“This is the best course I have ever done.”

“You have transformed the way I see education and the world.”

“I have never met anyone like you.You are a true inspiration.”

What do you say when you are told this? 

The first time I was flattered, tried to share the responsibility for this strong sense of achievement and appreciation. It was a one off. 

The second time again I put it down to the group of students and the incredibly supportive team of teachers I was working with. 

But when it happened for a third time, after the third course, I had to stop and ask myself what was happening that meant people said these quite unusual things, the same things each time. What was going on when we were working together that was so novel for them, that elicited such comments?

A new member of our teaching team had asked to sit in on one session so I asked him to focus on the process, rather than the clinical content, to observe what I did as group facilitator, and how the students (highly functioning middle to senior grade doctors) responded to the process. Our course is part of an international programme part of which develops doctors as teachers.  As soon as he took his seat at the back of the room I forgot about him. 

One of the group, a serious looking, hard working, thoughtful man who seemed slightly less integrated than the others, facilitated a sound piece of teaching but said at the end that he was not pleased with it. The others offered platitudes but I wanted to explore why. 

I pulled up my chair and asked him why, what had made him dissatisfied. Further questions about why he chose to do what he did in the moment, what else he may have chosen to do, what those choices did and may have led to, and the impact of what he had done on his learner group, led to him changing his view. He saw that rather than failing because he had not followed his plan, he had succeeded in flexibly following  the needs of his learner group, and that those choices were more difficult to enact but led to greater effectiveness if his group had their questions answered, and had been enabled to explore the things they were genuinely curious about rather than the things he had assumed they might be curious about. 

After fifteen minutes of group discussion on this, I posed the question again – how did he think his session had been. 

“Good,” he said, with a smile. 

The observer afterwards was fulsome in his praise for the episode. The way in which I had helped the serious young man to re think his plan, to appreciate the skill of his in-the-moment responses which in turn enabled his group to set their own agenda within the topic, and the way he then answered my questions to come to a realisation of his own of the techniques he had used, albeit unconsciously, intuitively, drawing on hidden skills he did not know he had. 

So that’s what I did, I mused on my flight back home. 

But why? What underpins this way of working? 

The skillset has been developed over my thirty year career, and was perhaps finally drawn into my own consciousness by a six day course over five months a few years ago that developed a deeper understanding of the use of questioning. But that would not account for the remarkable comments I had received three times this year whenever I have run this course. People were commenting on me, on the transforming perspectives they felt I had brought about in them. I am no messiah. I am not even particularly charismatic. I don’t enjoy public speaking. So what was going on?

Two things. 

Two positions I inhabit. Two views of mind in which I strongly believe and seemingly, manage to enact. One is a position of Unconditional Positive Regard. The other, an approach to human development, is called Appreciative Inquiry. I don’t set out on a morning to be a paragon of these perspectives, I don’t even think about them, in fact I had to look up Appreciative Inquiry to see what it really was before I realised I was perhaps using it. But I do go to work with the firm belief that I am working with talented, competent and remarkable people. I see my role as facilitator, as enabler, as catalyst who is able, most of the time, to create a safe space for people to relax and be the best they can be. To be safe enough to share their emotions and inner thoughts, to be kind enough to recognise in one another those special qualities that I see, and to be courageous enough to try something new, in the knowledge that trying will always be rewarded even if the results are not what they want to replicate in future. 

The concept of  Unconditional Positive Regard was introduced by the humanistic therapist  Carl Rogers who was himself an educator and has written widely on both education and therapy. Unconditional Positive Regard or UPR, is the basic acceptance and support for someone regardless of what they say or do, which, when activated can achieve quite remarkable results. Rogers and exponents of UPR believe that change can only come from within, and that people have within them vast resources for self and other understanding and for change if only these resources can be tapped  through a supportive environment. If we accept people for who they are then they can do the same and can move forward and take responsibility for themselves.  By showing others UPR and acceptance we are providing the best possible conditions for personal growth. 

When junior clinicians are treated as though they know nothing, are stupid, are all one homogenous, ignorant mass, they will sink to those expectations and respond accordingly. When treated as people who are capable of great things, they respond; we all respond.

I knew that I was able to bring UPR to my work, and thought I had been doing that for some years, so what had changed this year? 

A subtle shift in the way I teach, the way I offer and facilitate reflection and feedback that is less about itemising the good and the bad, and more about an approach called Appreciative Inquiry. 

When I looked it up it felt like all of my educational aspirations, practices and philosophies had coalesced into one approach; here was the description of all I believed in and tried to do, already articulated, in existence without my knowing it. 

Appreciative Inquiry is about self determined change. It is the collective enquiry into the best of what is, in order to imagine what could be. It is the collective design of a desired further state. It does not need incentives, coercion or persuasion, but we can guide it through the questions we ask.

It does not operate a deficit model. And this may be why it is not as widely used as it could be in either health or education, both of which are predicated upon a deficit model – what’s missing, what’s wrong, what’s deficient. Instead of asking what’s missing, Appreciative Inquiry asks, what works? 

Can you imagine working in a field that focuses on what works rather than the five per cent that does not work? When you have spent twelve hours looking after a range of sick patients or six hours containing thirty delinquent teenagers, and the only attention you get is for a small oversight: not completing a small administrative task on time; or a sharp word in a highly charged situation.  Imagine how it would feel if you were able to identify, with close and trusted colleagues, the things that worked today, that made a difference to the role you have, that enabled you to provide the support you went into this profession to provide? Imagine the impact of being surrounded by a focus on what works? 

That’s what I have come to do, intuitively and over many years of practice. 

There are five principles of Appreciative Inquiry. Simply they capture all we stand for in health and education. But just as they all facilitate appreciative enquiry, so they could all be manipulated to instead enact negative enquiry. We need to use them wisely.

Appreciative Inquiry is constructionist – it recognises that we co-construct the environment we work in – we all create the culture around us, as a result of our beliefs. If we believe our workplace is punitive and divisive we will unconsciously contribute to that. As a teacher I am lucky that in my classroom, I can set the tone, so I ensure my environment is open, shared, respectful and valuing of all. When working in a team this may take more work. 

A spontaneous approach is characteristic of Appreciative Inquiry. It does not take extensive planning to change – we can change the way we see things instantly. When asked why he had over 200 hundred recommendations to his report into the Mid Staffordshire hospital, Sir Robert Francis said he had only really one – to change the culture. Culture changes from bottom up as well as top down. By enquiring into systems we can change how we see them. We don’t always need to wait for top down systemic change; we can change the way we see things, the way we want to do things immediately and by asking questions of it we can change the way it is viewed by others. I wonder if the reason culture has not changed is because too many people are waiting for the commands when in fact changing our view, enacting our positive beliefs and making what matters happen, is so much quicker and more effective. The armed services have moved away from the rigid “pass it up“ command system and have situated some of the culture change within those who enact the culture with more effective consequences.

The third principle is that of stories. Organisations are experienced through stories. As an outsider in healthcare I often ask, “Why?” So often people believe that only one way is possible and yet a simple question such as “why?” or “who says?” can change a view in a second, open up the blinkers placed years ago. In an environment of UPR it is easy to ask those questions without people feeling affronted or attacked, because they know the questions are for their benefit not mine. 

Appreciative Inquiry is future oriented. In focussing on what works we are looking to carry on in this way. Being able to continue to use something that works not only benefits our patients, students and colleagues, but it also benefits us. The recent report from the GMC (link below) on clinician wellbeing outlines the need to have control over our work and to experience valued outcomes as two of the three vital needs of professionals. This is not new; studies have been talking about autonomy and competence for twenty years. Appreciative Inquiry is one way to achieve those things. 

The final principle is perhaps the most important to me, and is the third element in the GMC list of ‘must haves.’ That is belonging. Not a notional badge wearing, swipe-in swipe-out, we all wear the uniform, fake sense of belonging but a real sense of social cohesion. This is easily formed and easily broken, and is beholden on all of us to actively and positively commit to and uphold. Unconditional Positive Regard can promote that sense of equity and belonging and social responsibility and agency that is needed for Appreciate Inquiry to flourish. On top of that the facilitation of group reflection and reflexivity inherent in Appreciative Inquiry, can develop a greater sense of belonging whilst also developing skill and knowledge.

 UPR isn’t just for leaders and teachers, it’s for all of us. And if we are not feeling it one day then we have a duty to make sure we do. As the American author Peter De Vries once said, “writing is all about inspiration. So I make sure that every morning at 9am, I am inspired.”

It will be interesting to see what happens next time I run this course. Now that I think I know where the wonderful comments come from, will I be cognisant of my use of both Unconditional Positive Regard, and Appreciative Inquiry? And if so, will that higher level of awareness contribute to or compromise my work? 

I’m not sure. 

What I do know, is that going to those classrooms with the positions of mind I have, not only seems to help my students to co-create good work, but is incredibly rewarding for me. I get to spend time working with emotionally intelligent,  intuitive, reflexive, courageous and kind people, watching them develop further. It transforms me too. 

And the comments – well, they’re very nice, but they’re not necessary. The work is reward in itself.