Building perspective awareness as a workplace practice

Scaffolding and perspective awareness

As indicated in the introduction, there is a growing need for effective collaboration in workplaces today, and the amount of effort required to share and assess knowledge is therefore also increasing. In an organizational and institutional context where different professional and institutional logics with “logic-specific” horizons compete for influence and space, there are several obstacles that need to be overcome for learning to take place, for individual employees and for the organization as a whole. Facilitated models may act as a scaffolding; as a means to reach higher levels of complex interaction and decision capacities than would otherwise have been attainable (Andersson, 2015; Jordan, 2016). In the context of group collaborations, scaffolding as a metaphor has come to include various kinds of supportive tools or models which, in a variety of ways, support learning, issue-exploration and decision-making, as well as preempting conflicts in multi-stakeholder processes. Different functions that may require scaffolding during a meeting could, for example, include creating a safe space for interaction, neutralizing negative effects on asymmetrical power in a group, or specifying task focus and consequently assisting in directing the focus of attention. Models, such as PL, may serve as a mediating tool that represents a part of the reality that the various actors need to understand together and can thus function as a form of scaffolding.

The concept of “perspective awareness” denotes the ability to perceive the individual’s perceptions of his or her own role in relation to others, such as appropriate ways of performing a task, as well as the role of the workplace in its societal context (Jordan, 2011). The PL model was created with the aim of providing a scaffold for widening horizons of understanding between different professions and challenge the institutional and professional logics that hinder perspective-building capacities. The model thus emphasizes the individual’s reflexive ability and potential to not only reproduce different professional logics but also transform them. This view is connected to a realistic view of the relationship between structure and agency (Archer, 2003), in which structures (and logics) constitute conditions that are more or less persuasive, but where the transforming power always comes from intentional actions and reflexive considerations in individuals and groups. The concept of perspective awareness forms the foundation of the model that the analysis itself focuses on. The organizational and institutional context within which the model has been applied is understood here in terms of different professional and institutional logics with “logic-specific” horizons that compete for influence and space.

Perspective laboratories model

PL emerged through a collaboration of researchers in work science, incorporating theory and empirical ground from a prior model that had been used in different interactive projects (Gillberg, 2010), such as group dynamics theory and Buber’s dialogue model (Buber, 1971; Brown, 2000). In earlier iterations of different dialogue laboratories, themes such as gender equality, tacit knowledge and leadership were explored. The specific laboratory model used at the hospital units in Sweden – the PL – also has a theoretical base in adult development theory and adult learning when groups work on complex issues (Andersson, 2018; Jordan, 2011; Ross, 2006).

PL was first trialed in an occupational health-care organization in 2017, where it is still in use as a means to better understand the client across professional boundaries within the organization.

The central purpose of PL is to engage the participants in collaborative reflections, by sharing stories of work that elicit different perspectives. The model thus aims to support the development of a group climate in which individual reflection as well as co-reflection becomes possible. The basis for enabling this is through skillfully handled – and facilitated – dialogue processes. The participants’ stories of their work are contained in themes that the participants themselves have chosen to highlight at the commencement of their first session together (Figure 1). The starting point for the stories are the individuals’ – often problematic – experience of a work scenario. The participants’ perspective awareness is developed through their participation in PL, by being exposed to other staff members hx2019; stories and by building on and from these stories via perspective-creating questions.

The principal mode for sharing knowledge has a narrative structure (Keskinen et al., 2003). The elaborative work with the stories serves to create a resonance between the participants, as they come into close contact with matters of common concern. How to ask perspective-creating questions and build a climate of curiosity is absolutely central to PL and to the facilitators’ task of teaching the participants about the model. The stories thus evolve through the collective space of listening and finding out more through questions from the other participants. Over the course of the group sessions the participants take their own questions further via their jointly built landscape of work stories and adjacent inquiry.

The following four examples provide the reader with some idea of themes that were elaborated during the PL meetings:

• performance during triage in the emergency ward;

• the preparation and performance of spinal cord tests;

• how to approach the needs of concerned relatives of stroke patients; and

• how to improve communication within work teams during rounds.

In all examples, communication and understanding of different work needs, and task understanding are pivotal for collaboration.

Liberating disciplines

PL is a very structured dialogue model. The structure is designed to create stability in the dialogue process and to unpack a chosen work story and be able see different aspects of it. The process is also structured so that a relatively quick development of closeness between participants is enabled. This is considered essential for authentic meetings to take place between the individuals, which would then contribute to the individuals becoming personally involved in the process and not hiding behind norms governed by their work. The structuring guidelines are called “liberating disciplines,” inspired by Torbert and Associates’s (2004) action inquiry.

The main reason for limiting focus to very specific work themes is that the more issues that are being discussed simultaneously, the harder it will be to coordinate different perspectives and to generate new, collectively built, knowledge. By constraining creative and associative discussions, a creative elaboration within a more limited scope may emerge instead. With too broad a focus, contradicting information may fail to be recognized at all and conflict may persist (Mascolo, 2005). Thus, PL assists in task focus, as the facilitators guide the structured outline. Setting boundaries for the discussion as well as how things are discussed is consequently one of the central tasks for the facilitator. Argumentation is not permitted and everyone’s space and voice need to be safeguarded. It is important that the individuals in the groups are supported to convey their work stories without hindrance and are able to ask questions and formulate personal reflections.

The participants learn to ask perspective-creating questions to get to know both the story and the narrator better, which serves to liberate the participants from the usual norms of how work is discussed. During the course of the PL, the group members build common ground while and by creating a shared narrative of how different parts of their work scenarios are interrelated. In the learning round and reflection round, the participants first write down their thoughts before conveying them to the group, to enhance the process of authentic individual expression in the group. In the final PL, participants agree on what they want to document and convey to other staff members and organizational leaders. In the two hospital units, the groups gathered for three to five PL sessions per group. In Figure 1, the basic structure of PL is outlined. This quick reference guide was given to the facilitators, who in turn shared it with their groups.

Roles of the inhouse facilitators

In PL (as well as in earlier iterations of dialogue laboratories), the training of inhouse facilitators is an essential part. For the perspective project, facilitators were chosen from the different units by the contact manager. The qualities sought for in the facilitators in the units were individuals with a good ability to:

• understand the value of different competencies;

• keep track of conversations and meetings;

• create a basis for an open dialogue in a group;

• understand different situations and be able to take different perspectives; and

• respond calmly if discussions get heated.

These abilities were also developed during the training programme in which the facilitators learn and practice PL.

Study design: intervention, participation and roles

This study is an interactive intervention study with evaluative elements. This study rests on the tradition of action research conducted at the University of Gothenburg (Holmer, 1993), which in practice involves an interactive strategy where analysis and change take place in the form of an intertwined process involving those who are the subject of the intervention. This tradition is well in line with what is usually described as the fourth generation of evaluation (Guba and Lincoln, 1989), although the analytical model used in this article rests more on a realistic ontology than on a constructivist basic perspective. Considering that the article is also based on quantitative data, this study has ultimately acquired the character of a mixed-method study, which involved a broad empirical material that formed the basis for the final analysis.

Two hospital units participated in the intervention. In all, about 120 persons were involved: 20 process leaders and 100 were participating in parts of the interventions. The data collection consists of semi-structured interviews, questionnaires and field observations from the educators of the facilitators. The interviews (n = 25) were conducted with seven heads of wards, four facilitators and with seven co-workers who participated in PL. The selection of facilitators and participants for interview was evenly distributed over the two units. All facilitators also worked as nurses. The participants that were interviewed came from all of the participating professions, i.e. nurses, assistant nurses and physicians. The participants were interviewed twice; once before and once after participation, whereas the heads of the nursing wards, facilitators and facilitator educators were interviewed on one occasion. Participants from one unit (n = 50) received the questionnaire before intervention (T1) and one year after the implementation of PL (T2). There was relatively good response rate (T1 = 62%, n = 31; T2 = 68%, n = 34). The 31 participants answering both questionnaires had participated in the full intervention and were analyzed. The respondents signed informed consent agreements and all data were anonymized.

Qualitative interviews

The semi-structured interviews conducted with the facilitators consisted of three themes, namely, the context around how they became facilitators, how they experienced the facilitation process itself and how they saw it affect team collaboration outside PL. The interviews with the managers consisted of questions about the implementation process. The interviews with the facilitator educators concerned challenges with implementation and how the facilitators responded to the training programme. The interviews with the participants consisted of questions about their work, specifically challenging issues in their work, as well as their explanations for why these issues existed, their experience of participation in PL and if it had affected their work life outside the meetings. In the post interviews, they were asked to talk about the same issues, to probe for changes in their perspectives about the issues brought up in the first interview. The informed consent process was conducted at the time of the first interview with each participant, according to the Swedish standards. The facilitator educators were asked about the implementation process and overall challenges with introducing PL.

As the study and the results presented in this article are of an evaluative nature, a realistic analysis model has been used. This means that an analytical dualism guided the work, i.e. a conscious separation of contextual conditions and intentional reactions to these conditions. The aim has been to make visible the mechanisms that have influenced the implementation and results of the PL. However, the qualitative approach in the evaluation was more inductively driven during the first steps and a preliminary content analysis was carried out by the interviews. The content analysis was developed during the analysis work in the direction of a more abductive process, where the basic theoretical perspectives were weighed in. Based on the general thematization of the interview material, an analysis was conducted in which contextual conditions – such as logics, structures and normative ideas – are related to the experiences, strategies and activities that PL gave rise to in the participants. In practice, this means that the analysis focused on the relationship that exists between the design and possibilities of the change model, the contextual conditions that prevail in the specific theme being investigated and the effects that arose during the meeting.

Quantitative follow-up survey

A short questionnaire was compiled, including index of work satisfaction, work engagement, communication in team, social cohesion from COPSOQ II (Pejtersen et al., 2010) and clinical engagement in patient safety resp. quality of care (Strömgren, et al., 2016). Single items of collaboration within professional group, between professional groups and between managers and employees, developed from earlier qualitative studies in health care (Lindgren, et al., 2013) was also included. Thus, the questions operationalized aspects of the sense of supportive affinity, the experience of dealing with and learning about different perspectives on work-related issues, as well as different qualities of communication and collaboration. Descriptive analysis (mean values) and Wilcoxon Sum Rank Test of mean differences (95% confidence interval) was used.

Challenges and gains when implementing the model

During the facilitator training programme it had taken – according to the facilitator educators – quite some time until a reflective process about work took place between the facilitators, as they were used to talking about work on a concrete level, and unsure of how to start a process of reflecting on work in a structured dialogue. Also, they were trying to come to an understanding of their own role as facilitator. Over the course of the training, the introduction of the perspective creating questions functioned as scaffolding for enabling process reflection and building confidence in the facilitators. The educators’ challenge was to teach the facilitators to shift between different levels of talking about work: from work issues to reflections, to perspective taking and then to reflecting on the PL process itself.

From the managers’ perspective, it was difficult to get the work with PL into an activity-filled and strained everyday work life. In the different units, they had worked out different strategies for the implementation. The way that participants were nominated for the PL differed between the two units because of different change strategies in the units’ management. In one of the units the management made sure that all nurses and assistant nurses participated, and special schedules were created to enable this. In the other unit, the management decided that PL was to be voluntary and the facilitators were tasked to select participants. In both cases, it was the facilitators’ task to put the groups together and start up a PL. The facilitators were also tasked to present the model in the respective departments. This was described as one of the core challenges by the facilitators, but an even greater challenge was managing personnel resources, such as scheduling, in the unit where participation in PL was to reach all members of staff in due course. The practical solution in this unit was to switch from five to three PL per group before rotating groups, to make it available to the whole unit in shorter time intervals. The participants that were interviewed would have preferred to stay for more sessions, although they understood the need to make a concession for the whole workplace. Getting doctors to join the groups proved to be problematic because of the scheduling by some of the facilitators and by the lack of a mandate by those who invited the participants. In the end, only one facilitator was able to form a group that included all the intended professions. In the unit where participation was voluntary the facilitator managed to involve the doctors in the group, whereas in the unit where PL was scheduled, only the nurses and assistant nurses attended.

Another challenge for the facilitators was to introduce a model steeped in the concepts and theoretical framework used by work scientists when explaining the model. One facilitator confessed that he had even used Google to find out what “facilitator” meant. Other facilitators chose to use other words like “conversation leader” and “team development.” All the facilitators commented on the degree of structuring as initially somewhat restrictive, but they soon discovered that it facilitated the quality of the conversations. Above all, PL made it possible to navigate the difference between a normal discussion climate and an environment where all perspectives were considered and where deep listening took place. Working with perspective-creating questions was described as a fruitful way to create safety and focus in the group.

Now we ask questions in a different way, and after three meetings one has settled in and kind of feels that “yes, now I am safe with the group” and people who have not talked before have had the chance to talk then. Facilitator.

The facilitators also reported that over time the participants would generally perceive the form as liberating and positively process-focused. The facilitators gave several examples of how they succeeded in conveying the structure and transferring it to a collective responsibility, so that participants themselves would ensure the group adhered to the conversation structure.

Overall, all four interviewed facilitators considered that the conversations that took place during PL led to collective learning and new understanding of the chosen work themes. All facilitators noticed that those who participated created constructive group climates and it became easier to communicate with colleagues they had met during PL. Further, they reported that during PL, an understanding was built up of how others think and act, which led to increased calm in collaborative situations, such as in triage, or during rounds. The fact that each participant got the chance to talk about a scenario and receive feedback was experienced as something very positive. This specific tool of perspective-creating questions was described by several facilitators as central for the group climate as well as a tool that they could take with them in their daily activities.

All facilitators agreed that PL was successful in that it worked well and was appreciated. But three out of the four facilitators also relayed how difficult it was to apply this method to such a large organization with so many employees who frequently change jobs, and where it is so difficult to free up time for staff to participate.

The quote below from the interview with a facilitator provides a communication example of a PL interaction when different professions share perspectives.

Then there was an assistant nurse who said “I am not asked questions during the round. After all, I’m an expert on this. I am the one who meets the patient the most […] the doctor always turns to the nurses”. And then the doctor who is involved says, “I have never reflected on exactly what the assistant nurses do, and exactly what the nurses do. So, when I ask questions, I think that nurses have the overall responsibility and know. And then I automatically ask them. But I’ll think about that next time. Of course, I’ll talk to you.” Facilitator.

In summary, the challenges that were expressed by the facilitators had less to do with facilitating the meetings than actually organizing the meetings because of the effort it took to make them happen. The structured approach of PL made it fairly easy to adhere to the PL format, which consequently was quickly learnt by the participants. Some changes were made to make the language understandable and adapt it to the context of their workplace.

Participant perspectives

There are so few occasions in working life where you have time to be, think and feel based on how you experience your work. Participant.

The participants mentioned several positive effects on their work as a result of PL, including the value of being able to speak out and be able to feel truly understood, as well as learning from one another (also supported in quantitative analysis; Table 1). The participants’ comments conveyed a sense of having had an opportunity to understand the underlying reasons for colleagues’ behavior and indicated that this awareness had increased their tolerance during stress work situations. Interestingly, the PL served as a point of reference, a way to lower the thresholds for communicating about things that could create conflict, once the issues had been raised in PL. Participants also mentioned and rated in questionnaire that PL had improved work satisfaction by giving them new communication tools.

The patient perspective was also highlighted. One nurse accounted for a change in the treatment of patients as a result of increased reflection as well as individual strategies for stress management. Another participant described the mediating role of nurses between patients and doctors and about the importance of navigating patients’ needs when professionals (such as nurses, doctors and assistant nurses) do not share the same type of information about the patient.

There were insights about and improved practices of communication across professional boundaries. This understanding reappears as an interview theme and in follow-up questionnaire, as seen below in the quote and in Table 1.

When nurses look in the medical record or in the medicine module, it looks different from how the doctors sees the records. So, doctors cannot always understand why we do not see what they see. And that’s an eye opener. Then it is very clear that “well, that’s why you came and asked me all day, because you cannot actually see what I see.” Participant Nurse.

The pre- and post-interviews with the participants differ to some extent; there is more emphasis on the work environment and communication problems in the pre-interviews. Pre-interviews also discuss different types of communication problems, such as misinterpretations, as well as disruptive communication during stressful situations. In the post-interviews, there is an emphasis on solutions to communication problems, as well as more comprehensive accounts of new understanding of different work-related issues. For example, one concrete hindrance to communication flow between professions that was discussed during PL was where in the building they were situated, and a lack of knowledge about their respective routines, which meant it could be hard to reach one another. Understanding each other’s work environment better resulted in some improvements in communication strategies between nurses and doctors.

Participants from one of the units concluded that, although the workload was so burdensome, a more fundamental challenge was to remain patient and mindful when interacting with others; PL helped them to become more united on the issues they need to address together, instead of letting the workload affect attitudes toward one another. “Before, people just lashed out at each other, instead we [now] talk to each other with a good attitude.”

During the post-interviews, several participants pointed out different strategies for dealing with stressful situations. The participants felt that they had gained a greater understanding of each other’s work situation – a recognition of what is difficult – which in turn increased the sense of connection. PL also contributed to the understanding of a common goal, which had also given rise to greater readiness to help someone with their work when needed. Discussions about desired ways of handling difficult scenarios created a continued awareness of how they wanted to handle different situations, as well as the possibility to remind each other about it. Some participants described how PL had created new go-to scripts for highly stressful situations.

There was a marked change in how they described differences in approach and in the importance of being tolerant and understanding of both oneself and of others, as well as listening to staff members whose voices tended to be overlooked.

And with the usual work pace, it is easy to turn one’s focus on those who are fast and easy to talk to. But those who are a little more thoughtful and who may not take up so much space […] then their good ideas never come out. So that it is what I feel has been my biggest lesson. Participant.

The assessment of communication changed through PL, in particular between different professional groups. For example, a doctor said in the pre-interview that the communication was effective and there was “hardly any small-talk.” However, in the post-interview, the same doctor problematized situations where “the message did not get across in either direction” and continued to elaborate on the importance of listening to each other across professional boundaries, to get a more in-depth understanding of each other’s tasks to avoid misunderstandings and to get more perspectives during the rounds. Several participants shared their insights about communication based on the understanding that they are equal and share the same need to be heard.

Highlights from the study

What stands out in this study is that the most central theme was about how to listen and communicate, especially in challenging everyday life with a high work pace. In interviews, this was especially highlighted in the communication between professionals. Adding to this picture, the analysis of the participant questionnaire also showed small but significant differences regarding communication between and within professional groups as well as between managers and employees. Statistically significant improvements were also seen for other operationalization of communication, such as collaborations and social cohesion in the working group. Further, the general work engagement increased. The clinical engagement regarding patient safety and quality of care also increased but not statistically significant (p > 0,05).

The structured dialogue model was feasible to learn through the facilitator training, and with some ongoing support by the educators, and then to teach for the facilitators, which made it possible to focus on the needs of the group and the unraveling of the themes chosen to explore. The groups also took on the format, and there were examples where co-facilitation took place, for example when discussions led the group away from the structured dialogue. While working with PL was a positive experience from the view of the facilitators, managing the scheduling of it made it a challenging task and made some of them question whether the organizational structure was fit for this kind of group intervention on an ongoing basis.

Reflections on changes in perspective awareness

Both the facilitators and the participants testify that the type of dialogue that enables cross-professional understanding took place during PL. In the interview responses before and after participation in PL, we can see differences that indicate that participation has contributed to changes in how staff view themselves and others and how this in turn affects their approach to communication in the workplace. There were changes in both the understanding of what needs to be communicated, and how things need to be communicated, but also about a more general understanding of communication as a work tool. After participation, the participants elaborated in a more nuanced and composed way about the relationship between their own points of views and their understanding of others. Awareness of the limits of one’s own understanding and how feelings of stress could lead to negative interpretations of others’ motives for action was expressed in the post-interviews. Participants also formulated goals for how they want to work to maintain good working relationships, while at the same time, naming and valuing the circumstances of other staff members.

Some participants highlighted work factors that affect the different professions, as well as how their tasks are designed in ways that are important for collaboration across professional boundaries. Their assessment of work satisfaction increased substantially, and some proposals for changes in routines were implemented and communication strategies were developed. This study suggests that an increased perspective awareness was fostered by participation in PL. However, in a situation where stress and critical situations constantly create new challenges for skilled communication, there are limits to the effectiveness of PL to change difficult organizational challenges. We may conclude that although it helped the concurrent work teams and the individuals in it, at a larger organizational level, these effects were quickly lost through staff rotation and job changes.

Safe to interact – safe to learn

The participants in PL reported feeling safer in their interactions with peers. Here we can relate to “psychological safety” (Edmondson and Lei, 2014; Kahn, 1990). The term indicates the feeling of safety to show and engage one’s self without distress over negative consequences to status or career. Several participants reported feeling more comfortable when working with those they had met during PL, after having discussed various stressful scenarios that would occur, for example, in emergency triage and, notably, understood the responses of others without layering with their own, sometimes negative, interpretations. This may be an important prerequisite for learning. Knowing that they shared the same goals, even while approaching certain tasks in different and sometimes conflicting ways, the participants found a new platform for talking and learning about work outside PL.