Appreciative inquiry case study

Summary

Appreciative inquiry is one of the Patient Safety Incident Response Framework (PSIRF) tools that can be used to learn from patient safety incidents. Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares how she designed and introduced an appreciative inquiry tool at her hospital.

Setting and Context

In June and July 2022, I started to research more deeply the principles of appreciative inquiry. Working in clinical governance for 9 years and a qualified nurse for 14 years, the principles of appreciative inquiry felt to me to be potentially revolutionary.

I decided to design an appreciative inquiry tool template using the 5Ds (Define, Discover, Dream, Design and Deliver) and talked to my senior directors about the concept of introducing small scale but formal appreciative inquiry within the division. Working within an incredibly busy and pressured medicine division, including an emergency department, I would have fully understood if the senior leads had been cautious and wary of yet another new approach being implemented; however, they were enthusiastic and positive about focussing on what went well just as much as what went wrong, and felt the principles of appreciative inquiry could introduce valid discussion and learning. 

Challenge

A medicine division in an acute sector trust is often focussed on ‘what went wrong’ and the learning from harm. I felt that appreciative inquiry could not only give a wider, more holistic view to patient care but also provide further celebration and appreciation of the staff at the core of the services.

At the time of the introduction to appreciative inquiry, the services were witnessing severe pressures to deliver care to more patients and had still suffered elements of moral injury from the Covid pandemic. I wanted to recognise and celebrate the staff and learn from their example.

Despite the initial enthusiasm, it became apparent that although the concept was welcomed, introducing formal appreciative inquiry to the most acute area of an acute trust was not without its difficulties. The senior leads in the division were focussed (understandably) on keeping patients safe and being accountable and responsible for the lives entrusted to them. A few had suggested that formal appreciative inquiries were raised but none that materialised.

Actions

Within medicine, a team meeting is held for all senior leads to discuss operational pressures and, as a group, forward plan, debrief and raise any concerns or risks posed. This team meeting is attended by senior medics, nurses, pharmacists, operational managers, HR business partners, financial leads and governance leads. The meeting is minuted, has a set term of reference and is always well-attended and respected.

Define

In one of these divisional team meetings, the Chair (the Medical Director for the division) had asked the senior leads to discuss the last 48 hours in the Trust where the hospital had seen record levels of attendances and length of stay in the emergency department leading to delay in patient care and patients unfortunately having to be nursed on the emergency department corridor. The Medical Director wanted the team to debrief and go through their experience of the events focusing on what more could be done and what was the learning.

Discover

Some key stakeholders had started to talk about why they felt they had witnessed such extreme pressures in emergency department attendances and length of stay, what their frustrations were and what they were worried about moving forward. I started to observe the language being used and asked for a pause at a natural moment in the meeting. I asked the teams to take a breath and try to think about how we can change direction within the conversation. I asked the permission of the Chair as to whether we could consider this debrief as an appreciative inquiry. I reminded the team of the structure and assured them that although this would need them to consider the situation in a different way, it would still allow for raising and documenting any risks identified and this would not detract from the experience they had. I asked if anyone in the meeting could describe or give points regarding what went well and any examples where the management of the situation ended in a positive outcome.

The Medical Director then took the lead (I had discussed with him earlier the same month about the principles of appreciative inquiry and being allowed to take that pause). He gave the first example, noting the vast liaison with multiple agencies leading to a more cohesive approach. Other key stakeholders started to discuss the visible leadership on the wards, timely discharge prescriptions being completed to facilitate patient flow, pre-booking ambulances for patient discharge, pastoral care and kindness shown to team members, strong discharge lounge support (ward area dedicated to patients leaving the trust that day) and a discussion involving local partnerships that could create further improvements.

Dream

I then asked how the learning from these points could benefit the division moving forward. The team initially discussed reviewing the handover process to make the discharge lounge support more seamless. They considered what structure could be put in place to give consistency in the senior manager on-call role and how they could build relationships further with the local partnerships.

Deliver

As this was a time-limited meeting and needing to cover a lot of discussion, I offered to type up whatever feedback had been given and share with team members who were not present with the description of the ‘define’ element of the appreciative inquiry and sharing the final notes back to the group. One of the most important points raised, by a senior lead, was the need for more ‘pause’ points. The Chair suggested an away day to assess further in a safe space how the culture in the division could strengthen further. Following the meeting, an away day was hosted, local partnership meetings continued and the team identified that the visible leadership which had been celebrated would continue through quality walk rounds.

Impact

When considering the outcome of implementing potentially small-scale formal appreciative inquiries within the division, I may have been tempted to come to the conclusion that this was not a success as formal inquiries in a divisional governance structure at that time were not able to be facilitated. However, I believe the outcome of this example of appreciative inquiry was a success when focusing on how to introduce the elements of appreciative inquiry into debrief/huddle/team meeting discussion and to start to change the mindset of the power of language within debrief.

Following this example, the Divisional Medical Director used this approach in many team meetings and when chairing formal meetings. We also then started to create appreciative inquiries from audit and investigations, using the principles learnt in this meeting and discussion.

The theory at first did not match up to the practice until the structure was made bespoke to the service. One of the great things about appreciative inquiry is that it can adapt well in different situations and can be used informally and formally. There isn’t a right or wrong way to start to speak about positives.

Next Steps

Since this appreciative inquiry, the Trust has trained numerous staff members in After Action Review conduction and in Patient Safety Incident Response Framework (PSIRF) implementation, both of which are based on principles of appreciative inquiry and the scope for appreciative inquiry tools to improve patient and staff outcomes on a grand scale. We have everything to gain from focusing on what we do well.