A lot of our time in General Practice is either working as part of a team or being part of a group. It is an interesting exercise to look at the differences between them and although the boundaries between the two are blurred it is important to identify what we are doing and whether we are acting as a facilitator, chairman, leader or member.

DEFINITIONS

GROUP

A number of people or things located, gathered, or classed together
A common identity that defines the group
Members usually interact to share information, best practice, or perspectives and make decisions to help each other perform more effectively within each member's individual area of responsibility

TEAM

A group of players forming one side in a competitive game or sport or two or more people working together
Evolved as a specialized group
Team members have specialised roles

FORMATION

GROUP

No training necessary
Some structures in place for meetings
Leadership often ad hoc
Common vision not necessary
Expertise already assumed
Solutions are individual

TEAM

Training on how to work with a diverse group of people providing systems and structures that support team based work
Enlisting an experienced team facilitator or leader
Affirming a common vision
Developing supportive communication channels
Identifying and using appropriate team member expertise
Organising a process for controlled convergence on solutions and ensuring there are mechanisms to reward team achievements

Some differences between groups and teams

Criteria	Group	Team
Accountability	Individual	Individual and collective
Commitment	Individual	Shared
Conflict resolution	May be part of process	Essential part of process
Creativity and contribution	Not confined to tasks	Within tasks
Effectiveness measures	Direct external assessment of individual performance	Direct
Interactions	Information sharing	Problem solving
Leadership	Shared, determined by task	Strong leader
Measure of productivity	Sum of individual bests	Single
Operation	Discuss, decide, delegate	Discuss, decide, collaborate
Ownership	Individual work	Whole project
Participative decision making	Optional	Expected
Personal development	Optional	Expected
Purpose	Discrete for each member	Devised by team and management
Size	Small or larger	Defined and small
Skills	May be overlapping	Discrete for each member Can be developmental
Trust	Optional	Developed and essential
Understandings	Can be different	Work towards shared goals
Work products	Individual	Unified, more than the sum of parts

From “Groups or Teams in Healthcare – Finding the best fit” Journal of Evaluation in Clinical Practice (Saltman et al 2007 Feb;13(1):55-60.) Access via e-library on ovid.

performing model

Dr Bruce Tuckman published his Forming Storming Norming Performing model in 1965. He added a fifth stage, Adjourning, in the 1970's. The Forming Storming Norming Performing theory is an elegant and helpful explanation of team development and behaviour. Tuckman's model explains that as the team develops maturity and ability, relationships establish, and the leader changes leadership style. Beginning with a directing style, moving through coaching, then participating, finishing delegating and almost detached.

The progression is:

forming
storming
norming
performing
adjourning

Features of each phase:

forming - stage 1

High dependence on leader for guidance and direction. Little agreement on team aims other than received from leader. Individual roles and responsibilities are unclear. Leader must be prepared to answer lots of questions about the team's purpose, objectives and external relationships. Processes are often ignored. Members test tolerance of system and leader. Leader directs

storming - stage 2

Decisions don't come easily within group. Team members vie for position as they attempt to establish themselves in relation to other team members and the leader, who might receive challenges from team members. Clarity of purpose increases but plenty of uncertainties persist. Cliques and factions form and there may be power struggles. The team needs to be focused on its goals to avoid becoming distracted by relationships and emotional issues. Compromises may be required to enable progress.

norming - stage 3

Agreement and consensus is largely formed among the team, who respond well to facilitation by leader. Roles and responsibilities are clear and accepted. Big decisions are made by group agreement. Smaller decisions may be delegated to individuals or small teams within group. Commitment and unity is strong. The team may engage in fun and social activities. The team discusses and develops its processes and working style. There is general respect for the leader and some of leadership is more shared by the team. Leader facilitates and enables

performing - stage 4

The team is more strategically aware; the team knows clearly why it is doing what it is doing. The team has a shared vision and is able to stand on its own feet with no interference or participation from the leader. There is a focus on over-achieving goals, and the team makes most of the decisions against criteria agreed with the leader. The team has a high degree of autonomy. Disagreements occur but now they are resolved within the team positively and necessary changes to processes and structure are made by the team. The team is able to work towards achieving the goal, and also to attend to relationship, style and process issues along the way. team members look after each other. The team requires delegated tasks and projects from the leader. The team does not need to be instructed or assisted. Team members might ask for assistance from the leader with personal and interpersonal development. Leader delegates and oversees

adjourning - stage 5

Tuckman's fifth stage, Adjourning, is the break-up of the group, hopefully when the task is completed successfully, its purpose fulfilled; everyone can move on to new things, feeling good about what's been achieved. From an organizational perspective, recognition of and sensitivity to people's vulnerabilities in Tuckman's fifth stage is helpful, particularly if members of the group have been closely bonded and feel a sense of insecurity or threat from this change.

The Situational Leadership method from Kenneth Blanchard and Paul Hersey

This holds that managers must use different leadership styles depending on the situation. The model allows you to analyze the needs of the situation you’re in, and then use the most appropriate leadership style. Depending on employees’ competences in their task areas and commitment to their tasks, your leadership style should vary from one person to another. You may even lead the same person one way sometimes, and another way at other times.

Blanchard and Hersey characterized leadership style in terms of the amount of direction and of support that the leader gives to his or her followers, and so created a simple matrix (figure).

Leadership Behavior of the Leader

S1 - Telling / Directing - High task focus, low relationship focus - leaders define the roles and tasks of the ‘follower’, and supervise them closely. Decisions are made by the leader and announced, so communication is largely one-way. For people who lack competence but are enthusiastic and committed. They need direction and supervision to get them started.
S2 - Selling / Coaching - High task focus, high relationship focus - leaders still define roles and tasks, but seeks ideas and suggestions from the follower. Decisions remain the leader’s prerogative, but communication is much more two-way. For people who have some competence but lack commitment. They need direction and supervision because they are still relatively inexperienced. They also need support and praise to build their self-esteem, and involvement in decision-making to restore their commitment.
S3 - Participating / Supporting - Low task focus, high relationship focus - leaders pass day-to-day decisions, such as task allocation and processes, to the follower. The leader facilitates and takes part in decisions, but control is with the follower. For people who have competence, but lack confidence or motivation. They do not need much direction because of their skills, but support is necessary to bolster their confidence and motivation.
S4 - Delegating - Low task focus, low relationship focus - leaders are still involved in decisions and problem-solving, but control is with the follower. The follower decides when and how the leader will be involved. For people who have both competence and commitment. They are able and willing to work on a project by themselves with little supervision or support.

Effective leaders are versatile in being able to move around the matrix according to the situation, so there is no style that is always right. However, we tend to have a preferred style, and in applying Situational Leadership you need to know which one that is for you.

Likewise, the competence and commitment of the follower can also be distinguished in 4 quadrants.

Development Level of the Follower

D4 - High Competence, High Commitment - Experienced at the job, and comfortable with their own ability to do it well. May even be more skilled than the leader.
D3 - High Competence, Variable Commitment - Experienced and capable, but may lack the confidence to go it alone, or the motivation to do it well / quickly.
D2 - Some Competence, Low Commitment - May have some relevant skills, but won’t be able to do the job without help. The task or the situation may be new to them.
D1 - Low Competence, High Commitment - Generally lacking the specific skills required for the job in hand, but has the confidence and / or motivation to tackle it.

Similar to the leadership styles, the development levels are also situational. A person could be skilled, confident and motivated for one part of his his job, but could be less competent for another part of the job.

Situational leadership

Blanchard and Hersey said that the Leadership Style (S1 - S4) of the leader must correspond to the Development level (D1 - D4) of the follower - and it’s the leader who adapts. By adopting the right style to suit the follower’s development level, work gets done, relationships are built up, and most importantly, the follower’s development level will rise to D4, to everyone’s benefit.

Steps in Situational Leadership. Process

Make an overview per employee of his/her tasks
Assess the employee on each task (D1…D4)
Decide on the leadership (management) style per task (S1…S4)
Discuss the situation with the employee
Make a joint plan
Follow-up, check and correct

Strengths of the Situational Leadership model. Benefits

Easy to understand
Easy to use

Limitations of the Situational Leadership model. Disadvantages

Model fails to distinguish between leadership and management. What is called leadership style is really management style.
Leadership is not primarily about making decisions anyway - it is about inspiring people to change direction.
Leaders may indeed vary the way they inspire people to change. But this is when they have already decided on the need to change. Hence leadership style does not reduce to decision making style.
Focuses too exclusively on what the person in charge does.
Of course both leaders and managers have to behave differently in different situations. But that is just a trivial fact of life, rather than anything profound in terms of our basic understanding of what it means to lead or manage.

Assumptions of Situational Leadership. Conditions

Leaders should adapt their style to follower ‘maturity’, based on how ready and willing the follower is to perform required tasks (that is, their competence and motivation).
There are four leadership styles that match the four combinations of high/low readiness and willingness.
The four styles suggest that leaders should put greater or less focus on the task in question and/or the relationship between the leader and the follower.
Presumes that leadership is about how the boss makes decisions.

SIX THINKING HATS – TEAM DECISION MAKING

When you think of blue, think of the sky. The blue hat is the hardest one to understand. It deals with controlling the thinking process. The blue hat is often "given" to one person, who controls what hat will be "worn", hence controlling the type of thinking being used.

De Bono’s hats are indicative of both emotional states as well as frames of mind (i.e., perspective from which an issue is viewed). He noted: "Emotions are an essential part of our thinking ability and not just something extra that mucks up our thinking" One thinking style (or hat) is not inherently "better" than another. A full, balanced team recognizes the need for all hats in order for the team to consider all aspects of whatever issues they are facing.

Main benefits of Six Thinking Hats method:

1. Allow to say things without risk

2. Create awareness that there are multiple perspectives on the issue at hand

3. Convenient mechanism for 'switching gears'

4. Rules for the game of thinking

5. Focus thinking

6. Lead to more creative thinking

7. Improve communication

8. Improve decision making

Using the Six Hats

In most group contexts, individuals tend to feel constrained to consistently adopt a specific perspective (optimistic, pessimistic, objective, etc.). This limits the ways and extent to which each individual and thus the group as a whole can explore an issue. With the Six Thinking Hats, one is no longer limited to a single perspective in one’s thinking. The hats are categories of thinking behavior and not of people themselves. The purpose of the hats is to direct thinking, not classify either the thinking or the thinker. Indeed, by wearing a hat that is different from the one that one customarily wears, one may chance upon a variety of new ideas. Wearing a hat means deliberately adopting a perspective that is not necessarily one’s own. It is important that all group members are aware of this fact. A group member must clearly identify the color of the hat he is wearing while making a statement. Wearing a clearly identified hat separates ego from performance. The Six Hat Method is useful even for individuals thinking by themselves.

Hats may be used in some structured sequence depending on the nature of the issue. Here is an example agenda for a typical 6 hats workshop:

Step 1: Present the facts of the case (White hat)

Step 2: Generate ideas on how the case could be handled (Green Hat)
Step 3: Evaluate the merits of the ideas - List the benefits (Yellow Hat),

Step 4: List the drawbacks (Black Hat)
Step 5: Get everybody’s gut feelings about the alternatives (Red Hat)
Step 6: Summarize and adjourn the meeting (Blue Hat)

The different colours don't always follow in the same order. Depending on the situation, and the mix of people, it might be better to let people get their negative thoughts out first, or their intuitive sense, and then use yellow or green to move ahead. The blue hat comments on the thinking being used, asks for conclusions, decisions, etc. The blue hat can move from person to person, or can be a chairperson.

Heron

Be aware of the areas that facilitation covers in a working group and that the facilitator may need to act in different ways as the group develops. A model that looks at this was described by HERON who described 6 dimensions of facilitation and looked at how there were 3 modes that might be used effectively at different times and in different ways

The six dimensions of facilitation

1. The planning dimension. This is the goal-oriented, ends and means, aspect of facilitation. It is to do with the aims of the group, and what programme it should undertake to fulfil them. The facilitative question here is: how shall the group acquire its objectives and its programme?

2. The meaning dimension. This is the cognitive aspect of facilitation. It is to do with participants' understanding of what is going on, with their making sense of experience, and with their reasons for doing things and reacting to things. The facilitative question is: how shall meaning be given to and found in the experiences and actions of group members?

3. The confronting dimension. This is the challenge aspect of facilitation. It is to do with raising consciousness about the group's resistances to and avoidances of things it needs to face and deal with. The facilitative question is: how shall the group's consciousness be raised about these matters?

4. The feeling dimension. This is the sensitive aspect of facilitation. It is to do with the management of feeling and emotion within the group. The facilitative question is: how shall the life of feeling and emotion within the group be handled? The vital distinction between feeling and emotion is discussed in Chapter 3.

5. The structuring dimension. This is the formal aspect of facilitation. It is to do with methods of learning, with what sort of form is given to learning within the group, with how is it to be shaped. The facilitative question is: how can the group's learning be structured?

6. The valuing dimension. This is the integrity aspect of facilitation. It is to do with creating a supportive climate which honours and celebrates the personhood of group members; a climate in which they can be genuine, empowered, disclosing their reality as it is, keeping in touch with their true needs and interests. The facilitative question is: how can such a climate of personal value, integrity and respect be created?

Now these six dimensions interweave and overlap, being mutually supportive of each other. Nevertheless, I hold that each one has in practice an independent identity which will claim the facilitator's attention. They need to be distinguished from each other in thought and action to achieve effective facilitation. Yet they also need to be interrelated continuously in their application: they are to be distinguished only in order to be woven into an integrated mastery of the learning process. The challenge is to keep an eye on each dimension, and organize them all, over time, into a well-balanced whole.

What characterizes them, and the specific interventions that fall under each of them, is that they are pitched at the level of human intention. They are about the facilitator's purposes, about what he or she is seeking to achieve, with regard to various kinds of learning in the group. The full form of the facilitative question is: given that my purpose is to elicit and empower learning through an effect on this or that dimension, how can I go about it? Each intervention intends to achieve a certain result in a certain way.

The facilitative question

The facilitative ‘how’ question, defined under each dimension above, has a two-part answer. One part deals with who will decide about the issue raised by the question. Will it be the facilitator alone, the facilitator and the participants together, or the participants alone? And this takes us into the three political modes of facilitation, given below. The other part deals with what intervention is to be used in dealing with the issue. This, combined with the modes, is covered in the substantial inventory of facilitative interventions given in the chapters on each of the six dimensions.

The three modes of facilitation: the politics of learning

Each of the above six dimensions can be handled in three different ways. It is one of these three ways which will provide the answer as to who should make decisions on each dimension. From now on, in the description of modes and interventions, I shall refer to the facilitator in the second person, as 'you'.

1. The hierarchical mode. Here you, the facilitator, direct the learning process, exercise your power over it, and do things for the group. You lead from the front by thinking and acting on behalf of the group. You decide on the objectives and the programme, interpret and give meaning, challenge resistances, manage group feeling and emotion, provide structures for learning and honour the claims of authentic behaviour in the group. You take full responsibility, in charge of all major decisions on all dimensions of the learning process.

2. The co-operative mode. Here you share your power over the learning process and manage the different dimensions with the group. You enable and guide the group to become more self-directing in the various forms of learning by conferring with them and prompting them. You work with group members to decide on the programme, to give meaning to experiences, to confront resistances, and so on. In this process, you share your own view which, though influential, is not final but one among many. Outcomes are always negotiated. You collaborate with the members of the group in devising the learning process: your facilitation is co-operative.

3. The autonomous mode. Here you respect the total autonomy of the group: you do not do things for them, or with them, but give them freedom to find their own way, exercising their own judgment without any intervention on your part. Without any reminders, guidance or assistance, they evolve their programme, give meaning to what is going on, find ways of confronting their avoidances, and so on. The bedrock of learning is unprompted, self-directed practice, and here you delegate it to the learner and give space for it. This does not mean the abdication of responsibility. It is the subtle art of creating conditions within which people can exercise full self-determination in their learning.

These three modes deal with the politics of learning, with the exercise of power in the management of the different dimensions of experience. They are about who controls and influences such management. Who makes the decisions about what people learn and how they learn it: the facilitator alone, the facilitator and group members together, or the group members alone? The three modes comprise a higher order, political dimension which runs through all the basic six. As an effective facilitator, you are someone who can use all these three modes on each of the six dimensions as and when appropriate; and are flexible in moving from mode to mode and dimension to dimension in the light of the changing situation in the group. This is no doubt a counsel of perfection, but it broadens the facilitative imagination to entertain the total 18-part grid of options in the back of the mind.

Too much hierarchical control, and participants become passive and dependent or hostile and resistant. They wane in self-direction, which is the core of all learning. Too much co-operative guidance may degenerate into a subtle kind of nurturing oppression, and may deny the group the benefits of totally autonomous learning. Too much autonomy for participants and laissez-faire on your part, and they may wallow in ignorance, misconception and chaos.

The modes can include each other. You can be basically hierarchical, but with elements of co-operation and autonomy. Thus, within hierarchically given exercises, members will always be autonomous, self-directing in active practice when taking their turn. This is the heart of learning particular skills and awarenesses. Alternatively, the group as a whole may be in an autonomous phase, and call you in to do a piece of hierarchical work, etc.

The use of the modes: stages and presumptions

Each experiential group, depending on its learning objectives, will require a different balance of the three modes. And any given group may need this balance to change at different stages in its development, each stage depending on certain presumptions. The three stages below are not a formula for any learning group. It all depends on the objectives and the prior experience of group members.

Some groups, especially those attending in-service training courses for skilled people, may start at stage 2 or stage 3. But the three stages given here are classic ones for training absolute beginners, as they are for parenting. It is important to remember they can overlap, the earlier ones running on, in reduced form, beside the later ones.

1. Hierarchy early on. At the outset a clear hierarchical framework may be needed within which early development of co-operation and autonomy can occur. The presumption here is that participants are insecure and dependent in the area of learning, with lack of knowledge and skill, and have little ability therefore to orientate themselves. They will benefit from your command of events. There is also the presumption that your use of the hierarchical mode, making decisions for the learners, is based on their consent. Within the hierarchical framework, there will of course be autonomous practice and co-operative exchanges with you.

2. Co-operation mid-term. In the middle phase, more open collaboration with group members may be appropriate in managing the learning process. You negotiate the curriculum with them and co-operatively guide their learning activities, with various forms of staff-student contracting and agreement. The presumption here is that they have acquired some confidence in the area of learning, with a foundation of knowledge and skill. In this way, they are able to orientate themselves and participate with you in decisions about how the learning should proceed.

3. Autonomy later on. In the later phase, much more delegation and scope for the group to be autonomous and self-directed may be needed, with peer learning contracts and self- and peer assessment. The presumption here is that group members have considerable confidence in the area of learning and have acquired evident competence in a sizeable body of knowledge and skill. They benefit from full self-determination in their learning.

Participation in educational decision-making: the classic dilemma

People in our society carry around a lot of unprocessed distress caused by having been the victims of oppressive educational methods from the earliest years - both at home and at school - where their needs and rights as embryonic persons have not been fully honoured or realized. One result of this oppression is that they lack certain basic human skills: skills in handling their own emotions, skills in interacting with other persons, skills in self-direction and collective decision-making. There has been a gross deficiency in the range and depth of their education and training.

This leads to the classic dilemma of all educational reform. Students have the need and the right to be released from oppressive forms of education and should be encouraged to participate in educational decision-making. But they are conditioned and disempowered by these forms, and may not have the motivation, or the personal, interpersonal and self-directing skills required, to break out of them. So they may be neither satisfied nor effective when encouraged to co-operate with you and to be participative.

The resolution of this dilemma lies in mastery of the three modes and the three classic stages outlined in the preceding section. Only give away an appropriate amount of power at a time, otherwise neither you nor the students will be able to cope. And realize the huge array of options you have in combining the three modes in different ways, with varying degrees of emphasis, in relation to so many diverse facets of the educational process. There is no need to hasten inappropriately forward by gross leaps, when you can proceeed slowly by innumerable subtle steps.

HERON Self-Assessment of Facilitator Style

Decision modes of the facilitator
Dimensions of Facilitation	Direction: Facilitator does it for people	Cooperation: Facilitator does it with people	Delegation: Facilitator gives it to people
Planning The program of learning and development
Structuring The current learning activity of the group
Understanding Making sense of experiences, images and ideas
Confronting And raising consciousness about defenses, distortions, and avoidances.
Feeling The presence and managing the emotional dynamic of the group.
Valuing Choice and creating a climate of celebration and respect for persons

Self-scoring of a recent facilitation assignment: TM=too much , TL=too little, AR=about right, NA=not applicable

HERON Self-Assessment of Facilitator Style: Annotated

Decision modes of the facilitator
Dimensions of Facilitation	Direction: Facilitator does it for people	Cooperation: Facilitator does it with people	Delegation: Facilitator gives it to people
Planning The program of learning and development	Plan for the group. Chose what they will learn, make decisions for the learners	Plan program with the group. Negotiate, seek agreement, integrate their ideas with yours.	Delegate the planning to the group. Get out of their way. Group works out its own design
Structuring The current learning activity of the group	Structure learning activities for the group. Design the exercises.	Structure learning methods with the group. Collaborative design of exercises.	Delegate control to the group of own learning exercises. Peer directed.
Meaning Making sense of experiences, images and ideas	You make sense of what’s going on for the group. You are source of understanding of what is going on.	Group members participate with you in the generation of meaning. Collaborate in making sense.	Delegate interpretation, reflection and review to the group. Self-generated meaning making.
Confronting And raising consciousness about defenses, distortions, and avoidances.	You point out avoided issues and defensive behavior. You interrupt rigid behavior.	Work with the group to raise conscious-ness about avoided issues. Compare and share views with them.	Create a climate which enable group members to practice self- and peer confrontation
Feeling The presence and managing the emotional dynamic of the group.	You take full charge of the affective dynamic of the group for the group.	Work with the group, eliciting, prompting, and encouraging views as to different ways of handling feeling and emotions	Delegate the process of managing the group’s own affective domain – its life of feeling and emotion.
Valuing Choice and creating a climate of celebration and respect for persons	You care for group members. You reinforce your commitment to their fundamental worth as persons.	Create a community of value and mutual respect with group members, Inclusive and interactive as all emerge as self-creating persons	Delegate the affirmation of self -worth to group members. Let them celebrate the value of personal identity in their own way

What kind of questions?

Open – from fully open (Tell me more?) to more specific but still open (Tell me more about your headache?)

Closed – but open to the answer both in style and in giving time (Do you wake with a headache in the morning? ......) or closed in style and pace (You don’t get a headache in the morning, or feel sick, or get visual changes do you?)

Awareness raising questions

What did you think caused that?
When did it occur to you that those things were linked?
Where were you at the time?
How did that make you feel?
Who else does that affect?

Clarification questions

Can I check I’ve understood you correctly?
When did that happen?
What did the nurse say to you?

Reflective of...

The words said but just reflecting the content back
The meaning of the words
The feelings behind the words or non verbal cues

Linear – one after the other with no clear link or following a model which does not match what is needed

Strategic – Have you thought of trying this?

Hypothetical – I wonder if this would be a useful idea?

Circular – How change might affect other people. If you do that, what would X do and if they agree how would that affect Y? What perspectives do the people in your life have about you?

It is possible to keep asking questions which build on the information given earlier and which look at the relationship between the person and others or between the person and the “illness/ disease”.

(See more detailed handout on circular questions)

Reflexive – a question you and the patient or trainee don’t know the answer to but triggers them to start thinking about new perspectives. These questions can open unexpected avenues in the fourth Johari window of “unknown or undiscovered potential”

Helman’s Folk Model for the questions patients want answered

What has happened?
Why has it happened?
Why to me? Why now?
What would happen if nothing were done about it?
What should I do about it
Whom should I consult for further help?

Socratic

Conceptual clarification questions to “tell me more” to get more depth of thinking
Probing the assumptions, rationale, reasons and evidence behind someone’s opinions
Challenging the viewpoints and perspectives
Probing the implications and consequences of an opinion
Questioning the questions

Heuristic – facilitative questions to challenge the learner’s curiosity and develop an independent learning style

Non-verbal – using our non-verbal skills to encourage answers

Daft Laddie – Examining a patient and incidentally notice they have a rash they’ve not mentioned and saying “Is that a rash on your arm?” to trigger a response.

Some more detailed or deep questioning techniques

Questions that facilitate empathy have been categorized as queries, clarifications, and responses. Examples of each are as follows:

· Queries
"Can you tell me more about that?"
"What has this been like for you?"
"How has all of this made you feel?"

· Clarifications
"Let me see if I've gotten this right ..."
"Tell me more about ..."
"I want to make sure I understand what you've said ..."

· Responses
"Sounds like you are ..."
"I imagine that must be ..."
"I can understand that must make you feel ..."

Questions to challenge oneself

· How would I be feelingin this patient's situation?

· Could my attitude towards the patient be basedon something to do with my own experiences, anxieties, or fears?

· Why does this situation cause me difficulty?

· What beliefs and values underpin my actions in this situation?

Problem or symptom questions ( these help us to look / observe from different angles)

Who noticed the problem/ symptom first? Who last?
What is your father’s explanation as to why you are having this problem? How would you respond to this explanation?
Who does what in response to the symptom?
How does the problem affect your partner/ children/ parents?

Solution focused questions (These aim to look at the differences over time and use these to increase shared insight)

How are you feeling and what are you doing when you don’t have your abdominal pain?
Looking back over the last few days have there been times when you have been free of the problem? How can you explain that?
Can you remember a time when you could have given in to the problem but you didn’t? What happened then?
I am going to ask a question which may seem rather silly. How would you know you’re getting better?

Hypothetical questions ( by suspending the laws of nature we look at things differently)

If I were able to wave a magic wand that the problem disappeared what would your life be like?
What do you think will happen if your doctors can not find a solution to your pain? What will be the effect on you on your partner/ children?

Time (again a new angle to look at things from)

· What will it be like in 5 years, or what was it like 5 years ago?

· Imagine yourself at the end of your life.What else would you have liked to have done?

Relationship questions

How do you think your father sees his relationship with you?
Who is closest to your mother/ father? If I asked your brother/ sister that question what would their reply be? How would s/he explain the difference between your answers?
Who is most upset when you have a row with your partner?

Circular questions see brief information above and also the more detailed separate sheet.

For further information or ideas you may want to look at

Ten minutes for the family systemic Interventions in Primary Care Asen,E., Tomson, D., Young,V., Tomson, P. Routledge 2004

Circular questions

Are you happy at the moment?

How could I know that you are happy at the moment?

Or how does your partner know that you are happy?

What happens when you are happy?

Who (in your family or at work) does what when you are happy? (Who notices first? Who last?)

Think of 2 people in your family. Can you tell me about them?

Think of 2 people in your family. What would x say about their relationship with Y (and what would Y say about the relationship with X?) How was the relationship 5 years ago? How will it be in 5 years time?

How does your job affect your life?

Suppose you did not have your job. What would be different about your life? How would if affect your relationships, which would grow and which would be least affected? What would your children say about how your job affects your life? Friends partner…

Are you happy with your wife/ husband/ partner?

When was the last time that you think your children saw you and your partner being really happy together?

F (probably not appropriate to use with population like strict Jews or Muslims… could substitute question about strict religious observance)

Does anybody drink in your family?

In my experience every family (3 generations) has an alcoholic. Who is it (or will it be) in your family?

How do you think our consultations (these questions) have been going?

If your partner had been watching our consultations (these questions) what would s/he say about them? How would you respond to these comments?

Do you think anything will help you?

If you had a magic wand and could change one thing in your life what would it be? How would those around you know that it had changed?

What is (was) your father like?

How do you think your father sees (saw) his relationship with you?

What do your partners think about this course?

If one of your partners were watching this exercise what would s/he say to you? How would you respond?

What recent changes have there been in your practice team?

How did your relationship with the other partners change when you last had a new member of the team? Who gained and who lost? (what did they gain/ loose?)

If there was a video camera at your practice recording your working life what would it tell somebody about your relationship with your partners?

For further information or ideas you may want to look at

Ten minutes for the family systemic Interventions in Primary Care Asen,E., Tomson, D., Young,V., Tomson, P. Routledge 2004

Film

Grow your own

Good or at least thought provoking on mental illness, asylum seekers, how groups work, attitudes to GP

Dirty Pretty Things

an insight into the lives of illegal immigrants, also raises ethical issues

Dead Poets society

clip as an example of good teaching - his first
meeting with his class and his teaching which links a Robert Herrick poem
"Gather ye rosebuds...." with the phrase "Carpe Diem" and the long dead old
boys of the school

A Beautiful Mind
Russell Crowe gives a portrayal of a teacher who would rather be away from
class doing his research , also of managing mental illness as patient and family

What's eating Gilbert Grape

Family dynamics , obesity , secrets and doctors predictions

When a man loves a woman

Alcohol

Lord of the Rings 1

On meetings ( council of Elrond ) and personal stories

Ground hog day

On the importance of recognising what has become routine and monotonous/ dysfunctional

Truly Madly Deeply

Bereavement / loss

Educating Rita

Education and personal growth

Grease

teenage sexual health

Family Life

Depression

Books

Her Fearful Symmetry : A Niffenegger

Fantastic description of living with OCD

A Short history of Tractors in Ukrainian M Lewycka

Being an immigrant, old age and residential homes

Family Matters : Rohinton Msitry

Parkinsons and family dynamics

The Road Home : Rose Tremain

Arriving in UK ; isolation Britishness

Three Men in a Boat Jerome K Jerome

Lighthearted perspective on hypochondriasis and the dangers of access to medical information

Atonement Ian McEwens

Almost unbearable description of a migraine

Matters of Life and Death: Iona Heath

On being a Dr

Suburban Shaman : Cecil Helman

How being a Dr affects the Dr and the patients

Good Behaviour : Molly Keane.

Ageing

The lord of the Flies :Golding

Adolescence

To kill a mocking bird :Harper Lee

Childhood

The elected member : B Rubens

Drugs

Cancer Ward : Solzhenitsyn

Terminal care/ groups

The heart is a lonely Hunter : C Mc Cullers

Handicaps

The Bell Jar : S Plath

Mental illness

Life : Zeno

Prison

The Well of Loneliness : R Hall

Life as a lesbian (old)

The L shaped Room : Reid Banks

Social isolation

Curious incident of the dog in the night time
Autism/ Aspergers

Rabbit is dead : John Updike

Hero loses consciousness with a tachycardia, has an MI, experiences angioplasty, and dies.

Therapy : David Lodge

depression, what being on an SSRI is like, and what it's like to have internal derangement of your knee!

Non Fiction

Watching the English : The Hidden Rules of English behaviour : Kate Fox

Communication skills and cultural peculiarities

A-Z of Learning Activities

Admissions analysis

Advice

Agenda setting

Agony aunt

Alphabet game (create an entry for each letter relating to this subject)

Artefacts (bring in objects and get people to link to the subject/ use to bring it to life)

Ask others

Audit discussion

Blank paper

BMJ learning site

Bookmark (on your computer)

Brainstorming

Burning questions (what are yours on this subject?)

Buzz groups

Cards (prompt cards for discussion, or card games related to the subject)

Complaints review

Consciousness awareness rating

Contracts (what does the contract say about this?)

Critical incidents

Current affairs

Captions competition (what would the Daily Mail, or the Times ay about this subject, do a summary in the style of…)

D E

Debates Editorial

Define definitions (what exactly is…?) Elaborating

Demonstration Electronic Aids

Didactic teaching Entertain

Dissent encouraging Ethics

Drug reviews

F G

Fantasising Games

Feedback Goal setting

Files Goldfish bowl

Films (short clips) Group work

Guidance

H I

Headlines Industry Comparisons

Historical perspective Internet

Holistic Interview technique training

Hot topics

Joint interests

Jokes

Journal clubs

Jurisprudence

Just 2 minutes;

given a subject and others to check for repetition, deviation, hesitation! Good for revision and thinking fast and fluently on a subject!!

K L

Keypoints Leaflet design

Kindergarten approach Lecture

Knowledge assessment Letters review

Literature

Logbook

Loopholes

M N

Magazines NELH

Managers ` Next time

MCQs Non-violent communication

Mindmap Nurses as a resource or nurse eye view of this area

O P

On Call Pair work philosophy

Opportunistic Panel of experts

Oral questions (MRCGP) Pendleton

Playing games

Poetry

Postcards

Prepare

Prioritise

Protocols

Pass the Parcel!

(wrapped in the BMJ when the music stopped they had to answer a subject relevant question and received a Nestle free chocolate (!) Fun and good in a big group to get all talking)

P Q

Pair-work philosophy Questioning

Panel of experts Quit time

Pendleton Quizzes

Rehearsals

Resource

Results review and analysis

Role play

SEA

Searching the net

Set piece presentation

Silence

Spin doctor what would be the presentation?

Summary

Systems analysis

T U

Telephone advice Uncertainty

Text tutorial Understudy in trio consultation

The Comfort Zone

Your Comfort Zone is just that – comfortable – and includes everyday activities such as doing the same things and mixing with the same people. When most of your activities are in this zone life is, of course, ‘comfortable’ but you do not learn very much nor develop yourself – it’s simply more of the same and it can lead to the zone shrinking.

The Stretch Zone

Your Stretch Zone is the area of novelty, exploration and adventure. Here are the things that are a little or a lot out of the ordinary – the things you haven’t done for a long time or have never done before.

This zone is not really a comfortable place – but it is a stimulating one. It is where we stretch and challenge ourselves mentally, emotionally or physically. In social life it could be going to a different restaurant or pub. At work it could be handing a project in a new way or seeking a better position.

The Panic Zone

The Panic Zone is the area of things-to-be-avoided either because they are unacceptable to you or because they are currently a ‘stretch’ too far!

For example, being dishonest or abusive towards others could be in this zone because such activities are not in accord with your personal values. Participating in extreme sports might be here because you consider them too daunting but ‘also’ because you find the concept of deliberately flirting with danger unacceptable.

However you can also have activities in the Panic Zone which you wish were not there. Someone who experiences a phobic response when near a spider might prefer to have more choices in such situations. Again, to a teenager asking someone for a date could be a Panic Zone issue in which they would like to feel differently. And for many people public speaking falls into the Panic Zone with limiting effects on their career.

From http://www.nlp-now.co.uk/comfort_stretch_panic_2.htm

original concept attributed to Karl Ronke

SMARTIES

S Specific What is it specifically that I want to achieve or learn. You may need to break down a general aim into several specific statements each of which is a step , or a part of the overall Aim. (eating a chocolate bar do you eat a chunk at a time or try it all in one go? CHUNK AND CHECK.

M Measurable How will I know that I have learnt this or achieved my objective? When will I know I don’t have to go on with this taking it further? Where am I now and where do I want to be (exactly!)

A Achievable Is it all possible? How am I going to achieve this?

R Relevant Is it relevant to my career? Is it more relevant to do it now or later? Is this a hangover from a former career intention that I need to review? A need or a want?

T Time By what time will I be able to demonstrate that I have achieved this? What is my time limit on this plan?

I Interesting Do I find this subject interesting? If not how can I help make it more interesting? How will I make sure I do it if I am avoiding it?

E Economic Is it economic to do (remember economies need Time, and Money)?

S Success Success needs acknowledging, achievements along the way documented and records kept. This is all part of the evidence that you may need for revalidation . You may not get to the end of every area but will have travelled along the road towards this.

Remember Maths exams, some of the marks are for the answer at the end, but a lot of them are for the calculations along the way!!

ALOBA and SET – GO

These are alternative approaches to running the feedback to the traditional Pendleton approach. (As people know that the criticism is coming they are often braced for this and do not listen to the positives). Staying agenda led allows us to learn and practice the new skills we want to learn.

ALOBA

The principle behind the Calgary Cambridge approach has been given this acronym. Standing for

Agenda Led

(What is the agenda for the person who is being videoed or role playing the GP; which are the areas that s/he has already identified as needing change).Sometimes people look at the agenda before looking at the video and after as well ( self revelation can be easier than others ‘criticising’

Outcome Based

How can we keep this session practical and immediately useable, not drift off into the theory Hence the pattern in ALOBA based video sessions of doing “rehearsals”

Analysis

SET - GO

What I SAW

Observer(s) encouraged to make contemporaneous notes as they watch the video, including times of each event.

This should therefore be descriptive, specific and non-judgemental.

(It is often useful to ask one member of the group (if no group this is a task for the trainer) to watch being prepared to take on the position of the patient in future discussions or rehearsals.)

What ELSE did you see?

Facilitator tries to encourage some of the positives for balance if needed.

Or ask what happened Next in descriptive terms.

What do you THINK?

An alternative to 2. allowing the doctor in video to acknowledge and problem solve him/herself.

Facilitator then gets the whole group to problem solve.

Can we clarify what GOAL we would like to achieve?

Facilitator makes sure that the identified goals or areas are kept centre stage.

Any OFFERS on how we should get there?

Suggestions and alternative approaches to be taken up and immediately tried out very briefly – not long enough to be a “role play”, but there is already one person who is ready to be in patient mode, and so ideas are tried out… “what words would you actually use?…Ok go ahead!”

Mike Tomson 18.2.02 adapted from Kurtz Silverman and Draper

5 IMPORTANT “Cs”

CERTAINTY, COMPETENCE, COMPLEXITY, CAPABILITY AND CHAOS

I cheat a bit by using the term certainty when what we really have to help with is a learner’s UNCERTAINTY.

A lot of uncertainty is linked to the ability to make DECISIONS. With decreasing hours for hospital doctors, less continuity of care, increasing use of protocol led decision making and senior doctors making most decisions many trainees come to general practice with very little experience of decision making.

One way they try to deal with this is by trying to increase their knowledge. But as Bertrand Russell noted “What people really want is not knowledge but certainty.” And what we want is to help them through experiential learning to develop the skills to cope with not knowing and be comfortable with and able to manage uncertainty.

At the same time we are assessing them using a competency based model.

One definition of COMPETENCE is that individuals “know” or “can do” in terms of knowledge skills and attitudes.

But in the increasingly COMPLEX world of GP what trainees need to show is CAPABILITY which has been described by Greenhaugh (BMJ 2001; 323: 799-803 Coping with Complexity: educating for Capability) as

CAPABILITY – can adapt to change, can generate new knowledge and can continue to improve on their performance

And this is what we are really trying to assess in WPBA. This also includes our capability to assess someone’s performance as they show that they can actually DO.

And if we don’t get it right things can descend into CHAOS!

I suggest that COMPLEXITY THEORY can help us discuss with our trainees the issues that create uncertainty and how we become capable at dealing with complex situations.

It is easy to measure competence in "area A".

Everybody agrees what should be done and there is a high level of agreement for the trainee to follow. Commonly this high level of agreement is based on protocols which in themselves should be underpinned by good evidence. If a trainee has a protocol to follow they become more confident and certain that they are doing the right thing.

In discussion with trainees it is clear that the majority think their trainers are good GPs because they know lots and are usually very certain what to do. i.e. they work with a very large Area A.

But trainers know that most of the work we do is in Area B. (Also called the Marshy Swampland in some GP literature). Many of the things we deal with do not have a good evidence base to support clear agreement. But we have the capability of managing complex situations by developing shared agreement with patients and of knowing how to develop some certainty by discovery and discussion. We usually become comfortable about it being ok for an individual patient to be managed outside the usual norms. And we know that sometimes chaos is the lot of certain patients.

In practical terms we know that many things influence how we manage individual patients and most protocols don’t allow for this.

In complexity theory these influences are thought of as agents (Something that takes part in an interaction & is subsequently changed)

So I think of these as the things that affect how I manage the individual situation. And that each individual will be affected by different influences.

So for example a trainee might be certain that sending a patient to hospital is the only right thing because the protocol they used in A & E stated this clearly.

And then they learn the patient is also a carer for their wife, refuse to go into hospital, note that their next of kin is on holiday abroad and they are looking after their cat, won’t accept any tablets until their own “proper” doctor visits because you just don’t know what you are doing and it’s all an unnecessary fuss.

(As trainers you know this and many other variations and have learnt how to handle the situation in some form or other and deal with the “agents” that are involved – and you know the difficulties trainees have in doing this. We in our way become an agent and move things back to certainty. For example we use our skills to discuss risk and choices, can advise about emergency social support, arrange to speak to a relative on the phone etc)

And the final term I’ll mention from Complexity theory is Complex Adaptive Systems. (Defined as : A non linear system with the potential for self-organisation in an environment which at times is far from equilibrium. Its Evolution is based on its history. E.g. the immune system, stock markets, the human nervous system)

This potential for self organization is important and if we think linear we think teaching that is based on structure and knowledge.

If we think non linear we think of less structure and something based on;

Experiential learning.
Situational learning (shadowing, apprenticeship, rotational attachments)
Small group learning (case based, role play, problem solving peer support)
Problem based learning (how to find out, teamwork)
Self Directed (reflective practice, using patients learning log, networking informally)

And think of how we challenge trainees to become not just competent but capable and excellent. With the motivation of the exam as a driver for learning it is useful to remind ourselves of some of the descriptors of excellent practice in the 12 competency areas.

Communication and consultation skills

Uses a variety of communication techniques and materials to adapt explanations to the needs of the patient.

Appropriately uses advanced consultation skills such as confrontation or catharsis to achieve better patient outcomes.

Making a diagnosis/making decisions

Uses an analytical approach to novel situations where probability cannot be readily applied. No longer relies on rules alone but is able to use and justify discretionary judgment in situations of uncertainty.

Clinical management

No longer relies on rules alone but is able to use and justify discretionary judgment in situations of uncertainty.

Managing medical complexity

Is able to tolerate uncertainty, including that experienced by the patient, where this is unavoidable.

Maintaining performance, learning and teaching

Uses professional judgement to decide when to initiate and develop protocols and when to challenge their use.

Moves beyond the use of existing evidence toward initiating and collaborating in research that addresses unanswered questions.

If you want more detail that is relevant I suggest you read

BMJ 2001;323:799-803 Coping with Complexity: educating for Capability

Br J Gen Pract V.55 (510) January 2005 Complex consultations and the edge of chaos

http://www.ukapd.org/resources/group_work/complexity/complexity.htm takes you into the UK Association of Programme Director’s website and there is a good article by a colleague (Shake Seigel) on complexity.

7 Habits - Evaluation

1. BE PROACTIVE

How has the course changed the way that you view training? If so, in what way?

2. BEGIN WITH THE END IN MIND

How do you feel you have benefited from attending this course?

3. PUT FIRST THINGS FIRST

In what way might your approach to training be different having attended the course? (How will you put what you have learnt into practice?)

4. THINK WIN/WIN

What features of the course have most helpful to you?

5. SEEK FIRST TO UNDERSTAND

What single new understanding have you gained from the course

6. SYNERGISE

How will others know that you have been on the course?

7. SHARPEN THE SAW

How will you continue to develop the themes and ideas you have gained from the course?

Short version: Tuckman forming/storming/norming/performing model

forming - stage 1

storming - stage 2

norming - stage 3

performing - stage 4

adjourning - stage 5

Using the Six Hats

Planning

Structuring

Understanding

Confronting

Feeling

Valuing