Appreciative Inquiry: Bridging Research and Practice in a Hospital Setting (International Journal of Qualitative Methods, April 18, 2018)
Author: Hung, L., Phinney, A., Chaudhury, H., Rodney, P., Tabamo, J., & Bohl, D.
Hung, L., Phinney, A., Chaudhury, H., Rodney, P., Tabamo, J., & Bohl, D. (2018). Appreciative Inquiry: Bridging Research and Practice in a Hospital Setting. International Journal of Qualitative Methods, 17(1). https://doi.org/10.1177/1609406918769444
0 General Document comments
0 Sentence and Paragraph comments
0 Image and Video comments
Abstract
What is Already Known?
Bridging Research and Practice
Research Phases
Goals
Question Examples
Phase 1 (engage and look)
Vision, goals and team agreement, current state, and priority needs
What possibilities do you see for this research?
What are we doing well and what are the opportunities?
What might our future look like?
Phase 2 (think and act)
Video reflexive group, codesign of actions, and reflections and evaluation of actions taken
What do you like to have in the staff education?
What can we do better to generate more excitement for shared learning?
Phase 3 (evaluate and modify)
Reflection on experiences of participation in research and practice development, changes; identify lessons learned and future plan
What is your experience in participating in the research?
What do you need to sustain the development?
A - Appreciating the Power of Coinquiry
This comment illustrates that an engaged team is more likely to be ready for making practice change than an unengaged team because of the sense of ownership about their practice. The term ownership can be interpreted as an individual feeling of being part of the research, with an opportunity to shape change through expressing their opinions. Ownership can also imply a joint accountability, which is closely linked to sustainability. Other team members explained how inquiring together and hearing stories of others inspire commitment and evoke team emotion, which then becomes a source of commitment.Inclusion. It engaged everyone. The fact that this project has involved all the staff so people feel that they have ownership. They are contributing at every step in the way; people feel involved and heard—I think a sense of ownership is the key. (Darryl, physiotherapist)
In this account, we can see how new story lines were created as people found positive experiences and talked about them. The story lines made up a new narrative through telling and retelling, which allowed building a new prevailing culture to replace the old. The stories people told each other every day created a new social reality so what people choose to say can have an influence on the outcomes. Wanting to contribute to improve patient care was a reason for people to participate in the inquiry. Telling successful stories in focus group sessions made team members feel proud, which fostered a team spirit.When we encounter a difficult situation, someone would say, have you tried the GPA? For example, when a patient is upset, if you leave him alone, try to go back later. It’s called—Stop and Go. I think we have the GPA into people’s mind now. (Nancy, care worker)
In the focus group, the staff spoke at length about how each situation was unique and complex. The learning by doing was a constantly adjusting process in the application of knowledge. Storytelling was a good way to give a more realistic view of how the contextual factors influence a given situation. By combining the stories from the team members, a deeper level of understanding could be reached. For example, the staff spoke about working with patients with dementia, as it tends to require a deliberate effort to slow down, pause, and reflect, and a willingness to look beneath the surface to explore one’s own assumptions and the assumptions of others. A nurse explained:This project concentrated on people. It’s not so categorized. Like, I am in a research program. It’s all the same questions. “How do you feel? Satisfied? Very satisfied?” It doesn’t capture much about my experience. People aren’t just numbers. People experiences are much more complex. (John, nurse)
Developing practical knowledge requires a high level of understanding of patients’ experiences. The staff appreciated the power of coinquiry and learning different perspectives from each other. A nurse leader said, “Before [the research] we didn’t know what to do, everybody was just kind of floundering.” The learning together helped staff gained knowledge and confidence.If you don’t try to look behind the behavior and try to explore what might be going on with the patient, you can easily fall into the quick solution, he is agitated, and he needs a PRN or restraint. Remembering the techniques are not good enough; knowing how to use them appropriately in different situations to produce the effect is the key. (Sheila, nurse)
Story sharing was an effective way to engage the staff emotionally and the narratives that were produced in the group sessions. Action projects (e.g., peer-teaching videos and the fun fair) allowed people to feel that they belonged and were helping to foster a team spirit:When you get into this kind of discussion, and then you know that it will be implemented, you would want to join in. We are doing this because we want to be able to create a better environment and give better care for the patients. It’s like a game changer when people see that there’s something happening from this. (Isaac, nurse)
Tapping into the core motivation of the staff members who wanted to contribute to the team seemed to provide an impetus for change. The participatory approach helped the team connect their hearts through building trust and having team dialogue.We each have a different view about something. I think it’s helpful that we come together and talk about it. I think this is very “teamness.” These meetings drive a lot of team spirit, most of all, of course it is the contribution part, and we are all in this together. We have a sense of unity. I sense that. Coming to these meetings, we can share our opinions. Sheila may have her opinion, I may have mine, hearing each other’s, we can come together. (Georgina, unit clerk)
Working together on the team challenges each member on their guiding assumptions that they may have formed for their current perspective or way of thinking. In team dialogue, an opening can be created with new ideas and interpretations. For example, a staff member Sharnjit spoke about how she discovered a lot about a patient who seemed to be intimidating and physically aggressive.When you are asked to problem solve and contribute, you are taking a risk. You don’t know how others may react to your idea. But when you actually took the risk in providing opinion, the project takes roots better with people being together. (Darryl, physiotherapist)
The staff spoke about the work they do as requiring constant learning and support from each other. “Every day is a learning experience; you got to listen to those who say no, why this is not going to work, ask them what will make it work.” The staff maintained that their work must tap into the accumulated wisdom of the whole team.When I was helping this patient, I was really scared. Because he is tall, and he’s got some built up, right. He said he knows Kung Fu, and I think someone said he is a black belt in martial arts. Once he said to me, that’s bullshit, I am going to hit you. I felt he is just an aggressive man. Now hearing from you guys, I come to understand that he is scared, too.
Many benefits were found from customizing education to meet the needs of the local context. One nurse, John said, “watching the videos is so much fun.” Another staff added, “The video was kind of a really bite-size thing—right to the point. Here you go, one message at a time, pretty cool.” The staff pointed out that any tool that was made in the unit felt like it was “home built.” “Like it gives you a feeling of, it’s ours. If it’s done in other places, there is a hesitant in between. When it is made in our unit, by our team, our colleagues, we can trust it.” The customization not only provided more relevant information and credibility, but it gave a sense of pride, agency, and identity. Although staff reported earlier that learning new knowledge from outside is important, they clearly indicated that tailoring knowledge to make it fit to use in their particular context is imperative. Another important point that was brought up by the educator was the specific need in the acute context: “I think that dementia care in an acute care setting is unique. It is important to attend to the urgent medical needs and at the same time be creative in meeting the emotional and psychological needs of dementia” (Doris, educator).I haven’t seen anything like this before. It is so exciting to see the people in the video, who are actually the staff on the unit, and it was filmed right at our own place. I have watched them so many times, again and again. (Bernard, nurse)
As previously mentioned, changing practice is a social process, and shared ownership is needed to support mutuality and to drive the actions. In the project, people used terms like our unit, our patients, our future, and so on. In addition, many staff members spoke about wanting to use their learning to help others beyond the unit. The physicians, in particular, emphasized that many patients with dementia were on other units and they expected this project to spread the practice development to other units across the system: “We have to think about keeping our eyes on the prize of the success, and you need to think about 100 patients or more, that we have to serve a very similar need in other units” (John, physician).I honestly believe that patients with dementia are living in our surgical units because they also need surgeries. So, I am interested in how we take the learning from this work and put them into practice widely. How do we do that across the board?
The staff spoke about the need for learned knowledge to be applied to see how it works and under which conditions it could work better. A lot of experimentation with the specifics had to take place right away in real time, and quick corrections or adjustments were occasionally needed to make new knowledge work. For example, we tried painting at the bedside at first but quickly learned that the patients actually wanted the social processes—painting and chatting in a group. In our study, we noticed that new knowledge gained significance through its utility and whether or not people found it useful in routine practice. Because the inquiry and actions were joined in the project, the uptake of knowledge was quick. Adaptations and modifications could also happen at the same time, which made practice changes efficient and effective.Yeah, like it surprises us too. I know some of the patients really look forward to it and are excited to do it. They look forward to it because it feels good to paint with a group, the social atmosphere.
Despite the participants facing frustrations and uncertainties about the delay of physical renovation, we took time to celebrate successes to keep up the positive appreciative spirit and continued moving forward. A summary report for the action activities was created in a sketch (Figure 2), which showed our accomplishments. Social connection, a shared positive memory, and collective joy helped to fuel our desire for continuous development.Pardon me for being a cynic. But I have worked in the system for 25 years. Until you see the dream realized in concrete form, having that space to work in, and work with that space for a while, then you potentially see ways to make that space more malleable and changing it. (Darryl, physiotherapist)
A Collaborative and Positive Inquiry Approach
Barriers and Challenges to Engage Staff in Practice Development
Declaration of Conflicting Interests
References
General Document Comments 0
icons on the left to see existing comments.
0 archived comments