Communicating with RESPECT: An action learning approach for health professionals

Learning

"For any organisation or business to survive, the rate of

learning must be at least equal to the rate of change"

--Reg Revans – Founder of Action Learning

Acknowledgements

Firstly, I would like to thank my co-authors, Sascha Rixon and Dr Hansel Addae. Sascha Rixon, my wife and life partner as well as the brains of the family, really has helped to bring this book together through not only her editorial skills, but also her own great contributions and ability to pay attention to the important details that I often can overlook. Dr Hansel Addae was one of the key people to enable a book like this to be possible, given his direct and immediate connection to a busy emergency department not to mention his vision and passion around improving communication in healthcare and high risk settings.

Without health professionals to pilot the COIN training program, there would be no book, and we are indebted to the participation of the 25 Emergency Department professionals who participated in the pilot program and the first 2 cohorts of the training program including the COIN trainers consisting of doctors and nurses who courageously led the program.

Next I would like to thank Bob Dick for not only the great foreword he wrote in a snap, but also his general inspiration and wisdom around action learning and life in general. Dr Anthony Bell I would like to thank for writing our preface, but also for his motivating leadership and continuing encouragement along the journey well before this book was even thought of.

Finally, I would like to thank all those who I had the opportunity of working with and learning alongside during the time of the BP Global Leadership Development Faculty. In particular, delivering the Communication and Influencing programs across Asia-Pacific provided a foundational learning platform for my own understanding, development, adaptation and deepening of the conceptual elements for this book.

Thanks to Simon Kneebone for the illustrations and Emily Minton for graphics design.

Disclaimer:

The end of chapter case studies provided in this book were created based on experiences of the author, Dr Hansel Addae. The characters and names are fictional and any resemblance to any readers real life experiences are purely coincidental.

Foreword

You are about to read an account of the COIN¹ program, an improvement program implemented in the Emergency Department (ED) of a metropolitan hospital. Involved peripherally, I was able to observe some of what occurred. The program was designed and implemented by Andrew and Sascha Rixon, and the ED staff that also became participants.

Emergency implies that often there isn’t time for detailed planning. A situation may have arisen that demands urgent attention. The exact requirements of the situation may or may not be apparent. What if they are not? Intelligent trial and error may then be the most appropriate. And if so, the processes of action learning may fit well. The COIN program gave some ED staff an opportunity, using action learning, to acquire skills and understanding that would help them with their work in the ED.

The COIN program wasn’t solely action learning. It was much more than that. It included a more detailed initial diagnosis than is often available. ED staff identified the situations for which remedies were desired. ED staff members who wished to do so were able to choose a project relevant to their own work, and implement it. Ideas from a train the trainer approach were included, with some staff helping to spread the learning to other staff. The program was evaluated, again by individual and group interviews of ED staff.

But then, that’s how much action learning is implemented. Action learning practitioners often have a varied body of relevant experience to draw on, as Andrew and Sascha do. They use that experience to augment and enhance the action learning that they facilitate.

By now you may be wondering what action learning is. It can be characterised, briefly, as a democratic form of planning and implementation. Closely related to action research and experiential learning, it deals with real situations. It seeks improvement through action that is evidence-based. In identifying and implementing the action it is careful to involve those people who are likely to be affected by what is done. I think it is particularly well suited for situations where stakes are high and urgent action is required.

I can illustrate some of the features of an emergency by drawing on Jenny Rudolph’s doctoral research. She used a simulation of an operating theatre emergency to research the behaviour of anaesthesiology residents. The patient was a sophisticated computer-controlled manikin. It displayed ambiguous symptoms of a life-threatening emergency. Jenny Rudolph studied how the doctors reacted to the situation.

She expected that some doctors would become fixated on a particular diagnosis, as they did. Others, she assumed, would postpone judgment until they had better information. And that was true too. Her assumption was that those who postponed judgment would fare better than those who locked inflexibly onto one diagnosis. And they did. Not a lot better, however. The patient, if not a computer-controlled manikin, would still very often have died.

Unexpectedly, another group of doctors functioned substantially more effectively. Their patient seldom died. These doctors didn’t suspend judgment. They formed a quick diagnosis and acted promptly.

However, they didn’t fixate on their diagnosis. As they acted they paid attention to any information that challenged their current diagnosis. When such information arose they changed their diagnosis accordingly. They adopted what was now the most likely diagnosis and began to act on that.

In other words, they adopted an approach of trial and error. As they did so they continued to pay attention to the available evidence. In particular, they were able to modify or abandon their present strategy whenever the evidence was inconsistent with their current thinking. Their understanding of the situation improved as they proceeded.

You may be reflecting that Jenny Rudolph’s studies were simulations. What about real situations? Other researchers have also studied decision-making in life-threatening and urgent situations — in the field. Gary Klein is one of them. The decision makers he has studied include commanders in change of bush fire-fighting.

The commanders in Gary Klein’s research were experienced fire fighters. From their experience they had accumulated a large repertoire of possible problem situations and possible solutions. In urgent situations they made very quick decisions. They didn’t suspend judgment until they had more information. They decided what seemed to be happening. They then chose the most plausible response in their repertoire.

They enacted their solution twice, at first mentally and then in reality. Running through possible actions rapidly in their mind they judged its likely effects. If necessary, they adjusted it appropriately. If it became clear that it wasn’t appropriate they abandoned it. They then identified the next most likely situation and solution, which they implemented — first mentally and then actually.

From my own experience I doubt that the commanders consciously considered all the possibilities before selecting one of them. I think they sensed, almost immediately, the most likely nature of the situation. I suspect that their decision about the best response was also almost immediate.

In saying this I’m basing my opinion on my own experience. Unlike the people Klein and Rudolph studied I don’t deal with life-and-death situations. However, I often facilitate groups. I have been doing so for many decades — long enough to accumulate some relevant experience.

From time to time when I’m facilitating, my intended process begins to fail. My wish then is to act quickly before the situation declines further. But it’s not that I consciously select a diagnosis and a strategy for response. I become aware — from nowhere, it often seems — of the probable situation and a promising remedy.

If I am considering multiple possibilities I’m not doing so consciously. Conscious thought would take too long. I agree with Dan Kahneman that some decisions are better handled by our unconscious mind — our fast thinking, as he calls it. The slow thinking of our conscious mind isn’t equipped to deal with emergencies. Responding to an emergency is a performing art, guided by fast thinking.

Let me be clear that I don’t wish to decry the benefit of routines, checklists and the like. Group facilitation very seldom consists of continuous crises, one after the other. Nor do hospital operations or bush fire-fighting, I assume. Routine has its place, just as the COIN program has its suggested processes and established practices.

Action learning practitioners don’t reject checklists, procedures and routines. For those aspects that can be routinised, established procedures can be implemented easily and then conducted automatically. That frees up time and attention better devoted to other more challenging issues.

In other words, it is when an emergency occurs that I’m recommending fast and flexible action with attention to evidence. When people remain open to the possibility of being mistaken, acting reveals more about the situation. As their understanding increases they more likely to identify a good solution.

EDs deal in emergencies that can be life-threatening and urgent. There is often an imperative to respond in the moment even if the situation is unclear. The early actions elicit more evidence, allowing the actor to better understand what is happening. Edgar Schein has commented similarly on organisational change in general. If ... one cannot understand an organization without trying to change it, how is it possible to make an adequate diagnosis without intervening? The diagnosis emerges partly as a result of the intervention.

To say it differently, intelligent trial and error informed by curiosity and evidence may open a path to effective action. A mix of urgency and ambiguity presents a challenge best faced by a combination of action and open-mindedness. That’s partly a matter of having the requisite skill. But it is also partly a matter of attitude. Action learning is a good vehicle for practising and learning such an attitude.

Not only EDs. In hospitals there are also other situations where high-stake emergencies can arise. I therefore anticipate that the COIN program described in this document isn’t limited to ED use. It can usefully by applied elsewhere within the hospital too, and in other hospitals. And beyond hospitals. Elsewhere there are complex situations where the stakes are high and urgent action is desirable.

There are reasons to believe that such situations are increasing. Evidence indicates that we face an increasingly connected and fast-moving world. Globalisation is increasing. Technology continues to be enhanced. The processing power of computers, for example, continues to double every 18 months to two years.

Around the world, cities continue to grow in size. Many nations grapple with the demographic effects of ageing populations at a time of falling birth rates. There are researchers such as Jerome Glenn and his colleagues who track such developments regularly. They describe a world where inequality is increasing, youth unemployment is soaring, and civil liberties are being eroded. Each of these developments can have implications for society and for its organisations.

Such developments lead me to expect that in the future many organisations will face more turbulence, complexity and ambiguity. If so, fast action coupled with an attitude of curiosity and flexibility is likely to be valuable. Action learning and similar processes are one way of encouraging such an orientation. The COIN program, as I think you’ll discover, is a practical way of developing the orientation.

— Bob Dick

Inveterate Action Researcher

Brisbane, August 2016

Preface

There’s a first time for everything, including writing a preface, and having been in and around Emergency Departments for over 20 years means you’ve come across a thing or