The solution-focused approach to questioning.

The solution-focused approach is a support and supervisory model of reflection that, if used within the context of the CEC, can facilitate reflection and clarification of issues through dialogue. Such reflective practice supports the moral growth of the practitioner by facilitating understanding, which can then be used in any ethical situation that the clinician experiences in the future. This focus on reflection places an emphasis, not on ethical theorising or ethical models, but on dispute resolution, through a focus on exploring shared insights and formulating a plan of action. This focus is different in emphasis from some of the most commonly used approaches in UK ethics committee consultations at present. Many of the current models of review involve considering principles and duties against what appears reasonable,

as discussed in Chapter 6 and focus on the problem rather than the solution. As Agich (2011 p270) states:

“The skills identified and discussed in the ethics consultation literature are primarily cognitive in nature, involving knowledge of ethical concepts, principles, and theories or analytical, communicative and interpretive skills necessary to apply the ethical frameworks to the concrete circumstances of the individual cases”.

Rudd (2002), discussing the CEC approach to case consultation used in Bath in the UK, identifies this analytical approach as the committee’s preferred model, stating:

“The case referrals are the most challenging and difficult aspect of the work of the committee. For this reason, we would normally consult our ethicist as well as other members following a referral. We would hope to use a logical analytic approach to these [referrals]” (p494).

Rather than an analytical approach to ethical deliberation, focusing on problems, solution-focused reflection is a dialogical approach to deliberation to assist in decision making. Through the dialogue potential solutions to the issue are

considered and resources to achieve the solution are identified, whilst respecting the importance of context. As Widdershoven (2009 p237) states:

“A dialogical approach emphasizes that ethics is concrete and contextual. A dialogue is an interaction between people involved in real problems. This distinguishes a dialogue from a theoretical debate. A dialogical approach to ethics implies a crucial role for experience and learning. A dialogue

presupposes that the participants already have some interest in, and insight and knowledge through, an exchange of perspectives.”

The solution-focused approach aims to equip the CEC with skills that, through dialogue, can engage the clinician in a conversation about ethics. Through this conversation, the group enables the clinician to deepen their knowledge, explore perspectives on the situation and consider solutions. As Janisse (2004 p98) states:

“A narrative approach can be a useful ethics tool in the initial descriptive construction of the case and subsequently in normative reflection. Dr Rubin [2002] notes: ‘Narrative methods can sharpen out attunement to issues of how the narrative of a case or ethical dilemma are constructed, whose voices are given authority, which plot lines are considered relevant, and which possible resolutions are given consideration. The virtue of using a narrative approach is that it forces us to expose our assumptions and biases, to confront them, and to bring competing allegiances into dialogue with one another’.”

For nursing and many other healthcare disciplines, reflection underpins much of the training undertaken in pre- and post-registration courses. The space and safety of the CEC gives the practitioner an opportunity to reflect upon their practice. This process is not simply a vehicle to gather facts that will then be analysed; it is an active process in itself.

Leppa et al (2004 p195) describe reflective practice as an opportunity to “identify weaknesses, build on strengths and develop best practice”. She continues:

“Within ethics teaching reflection has become central to understanding the nature of ethical dilemmas and how they impact on those involved...Rolfe (2002) has outlined a paradigm for reflective practice in nursing education that calls for nursing educators to be ‘less concerned with disseminating knowledge than with facilitating the [clinical] practitioner to explore her (sic) own practice through reflection-on-action’.” (p196)

The solution-focused approach has been described as “simple but profound” (Fowler 2007 p1). The philosophy is built upon the assumption that the individual has the answers to the dilemma within himself. This “spacious simplicity” (Waskett 2012 p1) evolves out of mutual respect between those involved in the

conversation. It is becoming widely used in the health service in a range of team, client-focused and supervisory relationships and will therefore be known to many health service employees, especially those from the areas of social work, health management and health education.

Solution-focused approaches can be and are being used in a number of settings, for client-focused work and teamwork. Solution-focused methods are appropriate within difficult and complex situations. The key trainers in solution-focused approaches in the UK (BRIEF 2012) identify a number of areas in which such a philosophy has been used: supervision and consultation; solution-focused child protection; solutions in education; solutions with children and adolescents; solutions in mental health; solutions with drug and alcohol users; solutions in challenging situations; solutions in housing management; and building cooperation with reluctant clients.

Solution-focused therapy was developed in the mid-1980s, as a therapeutic technique by de Shazer and Insoo Kim Berg. It is underpinned by the humanistic

and behaviourist philosophy, which emphasises concentrating on the relationship in order to promote growth and development, and constructing a solution rather than solving a problem. Problems sometimes seem insurmountable and we can become embedded in problem focused rumination. Solution focused work seeks to harness the resources of the individual to find solutions not just explore at length the problem without an outcome. It was initially aimed at client-focused work, but is increasingly used in relation to team and personal development within the health services. Two essential components of the intervention, as described by Gingerich et al (2000) are “the miracle question, which asks the client to pretend that a miracle has happened and imagine a solution to the problem…[and] the scaling question which asks the client to rate how things are today”. There are over 32 published research studies on the application of this approach, including Beyebach et al (1996, 2000), Burr (1993), deShazer (1985, 1991), Macdonald (1994, 1997) and Nelson (2001). BRIEF (2012) reports that the outcomes of such interventions are perceived as successful “in 65-83% of cases”. There are no research studies looking at the solution-focused approach within CEC case reviews. The approach has been used and researched in challenging situations where conflict plays a substantial role in the discussion. Issues where the approach has been used relate to serious mental health problems, criminal behaviour and domestic violence. The approach appears to have contributed to learning that has shaped behaviour, and this learning has endured for years after very short interventions (e.g. less than four meetings). BRIEF (2012) do also offer an effective intervention, described as coaching that occurs within a single

meeting, making the format applicable to the single CEC review. The techniques used within the CEC should not be seen as “therapy” but as a harnessing of the

concepts of solution- focused work which are: (1) focusing on desired solutions rather than unsolvable value conflicts, (2) the CEC using a structure to their

questions that increase awareness of the resources within and around the clinician to help, and (3) support for the clinician in times of difficulty. Please see Appendix 2 for examples of some of the techniques as outlined by Iveson (2002 p150). Gingerich et al (2000 p477) review the research on the solution focused approach and conclude, “In less than two decades, solution focused brief therapy (SFBT) has grown from a little known and unconventional therapeutic approach to one that is now widely used in the United States and increasingly in other countries”. They continue, “it is short term and therefore relatively inexpensive”. Acknowledging that an empirical evidence base was necessary to support these benefits, Gingerich et al (2000) conducted a comprehensive review of the available research into the outcomes of the intervention. They note that empirical studies are few and involve varying methodologies and quality. Although the benefits of the approach could be identified, they express concerns about the methods used in many of the studies they reviewed. In some smaller studies they found that it was difficult to determine the benefits of the approach due to a number of other influencing variables. They did identify a well-constructed study by Cockburn, Thomas and Cockburn (1997) on psychosocial adjustment, and the impact of the therapy on return-to-work rates for patients with orthopaedic injuries. Gingerich et al (2000 p 483) state, “Although the sample size was small (25 treatment subjects, 23 control subjects), it was sufficient to demonstrate that the SFBT group was significantly improved as compared with the standard treatment group”. A number of other studies into the solution-focused approach also show benefits, but have not been reviewed in relation to the rigor of their research methods. One interesting work was

Sundmann’s (1997) study into the staff development of nine social workers who received basic training in solution-focused ideas. Those who had received the training made more positive statements, and showed more goal focus after six months. Learning the principles of this approach through a short education period (two days), could help the CEC to incorporate the solution focused strategies they could use to stimulate reflective deliberations with the clinician. It could then be evaluated whether this structure actually improves the effectiveness of the support offered by the CEC. Such evaluation is pivotal for CEC future development. Within the CEC review, the group and the clinician (s) and patient if appropriate work together. Solution focused questions seek to understand the values inherent within the situation. Once understood the CEC can offer to the clinician, patient or whoever is bringing the case a supportive environment in which the issue bringer can identify strategies to help move the issue forward using simple goal-setting techniques. Fowler (2007 p2) states that applying the solution-focused model in practice for clinical supervision, is based on:

“the idea that a warm, genuine and trusting relationship used to help a person focus on achievable, positive outcomes is an extremely powerful way to help people move forward”.

Not being constrained by the need to justify action by considering it against a traditional ethics model offers freedom for the CEC to simply ‘hear’ the issue. Leppa (2004 p200) discusses the use of a joint education programme with reflection to explore ethical cases, and identifies the benefits of not being tied to reflection through the lens of a single theoretical philosophical model. She states, “Getting away from our constructed pedagogical goals of highlighting specific ethical principles allowed students’ own experiences and dilemmas to guide their

ethics learning. This is an example of the ‘authentic problems’ that engage students in exploring multiple perspectives and solutions”. The solution-focused model adds to this opportunity, by enabling the discussion to be focused and structured, so as to facilitate resolution.

The focus of reflection within solution focused work is to set goals, and identify how the person will know they are achieving such goals, within a short timeframe. This supports the individual’s need to work within the time constraints of practice. The approach does this by finding a shared goal and working towards it, instead of focusing on conflicts that cannot be resolved. Dissecting relative ethical positions in a theoretical way is not necessary, as the focus is on a solution being reached by the person themselves, and not on a solution suggested by the CEC.

Triantafillou (1997 p309) states:

“A fundamental assumption of solution-focused supervision is that

‘recognising capabilities is more important than accentuating the intractable deficits, experiences and beliefs’ (Thomas 1996 p14).”

There is an educative element to this model, as the clinician may need to be alerted to any gaps in his knowledge, so that he can find a solution. Through prior learning and the confidence gained from post hoc review, using the model within the group the members can confidently question areas in the dialogue that appear to be blind spots or prejudices. This activity is in line with the stated overall goal for clinical ethicists as identified by the Canadian Task Force of the Bioethics Society and cited by Bishop et al (2010 p76) who states: “the overall goal of the ethicist is to provide leadership and resources to promote ethical decision-making”.