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“Conversations Inviting Change”: a workshop for practice managers

6 June 2008

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Helen Halpern

GP and Family Therapist
Innercity London

Visiting Tutor in Clinical Supervision
Tavistock Clinic and London Deanery

Helen works part-time as a GP, as an educator and also as a mum. This still leaves her some time to try to keep her brain fit by learning Spanish, and to try to keep herself physically fit by playing tennis and walking her dog. Helen has a theory that juggling all these activities has given her a useful insight into the everyday experience of practice managers

Practice managers have a unique role within the primary care team, with their complete overview of the practice combined with a need to lead and manage the team, while frequently also being an employee.

They are asked to sort out problems, and yet the final responsibility for the problem lies with the partners. Many practice managers feel that the rest of the team do not really understand their role. Indeed, the role varies depending on the practice they work in.

However, a common feeling is that they are pulled in many different directions. They perceive GPs as being good at giving answers to problems, but find that these solutions are not always useful.

Practice managers believe there is an expectation that they will rapidly solve a huge variety of problems that are thrust upon them: “One minute it’s a fuse, then the IT system is down, there’s a complaint to deal with and a staff member is
in tears.”

I facilitate courses on clinical supervision, run by the London Deanery. This is an organisation involved in postgraduate medical education. A practice manager who attended was excited by the ideas developed on this course, and felt the skills would be useful to her other practice manager colleagues.
She therefore approached me and asked if it would be possible to run a series of workshops just for practice managers in her locality.

What happened
A group of 13 practice managers took part in three workshops, entitled “Conversations Inviting Change”, which were held over the course of six months in a general practice setting. The managers were given a mix of theoretical teaching and small group work on skills building and case discussion.

The idea behind Conversations Inviting Change is to enable people to develop reflective practice and help them become observers of the processes in which they are taking part. The name was coined by two doctors who ran courses for primary care clinicians at The Tavistock Centre.(1) The theory behind this comes from Canadian psychologist Karl Tomm.(2)

At the first session, the managers completed the skills-based tasks extremely quickly, despite knowing there was more time allocated. They felt that they were able to develop a good relationship with the colleagues they were working with in the group, and could air some problems for which they received good advice and guidance.

Interestingly, I had explicitly instructed them not to give advice when discussing cases with each other. There were two reasons for this instruction. First, advice given by one professional may not fit the working context of the recipient. Second, one of the aims was to help participants to step back from their problem and solve it themselves.

However, it seemed that they found this instruction extremely difficult. In their usual working practice, managers need to respond rapidly to developing situations. Giving a quick piece of advice is their instinctive response. In addition, the person who presented the problem was ready to be told the answer without  having to agonise any further.

The managers were concerned that asking for help about practice difficulties put them in a position of being “takers” – takers of time, interest and care from their colleagues. For many, it was important to have affirmation from a professional colleague that they had taken the correct action in dealing with difficult situations.

One manager became quite distressed by the sensation of having time out of the practice to think about the issues that were going on, and was also worried that her distress could have a negative impact on the rest of the group. I was struck by the parental role the managers take on, and the little opportunity they have to discuss their dilemmas and difficulties in a structured way.

Most of the difficulties the managers wanted to talk about were related to staff employment. This seems to be an area that takes up an enormous amount of managers’ time, is emotionally draining, has repercussions within the rest of the practice, and satisfactory solutions can’t always be found.

The managers were able to offer each other a great deal of support in this area. However, they described this as more than just an effect of offloading. They found the conversations they had with each other increased the breadth and complexity of the initial problem presented, so that the solutions they came to were also more complex and felt more satisfactory than a simple patch.

Indeed, for some, the conversation had the interesting effect of changing the problem they had started with into something completely different.

Case study
Paula is a white, middle-aged British manager working in a large practice in an innercity area. The practice has recently employed a young South Asian receptionist, who is bilingual, speaking both English and Bengali.

The practice has been delighted with the way she has been able to use her language skills with patients, but she has been arriving late for work and is not mixing well with the rest of the staff. The manager asked for some supervision, as she felt she needed to tackle these issues but felt anxious about doing so.

In the supervision conversation with a colleague, she was asked a range of questions to broaden the perspective.

For example:

  • “Do you think the receptionist realises the effects of what she is doing?”
  • “What ideas do you have about why she is late for work, and why she may not be mixing with the other staff?”
  • “What is stopping you from talking to her about this?”
  • “What might your senior receptionist have to say about her?”
  • “Do you think there are cultural factors influencing your ability to say what needs to be said or to using the appropriate disciplinary procedure?”
  • “If you do nothing about this situation how might it affect the rest of the practice team?”
  • “If you felt too anxious about managing this yourself, who else might be able to help?”

Paula was able to reflect that she was mainly concerned with the cultural differences – age, ethnicity and social
background – between her and the receptionist, which made her anxious about seeming too powerful and overwhelming. She realised that trying to be motherly and protective towards the receptionist was likely to have a counterproductive effect on the team as a whole.

She felt that she could now approach the receptionist in a nonthreatening way to have a conversation with her, in which she would explore the receptionist’s problems and also put across the needs of the practice to try to prevent the situation developing into one that would require following a formal disciplinary procedure.

Paula felt supported by her colleague in understanding her dilemma and also empowered to take action, which she had previously been nervous to do.

Some of the outcomes
The managers described feeling more confident in bouncing problems back to the person who brought them, and having the skills to help that person find a solution. This is in marked contrast to how they would previously have felt, ie, that it was completely their responsibility to sort out the problem.

They talked about how they were learning to “split their brain”; listening to the other person, monitoring their personal response and trying to take an overview of the whole situation.

They had started to feel that it was alright not to come up with an immediate response and sort out everything in one go. “You don’t just need to react,” one manager said. “I’ve become calmer and can help the other person to think. You can start by dealing with a bit of the problem and hope that has a knock-on effect.”

This permission to take time out and to share responsibility with others was quite a new experience for many of the managers, and made them feel less stressed at work.

The managers also become better at monitoring their own reactions and feelings, and using these to understand some of the process of what was going on. Some reported that other people in the practice had noticed.

“One of the partners said, ‘Thank goodness you came forward and tackled that issue. I really like the new you – you’ve been more proactive on staff problems,'” said one manager.
Another reported: “I don’t get so worked up about things. I carry less anxiety and can concentrate better on the task in hand.”

One manager reported how she had noticed that all the partners were telling her different things about how to manage a particular practice situation. She felt able to point this out to the partners and ask them to let her know how they wished her to take things forward, based on the premise that they all had different ideas.

They described themselves as being more efficient and effective at work as they felt more able to delegate tasks, through working more strategically at what they described as “a higher level of thought”. As one manager reported: “I’ve stopped being the wishbone in the turkey”.

Even though I do not work in the same practice area as the managers who came to the workshops, I was concerned about how I might be viewed by them, and felt it was a compliment that by the third session they were able to tell me that they had forgotten I was a GP.

The group decided to meet every two months to continue to practise their interviewing skills. They also shared tele-phone numbers and emails so they had a quick resource to tap into for support if they were struggling with something in between meetings.

They felt that the focus of the group would be different from their existing Practice Managers’ Forum meetings. While the managers were concerned they might be seen as “elitist” in setting up this group, they also recognised that they felt comfortable working together, and were now willing to share their skills by helping to “pump-prime” other groups.

Skills in asking appropriate questions and helping colleagues to develop new ways of describing and understanding their difficulties can be taught and learnt fairly quickly. However, the managers realised they needed to continue to practise using these skills, and therefore valued the chance to meet regularly to discuss cases within this framework.

The workshops seemed to give many of the managers more confidence in tackling the everyday problems they faced and to be more proactive in the practice. This had been noticed by some of the GPs they worked with and was
generally appreciated.

The skills are transferable across many situations, and can be used in one-to-one conversations, in practice meetings, in meetings with other managers, with primary care trusts, in staff training and in appraisals.

It may be that developing this kind of reflective practice for managers can help improve job satisfaction and team morale, and reduce stress and burnout.

1. Launer J, Lindsey C. Training for systemic general practice: a new approach from the Tavistock Clinic. Br J Gen Pract 1997;47:
2. Tomm K. Interventive interviewing: part III. Intending to ask lineal, circular, strategic or reflexive questions? Fam Process 1988;27:1-15.