Cultivating a Positive Culture Through Appreciative Inquiry

CULTIVATING A POSITIVE CULTURE THROUGH APPRECIATIVE INQUIRY

Jacqueline Stavros, Lawrence Technological University

Anne Kohnke Meda, BenedictineUniversity

March 2003

ABSTRACT

Health care is a dynamic industry undergoing fundamental structural change as industry leaders struggle for long-term care survival in this increasingly complex industry. This Appreciative Inquiry (AI) project was designed and adapted to discover the positive core of Tendercare, Inc.’s Wayne Seniors (WS) assisted living center and to enable the staff to focus upon projects, process improvements, and rewards that are aligned to increase census while building a team spirit. AI is the cooperative search for the best in people, their organizations, and the world around them.

INTRODUCTION

In a study conducted by the U.S. Department of Health and Human Services (1997), the life expectancy of middle-class Americans has nearly doubled to 79 years over the last century due to the effectiveness of antibiotics, immunizations, and new cardiovascular treatments that vastly improve the chances of surviving serious heart conditions. Greater emphasis has been placed on creating and sustaining healthier lifestyles, which is also contributing to longer life expectancies. Although the life expectancy from birth for people in the United States is 74.1 years, those who live to age 65 will have an average of 17.7 years left to live, making their life expectancy almost 83 years. This growth will result in future increases of demand for long-term care services such as adult day care, assisted living, home health care, hospice, rehabilitation, and nursing homes.

Health care is a dynamic industry undergoing fundamental structural change as industry leaders struggle for long-term care survival in this increasingly complex industry. As the profile of a long-term care resident changes, so will the demand for services. This increases the need to change product-service mix so that the elderly will be appropriately cared for in terms of medical and social support needs.

The purpose of this AI intervention is to discover the positive core of the Wayne Seniors (WS) group to enable the staff to focus upon projects, process improvements, and rewards that align with corporate business policy and to increase census (the number of residents) while building a team spirit. The goal of this on-going project is to make this center the provider of choice by building an exceptional team through appreciation and developing resident loyalty thereby making the center a better place for the residents and staff.

PROJECT SCOPE

The scope of this project is to discover the qualitative elements of WS’ positive core, identify specific tactics that will enhance teamwork, and report out findings to all participants to positively impact the average daily census. The new knowledge generated expands the ‘realm of the possible’ and helps members of the organization envision together a desired future (Fry, Barrett, Seiling, and Whitney, 2002, p.6). A series of meetings to train a core team of participants on the AI approach was conducted as well as interviews and additional meetings to collect, theme, analyze, and interpret the data sets from the interviews. The final deliverable was a report of the key findings and outcomes of this project.

AN OVERVIEW OF APPRECIATIVE INQUIRY AT WS

AI is the cooperative search for the best in people, their organizations, and world around them. It involves systematic discovery of what gives life to a system (Cooperrider and Whitney, 1999). The hallmark of AI is an intense exploration of ‘unconditional positive questions’. The concept of the unconditional positive question assumes that whatever positive topic we want to study, we can study it unconditionally and significantly influence the destiny of our organizations and social theory (Ludema, Cooperrider, and Barrett, 2001, p.189). Alterations in linguistic practices including the linguistic practice of crafting questions—hold profound implications for changes in social practice. Hence, change begins at the moment a question is asked (Fry et al., 2002, p.5). The art and practice of asking such questions strengthens an organization’s ability to realize its full potential. AI engages the whole organization, often hundreds, sometimes thousands of people in interviews to discover the preferred future. In this project the whole system was invited to participate.

According to Watkins and Mohr, ‘there are as many theories and explanations of the phenomena of change as there are theorists and explainers’, (2001, p.3). AI is grounded in five core principles[1]:

1. Social Constructionist: we create our world by our conversations with others

1. Simultaneity: change begins the moment we ask a question

1. Poetic: human organizations are open books and we can choose what we study

1. Anticipatory: images of the future guide the current behavior of any organism or organization

1. Positive: the more positive the questions used, the more long lasting and effective is the change

These five core principles have inspired and moved the foundation of AI from its theory to practice (Cooperrider, Whitney, and Stavros, 2003).

AI is an approach for organization transformation that gives way to imagination, innovation, and inspired actions instead of traditional problem-solving approaches. AI is best learned and understood through the use of the 4-D Cycle of Discovery, Dream, Design, and Destiny (refer to Figure 1). This cycle can be as formal as a company-wide process involving every stakeholder. Or, it can also be as rapid and informal as a conversation between two colleagues trying to make a difference in their organization. When individuals or organizations discover and tap rich, inspiring accounts of peak experiences and link the positive core to any change agenda, business transformations never thought possible can emerge. The 4-D Cycle presents AI as a dynamic process of change (Cooperrider et al., 2003).

FIGURE 1: 4-D Cycle

This brief overview of the 4-D cycle provides the context for the study. During the first phase, Discovery, the interview guide was created by a core team. In this case, the team was called the core care team (CCT). The questions centered on what works best, is most valued, motivating and effective, and wishes. Interviews with residents and staff were initially conducted by the CCT. Then, there emerged interviewees who wanted to interview others during the project to discover best practices and life-giving moments within the center. In order to capture these life-giving moments, the questions asked during the interview were intentionally designed to solicit positive affirming answers. A central underpinning of AI is the move away from deficit discourse (Yeager and Sorensen, Jr., 2001, p.137).

Once the interviews were completed, the stories were shared and discussed in several meetings to create a shared vision, a future dream for the center. There are two goals in the Dream phase. The first is to facilitate a dialogue among stakeholders to share positive stories in a way that creates energy and enthusiasm. This is accomplished by asking those who participated in the Discovery phase to share their stories with the entire group. These stories are the vehicles for bringing out the positive core of the organization. It is almost as if the degree of deficit environment or experience creates a counter-need for increased positive or appreciative experiences (Yeager and Sorensen, Jr., 2001, p.131). Those who were telling the stories were encouraged to share the essence of the stories, not a bullet point description of events. The second goal is to allow the participants to start to see common themes. At this point, it is important to encourage the group to observe and value the stories rather than to critique, judge or analyze them. Unlike other organizational change methodologies, AI does not focus on problem solving but embracing change. Dreaming is a journey of mutual discovery, not an analytical journey. Therefore, it does not emphasize identifying one best idea. Instead, participants look for broad themes or life-giving forces that contribute to the organization’s success. These positive themes are the building blocks for the rest of the AI process.

Accomplishing these two goals helps the participants to imagine the center as they would like it to be. By building energy, excitement, and synergy, and by identifying the common themes or life-giving forces, the participants can begin to envision an organization of the future, an organization that embodies their images, hopes, dreams, and vision.

The third phase, Design, takes the dreams of what the center can be and creates specific action-oriented provocative propositionscalled possibility statements in this case. In the Designphase attention turns to creating the dream of the ideal organization. Future images emerge through grounded examples from an organization’s positive past. Good news stories are used to craft the possibility statements that bridge the best of ‘what gives life’ with a collective aspiration of ‘what might be.’ This is where the organization’s social architecture is designed. In this phase, the design elements were selected, and internal and external relationships were examined while creating the possibility statements.

The AI was conducted in conjunction with a census development campaign called the ‘+1 Campaign’ by the center’s parent company, Tendercare, Inc. The CCT created a unique business and social architecture based on an image of three rings. Tendercare's architecture places the residents in the center ring, the stakeholders in the second ring and the design elements in the third ring (refer to Figure 2).

FIGURE 2: Tendercare’s Business and Social Architecture

In the second step, staff and residents worked from the inside out to identify those relationships that help to build the positive core. For example, they listed those key relationships that affected ‘resident loyalty’, as shown in the two boxes above labeled ‘Internal’ and ‘External’ in Figure 2.

The third step was to go back to the AI analysis report and the Interview Summary Sheets (ISS) to identify those key themes that supported each topic area. The CCT called these themes the essential elements. These essential elements were listed on a large sheet of newsprint. During this step, there was a lot of open dialogue and stories told on what essential elements contribute to each topic area.

The final phase of the 4-D cycle is known as Destiny. The goal is to ensure that the dream can be realized. The AI perspective looks at the role of improvisation in building appreciative management into the fabric of organizational culture (Barrett, 1998). The design team publicly declares intended actions and asks for organization-wide support from every level. Self-selected groups plan the next steps for institutionalization and continued vitality. This is where the dream becomes reality. The CCT began its work with many different departments within the center to begin to realize its fullest potential.

The Destiny phase represents both the conclusion of the 4-D cycle, andthe beginning of an ongoing creation of an ‘appreciative learning culture’. Creating appreciative learning cultures involves transforming relationships into vital and life-enhancing forces that support innovative actions, strategies, and designs (Fry et al., 2002, p.9).

The techniques associated with the final phase of the 4-D cycle are self-organized and often resemble Open Space processes. Small groups have self-organized to implementthe possibility statements. These become inspired actions by the people who are passionate about implementing a particular aspect of the design step forward and join with like-spirited collaborators. It is a time of continuous organizational learning, innovation, and inquiry, which continues to implement and sustain the newly created social architecture. The participants are now living the positive core.

This study demonstrated how the center’s employees and residents moved together from Discoveryto Dream to create a set of possibility statementsin the Designphase. In the final phase, Destiny, the CCT publicly declares inspired actions and asks for organization-wide support from every level.

PROJECT SUMMARY

Tendercare, Inc. is Michigan’s largest provider of long-term care services with 37 health centers and over 3,400 employees. Earlier this year, the marketing team created a program called the +1 Campaign and selected Wayne Seniors (WS) as one of four facilities chosen to participate in this program based upon their potential for increased census. WS has a capacity of 120 beds with a current census in the low 90s. The budgeted census for this fiscal year is 102.

The +1 Campaign created by the marketing team was kicked off on April 25th, 2002 at the WS facility with the following goals:

1. Select and train a core team on the AI approach
2. Discover WS’ positive core
3. Educate the staff as to the importance of census building, its impact on the center and how they can help with the census development efforts
4. Create an environment of energy and excitement toward the center’s census goal
5. Build an exceptional team that demonstrates genuine appreciation each day
6. Develop a culture that respects and supports rich diversity

Four affirmative topic choices were selected:

1. Provider of Choice
2. Resident Loyalty
3. The Exceptional Team
4. Genuine Appreciation

The main goal in using the AI approach was to constructively obtain information as to what is working best at WS and to learn what can be done to improve as it relates to the four affirmative topic choices.

The initial AI training of CCT was conducted on April 29th, 2002. The significant outcomes of this meeting were 11 AI staff interviews completed, an introduction of the AI 4-D Cycle to the CCT team, and an appreciation for and understanding of each person’s commitment to creating the best center. The next meeting discussed the common themes of the 11 interviews, an in-depth learning of the Dream and Design phases with the significant outcome being the co-creation of possibility statements for the Resident Loyalty and Provider of Choice topics.

Resident loyalty resounded from the feelings that everyone should be valued and respected. The main themes from this part of the interviews included being treated kindly, friendly, and with dignity.

The Resident Loyalty Possibility Statement:

At Wayne Seniors, residents are our life-line. We maintain this life-line by building relationships with our residents and their families to ensure a caring, consistent, and positive living experience.

We always strive to nurture relationships by creating an environment of listening, understanding, and trust.

Residents trust us with their lives -- a responsibility we hold sacred. We earn this trust through an unwavering commitment to superior care, tempered with compassion and respect.

To provide superior care, we provide knowledge to residents, staff, and families to ensure consistent and compassionate service delivery.

With dedication to these ideals, Wayne Seniors nurtures resident loyalty thereby effectively serving the community.

Being the provider of choice results from the direct care of employees and how they understand, respect, and care for the residents. The main themes that emerged from the data were exceptional depth of concern and compassion that the WS’ employees have for the residents and co-workers.

The Provider of Choice Possibility Statement:

We are the provider of choice because we have a high quality, experienced and caring staff to meet the needs of our residents. We create a positive culture that radiates energy and life through a superior dining experience and activities that encourage participation and increase the quality of our residents’ lives. We are a fun, clean, caring and friendly community.

Then, an interview list of staff and residents was distributed. The project ended with a design and destiny meeting to transform and create the best possible center the residents and staff wanted based on the data from the interviews.

METHOD

The research method used for this project is a qualitative paradigm that used multiple methods to ensure greater validity (Brewer and Hunter, 1989). The reason for selecting a qualitative paradigm is that the nature of this study’s challenge was exploratory, to discover and understand. AI is a generative process of search and discovery. It is referred to as a method of action research and theory in which study of the best practices of an organization show how their social forms cohere and evolve (Cooperrider and Srivastva, 1987).

A comprehensive survey was designed to identify attributes of as many staff and residents respondents as it related to the four topic choices. The survey information was collected over a three-week period administered in an interview format face-to-face with the individuals. This method was used to build an environment of trust and openness and received very favorable feedback as it gave each individual an opportunity to talk about what was important to them. The total number of AI interviews conducted was 74 (24 staff and 50 residents). The data from both the staff and resident data sets were themed, analyzed, and interpreted into topics, themes, and possibility statements. It was from this grounded theory (Strauss and Corbin, 1990) that the possibility statements were created.

In the last decade, qualitative research techniques have gained significant respect as a viable and valid form of inquiry, especially as researchers have entered fields that include complex human systems and multiple human perspectives (Creswell, 1994). This is evident in the qualitative research techniques now being used: grounded

theory building, action research, ethnomethodology, phenomenological inquiry, and participative research.

PROJECT CONCLUSION

The AI training and approach were favorably received by the staff and residents and yielded very insightful information about how the staff relates to each other, how the staff relates to the residents, and how the residents relate to each other. For example, four managers, who work at the WS center, remarked how drastic the culture had changed due to this project. It was observed that the culture had gone from a negative to a very hopeful and positive one in a matter of days. Another example involved three individuals who were reported to be skeptical and the most negative of the employees. At one point each person cried during her AI interview and offered excellent ideas for improvement and a hopeful future. The last meeting with the CCT was held on June 4th. The Master Wish List created by staff and residents was reviewed. Many ideas were shared including solutions to improving the four topic choices that were evident from the data sets, namely the activities, food, and the overall center. This Master Wish List became an inspired action list used by management and employees to implement the ideas to improve the overall quality of work life and living conditions at WS.