Strategic Visioning With Stakeholders

AMEE GUIDE

Appreciative inquiry in medical education� John Sandars and Deborah Murdoch-Eaton

Academic Unit of Medical Education, The Medical School, The University of Sheffield, Sheffield, UK

ABSTRACT The practice of medicine, and also medical education, typically adopts a problem-solving approach to identify “what is going wrong” with a situation. However, an alternative is Appreciative Inquiry (AI), which adopts a positive and strengths-based approach to identify “what is going well” with a situation. The AI approach can be used for the development and enhance- ment of the potential of both individuals and organizations. An essential aspect of the AI approach is the generative pro- cess, in which a new situation is envisioned and both individual and collective strengths are mobilized to make changes to achieve the valued future situation. The AI approach has been widely used in the world of business and general education, but is has an exciting potential for medical education, including curriculum development, faculty development, supporting learners through academic advising and mentoring, but also for enhancing the teaching and learning of both individuals and groups. This AMEE Guide describes the core principles of AI and their practical application in medical education.

Introduction

A problem-solving approach, in which making a diagnosis is based on a series of questions that ask about “what is going wrong” with a situation, is typical of the clinical prac- tice of medicine. A similar approach is also frequently applied to many aspects of medical education, from devel- oping a new curriculum to supporting students in difficulty. However, an alternative approach is Appreciative Inquiry (AI), with a focus on “what is going well” with a situation. The AI approach requires an alteration in the mind-set of the person asking the questions, with the key aim of mobi- lizing individual and collective strengths to change the cur- rent situation. An essential aspect of the AI approach is the generative process, which occurs through collaborative dis- cussion, of envisioning a new situation. This process taps into the factors that individuals consider to be important for themselves and others, with the result that the potential of individuals, and also the organizations in which they are an integral member, can be developed. We consider that AI is at the heart of medical education but there has been lit- tle published work on the application of AI in medical education.

The AI approach has been enthusiastically used over the last few decades for organizational development (Watkins et al. 2011), and is also increasingly being applied in the world of business for the development of individuals, including leadership development (Hart et al. 2008) and mentoring (Gordon 2008). Over the last decade, AI has also begun to be applied as an important guiding principle within general education.

In this article, we describe the core principles of AI and their practical application in medical education to inform curriculum reform, as a creative approach for faculty devel- opment, as a foundation for “appreciative education” and “appreciative advising”, and to inform medical education research.

The principles of appreciative inquiry

The essence of AI is that of a positive and strengths-based approach to introduce change in a current situation to achieve the potential of individuals and organizations.

The core principles of AI

Five core principles that underpin the practice of AI have been described and are based on extensive practical experience in organizational development (Cooperrider et al. 2003). These principles are:

Practice Points � Appreciative Inquiry (AI) provides a positive and

strengths-based developmental approach for both individuals and organizations to achieve their potential.

� The strength of both individuals, and also the organizations in which they are integral members, can become mobilized to create a vision for change that is considered to be important to themselves and also to their organizations.

� The AI approach has been widely used in the world of business and general education.

� The AI approach has an exciting potential for medical education, including curriculum develop- ment, faculty development, supporting learners and enhancing teaching of individuals and groups.

CONTACT John Sandars [email protected] Academic Unit of Medical Education, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK�This paper forms part of AMEE Guide No. 113, available from www.amee.org.

Supplemental data for this article can be accessed here.

� 2016 AMEE

MEDICAL TEACHER, 2017 VOL. 39, NO. 2, 123–127 http://dx.doi.org/10.1080/0142159X.2017.1245852

1. The constructionist principle: Fundamental to this prin- ciple is the view that an individual creates, or con- structs, the reality of their world through an active process of interaction and discussion with other peo- ple. For example, the deficit – view is that a glass is considered to be half-empty but this can be positively co-constructed to be regarded as half-full.

2. The simultaneity principle: This principle considers that inquiry and change are not separate processes. Whenever there is inquiry, and questions are asked about a topic, there is a simultaneous beginning of a change process since new insights and understand- ings will influence how the topic is viewed in the future.

3. The poetic principle: In reading poetry, people focus on making meaning from the words. In AI, the deficit- focused words can constrain not only how the topic is understood but also the possibilities for change. An essential aspect of AI is the reframing of current views of a situation.

4. The anticipatory principle: The envisioning of future potential changes creates a feeling of control over a difficult situation and enhances their motivation to change the situation.

5. The positive principle: This principle underpins all of the other AI principles and also all parts of the AI methodology. The concept is that questions that seek to identify strengths engage people in positive change.

The methodology of appreciative inquiry

The original methodology of AI was for organizational development and used the “4-D” cycle (Cooperrider et al. 2003). This method is still widely in use, although recently the “5-D model” has been introduced (Watkins et al. 2011), with an additional “Definition” phase that precedes the four phases that are found in the 4-D cycle. This additional phase essentially defines “is this worth doing”?

Figure 1 describes the main phases in the 4-D cycle, along with the purpose of each phase and the typical ques- tions that are asked. These generic questions can be readily adapted to the particular context and application.

The application of appreciative inquiry principles to education

There have been three main trends in the application of AI principles in education: Appreciative Education, Appreciative Pedagogy and Appreciative Advising.

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“What is working well?”

“What is good about what you are currently doing?”

“What have been the best times or best experiences?”

“What do you value (about yourself, your work, your organisation)?”

ehtniekilebdluocnoitautistnerrucehttahwgninoisivnEmaerD future.

“What might the situation be like? “

“What would it look like if it were working well all the time?”

“What would the ideal future situation be like?”

“If you had a wish, how would the situation be different?”

.llewkrowdluowtahtsessecorpgnisitiroirpdnagninnalPngiseD “What needs to be done differently to achieve your chosen future situation?”

“What resources are required, or who can help you, to achieve your chosen future situation?”

“What do we need to do to realise that future?”

Discovery The identification of processes that work well.

Destiny (or Deliver) The implementation (execution) of the proposed design. “How can we sustain what we are doing?”

“What needs to be done to ensure that the changes continue?”

“How can we make it happen?

Figure 1. The main phases in the 4-D cycle.

124 J. SANDARS AND D. MURDOCH-EATON

Appreciative education

Appreciative Education can be considered to be “a frame- work for delivering high-quality education on both an indi- vidual and organizational level. It provides an intentional and positive approach for bettering educational enterprises by focusing on the strengths and potential of individuals and organizations to accomplish co-created goals” (Bloom et al. 2013, pp. 5–6).

Appreciative pedagogy

Similar to the concept of Appreciative Education is the con- cept of Appreciative Pedagogy, with the adaptation of AI principles to inform all teaching and learning activities, whether these activities are only a short 20minute one to one session, a one hour workshop or a whole program (Yballe & O’Connor 2000).

Appreciative advising

The principles of AI have been applied to Appreciative Advising, with a focus on supporting College students who are experiencing a variety of academic difficulties.

The practical application of appreciative inquiry in medical education

Many practical applications of AI can be envisaged within medical education, from individual and group teaching and learning endeavors, to the development of educational organizations, with the enhancement of curricula and development of faculty members.

Working with individuals

The principles of AI, with its generative and strengths- based focus, can infuse all interactions with a learner. Roarty and Toogood (2014) offer some useful and practical tips on how AI principles can be used to structure all learn- ing conversations:

1. Identify an outcome focus. A clear outcome focus, or goal, is associated with the increase of internal motiv- ation to mobilize their strengths to achieve their own desired outcome (Covington 2000).

2. Focus on what is already working well. An essential aspect of AI is to build on current strengths to achieve intended goals.

3. Reframe any “weaknesses” into strengths to be devel- oped. The act of reframing can produce a marked change in an individual’s self-esteem that internally motivates the learner. Inappropriate attributions about ability can quickly produce negative emotions that result in a spiral of decreasing motivation and perform- ance (Weiner 1985).

Working with groups

The 4-D cycle of AI has been applied to the experiential learning cycle and problem-based learning. Evaluations of these applications have shown increased motivation and

engagement by students in the learning process, an increase in positive attitudes towards other students and the teacher, and more relevant and personally meaningful concepts (both academic and personal) being identified (Yballe & O’Connor 2004; Conklin 2009; Roberts 2010).

Application to Experiential Learning An important aspect of Experiential Learning is the identifi- cation of the question for inquiry and the process of inquiry, with traditional Experiential Learning having a focus on problem solving. Neville (2008) proposes that AI can be used as a complementary approach to Experiential Learning, with a focus on solutions. For example, the ques- tion for inquiry can be reframed from “What is the biggest problem in improving patient safety?” to “What approaches have been used to effectively improve patient safety?” An illustrative of the use of AI in Experiential Learning to teach professionalism is shown in Figure 2 (available online as Supplemental Material).

Application to Problem-Based Learning Typically, PBL has a focus on the identification of a problem to produce a solution and Roberts (2010) discusses the limi- tations of PBL in the context of occupational therapy, espe- cially the focus on what is wrong or dysfunctional. Figure 3 (available online on as Supplemental Material) describes how AI can be integrated into PBL in an attempt to develop a more client-centered and strengths-based approach.

Appreciative advising

The usual approach to help learners who are experiencing difficulties in their academic studies is often a “deficit remedial education model” which has a focus on the identi- fication and remediation of their weaknesses instead of their successes (Kramer & Associates 2007). However, in contrast, the advisor could adopt a strengths based model that increases the learner’s self-efficacy beliefs about pos- sible change and motivates the learner by helping to iden- tify how previous coursework successes were achieved. Academic Advising using a model of six phases within an overall AI approach (Bloom et al. 2008) is illustrated in Figure 4 (available online as Supplemental Material).

Appreciative inquiry for curriculum development

AI can provide a useful method for curriculum develop- ment in medical education, including evaluation and qual- ity improvement that builds on current strengths (Chacko 2009). An illustrative example of the development of a socially accountable medical school curriculum is provided in Figure 5 (available online as Supplemental Material). The AI approach offers a potentially useful method to respond to the complexity of this challenge.

The AI approach also lends itself to tackling a negative culture to change in the curriculum. An important aspect of curriculum development is course evaluation, but often this is by a simple questionnaire, with both students and staff concentrating on problems instead of the strengths of the curriculum. Figure 6 (available online as Supplemental

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Material) illustrates successful use of an AI approach for curriculum development and cultural change.

Appreciative inquiry for faculty development

Steinert (2000) has highlighted some of the key challenges for faculty development, including the need to effectively respond to changes in both medical education and health care delivery as well as to the roles of faculty members. Responding to this challenge requires an appropriate method and AI has an exciting potential for faculty develop- ment by using a generative and strengths-based approach.

Figure 7 (available online as Supplemental Material) illus- trates how an AI approach was used as one of the main methods for the development of faculty and residents in a US medical school were used to ensure that all medical stu- dents would witness a high level of professional behaviors in the academic and clinical teaching staff (Fryer-Edwards et al. 2007).

Appreciative inquiry for medical education research

There has been increasing interest in the use of participa- tory research methods in educational research, with a focus on collaboratively working with a range of stakeholders, from students to teachers and administrators, with the intention of addressing questions and issues that are sig- nificant to these stakeholders (Cohen et al. 2013). An essen- tial aspect of this research method is empowerment of the stakeholders so that they become active participants in the research process. The intentions of the AI approach are similar to the focus of participatory research methods and AI has been applied to general educational research, espe- cially to structure interviews.

An illustrative example of the use of the principles of AI to structure interviews in general educational research is the work of Michael (2005) on the experiences of being a school teacher. Questions were asked that were related to the Discovery phase of the AI cycle, such as “What’s your favorite memory of working here?”, “What do you like best about your job?”, “What do you think is at the heart of your organization’s success?” and “What makes your organ- ization special, or different from other organizations that you know?”. He noted that participants were eager to tell their stories and were more open to disclose unrehearsed information, including greater understanding of the factors that impacted on the positive experiences that they wanted to experience. An interesting aspect was that participants began to feel empowered during the interview to change their current teaching practice, with spontaneous move- ment towards the Dreaming phase as their interviews pro- gressed. Similarly, Giles and Kung (2010) also used AI to explore the professional practice of a lecturer in higher education by identifying their peak experiences as an edu- cator through the use of written reflective accounts that were discussed with a researcher. In addition to the Discovery phase in the discussion, the researcher also began the Dream and Design phases with generative dis- cussions to empower the teacher to transform their profes- sional practice.

There has been little application of the AI approach to specifically research medical education but it offers a potentially useful and innovative participatory method. An

illustrative example of the use of a group participatory AI approach to understand the professional use of social media in medical education is shown in Figure 8 (available online as Supplemental Material) (Pereira et al. 2015).

Personal development using appreciative inquiry The main change is a mind-set that has a focus on identify- ing personal strengths, providing increased motivation and emotional energy to change but also enhanced resilience, satisfaction and self-esteem (Reeve 2014). This approach is in contrast to the traditional focus on identifying “weaknesses”, with its negative connotation and subse- quent draining of emotional energy and reduced motiv- ation. A strengths-based and appreciative mind-set does not ignore “weaknesses” but reframes this situation as being a strength that needs developing, such as to increase particular knowledge or skills. In addition, there is identifi- cation of existing strengths that will be required to be mobilized to achieve the desired outcome.

There are two practical methods for the identification of personal strengths:

1. Reflect on personal strengths after any event, such as a teaching session or a curriculum development-plan- ning meeting.

2. Seek feedback from others about what they notice about the strengths that have been used, and espe- cially how these strengths have influenced change in others or a situation.

An important role for any medical educator is leader- ship, whether “micro” in a teaching session or “macro” with a formal leadership position in an institution (Srinivasan et al. 2011). The personal effectiveness of leaders can be increased by having a strength-based mindset that is applied to their practice (Roarty & Toogood 2014).

Conclusions

The AI approach provides a unique and innovative develop- mental opportunity for both individuals, and the organiza- tion in which they are an integral member, to identify and mobilize individual and collective strengths to achieve their individual potential and that of the organization. An essen- tial aspect of the AI approach is the generative process, in which a new situation can be envisioned and motivational energy is created to achieve the desired future situation. This process is at the heart of all personal and organiza- tional development.

There is an exciting potential for the AI approach to become increasingly used in medical education, including curriculum development, faculty development, supporting learners through academic advising and mentoring, but also for enhancing the teaching and learning of both indi- viduals and groups. The AI approach can also inform the methods used in medical education research.

The potential of the AI approach will only be fully real- ized if the principles and their application are closely fol- lowed, but also that there are opportunities for the identified change in situations to be effectively implemented.

126 J. SANDARS AND D. MURDOCH-EATON

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Glossary

Appreciate enquiry: A positive and strengths-based develop- mental approach for both individuals and organizations to achieve their potential.

Generative process: A process in which a new situation can be envisioned and motivational energy created to achieve the desired future situation. This process is at the heart of all per- sonal and organizational development.

Notes on contributors

John Sandars, MBChB (Hons), MSc, MD, FRCGP, MRCP, FAcadMEd, FHEA, Diploma in Counseling Cert Ed, is Honorary Professor in Medical Education in the Academic Unit of Medical Education at The Medical School, University of Sheffield, UK. Previously he was an Associate Professor and Associate Director for Student Support in the Leeds Institute of Medical Education, School of Medicine, University of Leeds, UK. He has a long-standing interest and experience in personal and professional development across undergraduate and postgraduate medical education.

Deborah Murdoch-Eaton, MBBS, MD, FRCPCH, FAcadMEd, FHEA, is the Dean of Medical Education at The Medical School, University of Sheffield, UK. She has worked in substantive Clinical Medical Education posts for 23 years, and was awarded a National Teaching Fellowship in 2004 by the UK Higher Education Academy. Her academic interests focus on developing students’ potential and individuality, and the role of feedback in the development of learning skills.

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