One major obstruction to NHS modernisation is the poor connection between strategic and operational levels (1). They function according to different agendas, using different languages representing different mental models, in effect experiencing different realities, resistant to imputed hierarchical authority from each other. One mental model they have in common, however, is a deficit-based approach or ‘problem solving’, a legacy of the rationalist traditions of management and medicine. They both look for what is bad and try to fix it, usually with the application of resources.
However, problem solving is unsuited to situations of complexity with uncertain cause and effect, and is inherently critical of the present in order to find the problems to solve toward a better future. Managerial problem solving struggles to influence professionals especially within clinical microsystems (the individuals including patients, their relationships and interpersonal interactions that co-create patient care) or to shift the operational focus from task-finish, itself a form of problem solving. When it is used to manage behaviour the problem tends to be identified with individual(s) risking scapegoating.
Appreciative Inquiry (Ai) is a social constructionist alternative to problem solving. It contends that asking questions about the future can create that future first by use of language to envision it together, then by collective actions. The first question determines the direction in which the vision will develop. A personal and collective vision of the future with its foundations firmly grounded on what is known to work well including profoundly valued personal achievements and beliefs removes much of the anxiety that is a major obstruction to change. Reflection on successes leads them to become new benchmarks (2,3).
Since Ai is derived from story-telling, a human interaction familiar to all societies and cultures, no special skills or technical language are necessary to take part. Ai builds inclusion and positive personal relationships, encourages democracy and self-organisation and promotes the ‘positive core’ of competencies, values, inspirations and wisdom that is any organisation’s most potent renewable source of energy for change. (4). Although, like the NHS modernisation agenda, the focus of Ai is on change and the future, Ai has had only limited application in the NHS to date.
We postulated that Ai could link strategic and operational levels and performed the following preliminary project to assess if it might have a role in motivation toward quality at the clinical microsystem level. The stories were received with minimum interruption. Active listening prompts focused on detail and led from events to communication to emotions to the significance for the respondent. Immediately after completion, a reflection was written with the respondent recalling ‘quotable quotes’ from the stories.
Following reflection on the process, feedback was written and the respondent read and sanctioned the record. Confidentiality, collective ownership of the data and intention to publish were restated. Availability of counselling in the Trust Occupational Health department was pointed out. Even though it was undertaken as an organisational and personal development project, the Trust research ethics committee was consulted informally at the outset when the chairman decided that it fell outside the committee’s remit.
The project was reviewed and accepted again by a different chairman during preparation for publication. Themes were counted by first giving descriptive titles to the quotes according to the essence of the respondent’s meaning in context. The titles were grouped under empiric headings as themes. This open coding method is based on Grounded Theory (5). The records were then counted if they had each theme. The same process was applied to the feedback.
The grouping was repeated by an independent reviewer with experience in qualitative research showing good agreement with concurrence on all themes and feedback responses supplied by more than 50% of respondents. Considerable efforts were made to avoid the obstacles of thematic analysis; projection, sampling bias and mood as described by Boyatzis (6). Thirty-two ward staff of a National Paediatric Liver Service took part, while two repeatedly delayed interview, recognised as passive refusal.
The 34 included all nursing staff on the Liver Ward (M) when the project started (nursing complement 41 whole time equivalents (WTE), vacancy rate 20-27% during the project), and 1 pharmacist, 1 dietitian and 1 play therapist associated with M. During 16 months to complete 5 staff left and 6 joined. Of these, 3 were approached and interviewed. In March 2004 in order to assess if the interviews had left any lasting effect on respondents those still working in the Trust were contacted with two questions in writing as follows: “What do you remember about the Appreciative Inquiry interview we undertook 2 years ago?
” and “What difference do you think the interview has made to you since then? ” Recruitment, resignation and vacancy data and sickness absence rate (SAR) were obtained from the Trust STARS database from March 2000 to July 2003, 25 months before the project to 8 months after, and compared with data from a general paediatric ward (15 beds, 31 WTE staff, Ward B) and a paediatric surgical ward (12 beds,16 WTE staff, Ward P).
SAR was not held on STARS until November 2000, month 8. SAR was also noted in March 2004. Project data were collected on a Microsoft Excel spreadsheet (Microsoft Seattle USA) and processed using NCSS software (NCSS, Kaysville, Utah USA). Statistical significance was calculated by analysis of variance (ANOVA) and p<0. 05 was considered significant.