R.M. 99 Ryle, Gilbert 37–8 St Louis Encephalitis (SLE) 5, 49–61 Salancik, G.R. 53 Salancik, Jerry 20 Sallee, Bob 250–2 Sandelands, Lance 244 saying, seeing 17–18, 27–9, 34, 41–2, 137, 266–7 Schein, E.H. 177, 238 Schneider, S.C. 69–70 Schomburg, Calvin 115 schoolteacher example, requisite variety 160 Schulman, Paul 116, 153–4, 161 Schutz, Alfred 12, 189–90 Schutz, William 20 Scott, W.R. 170 searches for wisdom, organizational theory 9–23 seeing believing 34–5, 86–103, 113–16, 266–7 ‘response repertoires control noticing’ assumption 16, 125, 134 saying 17–18, 27–9, 34, 41–2, 137 ‘seeing is forgetting the name of the thing seen’ 34–5, 87, 113–16 self-efficacy 143 self-esteem 143 self-fulfilling prophecies 37, 58–9, 193–204, 213 see also enacting self-justification issues, sensemaking 176–86, 202–3 self-knowledge 97–8 self-organization theory 51, 56, 59–60, 154–5 self-referential inconsistencies, concepts 40–2 self-remembering 97–8

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self-respect 216–20, 236–9, 267 see also respectful interactions . . . selflessness ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 176, 244–5 impermanence 94–5, 101–3 Senge, P. 237 sensegiving 142–3 sensemaking see also interruptions; order; recovery; SIR COPE actions 136–48 blurred images 109–27 bracketing 134–48, 225–7 cognitive processes 55–61, 114–16, 130–48, 273–4 collective cognition effects 55–61 communications 137–48, 183, 199–204 compasses/maps 264–8 complexity 56–60 complexity theory substitutions 59–60 concepts 5–8, 20–1, 27–44, 47–61, 85–103, 109–27, 131–48, 175–86, 189–204, 235–9, 264–71 conversations 4–8, 33, 39–42, 109–27, 131–2, 200–4, 219–20 cues 7, 35, 41, 49, 57–61, 95–103, 129–48, 190–1, 219–20, 270 decision making contrasts 265–6 definitions 39–40, 55–6, 131–2, 194–5, 264–5 distributed sensemaking 6, 47–61, 132, 145–8 doubt 6, 15, 19–20, 55–61, 153–4, 216–20, 261–71 emotions 144–8 enacting 36–7, 49, 58–61, 139–48, 189–204, 218–20 flux 134–48, 225–7, 273–4 identity 129–30, 142–8, 190–1, 194– 204, 219–20, 270 information overload 6, 65, 73–81, 141–2 instigations 140–1 institutions 132, 144–8, 190–1, 198–9, 201–4 interactions 7, 12, 22–3, 154–70, 207–20 intraorganizational evolution 130, 138–48 labeling 27–9, 32–44, 81, 87, 110–27, 134–48, 273–4

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INDEX

leadership challenges 264–6 nature viewed conceptually 12, 138–43 nature viewed descriptively 132, 133–8 nature viewed prospectively 132, 143–8 ongoing concepts 7, 41, 49, 57–61, 121–7, 129–48, 190–1, 194–204, 219–20, 270 organizing 6, 129–48, 194–204 Paul Gleason 19, 49, 56, 176, 216, 261–2, 265–8 plausible stories 7, 41, 49, 57–61, 80–1, 130–48, 190–1, 194–204, 219–20, 264–6, 270, 274 poetry 11–23 politics 146, 203, 255–6 power 132, 144, 146–8, 161–3, 166–70, 203 powerful mechanism for sensemaking 175–86 presumptions 136–48, 197–204 processes 6, 129–48 properties 6, 56, 129–48, 190 resources 7 retrospect 7, 12, 41, 49, 57–61, 129–48, 189–204, 219–20, 270, 274 skills 147–8 subtle dynamics properties 56 systemic aspects of sensemaking 136–48, 153–70 truth 141 sensing mechanisms 35, 153–5 sequences 4–8, 10, 22, 28–44, 225–39 concepts 7, 225–39 recurrence 7, 28–44, 225–39 routines 7 streaming experiences 4–8, 10, 117–27, 129–48, 274 Shackle, G.L.S. 9 Shakespeare, William 262 shareability constraint 110–27, 273–4 shared beliefs 145 significance factors, information overload 66, 72–81 Simon, Herbert 71, 80–1 simplicity see also complexity . . . ; generalizations Columbia shuttle (STS-107) tragedy 119–27 concepts 7–8, 20–3, 98–103, 112–27, 164–70, 218–20, 274

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297

HRO processes 7, 20, 98, 101–3, 112–27, 164–70, 218–20, 274 informal system theories 166–70 SIR COPE 41, 49, 57–61, 190–1, 194–204, 270 see also cues; enacting; identity . . . ; ongoing . . . ; plausible . . . ; retrospect; social . . . skills explanations for the failure to drop tools 252–4 sensemaking 147–8 SLE see St Louis Encephalitis small entrapment actions, Bristol Royal Infirmary 175–6, 177–86 smoke 4, 6, 32–3, 37, 42 see also complexity; conversations; variety Snook, Scott 79–80, 132, 209 social loafing 209–10 social order assumptions 10–23 concepts 3–8, 10–23, 41, 49–61, 114–27, 136–48, 183, 190–1, 194–204, 253–4, 270, 273–4 explanations for the failure to drop tools 253–4, 257 loosely connected organizations 48, 53–61, 123–7, 163–70 social resources 7, 219–20 see also conversations; interactions social workers 28–44, 160–3 South Canyon disaster 216, 247, 250–7 see also dropped tools background 250–1 explanations 251–4 Southern Pacific Railroad 196–7 Sparrow, P.R. 69–70 Speier, C. 69–70 Spence, Kenneth 257 Spreitzer, G.M. 262 SRS see Supra Regional Service stabilizing event clusters 6–7, 134–48 Stacey, R.B. 67–8 Starbuck, Bill 21, 29, 66, 110, 118–19, 127, 141, 142, 189–90, 210–11, 257 Stephen, Fitz James 23 Stevens, Wallace 226–7 STICC 208, 215–20, 261 strategies, permanence illusions 6–7

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298 streaming experiences see also labeling concepts 4–8, 10, 111–27, 129–48, 274 definition 10 STS-107 see Columbia shuttle . . . STS-114 mission 122 styles of analysis 8, 9–23, 27–44 of thinking 8, 9–23 substantiating concepts 28–9, 32–3, 39–44 definitions 39–42 substitutions, complexity theory 59–60 subtle dynamics properties, sensemaking 56 suffering, ‘cardinal meditation involving impermanence, suffering, and egolessness’ dynamic 86, 91, 93–103, 130, 176, 244–5 superficial simplicities 20–1 Supra Regional Service (SRS) 178 surprises 6–7, 140–8 Sutcliffe, Kathleen M. 66–84, 85, 117, 130–51, 165, 167, 176–88, 210, 213, 218, 220, 274 ‘swiss cheese’ model 215 systemic aspects of sensemaking 136–48, 153–70 systems 12, 15, 22–3, 32, 56, 59–60, 136–48, 153–70, 209–10, 214–20 see also heedful interrelations . . . ; mindful organizations . . . ; requisite variety; respectful interactions . . . active/passive systems 162–70 boundaries 160–3, 167–70 closed/open systems 167–70, 214 determinate systems 168–70 entropy 32, 59–60, 209–10, 214–20 false negatives/positives 166–7 feedback loops 3–8, 38–9, 185–6, 194–204 flow charts 169–70 informal system theories 166–70 mechanical systems 169–70 natural systems 170 partisans of neglected perspectives 161–3 regulators 153–70, 190–1 variety as a property 159–63 tacit knowledge 138, 261 task interdependencies, concepts 54–61

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Taylor, James 4–5, 8, 21–2, 32–3, 53–6, 57, 59, 137, 200–4, 274 temporarily stabilized event cluster, concepts 3–4, 134–48 temporary systems, concepts 6, 9, 154, 207–20 Tenerife disaster 14, 209, 244 terrorist attacks Madrid train bombings 67–9 UA flight 93 on 9/11 3 texts see also crystal concepts 4–8, 33, 39–42, 131–48, 273–4 generation of texts 5–8, 131–2 Thanissaro, B. 92–3 Thera, N. 91–4 Thomas, J.B. 142–3 Thompson, James 47, 54, 71, 168–9, 243, 247–50, 254–7 Thorngate, W. 40–1 threats see also interruptions economists 256–7 undifferentiated backgrounds 32–44, 74, 112–27, 134–48 thrownness see also interruptions concepts 39–41, 72–81, 263–71, 273–4 information overload 72–81 relationships 263–4 time pressures, information overload 70–81 ‘tiny steps’ 230 Tolman, Edward 257 total quality management (TQM) 256 train-robbing analogy 3, 8 transcendental meditation 97 transformations in an author’s mind 12–13 transitory aspects information overload 66–81 mindfulness 94–103 Travelers 196–7 treatments, diagnoses 28–44, 157–70 trust 124–7, 155–70, 209–20, 236–9, 252–4, 267 see also respectful interactions . . . explanations for the failure to drop tools 252–4 trustworthy observers 216–20, 236–9, 267

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INDEX

truth ideas 14–15 impermanence 32–3 mistakes 32–3, 135–6, 165–6, 211–13, 273–4 plausible stories 141–8, 165–70, 264–6 sensemaking 141 Tsoukas, H. 34, 41, 96–7, 133, 135, 273–4 turbulence 51, 59–60 Turner, B. 48, 119, 203 Tushman, M.L. 232–4 UA flight 93 on 9/11 3 unanticipated consequences concepts 13–14, 124–7 positive aspects 14 uncertainties concepts 49, 71–2, 109–27, 261–71 definition 71 uncertainty absorption, distributed systems 109–27 Uncertainty and Surprise in Complex Systems . . . (McDaniel & Driebe) 49 understanding complexity/simplicity 20–1 information overload 66–81 stages 20–1 understanding backwards and living forwards 40–2 undifferentiated backgrounds, threats 32–44, 74, 112–27, 134–48 unexpected events managing the unexpected 47–61, 71–2, 117–27, 183 normalization tendencies 54–5, 60, 112–27, 183 unexplained, inexplicable 129–30 unfreeze-change-refreeze 7, 225–9, 237–9 Union Pacific Railroad 196–7 unknowable world 27–9, 36–7, 38–44, 129–48, 211–15, 264–71, 274 unlearning, dropped tools 248–57, 268–9 unready-to-hand disruptions 10, 14, 40–2, 72–5, 76–8, 100–1 unsatisfactoriness quality, impermanence 94–5, 101–3 updating of changed impressions 7, 146, 219–20, 264–6 see also ongoing concepts USNCB 67–9, 81

bindex.indd 299

299

Valéry, Paul 12 values, entrapment cultures 177–86 Van Every, Elizabeth 4–5, 8, 21–2, 32–3, 53–6, 57, 59, 137, 200, 201–4, 274 Van Maanen, John 256–7 Varela, F. 32, 94 variable disjunction of information 48–9 variation concepts, evolution assumption 17–18, 139–48 variety 4, 33, 60, 153–70, 207–20, 226–39, 269, 274 see also diversity; requisite variety; smoke adversity 153–70 concepts 153–70 heedful interrelations within groups 154–5, 158–70, 207–20, 274 properties of systems 159–63 respectful interactions between individuals 154–70, 207–20, 226–39, 269, 274 Vaughan, Diane 58, 112–27, 183, 203 viable realities 10 Vietnam war 195 virtue concepts 91–103 see also mindfulness viruses, West Nile virus 6, 9, 47–64 vision 229–32, 262 vitality 208–20 vocabularies 33–44, 145 Vogus, Tim 220 voids, mindfulness 95–103 Wageman, Ruth 255–6 Wallace, B.A. 90 Wallenda, Karl 248 warranted assertions, concepts 14–15 wars 261–2, 267–8 wary improvisation 37–8 Waterman, R.H., Jr 230 Weber, Klaus 145 Weick, Kyle 127, 177 Wells, H.G. 81 West Nile virus 6, 9, 47–64 collective cognition effects 55–61 conclusions 59–61 loosely connected organizations 53–61 overview of the event 51–3 sensemaking 41, 49, 57–61 SIR COPE 49, 57–61

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300 Western philosophy/psychology Eastern connections 99–103 mindfulness 35, 85–7, 95–103 Westrum, Ron 28–9, 31–2, 36, 125, 140, 167, 213, 273–4 Westwood, R. 190–1 Whetton, D. 142 Wildavsky, A. 124 Wilde, Oscar 271 wildland fires see firefighters Wilkof, M.V.D. 238 The Will to Believe ( James) 23 Winter, S. 234 wisdom definitions 19–20, 38, 213, 244 discarding 36

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INDEX

of impermanence 10–23 macrocosms 215–20 negative organizing 213–14 ‘not wobbling’ capabilities 86–7, 89–103 organizational theory 9–23 positive organizing 213–20 Wisheart, Dr James 179–80 WNV see West Nile virus Woods, D.D. 75–7, 166 workflow interdependencies 59–61 Ylvisaker, Paul 263, 268–9 Yugoslavia 261–2 Zen 97 Zucker, L.G. 144

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