This morning I fell down the stairs.

Standard

Here is the latest blog post from Alison Jones, our LfE fellow:

 

This morning I fell down the stairs.

I woke up and my first thought is always ‘a nice cup of tea’ so I got up and headed for the kitchen.

As my heel slipped over and beyond the edge of the second step I realised this was not going to end well and in that often-reported, slow-motion sort of way, I crashed bottom first, toe and groin twisting second, forearms third, bump, bump ,bump into the stairwell.

I knew, as I righted myself that there was no significant personal injury but my goodness I was shocked.

My 2 boys were still asleep and blissfully unaware. They would need breakfast and guidance for their home school day. A work day for me too, thankfully: zoom teaching, data crunching and emails so no need to ‘let anyone down’.

I’m really sore now. I think I’ve responded to everything I really needed to today as well as I can. Plus, my boys have been kind to me, they’ve eaten, done school work and we managed a short dog walk (knowing that I needed keep moving and stretch my aching muscles).

So now it’s 10pm and I’ll admit, I’ve had a relaxing glass of wine.


This experience has given me a new analogy, a fresh insight.

We ‘got up’ wanting our usual days in March 2020 only to fall into the stairwell of CoViD19.

Copied and pasted from above: ‘I knew, as I righted myself that there was no significant personal injury but my goodness I was shocked.’

I am incredibly blessed that no-one in my closest circle of family and friends has passed away this year. However, as healthcare professionals, we are dealing with a pandemic. For many there have been considerable personal consequences plus everything else that life can throw at us like loss/hurt/conflict/illness other than CoViD and serious social and political concerns  …

I thought, as an active member of the LfE movement, research and well-being teams, I understood or at least empathised with much of what was being experienced. Still, it took a profound shock and the consequent physical limitations to help me understand more deeply the real impact of all the anxiety and threat we are managing at this time.

Copied and pasted from above: ‘I’m really sore now. I think I’ve responded to everything I really needed to today as well as I can. Plus, my boys have been kind to me, they’ve eaten, done school work and we managed a short dog walk’.

In the last 48 hours I have felt anxious, tearful and rather fuzzy-headed and I have been forced to pay attention to these symptoms. Of course this is an entirely human, even predictable response to a tumble down the stairs. But it has made me wonder – how many of us are currently functioning at this level which feels ‘less’ somehow and compromises home and/or work as necessary as each day in CoViD recovery unfolds?

So this is my opportunity to ask ‘How are you?’ ‘How are you really?’ and to say ‘Take good care of yourselves and each other’. Here are few Appreciative Inquiry-style questions for you to play with when you have a minute:

How can I use the current slower pace of life to notice feelings and emotions in myself and others?

What resources do I have to help me cope (or even to thrive)?

How am I expressing gratitude, moving my body, getting outside, helping others today?

Which stories do I want to be part of in 2020?


Alison Jones

The view from the corridor

Standard

The following blog is from LfE fellow, Alison Jones.  Alison’s professional role has changed significantly during the pandemic, and here are her reflections on her recent experiences:

 

One of the central tenets of Appreciative Inquiry is the importance of storytelling or the power of narrative. MariaSirois said in her DLCCenterforAI webinar that if we talk authentically about how we have lived events, our story will resonate with someone, somewhere and as a consequence meaning will be added to both experiences. This story was part of my #COVID19 experience:

I have a background in adult ICU nursing but haven’t been registered with the NMC for many years. With the onset of the pandemic my greatest wish was to regain registration and join my colleagues on the ‘front line’ to help ‘fight’ this dreadful virus (the language of war we so easily adopt in these scenarios). It soon became clear that I had been away from the bedside too long to qualify for expedited re-registration; I was deeply disappointed and also experienced a strong sense of guilt at not contributing in the way I felt I should.

And so my role during COVID19 became that of ‘clean runner’ outside the intensive care unit at the children’s hospital where a new zone was created: an area made necessary by COVID19 isolation procedures. In this space, along with numerous hand sanitizers and the sequential PPE donning stations (first a gown, next a mask, then goggles, visor and finally gloves) a new team convened whom I shall call the Corridor Crew!

Once a nurse is in PPE and through the unit doors, s/he cannot come and go from the patient’s bedside out to store rooms and facilities beyond the isolation area. So they need ‘runners’. Runners for supplies – linen and IV fluids, blood products and medicines, ventilators and feed pumps; send swabs and specimens, bring tubes and wires.

In my role as a clean corridor runner I have been struck by the variety of people and emotions and responses passing through and gained a new perspective on this COVID experience: the view from the corridor:

Mums

Some in wheelchairs hours after an emergency C-section, some beginning to establish a routine – new normal. Post-partum people trying to heal and bear milk (often difficult enough at home with a healthy baby) now having to navigate the land of critical care, separation from baby, family, other children maybe … and carers in full PPE another type of separateness. I see in them dependency, vulnerability, shock and disbelief – how on earth did I get here? 3 weeks ago I was a chief exec/happy-go-lucky 17 year old/ran my own business/had all my ducks in a row.

But the thing I remember most is what they said to me in that corridor: ‘I have never met so many lovely people in one place’ and, tearfully, ‘you are all so kind, I can’t thank you enough’

Dads

Red-eyed dads displaying anguish, fear and frustration. Not in an aggressive way, although I know that happens too, but in a keyed-up, dumbed down sort of desperation. Through no fault of their own they are facing their greatest challenge; not only does their child require intensive care, but the world is in lockdown, global pandemic. Visiting is restricted, medical teams are cloaked in PPE and of all things, touch is prohibited. We witnessed brave but ever so slightly broken young dads walk past whilst we simultaneously adhered to social distancing and resisted the most natural instinct to give physical reassurance. Caring at arms length takes its toll on all of us.

Seeing, thinking, feeling these things emboldened me to enquire – how are things today? (eye contact, be brave, the answer might be tough to hear but it’s his answer and this is how we must express our love in the time of COVID).

The Day Shift

Mindful, rehearsed, #weareinthistogether. As they calmly progress through the donning stations I hear breathing exercises, the odd mantra and, whenever I ask ‘Are you hydrated? Feeling OK? Ready?’, ‘As I’ll ever be! Oh yes! Absolutely!’ come the replies. Thanks to stellar leadership from the ICUnurse management team we are as prepared as we can be for the daily evolution of the COVID19 response.

Throughout the shift they appear at the unit entrance often with gloved hands folded, steady eye contact and clear articulation through the mask: ‘Could I please have the special feed for Sally Morris, the blue thingy that adds a neb to the vent, some Micropore and a small sharps bin. The nurse next to me needs a temp module for the Philips monitor and 2 Weetabix cos her patient has kept free fluids down for 4 hours. I’ll come back for them, thank you so much’. They turn on their heels, speed walking back to their patient so they don’t waste a minute of care-giving time.

Short, frequently interrupted conversations punctuate the clean corridor day. Full of intimate details shared now like they never would be on a normal office day. Brief exchanges spanning the whole of our current existence: the grey roots showing in our hair (reframe: appreciation of hairdressing as a craft), supermarket queues (reframe: how lucky are we to live in a land of plenty), Generation C19 – adolescents with no exams and no motivation, the death of a neighbour (oh god, I’m so sorry) and dad’s had surgery so urgent not even COVID19 could stop it …nurses have lives too.

To The Corridor Crew:

27,000 steps today. We bring our whole selves to the job at hand – manning the corridor can be a fetch and carry task or an observing, serving, providing, learning experience

I know more about you now than I did before [Simon/Esther/John/Jen]

More unites us than divides us [tech/stores/pharmacy/labs/housekeepers/admin]

(Corridor) Music soothes, lightens, connects and heals

Thanks for the opportunity

So often we dismiss the value of our own stories and dwell on what we are not.We must cultivate an appreciation of who we are and the stories we have lived; show up to the situation as we can and bring our whole selves to the task. And the best stories end with an invitation into the next chapter so, when you tell your stories of what happened during COVID19, enrich them with how it made you feel, who or what inspired you and what good has or could come of the experience.

Alison Jones

On exnovation

Standard

I attended an excellent meeting in OLVG Hospital, Amsterdam recently. It was a convention of healthcare practitioners with an interest in LfE and safety-II. Delegates shared some presentations on LfE implementation and some related topics, including Appreciative Inquiry and joy in work. It was a stimulating and inspiring day, and as I reflected on what I had learnt, I became aware of a stream of thought about LfE and related endeavours: there is no single way to “do” LfE, Safety-II, appreciative inquiry or “joy”.  None of them is a panacea, and none should be ‘done’ in isolation. But they share a common thread of positivity: a kind of positivity that naturally emerges in a deficit-based culture. This type of positivity is not a highly energetic, celebratory force (although, I’m sure that sort of positivity has its place); it is a calming, warming, appreciative, nurturing sort of “everyday” positivity.

This thought has been with me for a while, just out of reach. But it started to take shape during the seminar while I listened to a lecture on exnovation, by Professor Mesman.

I first came across the term exnovation when I read Hollnagel’s “Safety-I to Safety-II”. It was listed, along with Appreciative Inquiry, as a methodology which may be used to facilitate safety-II. I confess that I never found the time to investigate further, and so I was pleased to find myself listening to a lecture on the subject.

I learned that exnovation is, in some respects, opposite to innovation. Where innovation may be considered to be the creation of novel improvements; exnovation is the process of improvements based on understanding current solutions within a system; many of which we don’t see because we take then for granted. Exnovation is a process to help us see what is right in front of us.

Exposing (or unmasking) these solutions, for the purpose of improvement, is the business of exnovation. Prof Mesman demonstrated how this can be done with in situ video ethnography. In other words – filming daily activities and then reviewing and analysing these videos in order to understand what is working.  The beauty of this approach is that the “solutions” or “recommendations” already exist and can be shared more widely.

Reports from the LfE initiative often focus on “everyday” excellence, and therefore, the potential to collaborate with the process of exnovation is worth further exploration. A vital part of exnovation is the recognition of something which works, and this is also the business of LfE. In both LfE and exnovation, the recognition of something good comes from the staff who are actually doing the work. This makes the process highly valid and relevant.

I returned to work inspired to see if I could turn my appreciative eye to some everyday excellence: something apparently mundane which I could learn from, or could share with colleagues. Whilst I was bemoaning the length of our ICU ward rounds, I noticed that a colleague routinely delegates certain tasks to team members during a ward round. This simple act saves vital time, minimises stress and inspires team members to engage with the round. Such a simple act is typical “everyday excellence” and I immediately adopted into it my practice.

Have you seen everyday excellence recently? Try actively looking for it, by watching your colleagues go about their work; and you might be pleasantly surprised about how much you learn.  Feel free to share examples (or other comments) below.

Adrian

Some tips on AI from an expert

Standard

The following guest blog is from Dr Elspeth McAdam, Retired Consultant Child and Family Psychiatrist & Organisational Coach.  Elspeth’s blog is a reflection on her experiences of using Appreciative Inquiry in healthcare.

The old English adage – “You learn by your mistakes” has been a travesty to humanity.  The more you go over what you did wrong, the more you become an expert in how to do the wrong thing! Each time you repeat the action/activity you automatically go through what your “body“ knows and you have to stop and think about what not to do.  By closely examining excellent practice, on the other hand, you are looking at what has worked brilliantly, so subsequently you may act in the same way. In-depth questioning about what made it work so well can help others understand how to repeat it.  Whilst going through these details of the excellent practice, the skills and abilities used should be identified, named and given to the person who accomplished it.  Once these skills are named and accepted by the person who performed them, they then become a resource to that person, as well as a learning item for the observers.

The other valuable resource that comes from Appreciative Inquiry is to DREAM.  REMEMBER EVERY PROBLEM IS A FRUSTRATED DREAM.  If you did not have dreams of good practice you would have no problems! So instead of dissecting the problem, have a dream about how you would like it to have gone. Remember to dream as if you are living it at that moment, so speak in the present tense.

For example:

Let’s dream, with all the staff present, about what an excellent ward round looks like. What is each of us doing; how did we prepare for it; how are we talking to the patients; how we teaching? What explanations are we giving the patients/staff/students etc?  Talk as if you are doing it in the now.  If you are working with a larger group, divide the group into smaller groups of 6, so everyone has a chance to speak their ideas.  Dream what an ideal hand-over and ward-round looks like.  Imagine it is now 2018, and all the current problems are solved.  What are we doing so well now?  When we follow this process, the past difficulties become part of the process of creating the dream.  This gives us new ideas from “the frustrated dream” to inform our “future-present”.  E.g. we learnt a lot from that, now we do it this way…  The more detailed the dream the more likely it is to be lived in the future.

What is AI? – part 3

Standard

This is the third of three blog posts about Appreciative Inquiry, from Simon Blake.

Many overviews of AI begin in the same place: AI started life within the context of a healthcare organisation. Through my attempt to gain an up-to-date overview of the presence and use of AI within healthcare contexts I have, though, managed to inadvertently become embroiled in something that doesn’t sit very easily. The perceived problem? So much of the relevant literature I have come across and read seems to come from authors with a nursing background. Resistance to any conclusion that doctors just don’t seem to do (much) AI drove me on – and in any case, this is backed by the certain knowledge that the early work on AI came from a researcher working closely with doctors in the US.

David Cooperrider’s founding work – a ‘conceptual reconfiguration of action research’ – centred upon a case study at a private (but non-profit) healthcare facility in the US. It’s worth reflecting upon why it was that he used a healthcare organisation – the Cleveland Clinic (CC). Other than the convenience of the close proximity of CC to Case Western Reserve University – where he was registered as a student – a long-standing relationship had developed between the two organisations (propinquity, perhaps?). This connection was driven by the innovative doctor-led and -managed co-operative structure that the CC had taken from the 1970s onwards. A number of other graduate students had already conducted their research projects at the Clinic. Indeed, Christopher Johnston suggests that it was the good fortune for Cooperrider of having his supervisor, Professor Suresh Srivastva, point him in the direction of another student’s study into the innovative doctor (physician) leadership at the Clinic, that inspired the development of AI.

 

But does this genesis provide an indication that healthcare organisations, and the ways that healthcare professionals engage in organising their work, are particularly suited to appreciative approaches? I have wondered what would have happened had Cooperrider conducted his research in an organisation in a different sector, say, an investment bank. Would we even have AI (at least in the form and spirit that we do today)?

Healthcare organisations are, after all, different in many ways from other organisations; private, public and Third sectors. In addition, hospitals are quite different from high reliability organisations, (despite some recent claims to the contrary). Although, clearly if arguably, there are also some similarities, traces, resonances, with other organisations, one commonality is the claimed relevance to them all of an appreciative approach. And the same line of argument might follow for the healthcare professions, too.

This is perhaps an obviousness, given AI’s roots in organisational development (OD). Organisations from any sector might consider and use AI in their OD processes. However, health researchers are now making a point of asserting a clear distinction in the use of AI as a research approach (as distinct from an OD tool). Suza Trajkovski, a specialist neonatal nurse and academic at the University of Western Sydney, Australia, asserts and demonstrates the power of AI as a healthcare research approach which moves beyond (negative) problem-focussed towards positive inquiries. Suza has devised a structured review of the usage in healthcare of AI as a research methodology. Her conclusion is that AI is an “engaging, inclusive, and collaborative” way of exploring issues pertinent to healthcare, especially so because it aligns neatly with the current health sectoral interest in the Safety 2 paradigm.

 

Others see the relevance in a slightly different light. For instance,Professor Bernie Carter in the UK suggests it is the “high degree of involvement, participation, goodwill and collaboration apparently engendered by using AI” that make it a good fit. From a US perspective, Nancy Shendell-Falik and her colleagues at the Newark Beth Israel Medical Center, assert that AI’s strength as a novel healthcare approach is because it is “evidence based (using people’s experiences)” as well as being focussed upon relationships. They deepen the connection drawing attention to AI practitioners’ abilitiy to encourage “people to identify, engage, and strengthen the core values and ‘‘life-giving forces’’ within the (healthcare) organization”.

These researchers have deployed AI in areas as diverse as exploring family-centred care in a neonatal unit, clinical handover within an adult care hospital, and multi-agency complex care service provision for children. The applications and uses by others of AI in healthcare extend across specialities and organisations from maternity service reprovision to outpatient cancer care service innovations. Trajkowski’s review identified only 9 research papers which detailed how they’d used the 4D cycle in healthcare, but her wider review unearthed over 750 published works (to the end of 2011).

Those ‘in the know’ might already have noticed that the selection of significant, recent ‘AI-in-healthcare’ research offered so far has all been authored by Registered Nurses. Indeed, in searching for and through the AI literature, there appears to be a subtle, yet discernible, ‘healthcare professions bias’. As you might hope and expect (given Cooperrider’s initial focus upon physicians) that doctors and the allied healthcare professions are also present.

For example, in the UK, a key study of AI use in the NHS, published in 2005, was driven by Dr. Alastair Baker, a London-based consultant paediatric specialist. Whilst the AI interviews were conducted by Baker, and the study indicates a noticeably greater involvement by nurses. However, the research analysis and discussion was rather mute on this professions issue. Two leading figures in the use of AI in healthcare settings in the US are Drs. Julie Haizlip and Margaret Pews-Ogan of the University of Virginia. They have been involved in a key project which has had a wide-ranging impact across a number of organisations – driven by research, medical education and training centred at the Center for Appreciative Practice. This has included the acknowledgement of particular features of medicine that necessitated adaptations to AI in order to enhance the chances of attaining a successful transformation of the culture across four key organisations. Internal AI champions and clinical change agents facilitated the moulding of language, expectations and infrastructure. A model for other healthcare organisations? Certainly, the thoroughness of their work is indicative of a balanced and realistic management of the potential for and actual resistance to the AI approach.

As with the earlier adoption of AI by many nurse academics and leaders, so more latterly with medicine. Recent applications address the reform of medical student education, identifying exemplars of patient transfer (sign-out) when designing new handover tools, and finding out best practice in medical professionalism when using social media.

Against the backdrop of continued resourcing, policy and other (political) pressures, is this the environment within which to take an appreciative approach to healthcare? Some would say most definitely “Yes!”. Recall Gervaise Bushe’s injunction that AI isn’t only about the ‘positive’. In addition, the time appears right to enhance the impact of AI through alignment with other approaches such as mindful inquiry, compassionate healthcare and narrative medicine, as well as incorporating it into other offshoots of action research such as co-inquiry. Drawing upon interesting work within community development, a critical AI approach may also be a ‘good fit’ in healthcare settings. Indeed, if you work within the healthcare sector, can you think of a reason why you should not be appreciative in your approach?

Simon Blake
November 2015

What is AI? – part 2: A brief history of AI

Standard

Here is the second in a series of blog posts from Simon Blake about Appreciative Inquiry.

A brief history of AI.

Charting the course of the development of ideas can be tricky.  Too heavy on the history and it might be too specific to communicate the broader and deeper lessons-learned.  Too much of an emphasis on philosophical ideas and then the detail – and engaging nature – of the historical narrative might be lost.  This short blog post won’t, then, even attempt to be a ‘complete’ history.   And, in any case, decent histories already exist.

Appreciative Inquiry’s (narrative) history has been captured in a timeline reaching from it’s genesis in David Cooperrider’s doctoral research project at a medical clinic in the US in 1980, through to the more recent globalisation of a movement.  Jane Magruder Watkins and others set this out in a succinct manner in their introduction to the development of AI.  They do, though, occasionally miss inspirational events.  A case in point is the first meeting between Diane Whitney, Cooperider and Ken Gergen in the early 1990s, which led to the founding of the still influential Taos Institute. This is related in Gervase Bushe’s recent fulsome-yet-compact article.  Here, despite collating together a number of fascinating historical events,  Bushe sets out some of the broader principles and themes of AI within a historical context.

Questions which have been addressed through the past 35 years of AI practice and development, and which still remain open, relevant and challenging for us to consider as part of the LfE project include:  Is AI a philosophy (perhaps, a way of seeing and understanding the world) or a methodology (a means to get at that meaning) or both?; Is AI just action research with a positive question?; Is AI an approach which can uncover the truth about what works in an organisation?  What are the dangers of ignoring the equally real obstacles to the growth of human wellbeing and potential?

As a history, AI’s contains elements which can be inspirational.  The more recent moves towards a globalised perspective, with emerging as well as developed nation practitioners finding their own nuanced understandings and uses for AI, are exciting and stimulating.  Such developments serve to lend further support to the social constructionist underpinnings of AI.  That is, that our meanings and understandings are co-created through our attempts to understand.  Although this can still sound contentious, it is a central tenet of AI that there is not one ‘truth’ out there somewhere, waiting for us to discover.

Tracing the history of AI reveals that unresolved tensions remain; between generativity and positivity, and between appreciation and problem-solving.  This relatively brief history of AI has thus far demonstrated a failure to resolve them.  But, the beauty of the AI approach – regardless of which nuanced form one prefers – is that this is in itself generative.

The next blog post from me will collate some of the key moments from past and present uses of AI within the healthcare context.  Whilst not dispensing with this past – indeed, drawing upon the issues and themes which have already begun to be highlighted – there will also be a look into the future of and for AI, and for the LfE project in particular.

 

Simon Blake

October 2015

What is AI? Part 1

Standard

Here’s a blog from Simon Blake, from the Learning from Excellence team.  This is the first of a series of blog posts about Appreciative Inquiry (AI):

The National Health Service we work within, use, support and care about has changed immensely since its foundation in the 1940s.  Perhaps it is proof positive that broad-based transformational change can and does happen.  Change clearly also occurs on a smaller, but no less significant scale;  on the shifts on which healthcare professionals work, and in the wards, units and departments that you lead, manage and operate within.

Lurking within many approaches which attempt to understand such change – whether it is incremental or transformational – is a persistent expectation that, for things to get better, we must focus upon and learn from our mistakes.  Further, such a logic of thinking seems to suggest that in order for us to meaningfully change we must break with the past and build anew.  You can guess where this is heading, yes?

For a long time, it has been evident to some that there is an alternative approach. Helen Bevan wrote in 2004 that instead of always focussing upon problems, by “asking questions and having conversations that were intentionally positive…(researchers have found), even in organisations with the greatest performance challenges, potential to transform them in ways previous unimagined.”. Helen is now the Chief Transformation Officer for NHS Improving Quality.  And it is in this role that she was recently part of the Challenge Top-Down Change Panel (a collaboration between the Health Service Journal, Nursing Times and NHS IQ) which identified Appreciative Inquiry (AI) as a key solution to engendering successful change in the NHS.

A key element of AI is that it doesn’t require us to jettison what we are currently doing, in order to create successful change.  Rather, as the Change Challenge identified, “the focus (of AI)  is on strengths, solutions, what is already working, what looks good, and what people want more of”.

At the heart of AI is a positive way of thinking.  A perspective which says that whilst healthcare professionals experience and attempt to workaround everyday problems, the seriously untoward incidents that garner the headlines are unique, infrequent and not everyday.  Empowering professionals to enhance their identification of and learning from these everyday successes requires a different way of thinking and understanding the work that you do.

This is the first of a short series of blogs about the appreciative inquiry approach.  It is but one approach among many which derive their energy and force from a positive psychological perspective and movement.  To understand a little more about the roots of this movement, and of AI itself, please dip into the next LfE blog.

Links:

Helen Bevan (2004) ‘What Works:  Appreciating Our Assets’.  Available from:  http://www.institute.nhs.uk/quality_and_value/introduction/article_1.html

HSJ/NT/NHSiQ (2015) Challenge Top-Down Change.  Available from: http://m.hsj.co.uk/5083743.article

Simon Blake

September 2015