Chapter 8
Person-centred research
Belinda Dewar1, Aisling McBride2 & Cathy Sharp3
1University of the West of Scotland, UK
2University of the West of Scotland, Hamilton, Scotland
3Research for Real Edinburgh, Scotland, UK
Research that explores person-centredness has adopted a range of methodologies. This chapter presents one methodology – that of appreciative action research. I begin by sketching out the principles of appreciative action research and then present an argument for the use of this methodology for research into person-centredness. This is illustrated through case examples about how these principles are promoted in practice. I include an introduction to the caring conversations framework that supports animation of the appreciative dialogue in practice as well as promoting person-centred caring cultures. In conclusion, the chapter suggests that affirmation, provocation, inquiry and collaboration are core elements that enhance a more hopeful and improvisational approach to innovation in health and social care.
Introduction
The health and social care landscape is characterised by paradox, ambiguity and complexity, and now more than ever before there is a need for an approach to inquiry that can accommodate the challenges of the dynamic world of practice, the variety of people with whom practitioners work, and the dominant discourse of helplessness, negativity and control.
A range of participative research methodologies have been used to explore person centredness (Glasson 2006; McCormack et al. 2011; Manley et al. 2014). Participative methodologies, such as action research, are appropriate as they align with principles of person-centredness in that they aim to be inclusive, democratic and collaborative. In addition they support people to learn from experience and support the blending of research and practice, which fits well with the discipline of nursing (Cowling 2001).
What is appreciative action research?
Action research ‘seeks to bring together action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people’ (Reason & Bradbury 2001, p. 1). In this sense it is a problem-solving approach that aims to create practical knowledge through inquiry.Appreciative inquiry shares the social constructivist foundations of action research and aspires to the same goals, that is, to work towards emancipatory transformation (Reason & Bradbury 2001; Grant & Humphries 2006; Reed 2007). Yet, appreciative inquiry has a distinctive positive and generative philosophical stance that claims to:
unleash a positive revolution of conversation and changes in organisations by unseating existing reified patterns of discourse, creating space for new voices and new discoveries, and expanding circles of dialogue to provide a community of support for innovative action.
Ludema et al. (2001, p. 189)
Appreciative inquiry has been used in an array of differing organisational contexts to transform practice by developing theory of what ‘gives life’ to an organisation, and what it is that works well (Carter 2006; Dewar & Mackay 2010; Bellinger & Elliot 2011; Rubin et al. 2011; Doggett & Lewis 2013). From this premise, theory embedded in the direct experiences of stakeholders can be developed to allow the focus of any ‘action’ taken forward to be based on ‘the most positive core – their values, visions, achievements, and best practices’ (Watkins & Mohr 2001, p. xxxi).
The principles of appreciative inquiry are:
- that inquiry begins with appreciation of what works well and what is valued;
- that it is applicable to the system in which the inquiry takes place and is validated in action;
- that the inquiry should be provocative, encourage reflection in and on action and create new knowledge compelling to the organisation members;
- that it is collaborative, in the sense that participants must be part of the design and execution of the inquiry (Bushe & Kassam 2005).
Here I argue that action research that uses an explicit appreciative focus of inquiry, and so of how problems are framed in the first place, enables practitioners to make ongoing judgements about what will be ‘life giving’. This deliberate stance away from a deficit-focus enables practitioners to respect the complexities of situations they face and keep conversations person-centred and generative whilst exploring vulnerabilities, fears, distress and criticism as well as ‘moments of excellence’ (Fry 2014, p. 48).
In this way, appreciative inquiry shares the core of all person-centred approaches in shifting from focusing on the negative (the problems and deficiencies) in people to recognising and so releasing people’s potential (strengths and abilities).
Appreciative action research (AAR) has been described by Egan and Lancaster (2005) and tested out by Dewar (2010) as an approach that combines the principles of emancipatory action research with those of appreciative inquiry (AI). The framework for appreciative action research shown in Figure 8.1, developed and tested by Dewar (2010), combines these key principles into one framework. This ensures that the positive perspective of appreciative inquiry is combined with a systematic approach to experimentation in practice, the taking of action, reflection on action, and evaluation of processes and outcomes. Evaluation is built into the day-to-day process of the inquiry and is a process of continuous reflection, valuing and feedback.
Figure 8.1 Appreciative action research.
Source: Dewar and MacBride (2014). Reproduced with permission from Rory Dewar.
The approach of appreciative action research goes through a number of phases, which it is helpful to make explicit. It starts with the discovery of what is working well – what excites us in our work; what makes a difference to staff, people that use services and their families; what are we proud of; why do things work well; what helps it to happen; how do we make sense of what is believed and said about the system at its best? It also looks at and explores what matters and what is valued.
We then feed back learning from the discovery phase to work with people to envision the desired future. This is followed by co-creating with all those involved ways of achieving the ideal and developing strategies to articulate learning and achievements. And finally the phase of embed, which is about embedding new developments in routine practice, and considering what people need to continue learning and flourishing.
Throughout all of this there is a need to create opportunities for processes of feedback reflection and valuing. In these processes, conversations and language matter in how we make sense of what is going on and consider possibilities. We do this through appreciative dialogue, which is:
dialogue in the sense of enabling us to talk to each other about what we aspire to do, and appreciative in the sense of supporting people to engage in meaningful conversations that help them analyse and articulate what works well and when. This raises these positive practices to consciousness and motivates practitioners to make this way of behaving happen more often.
Dewar and Sharp (2013, p. 2)
Appreciative action research as a relational practice
The relationships existing between people in an organisation or system are the organisation, and form the basis of its strength or weakness. We know that the quality of relationships determines outcomes for staff experience and well-being as well as patient and family well-being and care experience (Nolan et al. 2006).
Appreciative action research celebrates both individual and mutual successes to create a positive relational language of inquiry and dialogue. An appreciative stance to inquiry is inevitably a form of relational practice as it has to be done ‘with’ rather than ‘to’ people. Strengths attributed to the appreciative approach include engagement, inclusivity and collaboration encouraging the acknowledgement of experiences and also individual skills (Trajkovski et al. 2012).
The various diverse formal roles within health care, such as nurse, clinician, patient, health-care assistant or relative, can act as a barrier to authentic relationships if a dialogue of mutual understanding is not encouraged. An appreciative stance enables a more humanistic, authentic and relational approach to research and practice development that helps people to step out from their formal ascribed or assumed roles and be more fully present with each other; what John Rowan (2001) calls ‘research as if people were human’ (Rowan 2001, p. 121)
What is important for person-centred practice or relational practice is that the philosophical values of exploring the uniqueness, wholeness and essence of human life in the context of one another are central to the research design. A framework of caring conversations has been developed to support appreciative dialogue and explore possibilities in relationship. It is this appreciative dialogue that helps us to engage in all the phases of AAR and may additionally support practitioners to evoke the Person-centred Nursing framework (McCormack & McCance 2010). The caring conversations framework arose through analysis of more than 240 hours of observation of practice, and eliciting stories about the experience of caring in an acute ward for older people (Dewar 2011; Dewar & Nolan 2013). The study was conducted as AAR (Dewar & Mackay 2010).
The framework asks that we consider seven key attributes in our interactions aimed at supporting learning and action (the seven Cs). These are illustrated in Table 8.1.
Table 8.1 Caring conversations to promote appreciative dialogue
| Be courageous | What would happen if I did something or did nothing? What would it take to give it a go? |
| Connect emotionally | How do you feel about what I have said? |
| Be curious | Help me to understand what happened? What do you care about or hope for? What do you notice? What are you wondering about? |
| Collaborate | Is there anyone else who could help us with this? How can we work together? |
| Consider other perspectives | What would others say? |
| Compromise | What is the ideal and what would you settle for? How can we achieve this together? |
| Celebrate | What has worked well and why? What do we value? |
The caring conversations are the ‘how’ of AAR. The framework guides people to have different kinds of conversations that are appreciative, provocative, more open and inquiring. Some evidence suggests that Caring Conversations help to achieve relationship-centred practice where the senses of security, belonging, continuity, purpose, achievement and significance (the Senses Framework) are fulfilled (Dewar & Nolan 2013).
Related practice inquiry tools developed by practitioners and researchers to help care staff have Caring Conversations, including the Positive Inquiry tool, emotional touchpoints and the use of photo elicitation (Dewar et al. 2010; Dewar 2012). These practice inquiry tools have been used effectively in a range of settings, including care homes and with community-based health-care staff, to explore patient and family experience and to learn from a range of staff involved in caring across health and social care boundaries (Sharp et al. 2013; Dewar & MacBride 2014).
Core principles of appreciative action research
Through using the framework of caring conversations and associated practice tools we are able to highlight three important elements to AAR that enhance the relational and person-centred elements of this approach to inquiry. These are:
- Affirmation as provocation and innovation
- Collaborative inquiry as intervention
- Improvisation.
The next sections will explore these specific principles and use examples to illustrate their use in practice alongside suggestions for supporting the utilisation of the Person-centred Nursing framework (McCormack & McCance 2010).
Affirmation as provocation and innovation
The term provocation is perhaps best understood when aligned with positivity. Provocation here means that which is intended to excite, intrigue, dare, arrest thought or interrupt flow. It helps us to look at things from a different vantage point aimed at challenging assumptions, and say out loud that which is often not said, with the ultimate purpose of creating possibilities for thinking (and acting) in a different way. In this respect, it is a form of disruptive innovation, in the sense of novelty, but one that does not invoke defensiveness.
It has been suggested that an incremental approach to innovation that adopts and recombines things that already exist in new ways is more likely to be effective in health and social care (Mulgan 2013; Pennacchia 2013). I have found that asking appreciative and provocative questions and encouraging dialogue about hopes, passions, values and emotions are valuable ways to drive ‘incremental or additive innovation’ by building on the best of what already exists, and so in this way be transformational.
To be positive and provocative in unison in the context of health care and practice development means to question assumptions of how things are; is there another way to do something that may be more supportive to all within that practice setting? Is that possible? Could it be explored further? It worked well on an occasion, why was that? Barrett and Cooperrider (1990, p. 232) claim that a good metaphor ‘provokes new thought, excites us with novel perspectives and enables us to see the world with fresh perspectives’. A generative metaphor is both a positive and provocative statement intended to enable an alternative perspective on practice to bring about transformational change by harnessing the potential that already exists within an organisation. The development of each ‘generative metaphor’ stems from the direct experiences of the people who work within that organisation or system. This stimulates the exploration of the possibility of positive change stretching beyond any current problematic situation (Richer et al. 2010).
Generative metaphors that emerged from the direct experiences and conversations within an older people acute care setting had a significant impact on future action (Dewar 2011).
As facilitators, noticing and being playful with language ‘from a posture of empathy rather than attack’ (Ludema et al. 2001, p. 197) is one of the most significant ways in which we have supported practitioners to explore taken-for-granted assumptions, develop a language of possibility and create generative metaphors.
I noticed, for example, that one support worker referred to a lady she was caring for as ‘the lady who likes to be on the move a lot of the time’. The positivity of this statement struck me. I shared what we had noticed with the support worker, who reflected on this and shared other insights. This prompted others to say they often referred to those residents as ‘wanderers’, but that this way of saying things was better as it did not label the person, but explicitly identified what she liked doing, even if at times this behaviour was difficult for staff to manage.
Such dialogue is generative; this one curious encounter with language prompted staff to engage in a whole process of inquiry about the language they used. They developed a language poster to start noting and sharing language they valued, was person-centred and could be developed (Dewar & MacBride 2014).
The prerequisites stated in McCormack and McCance’s (2010) Person-centred Nursing framework highlight what is required of the practitioner to enable person-centred care. Qualities such as ‘knowing self’, ‘developed interpersonal skills’, and clarity on ‘beliefs and values’ may require to be nurtured. To move away from ‘task’ orientation to care, to that of a therapeutic relational interaction – these qualities are essential (McCormack et al. 2010b). Opening up dialogue that is positive in its provocation of questioning why certain language and patterns of care are followed could aid the enhancement of these prerequisites to person-centred practice.
A skilled facilitator of AAR needs to be able to nurture this kind of appreciative dialogue and inquiry. They have to develop language ‘antennae’ to notice and help others notice beautiful utterances. In addition they need to notice language that does not feel person-centred or relational and be courageous in tactfully interrupting dominant negative discourses and supporting others to reframe this in a sensitive and inspiring manner.
Collaborative inquiry as intervention
The moment we ask a question we begin to create a change. Inquiry is explicit, and asking the right questions is perceived as a first-step intervention that provides a meaningful platform for further development and discovery (Cooperrider et al. 2008, p. 9). One of the most impactful things an appreciative inquirer does is to articulate questions as an invitation to inquire together. The questions we ask set the stage for what we ‘find’, and what we ‘discover’ creates the stories that lead to conversations about how the organisation will construct its future.
The My Home Life leadership support programme aims to promote quality of life for those living, dying, visiting and working in care homes through relationship-centred and evidence-based practice (NCHR&D 2007). The programme has appreciative inquiry, relationship-centred practice and caring conversations as its underpinning philosophy. Appreciative questioning became a different way of working for some practitioners. For example, a care home manager talked about how she found it difficult to work in situations when staff did not appear to ‘get on’ and were constantly bickering. She would normally bring them into the office and ask what the problem was. Through using appreciative questioning she learnt to reframe the questions she was asking. The manager was able to change her language from one of problem-solving to one of inquiring and learning together. She wondered and was curious about what was happening and what could happen. She started to ask:
- How do you feel about what is happening in your relationship?
- How would you like to feel?
- What could be different?
- Suppose you come to work tomorrow and it is all working well what would this look like?
- Is there one small step you could take together to move towards the way you would like it to be?
Necessary elements of the Person-centred Nursing framework within the care environment are ‘effective staff relations’, ‘power sharing’ and ‘potential for innovation and risk taking’ (McCormack & McCance 2010). The use of appreciative collaborative inquiring could go some may in supporting these key aspects of the care environment. Being open and finding new ways of working that can have a positive impact for all require both sharing power and taking a risk in using a different approach. Additionally, with conflicting demands often directed towards care staff, having the courage to ask appreciative questions alongside a willingness to compromise, may encourage an ability to remain ‘present’ and maintain supportive, authentic relations within interdisciplinary teams for the benefit of a person-centred care environment for all.
Improvisation
In their review of appreciative inquiry as an approach for changing social systems, Bushe and Kassam (2005) suggest that appreciative inquiry can be transformational where it focuses on changing how people think instead of what they do, and supports self-organising (improvisational) change processes that flow from new ideas.
It is important to note that when we advocate ‘action’ in AAR this relates to bringing to life insights from conversations through active experimentation in practice, rather than advocating specific actions; the ‘new actions’ are co-designed in the light of the new thinking.
Bushe and Kassam (2005) warn against implementation – a specific tangible change achieved that had been agreed upon by assumed key decision-makers. They prefer the concept of improvisation, where numerous diverse ideas for development are pursued by a range of actors and where there are many changes that link to a deeper fundamental change in how the organisation is perceived.
An example of a deeper fundamental shift to a new way of thinking was highlighted in one study using AAR. Participants believed the process had changed their approach to what they felt was sometimes characteristic of learned helplessness, where they responded to things negatively and often felt powerless to change things. Instead, the process enabled a way of being more characteristic of ‘learned hopefulness’, in which they now felt they had a framework in place that helped them to explore possibilities with people even in the face of difficulties (Dewar 2011).
Examples of outcomes pursued by a range of participants in AAR projects have included:
- celebrating more openly what works well;
- engaging at an emotional level to learn and act upon the things that matter to people;
- developing ways in which caring acts can move from the unconscious to the conscious and collective;
- being more aware of defensiveness and working hard to enhance engagement;
- encouraging wider and more collaborative inquiry;
- devolving responsibility for noticing how things are, offering ideas and trying out new ways of doing things;
- challenging organisational thinking about implementation and roll-out to a model of progressive wider adoption through nurture and positive ‘contagion’.
These changed the way practitioners worked and provided a meaningful and personalised vision for maintaining compassionate caring activities within the care settings.
Barrett (1998) draws on the metaphor of improvisation in jazz as a prototype for developing organisational cultures where people are enabled to experiment and learn in collaborative action. He makes the case that improvisation is happening all the time in organisations, but that successful improvisation is not a haphazard or accidental process; just as ‘musicians prepare themselves to be spontaneous’, practitioners can prepare organisations to learn while in the process of acting. This perspective is a hopeful, appreciative one rooted in belief in the human capacity to think afresh, generate novel solutions and create something new and interesting by learning in action. Important elements of improvisation are illustrated in Box 8.1.
Box 8.1 Elements of improvisation
- Trial-and-error thinking – being open to making ‘mistakes’.
- Feedback.
- Planning ahead as play.
- Challenging habits, routines or conventional practices.
- Taking turns to ‘lead’ (going solo) with accompaniment from supporters.
- Suspension of the tendency to criticise, judge or express disbelief.
- Developing supporting behaviours including good listening.
- Acknowledging achievements including rewarding those who support others and making room for contributions from peers.
- Designing more interdependence into tasks to enhance responsive capacity.
- Willingness to take risk and see errors as a source of learning and new lines of inquiry.
- Embrace the unknown.
- Cultivate serious play as a fruitful, meaningful activity that remains open to cues from the environment.
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