Use of an Appreciative Inquiry Approach to Enhance Quality Improvement in Management of Patient Care
Luhalima TR1*, Mulaudzi FM2, Phetlhu DR3
1Department of Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa
2Faculty Community and Health Science, University of Pretoria, Pretoria, South Africa
3Department of Health Science, University of Sefako Makgatho, Ga-Rankuwa, South Africa
*Corresponding author: Luhalima TR, Department of Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa
Received: 03 June 2022; Accepted: 24 June 2022; Published: 06 August 2022
Citation: Luhalima TR, Mulaudzi FM, Phetlhu DR. Use of an Appreciative Inquiry Approach to Enhance Quality Improvement in Management of Patient Care. Archives of Internal Medicine Research 5 (2022): 357-364.Share at Facebook
Background: Different approaches are available to facilitate employees’ motivation, involving them in decision making and participating in different activities. Due to changes and the widespread dissatisfaction with the management of the current South African health system, various approaches to enhance quality improvement in management have emerged. However, their effects on the quality of care have been unsatisfactory. This article describes how an appreciative inquiry was used to facilitate motivation and promote organisational quality improvement in the management of patient care.
Methods: The AI approach which comprises an appreciative topic and acting on this theme through the 5-D cycle: namely Definition of the affirmative topic, Discovery, Dream, Design, and Destiny was used.
Results: An appreciative inquiry approach offered employees an opportunity to reflect on the existing strengths within their practice situation, leading them to discover what is important and enhance quality improvement in the management of patient care in South Africa. Furthermore, AI is reported to have significant transformational as it has shifted the focus from problems to be solved to discovering and building on what works well within an organisation and used that as the starting point for implementing change.
Conclusions: New approaches such as AI have the potential to improve patient care and enhance individual and group motivation by changing the way participants think about, approach, and imagine the future.
Appreciative Inquiry, Quality Improvement, Management, Patient Care
Appreciative Inquiry articles; Quality Improvement articles; Management articles; Patient Care articles
Cooperrider and Srivastva developed the Appreciative Inquiry method in the 1980s . The adoption of an appreciative inquiry (AI) technique by managers to improve quality inpatient care is described in this paper. Employee motivation can be aided in a variety of ways, including involving them in decision-making, teamwork, and participation in various activities. Various techniques to promote quality improvement in management have evolved as a result of changes and public unhappiness with the current South African health system's management. Their impact on the quality of care, however, has been unacceptable. This necessitated nurses who were motivated to accomplish their jobs, and because the challenge is still ongoing, nurses must remain motivated  demonstrated that in order to enhance quality care, nurse management should advocate for both the patient and the nurses. Cooperrider was the first to describe AI as an action research method for organisational growth . In addition, AI was employed to improve management quality, resulting in a more contented work atmosphere. According to Cooperrider and Coghlan [4, 5], AI has acquired importance and is used over the world, and its popularity is continually expanding. The positive and transformative effects of AI on individuals, groups, organisations, and multi-stakeholder collaboration are well documented.
It's a method for facilitating positive change in organisations, resulting in higher-quality care. Frankel and Moorer [6, 7] focus on what works well and produces positive outcomes rather than changing the individual. The approach, according to Cooperrider , incorporates the 5-D cycle, which consists of five phases: Definition), Discovery, Dream, Design, and Destiny. According to a study conducted by  AI helps to enhance organisational ties and increase pleasant feelings about what people value. Appreciation is defined as recognizing "...the best in individuals and the world around them" and involves acknowledgement, valuing, and gratitude . The sense of things that provide living human systems vitality, vigor, liveliness, and quality . "It connotes a search for new possibilities, as well as a sense of awe, surprise, and eagerness to learn." It implies a willingness to adapt" . Furthermore, AI is a fully participative method that primarily focuses on how best practices in an organisation may be formed and maintained . Cooperrider (1987) chose to focus on stories of success and excellent practice after recognizing the highest degree of energy and effort associated with them in building a research method that adds value to organisations based on a constructionist orientation to meaning and reality. Furthermore, rather than discovering pre-existing truth, AI is intended to co-create and drive the desired reality based on participants' experiences and goals . It is based on the assumption that whatever is "looked at" gets magnified, and that focusing on issues is unlikely to lead to their decrease. The notion of confining reactions to positive behaviour is used in behaviour modification strategies to eliminate undesired behaviour . The methods of Appreciative Inquiry were founded on the first set of four principles . The original method demonstrated that investigating a social system's social potential should begin with appreciation, be collaborative, provocative, and practical. Furthermore, constructivist, simultaneity, poetic, anticipatory, and the positive principle are used to clarify planned outcomes and organisational relevance .
Organisations are socially co-constructed realities, according to the first principle. As a result, AI should enlist the participation of as many stakeholders as feasible in the investigation of ideal communal futures. The concept that inquiry is intervention, that as we enquire into human systems, we affect their behaviour, is the foundation of the principle of simultaneity. "The seeds of change – that is, the things that people think and talk about, the things that bring about the organisational change, all aspects and concerns are critical . A prevalent criticism, according to Fitzgerald , is that AI's concentration on positive, high-point topics of organisational life may eclipse most of the members' bad experiences and the resulting essential expressive conversations. A number of practitioners criticized the 4-D model for omitting a critical first stage in the AI process: determining the inquiry's focus. Several practitioner critics noted that the 4-D model skipped a critical first stage in the AI process: determining the inquiry's focus. Several practitioner critics noted that the 4-D model skipped a critical first stage in the AI process: determining the inquiry's focus. Bushe  claimed that the Clergy Leadership Institute in the United States and others refer to the 5-D model as an investigation into "the best of what is in order to imagine what could be." Furthermore, the 4-D Cycle's final phase (also referred to as Destiny). Although Cooperrider's dissertation referred to this as the "affirmative topic," many models still use that term. The precise definition of that topic has not been fully articulated, although it is widely viewed as critical to the effort's overall success . The five stages of the 5-D cycle  are depicted in Figure 1. The 5-D cycle of an Appreciative Inquiry.
1.1 Significance of the study
An AI approach may be used to develop policies at rural hospitals since it encourages people to do positive activities that lead to favourable outcomes. More studies might be done to add to the body of knowledge and nurse education about what activities should be performed to effectively encourage nurses in remote hospitals. In education, AI may be utilized as a research methodology that focuses on positive inquiry rather than problem-solving.
1.2 Aim of the study
The purpose was to describe how an appreciative inquiry was used to facilitate and promote organisational quality improvement in the management of a rural hospital.
1.3 Research question
Is AI approach a possible change management technique to enhance quality improvement in the management of public rural hospitals?
1.4 Objective of the study
To improve the management techniques by using an appreciative inquiry approach to enhance quality improvement in the management of public rural hospitals.
1.5 Definition of terms
For consistency and for a better understanding, the definitions of the key concepts, as applied in the current study, are presented.
1.6 Appreciative inquiry
Appreciative Inquiry is the cooperative search for the best in people, their organisations, and the world around them. It involves systematic discovery of what gives life and is utmost activity and proficiency in the economic, ecological, and human terms in an organisation . In this current study, AI refers to the positive way of soliciting the best practice that could be harnessed to improve quality care in a rural hospital.
1.7 Quality improvement
Quality improvement refers to the system in which the quality of health service is formally monitored and assessed to improve the quality of the service provided. It implies putting quality into practice  in the pursuit of providing the best possible service within the constraints of certain circumstances. In this study quality improvement refers to opportunities for improvement identified and mechanisms provided to bring about and maintain improvements.
1.8 Rural hospital
A rural hospital is a facility or structure in the countryside and not in a town or city where people who are ill or injured are given medical treatment . In this study, rural hospital refers to hospital in an underdeveloped area in the Limpopo Province of South Africa.
Assumptions are “embedded in thinking and behaviour and therefore influence the development and implementation of the research process” . In addition,  stated that an assumption refers to “a basic principle that is believed to be true without proof or verification”. The current study was guided by the following question embedded in naturalistic assumptions.
1.10 Ontology: What is the nature of reality?
The researchers believed that all stakeholders involved in managing rural hospitals could use the available intrinsic and extrinsic factors towards creating a positive work environment. It was the researchers' belief that by asking positive questions relating to the intrinsic factors and those that influence the motivation of nurses, stakeholders would become more positive towards both these sets of factors. People have more confidence and comfort in to journey towards the future when they carry forward parts of the past. For this reason, if nurses thought positively about their challenging work environment, it would turn out to be a positive work environment. Researchers believe individual differences should be valued and appreciated because it brings more views and possibilities.
1.11 Epistemology: How are the inquirers related to those being researched?
The researchers in this current study believed that the participants needed to be actively involved in sharing their perceptions regarding the extrinsic and intrinsic factors that worked well for them. She obtained in-depth information by allowing them to talk freely and telling her what should be done to influence the achievement of a positive work environment.
1.12 Methodology: How is evidence best obtained?
The naturalistic paradigm is best applied by pursuing the study and description of first-hand information, thereby acquiring data from the nurses' own personal experiences in rural hospitals [19-21]. The data was gathered using a qualitative method. At this study, researchers employed artificial intelligence to ask a question on what motivates nurses to provide high-quality patient care in a rural hospital. The problem of human complexity was addressed by looking into it directly . The AI, for example, was used by the researcher to allow participants to reflect on their perceptions. The data collecting and analysis operations were carried out simultaneously.
The appreciative inquiry technique was employed. The goal of this strategy is to offer participants the freedom to tell their stories, and interviews will let them provide in-depth information about their situation. Individual interviews were done using an exploratory, descriptive, and contextual design to examine and explain nurses' impressions of the intrinsic and extrinsic elements that encouraged them to provide high-quality patient care in rural hospitals despite the difficulties.
2.1 Research design
A qualitative AI based on the 5-D cycle was used to design and implement action plans toward excellence by asking positive questions to a group of stakeholders (nurses who directly provided patient care) . The research design aided the researcher in carrying out the study in such a way that the findings were as trustworthy as possible.
2.2 Appreciative inquiry approach
For this research, an AI strategy based on the 5-D cycle was used, which entailed asking positive questions to a group of stakeholders in order to design and implement action plans aimed at reaching excellence. The five steps of the 5-D cycle that were used in this study's three phases are briefly outlined.
2.3 Defining stage
For this study, an AI strategy based on the 5-D cycle was employed, which involved asking a group of stakeholders positive questions in order to build and implement action plans targeted at achieving excellence. The five steps of the 5-D cycle used in each of the three phases of this study are briefly described.
2.4 Discovery stage
In this study, semi-structured interviews were conducted with nurses working in a rural hospital. Appreciative Inquiry approach questions were asked to allow nurses to appreciate the positive aspect of their work. The intrinsic, as well as extrinsic factors, were determined from what the nurses themselves voiced. Qualitative research is a method of getting insight into people's views and "the world in which they live" by discovering meaning or a sense of their perceptions and "the world in which they live" . Using an AI approach, researchers explored the perceptions of nurses with regard to factors that motivate them to render quality patient care in a rural hospital. Interviewees were asked to share their positive experiences through interviews regarding who they were and who they wanted to be.
2.5 Dream stage and design stage
The design stage involved reshaping the future through dialogue. A process of common ideas was sought through sharing the intrinsic and extrinsic factors that motivated participants in their work environment. Questions such as what opportunities for personal growth, achievement and recognition should prevail in the work environment, were asked.
2.6 Destiny stage
The feasibility of implementing the dream and design stages in the operational plan (or the work plan) was evaluated. This involved transforming the design stage into more specific sets of tasks or activities to be put into action. The plan of action will be presented to supervisors, managers, and nurses so that they could be empowered to promote a positive work environment. This will be an ongoing strategy to improve the quality of patient care.
2.7 Data collection procedures
Focus group interviews were conducted to assess the motivation of nurses working in hospitals. Questions asked were what are the intrinsic factors which motivate you to render your service each day? what are the extrinsic factors which motivate you in your hospital? how best do you think your manager could motivate you to work willingly and effectively? Nominal Group Techniques (NGT) were used to reach consensus with the participants. NGTs are essential for the successful implementation of AI because they bring out the best in people and organisation. AI interviews, according to , are critical for the effective deployment of AI because they bring out the best in people and organisations, and they give nurses in this study the opportunity to speak and be heard.
2.8 Data analysis
For data analysis, the semi-structured interviews were audio captured and transcribed verbatim in written format. The transcribed data were subjected to an analysis based on Tesch's methodology . During the thematic analysis, the six steps of  were used, because it concerns intrinsic and extrinsic variables, coding guaranteed that a small number of themes or categories were developed, which were in line with Herzberg's two factor theory . The themes occurred as main findings in this study and were listed under various headings in the findings .
2.9 Phase 2: Dream stage and design stage
The researcher held a session in Phase 2 where the AI technique was employed. The researcher used positive AI approach questions to spark transformative conversations with nurses in a rural public hospital about the elements that could help them provide better patient care. The nurses began to fantasize about possibilities (intrinsic and extrinsic variables) that could inspire them based on their shared experiences during the discovery stage. The participants saw and understood things differently during the focus group interviews and as the conversations progressed.
2.10 Design stage
The third stage entailed deciding on what should be done . During this stage, people are establishing future plans . Participants had the option to plan their future during this stage. The researcher looked at the practicalities that were required to support the vision that was required for the dream to become a reality.
2.11 Data analysis
The interviews were transcribed verbatim for analysis, just as they were in Phase 1. The information gathered during this phase was in the form of group report scripts. Tesch's technique was used to analyze the dialogues . The focus group conversations were analyzed for themes using Tesch's  open-coding and analysis technique .
2.12 Phase 3: Destiny stage
Nurses are more likely to respond positively when we strive to see the best in one another . At this point, a consensus was achieved on the elements that were deemed to be the most important in terms of improving care quality.
2.13 Summary of the findings
“What are the changes that nurses would like to see in their work environment.
The need to achieve professional growth and the need to teach others ranked as the top two most important motivators for nurses. The following strategies were recommended for nurses to sustain their responsibility to stay motivated when rendering quality patient care. Figure 2 Numerical intrinsic factors below illustrate the percentages of what are the changes that nurses would like to see in their work environment. Recognition for good work was ranked number 1 with a total score of 315 (12.09%) and need for positive feedback with 291 (11.17%). The findings showed that nurses needed positive feedback for their extra efforts to be recognised. It also showed that financial incentives could increase nurses' motivation. Good interpersonal relations are pivotal in bringing about positive changes in a rural hospital. Managers should be specific when informing nurses about expectations and behaviours. Nurses should be given time to acknowledge what had been said to make sure that they understood the communication correctly. An effective communication strategy is essential to bring about positive change. The need for personal security was ranked number 10 with a total score of 190 (7.29%). However, there was a significant need for job security. Involvement in decision making motivated them and they worked wholeheartedly if own the processes, making sure that they sustained the good reputation of their institution. Below is the Figure 3: Numerical extrinsic factors with percentages showcasing the participants’ needs that could bring changes in the working environment. The findings revealed that nurses would like to see the following changes in their work environment: The employer should increase nurses' salary scales to be in line with their qualifications. The employer should pay Organisational Specific Dispensations to all categories of nurses. Tight hospital security in all strategic risk areas should be provided by state-of-the-art facilities.
3.1 Phase 3: Destiny phase
Managers should provide opportunities for nurses to improve themselves and make it clear that they want to be better than they are. Nurses should be given adequate work, neither too much nor too little.
3.2 Reasons why respondents wanted to continue working in the rural hospital
Despite the limitations, the research revealed that nurses enjoyed working in their rural hospital. The following reasons influenced nurses' decision to stay in the remote hospital:
- Love for their employment
- Love for their community members
- Need to be with their families
- Less crime than in the city
- Less expensive lifestyle
- Rural allowance
- Challenging duties
- Shorter commute to work
The goal of this study was to find out what motivates nurses to provide high-quality patient care in a rural hospital and to summarize their thoughts on the subject. It was hoped that gaining a deeper knowledge of these nurses' perspectives of what motivates them will give them insight into the current motivational elements that push them to offer high- quality patient care in a rural hospital. According to Routasalo and Suominen , the subject of employee motivation has been central to management practice and philosophy throughout the twentieth century. They stated that if they are sent to various training programs that are either initiated by the government or if they are given the option to progress themselves, they will become more motivated. "Once motivation and a reflexive learning process are in place, a self-motivated learning experience can be transformed into a way of life" .
Participants are motivated by the following factors, according to the findings: affection for their patients, meeting their expectations, empathy, and patriotism. Despite the problems they face at their rural hospital, the volunteers are extremely driven to provide good, quality patient care, according to the findings. The outcomes of this study support the Appreciative Inquiry (AI) notion that "something works" in any community, organisation, or group . The current study's findings are consistent with those of [33, 34], which found that participants described their work as a "calling" and that they enjoy helping others and are content with their jobs. The findings found that having access to and support for training, education, and opportunity to develop new skills appears to drive nurses in a remote hospital to provide high-quality patient care. These findings are comparable to those of [35, 36], who confirm that the nurses' demand for achievement is generated from initiatives or discretions demonstrated in the way they operate, which encourages them to enjoy the type of work they conduct  described training as a means of gaining critical information to accomplish their profession and as a component that boosts motivation. The findings also show that when participants are part of the decision-making process, they take ownership of the processes and become more devoted and clearer about the hospital's goals. This finding is consistent with that of  who discovered that participants expressed an interest in becoming more involved in decision and policy making at work. Apollo et al.  and  believe that nurse managers should collaborate closely with nurses' union representatives and their nursing staff to develop measures that make rotation work more appealing. All of the participants agreed that being recognized, praised, and rewarded motivates them to become more goal-oriented, take ownership, encourage active participation and involvement, and improve the achievement of the institutional goal and sustainability in providing quality patient care in their rural hospital .
Furthermore, the data revealed that financial incentives for achievement, such as pay increases, as well as non-monetary incentives and other perks, play an important influence on motivation. Nurses want to be recognized for their hard work, according to the findings of this survey. Nurses believe that recognition is the most beneficial component of work motivation, according to researchers such as  and . Nurses are urged to be motivated since it can lead to benefits such as acknowledgment for strong job performance, which can improve job satisfaction. The volunteers in the current study also appeared to be joyful and felt a personal feeling of protection and security because they offered a much-needed service in their community, according to the findings  found similar findings, stating that the participants in their study felt comfortable since they provided an important service in a politically stable area where their personal safety was guaranteed at rural health institutions.
4.1 Original contribution
One of the study's primary achievements was to involve participants in several stages of AI, allowing them to identify their skills, possibilities, and ambitions in their own surroundings while also learning to appreciate what they have. The participants learned about components of this approach for conducting research, such as employing AI and the processes to be followed, as well as having the opportunity to dream and design. Another benefit was that the participants learned that whatever they focused on could become a reality, regardless of the challenges they were facing; if they focused on the positive aspects of their rural hospital and worked to create and maintain a positive work environment, it could become a reality. The participants also learned to look at things in a positive light rather than a negative light. Furthermore, the study added to the body of knowledge, and the AI technique allowed staff to reflect on current strengths in the practice environment, allowing them to find what is vital and improve quality in rural hospital management in the Limpopo Province. The AI technique might be utilized to conduct research studies to add to the body of knowledge and education of nurses about how to improve quality in the management of rural hospitals in other developing countries.
The study's limitation was that it was limited to only one hospital, a secondary hospital in the Limpopo Province of South Africa, one of nine provinces in the country, and did not include more comprehensive rural institutions. Because it is difficult for some people to keep a happy attitude, there may be hazards in utilizing Al. Furthermore, the AI model's flexibility and lack of scientific consistency and thoroughness could be considered flaws.
4.3 Trustworthiness of the study
The reliability of this study was established, which ensured its validity. The term trustworthiness was used to explain how the researcher applied the Guba and Lincoln model to improve the validity of the findings (29). The following criteria were utilized to guarantee that the findings were trustworthy: credibility, transferability, dependability, conformability, and authenticity.
4.4 Ethical considerations
The Research Ethics Committees at the University of Pretoria's Faculty of Health Science, as well as the Limpopo Province Department of Health's approval to conduct the research and permission from the hospital where the research was done, all gave their approval.
The researchers took the best ideas and put them into reality in this little rural hospital. The researchers used AI as a tool for creating good improvements in hospitals. The AI also serves as a foundation for the strength-based strategic planning approach, which emphasizes strengths, opportunities, ambitions, and outcomes (SOAR). AI offers a path ahead in implementing change in organisations without the use of coercion, allowing management and employees to positively affect the work, design, and management of health care.
Ethics approval and consent to participate
Ethical clearance was granted by the University of Pretoria ethics committee. The protocol number is (65/2013) Consent was given by the participants before data collection.
Consent for publication
Consent for publication was obtained from the participants.
Availability of data and material
The datasets generated and analysed during the current study are not publicly available. The researcher agreed with the participants that all information given will be confidential between the researcher and the participant’s promoters, and independent coder where it was necessary.
The authors declare that they have no competing interests
The researcher was supported by University of Pretoria research funds to pay tuition fees
TR, FM, and DR conceptualised the study. TR collection data. TR, FM, and DR analysed and interpreted data and TR was the one writing manuscript. All authors read and approved the final manuscript
I acknowledge participants and school of health professors to assist in manuscript writing.
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