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We train doctors and dentists in


conversational skills for supervision by focusing on the process of supervision. We emphasise the functions of supervision, including not only monitoring performance, but also caring for supervisees (Launer, 2010b) and promoting ethical responsiveness in both supervisee and supervisor (Burnham, 2010). Creating space and allowing for time to refl ect on encounters is one way to improve patient safety (Launer, 2010b). We call these workshops, Conversations inviting change (Launer, 2008). For convenience, we have summed up


the principles of this approach with seven words beginning with the let er C Conversations Curiosity Contexts Complexity Creativity Challenge with caution Care T ese principles are a mixture of


process and content. T ey remind us that, not only the words we choose to use, but also our tone, our facial expression and body language communicate our at itude to the interaction and have an eff ect on the episode of supervision. Referring to the supervisory interaction as a ‘conversation’ promotes an equalising of the power balance between the participants. T e importance of it being a two-way iterative process of joint sense-making is foregrounded. By highlighting the importance of curiosity, the supervisor is encouraged to take a position of commit ed detachment in which they are conscious of prejudices, perhaps even placing them in parentheses. T rough curiosity, the supervisor is permit ed to dig further into the story of the supervisee and investigate beyond surface assumptions. Emphasising again and again the importance of exploring context underlines all the diff erent power relations that are involved, not only in the issues that the supervisee may bring, but also in interactions in the room between supervisor and supervisee. Highlighting the importance of context allows the supervisor and supervisee to consider the impact of diff erences (Burnham et al., 2008). Complexity reminds us to seek momentary confusion, to ensure multiple perspectives are viewed, and to resist the temptation to fi nd the lineal “cause and


Context February 2012


eff ect” solution. Improvising creatively frees us to play and co-construct new stories. T e delicate balance of challenging enough to allow new learning and critical refl ection to happen but not so much so that the supervisee becomes defensive or feels unsafe and not too lit le to render the supervision too comfortable to be useful, is hard to strike. To achieve this, the supervisor must be at entive to minimal cues in body language and eye contact as well as speech content and structure. T e overall commitment to and care for the supervisee is paramount. During the workshop, we use various


large and small-group activities to explore the meanings of these words in the context of supervision. T rough this exploration, we unpick the aspects of supervision and hone in on the process of an eff ective supervision, thinking about what elements make it eff ective. Following an exploration of the seven


Cs and a live-supervision demonstration, the main focus of our training sessions is around small groups of live supervision. Participants are invited to off er current unresolved issues relating to work (these are usually either team issues or cases). T ey then take it in turns to take the positions of supervisor, supervisee, and observing-team member (facilitated by one of the team of trainers). In addition, we have large-group


discussions, power point theory presentations, large-group exercises and a mixture of role-play and other improvised teaching-exercises. During the small-group skills-practice,


we give three simple instructions to the supervisor: • Ask short, simple open questions • Follow the language of the participant supervisee


• Save any off er of advice until the end Based on the seven Cs we encourage


exploratory questions about meaning, context, gender, power, culture, values and beliefs, as well as orientating facts. We ask participants to follow language


carefully and balance challenge with caution and care. As with any new learning, we may


observe in participants’ confusion (Claxton, 1996), cognitive dissonance (Neighbour, 2005), and varying degrees of resistance to change as the participants slowly experience a diff erent way of being supervised or of supervising others.


Although some fi nd it easier than others to adopt this questioning technique, most people are able to resist the “logical force” (Pearce, 2007) to give advice, or assume too soon that they know a solution (Stewart et al., 1991). T ey become skilled at drawing out the supervisee’s own stories and at promoting critical refl ection. We reiterate the point that these


skills can be integrated with the already well honed more direct approach that is appropriate in set ings when the supervisee needs instruction (e.g. “Start chest compressions now”). As supervisors, we aspire to behave in


a manner congruent with our approach (Whiting, 2007) and to signpost when we off er a diff erent approach (Burnham, 1992).


Eff ect on me I have noticed over time that I am


slowly developing a diff erent at itude of mind. I more easily seek multiple perspectives and try not to get wedded to my own hypotheses. My work colleagues in general practice have remarked that I am oſt en the one to explore the process of interactions, and to encourage hearing diff erent views. I am able to maintain my curiosity and challenge my assumptions and those of others and I am much more able to critically refl ect on interactions. I am more at entive to language than I used to be. In consultations with patients, I commonly bring other family members into the story that the patients bring (“Who is most worried about x”, “If your mother was listening to this conversation, what you think she would say?”). In supervision sessions with trainees, we play with power diff erences (for example, I ask the supervisee to give me constructive feedback on my consultations), I take risks more freely (Mason, 2005), and explore context . To illustrate, here is a snippet of a recent supervision conversation I had with a colleague (to preserve anonymity all identifying features and personal details have been changed in this vignet e):


I was recently supervising a colleague


(Alison, a local GP) who had had a diffi cult consultation with a patient. T e patient was a large, white middle-class, middle-aged man, whose wife was a doctor. He had come requesting a private referral to a hospital on the instruction


17


Medical conversations inviting change


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