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PROactive Management of Integrated

Services & Environments

PROGRESS PROCESS PROMOTE PROTECT

Even Better If…

Beyond Appreciative Enquiry


How many passes did you count?


The correct answer is 15, but did you see the gorilla? Chabris and Simon in their book The Invisible Gorilla describe findings from the short film above. About half of the people watching the film miss the gorilla. The woman wearing the gorilla suit walks into the court, thumps her chest and moves on. She is on the screen for 9 seconds and no one who is not engaged in the task will miss the gorilla. Viewers who haven’t seen the gorilla are convinced that there is no way that they could have missed such a striking event. However the task is difficult and completely absorbing. The impact of focusing on the rapid passes by those wearing the white shirts while neglecting those wearing black has two impacts:



What does this mean for a frontline staff in a busy mental health ward environment? There are so many balls that are up in the air, they have to be completely focused on the task at hand. The fact that staff are dealing with emotionally charged issues further compounds the situation. Like the gorilla, obvious opportunities to proactively influence the patient journey go unnoticed. The enquire phase of the promise process is about creating the reflective space so that such opportunities may emerge from the blind spot into consciousness.  

How do we do this?


The wise man doesn't give the right answers, he poses the right questions. - Claude Levi-Strauss


So what is the right question to ask is the question. We have pondered long and hard on this specific issue. Within PROMISE we have found that staff involved in physical restrain or for that matter in any form of coercive practice genuinely believe that they are acting out of necessity and in the patient’s best interest. Any perception of criticism regarding current practice is bound to bring the defensive shutters down and the opportunity for open honest dialogue will be lost. Spending time framing the questions and also thinking about the stage at which a question will be appropriate is time well spent.


Powerful questions simultaneously open up and focus attention paving the way to shared inquiry. They are like a spot light, lighting up a specific territory to explore. Creating new assumptions is usually easier that eradicating old ones and the most powerful questions can facilitate this process. In The Art of Powerful Question Vogt, Brown and Isaacs describe a powerful question as one that:



They describe three dimensions to a question, construction, scope and assumptions. Each has an impact on how we engage with enquiry.


Construction


Whether we open our minds to a future full of possibilities or narrow down the enquiry to the reality of the present depend heavily on the words and the framing of the question. Yes/no, either/or questions have only limited potential. Reporting requirement for physical interventions often boils down to a numbers story of did the restrain happen or not. Interrogatives like what (happened) have been added in to find out about prone restraints. Research is being carried out to establish who or which patient group is getting more restrained. When does it happen, where does it happen, what happened before and what happened after, why did it happen? These are all important question to answer, after all we manage what we measure and without establishing a baseline we will not know whether we are making progress. However do they really create space for reflective conversation and genuine curiosity that will make staff ask what if… Or do these questions help staff with the answers needed to deal with the cognitive dissonance they might face around missing the opportunities they did not even realise existed.


Even if one is starting from yes/no questions creating reflective space is an art. With the goal of guided discovery to eliminate reliance on force consider these questions:



As one moves towards the questions with what, how and why one will provoke more thoughtful exploration. However one needs to creatively frame questions with why as they might generate a defensive response as people answering will often justify their position. This can be overcome by taking an appreciative enquiry stance, what is working well and even better if…


Consider the following question:


Why is it that sometimes irrespective of how unwell a patient is things go well and sometimes they don’t? The question acknowledges that at times things work well and then generates curiosity and encourages reflection regarding what is different in the two situations. Even such a question can very quickly be closed down by focusing just on the problems rather than embracing the possibilities around replicating when things went well. Thus guided discovery of ‘what if’ scenarios is vital in maintaining the appreciative enquiry stance.


Scope


The question we ask needs to be relevant to the objectives of the guided discovery process. One needs to understand where one is on the journey so that they can appropriately change the scope of the questions they are asking. Depending on the stage one has to be precise about the remit or else it will end up being an interesting theoretical discussion rather than one in which frontline staff can take realistic action. On the PROMISE journey our remit has progressively enlarged. Consider the following questions:



The latter will bring it to the edge of our current abilities and although the answer to this question could be within our reach in six months time one has to be careful not to expand the remit to the extent that the frontline start feeling that they cannot positively influence the outcome. One cannot emphasise enough the importance of thinking about the audience for which the question is being framed and their sphere of influence.


Assumptions


Either explicit or implicit, all questions will have assumptions built into them. “How many prone restraints have we had in the last month?” This is a routine question we ask of the data generated from our incident reporting system each month. The assumption that at this stage of our journey we will have prone restrains is fairly explicit. Consider the question “How will we eliminate reliance on force?” This implicitly assumes that those exploring the question have agreed that eliminating reliance on force is desirable.


Such is the nature of language that these assumptions will exist, however awareness of this existence and its appropriate use can help open up reflective space and honest dialogue. In The Art of Powerful Question the authors ask us to contrast the following questions:



Clearly the former assumes error and blame and invariably the respondent will feel defensive. The latter though will encourage reflection and stimulate learning and sharing. Either question has the ability to set out the trajectory of the conversation. It is very difficult in a culture where leaders feel that they are being paid for fixing problems rather than fostering breakthrough thinking not to align oneself to the first question, but how far does it take us. Fran Peavey, a pioneer in the use of strategic questions, observes: “Questions can be like a lever you use to pry open the stuck lid on a paint can. . . . If we have a short lever, we can only just crack open the lid on the can. But if we have a longer lever, or a more dynamic question, we can open that can up much wider and really stir things up. . . . If the right question is applied, and it digs deep enough, then we can stir up all the creative solutions.”


Assumptions like ‘we will always have unwell patients who will need us to act on their behalf’ and ‘at some level coercive practice is inevitable in those cases’ plays into the questions we frame. Within PROMISE we have questioned these assumptions and it has broadened our thinking. In effect questions have strategically shifted our thinking. Consider the two questions:



The second question changes the context by challenging our traditional paradigm of Cambridge and Oxford competing with each other. In her book The Art of the Question, Marilee Goldberg writes, “A paradigm shift occurs when a question is asked inside the current paradigm that can only be answered from outside it.” The question that we were asking of ourselves was “How can we repeatedly redefine frontiers of humane care in mental health?” This will cause for an exponential increase in knowledge base and its translation into clinical practice. A competitive model can only go so far but a partnership one had the potential to realise our aims. At the heart of PROMISE global is the desire to fruitfully answer the question and thus the aspiration to embrace the possibilities that go beyond the current paradigm. A ‘what if’ scenario emerges. What if we had a global vision for local agendas, what if we all worked together to push the frontiers... It’s this kind of paradigm shift, based on powerful questions, that may be necessary to create truly innovative solutions to our most pressing concerns.


“If I had an hour to solve a problem and my life depended on the solution, I would spend the first 55 minutes determining the proper question to ask, for once I know the proper question, I could solve the problem in less than five minutes.” — Albert Einstein


Now watch the following video:





Doubt comes in at the window when inquiry is denied at the door.

Benjamin Jowett