Relational Systems

Social relationships are well understood to have a significant impact on health and well-being, with studies from across psychology, epidemiology, sociology and demography highlighting the importance of multiple and interacting social mechanisms influencing mental health, health behaviour, physical health, and mortality risk. In 2010 a meta-analysis of 308,849 deaths suggested that, at a conservative estimate, people with adequate social relations will have 50% increased odds of survival, across all age groups, compared to those without. This is equivalent to stopping smoking and represents a greater impact on mortality than other more well-known risks, such as obesity. People who have quality social relations live longer lives.  We are wired for social connectivity. This knowledge has obvious implications for health and social care organisations:

(a)  It introduces the need to get to grips with how to recognise the effect of social relations directly on patients or users, and how we might enhance or enable naturally occurring social and community relations to negate or ameliorate health concerns, improve health seeking behaviours, or reduce reliance on health or social care systems.

(b) It introduces the need to recognise the state of relationships within the organisational system and its impact on the health and well-being of everyone connected to it.  For example, the well-being of health and social care staff can be connected directly to performance, or the fact that relational breakdown between stakeholders is pinpointed as central to large scale health organisational failings. Recognising this relational cascade is clearly an important task.

Why are relationships hard to measure?

When it comes to measurement, relationships tend to be expressed or categorised in one of two ways. The first way is about recognising patterns in the networks or structure of relationships. These patterns can be predictive based on the target's (person/group or organisation) position in the network e.g. 'who is accessible' and 'with what level of influence' can be related to centrality within a particular network. If you are not connected you can’t share information.  The second way is to think about the functions or support social relations can provide e.g. what resources, perceived or real, the connections might provide or enable for others. Effectively, the two ways of looking at relationships are intrinsically linked, i.e. the nature of the network within which people are embedded will impact on the resources and support available, which correlates with a range of health and social outcomes. However, difficulties in recognising and measuring relationships can come about because of our tendency toward reductionist and individualist thinking.  Relationships under this paradigm are defined on the basis of the inter-dependence between parties to a relationship, for example between individuals, groups, organisations or countries.  The relationship is then irreducible to any of the distinct parties, and dissolves when one party walks away. This makes sustainable measurement using traditional data collection tools notoriously difficult as there needs to be some method of capturing all sides of the intangible relation to create a useful picture.  This often translates to reducing down the relations we are looking at to either dyadic (between two parties) and/or aggregates (whole network structures seen as deterministic of certain behaviours and outcomes). Measurement difficulty is also evident in the complexity of the inner workings of relational environments, within even tiny numbers of people.  If we look at communicating information, an obvious vital element of building and maintaining relationships, the number of possible ways 3 people might communicate a straightforward message (a to b to c etc.) is 9. By the time this communicating group reaches 8 people there are a staggering 1056 different potential configurations which might be suggestive of different outcomes depending on an individual’s position.   Overlay the relational environment with people entering and leaving employment, liquid and temporary project working arrangements, add in the silos of professionalism, relationship history and everyday human ups and downs, and it can become a daunting if not impossible task to build a clear relational picture. When this is considered in detail, it’s easy to see why relations or the ‘the soft stuff’ is often the hardest to understand and manage, even in the smallest organisational environment.  Further difficulties emerge when developing tools or frameworks because relationships are difficult to discuss for many of us. These difficult conversations are made harder within professional or bureaucratic environments which seek to create ‘arm’s length’ relations between practitioners. Disconnecting relationships from tasks is useful, when for example we consider the need for organisations to carry on functioning when someone leaves. However, a focus on relational attributes can help organisations to shed light on why strategy does not connect with operations, leverage the power of strong pro-social relations and consider how robust the system-wide relationships might be, in times of extremis.

How can we measure social relations across a system?

So how can such relational complexity be understood or mapped out contextually and over-time? For us the answer lies in recognising relationships as part of a system, both in terms of being a resource and also because this relational resource has an impact.  And the impact doesn’t simply remain within the relational domain, it impacts on other resources over time, so that actions in one part of the system can impact on other parts, producing patterns of behaviour over time. This brings life to what otherwise appears to be either a mass of disconnected entities or a fixed and intransigent arrangement that is resistant to our attempts to influence it. The patterns we seek to present through the relational value framework (Rv) provide a picture of the attributes that underscore and maintain the relationships.  A depletion of these underpinning attributes within the system would indicate that the relationships themselves are under pressure and may fail under that pressure. By first identifying through formal research methods, and then examining some of the underlying practices, processes and behaviours of relationships, we have built a framework that can take a snapshot of the ‘relational value’ of the system at any one-time.  We have identified 5 key attributes and have developed a user-friendly language and mechanisms for exploring each of them, within a system. Take compassion, one attribute of our relational framework.  In a systems view compassion is vital not just from a person-centred patient or client perspective (though this is how similar measures are normally manifest) but also across the organisation. For example, within organisations, compassion also increases employee satisfaction and commitment, enables activation and mobilisation of resources in a crisis situation, influences creativity and innovation by fostering good will that enables people to suspend judgement and to comprehend difference, and is an essential component of leadership required to deliver change and manage crises. This system-wide influence is well established and WSP have previously expressed, from their experience and research, the need to understand that, for example, compassion should transcend nursing within health systems. However, there are also reservations that there is real danger of creating assessments that reduce the capture of compassion behaviours to the level of ‘measuring smiles’ and the ever present danger in such circumstances of violating Goodharts Law and producing measures that become targets. In order to minimise these concerns we have embedded the 5 identified relational attributes into a systems framework and expanded the overall picture to look at how compassion, and the other attributes, are expressed through key disparate elements such as culture and vision of the organisation, the individual experience of the shared technology and infrastructure, and training or learning routines.   For example, we know that listening and sharing of stories and the treatment of others as whole people are key indicators of compassion in the elderly care sector, and look to examine the rate at which these are expressed and supported though the different stakeholders within the system and across culture, vision, people, process, technology and infrastructure. We can take the range of underpinning behaviours, processes and practices comprising the 5 attributes and by identifying and targeting the key audiences with contextual questions we can build a picture of the relational environment that enables further scrutiny and support, resulting in patterns that can be compared across time.  A model of sustainable measurement of Rv might look something like this:

  • Identify the system or sub-system under investigation
  • Discuss the potential outcomes or impact on key performance indicators connected with the potential depletion of Rv (we have a known list that can be refined)
  • Introduce key people to the idea, role and language of Rv through research and practice case studies
  • Take a snapshot of Rv across the system and make connections to poor performance or outcomes
  • Plan targeted interventions that have the potential to improve Rv
  • Set up periodic evaluation of RV using our online tool

This whole agenda is made more urgent by what we know as the ever-increasing strategic aim of more integrated forms of working that are attempting to bring health and social care closer together, and the need to embed relationships at the heart of health and social care.  If you want to build, maintain or improve relationships then there is a need to look across the system and see where the stresses are to start to monitor their impact and start to improve. Rv helps you do that.