Chapter 5 reviews specific methods of effective communication within the organization. The provision of healthcare is often viewed from a perspective of deficits and limitations with all staff being trained to focus on the negative and on what is wrong or could go wrong in any given situation. Given this view of leadership and organizational oversight, recent research into the most essential attributes of leadership has shown that a leader’s ability to build trust among employees is highly important, appreciating the contributions made by employees at all levels of the organization. One of the most promising ways to accomplish these goals system wide is through appreciative inquiry.
1. Appreciative Inquiry and Moral Distress: A Communication Change Agent Based on the premise that human systems grow in the direction of their deepest and most frequent inquiries, it is understandable that within the LTC environment the most frequent
inquiries are often rooted in problems and shortcomings relating to the care provided.
Appreciative inquiry provides a means of understanding the operation from another perspective, a positive perspective that seeks to focus on what is being done correctly and positively within the organization and to build upon those accomplishments. Developed in the mid-1980s by David Cooperrider and his associates at Case Western Reserve University, appreciative inquiry challenged the common problem-based approach, encouraging inquiries that would reflect what is working well within the organization and building upon that.
Appreciative inquiry seeks to focus on building upon strengths in order to eliminate those operations that may be carried out poorly. Because appreciative inquiry allows the focus to shift to the positive, it brings the positive mental models to the surface to be employed for more creative approaches to issues within the organization. Whitney and Trosten-Bloom identify the following concepts or assumptions as foundational to appreciative inquiry:
• People individually and collectively have unique gifts, skills and contributions to bring to life.
• Organizations are human social systems, sources of unlimited relational capacity, created and lived in language.
• The images we hold of the future are socially created and, when articulated, serve to guide individual and collective actions.
• Through human communication – inquiry and dialogue – people can shift their attention and action away from problem analysis to lift up worthy ideals and productive
possibilities for the future.
must operate, help to support a system-wide approach when applied to issues of moral distress. Developing an understanding of the concept of mental models is one of the most important factors to consider when seeking information that will help to clarify one’s own perception of moral distress. The impact that such models have on the way each individual views a particular set of circumstances determines to a large degree what might trigger experiences of moral distress for a given individual. Senge describes mental models as “deeply ingrained
assumptions, generalizations, or even pictures or images that influence how we understand the world and how we take actions. Very often we are not consciously aware of our mental models or the effects they have on our behavior.”
Both the significance and the impact of mental models on the experience of moral distress cannot be understated, as mental models help to explain why the experience of moral distress is so individualized and why it can only be addressed systemically throughout the
organization. This notion is contrary to previous approaches that attempt to identify the potential for moral distress by isolating specific incidents thought to trigger such distress for large
numbers of individuals within the organization. Understanding the role of mental models becomes a shared responsibility between the individual healthcare practitioner and the
organization. Just as individuals have mental models or sets of assumptions upon which they make their decisions, organizations develop their own sets of metal models based on the workgroups that exist within the organization. The assumptions of the work group come to define shared beliefs and ultimately cause the group to act in certain ways. The organization must strive to seek out this information from its employees, who must be willing to share their own views if actions are to be taken to address issues that may lead to moral distress.
their workplace has been shown to influence an organizations’ ability to embrace the tenants of appreciative inquiry.
2. Appreciative Inquiry in Healthcare
The healthcare environment is well suited to benefiting from the techniques of appreciative inquiry, given the relational aspect and active listening approaches that help to define it. The following provides two examples of the successful implementation of appreciative inquiry in helping to address two very different concerns in a hospital setting.
The first example is taken from the University of Virginia Medical Center, which in 2007 was confronted with its house staff training program’s being placed on probation by the
Accreditation Council for Graduate Medical Education. The effects of loss of full accreditation had the potential to greatly reduce the stature of the school and the reputation of the hospital. The medical center turned to the appreciative inquiry process in an attempt to better understand what the school had previously excelled in and to seek solutions that would allow them to build upon their strengths. The school regained its full accreditation, and in the process the
administrators learned that the appreciative inquiry process had increased employee engagement, improved communication across departments, and improved the sense of psychological safety, which is critical to creating an environment of trust. Building upon the lessons learned during this process, additional departments began to use appreciative inquiry when confronted with operational challenges that might previously been addressed from a more negative perspective. The second example is taken from a study undertaken by Dewar and Nolan, which sought to develop a compassionate relationship model of care that could be implemented in an acute care hospital serving older adults. The appreciative inquiry model was used in this study to
developed to draw out positive feedback from the patients and would assist the caregivers in strengthening the relationship with the patient and creating opportunities for caring
conversations. The survey included such questions as “What matters to you most whilst you are in hospital?” “Tell me something that will help us to care for you here?” “What things have worked well for you here?”
The lessons learned from the problems at the University of Virginia and the study on creating compassionate relationships in an acute care setting support the use of appreciative inquiry as one means of enhancing the quality of conversations that might lead to positive change within the organization.
3. Appreciative Inquiry and Conversational Capacity
In his book Conversational Capacity, Craig Weber puts forth the notion that despite the amount of knowledge and expertise that a given team may have regarding their subject matter, the team will be ineffective and inefficient if it is lacking in what he terms “conversational capacity.” The foundation for this capacity is rooted in psychological safety and in the ability not only to ask questions but also to ask them correctly, as described in discussing the methods used with appreciative inquiry. Conversational capacity seeks to have conversations about difficult subject matter in a non-defensive balanced manner.
Certainly, given the personal nature of issues involving the experience of moral distress, the need for the ability to raise issues of concern effectively is critical in helping to confront such issues. While the systems approach to addressing and resolving moral distress within the
organization is paramount in addressing such distress, responsibility must be shared with the individual practitioner. These practitioners must seek to understand themselves well enough to
appreciate what might act as a trigger in producing moral distress within themselves and work with the organization to address such triggers.
Craig Weber has identified several triggers, including how much we care about the issue, what our status is within the organization, the level of expertise we may have in a given subject, and the perceived risk of speaking up versus the perceived risk of not speaking up. Despite policies that are consistent with the operating goals and the mission of the organization, the responsibility lies mostly with healthcare practitioners to both stand up and speak up for
themselves in situations that they believe are inconsistent with their own moral beliefs. The role of organizational leadership in cultivating a non-threatening/non-judgmental environment that permits effective conversations about concerns is essential for ultimately reducing the experience of moral distress across the organization.