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Kicking Eeyore into touch: ‘Living-strong’, ‘nursing-
strong’ and being appreciative and solution-focused
Dr Bernie Carter
Professor of Children’s Nursing
Department of Nursing
University of Central Lancashire
Preston, United Kingdom
Abstract
The potential benefits of moving away from a problem/needs oriented approach to a
solution-focused, appreciative way of working with children and their families are explored
in this paper. It aims to acknowledge and celebrate the expertise of children and their
families and the nurses who care for and with them.
I draw on both Appreciative Inquiry - a dynamic, dialogic framework for appreciative
thinking with people about situations and settings - and Solution-Focused Nursing as means
of underpinning my proposal to further shift the way that children’s nurses think and work
with children and their families. I argue that a paradigm shift is needed in which children’s
nurses celebrate and focus on the things that are working well within families and
genuinely consider the families’ expertise and knowledge. This requires us to be attuned to
the diverse ways of experiencing things and multiple ways in which nurses can care with
families. It requires us to carefully consider not only what we say but how we say it and the
impact that our dialogue with children has on them. Equally it requires children’s nurses to
acknowledge and celebrate what they do well and embrace and engage with the energy and
creativity that underpins strong, resourceful, innovative and expert practice.
I propose a manifesto for children’s nurses that acknowledges these attributes and
encourages us to ‘think solutions’, to be nurses that children will remember who help
children and families to live well and live-strong with their illness.
Key words: appreciative inquiry; child; children’s nurses; Eeyore; paradigm; solution-
focused nursing.
Introduction: nursing beyond Eeyore
Most of us have a touch of Eeyore in us. Some days, Eeyore wins out and we see the world
in a rather gloomy, pessimistic and slightly melancholy way. We think of the things that we
would like to do but which we cannot because we have not got the time, resources or
facilities. We negatively problematise the world, our practice and, by default, the children
and families we care with and for. Yet, despite our occasional forays into Eeyorishness, I
firmly believe – with absolutely no empirical evidence upon which to support this belief –
that most children’s nurses have more Piglet and Kanga in them than Eeyore
i
.
It’s quite easy for children’s nurses, regardless of their role – practitioner, manager, or
academic - to get complacent about the philosophical underpinnings of children’s nursing.
It sometimes takes a moment of dysjunction to propel us, either as individuals or as a
group, into adopting a new mindset about our practice. What I’m advocating in this paper
are the potential benefits of moving towards a solution-focused, appreciative way of
working with children and their families. This does not mean that there would be a
wholesale revolution resulting in the overthrow of philosophical frameworks, such as
‘child/family-centred’ care, that most of us hold dear to our hearts but for which there is
conflicting evidence (Shields, Pratt & Hunter 2006). However, it would require a significant
readjustment about how we work within these frameworks. In the United Kingdom,
children’s nurses have embraced many changes. These include the shifts to community
based care (British Association for Community Child Health (BACCH) 2005), more active
approaches to partnership and collaboration (Kirby et al. 2003), the notion of the expert
patient (DoH 2006; Hawley 2005a; Hawley 2005b) and the shift in perceptions of children
having their own active social agency (Hill et al. 2004; Mayall 2006; Roberts & Petticrew
2006).
Whilst all of these changes have been laudable and necessary we still have a tendency to
work in a problem-oriented way. We assess needs and problems and consider interventions
to provide support and care. Whilst these are, arguably, fundamental to our role we less
frequently frame our practice with children in relation to what they are achieving, their
successes, what they can do or what they actually want (Bricher & Darbyshire 2004). Being
oriented to problems and needs is not, in itself, wrong. However, it is constraining both for
ourselves as practitioners and also for the children and their families. To a greater or lesser
extent it takes some of the joy out of our relationships with children and their families.
Children’s nursing has the potential to be celebratory; a sharing of expertise; a way of
being–with children who are ill or require nursing. We should recognise this and try and
ensure that our practice is more joyous, more generous, and more affirmative (Carter
2006a).
To some extent this paper represents a set of personal thoughts in progress. Where
references exist and where I think they add to the argument I am developing I have used
them; elsewhere the text is free from references. It is a paradox to try and reference
something which is a new idea – the evidence base does not fully exist. This paper aims to
add to the literature exploring the potential of solution focused children’s nursing and the
need to shift to a new paradigm. I anticipate that this paper may challenge some people,
be dismissed by some but intrigue others; I would be delighted with all and any of these
responses.
A shift to a new paradigm: out of the comfort zone?
There are many pitfalls and pratfalls associated with proposing change, especially when it
comes to suggesting a shift in the way we think about children’s nursing. Yet, I do think it is
time for a paradigm shift. The paradigm we are working in is comfortable; we share a
general understanding of what philosophically underpins children’s nursing. Most of us will
swear allegiance – without necessarily thinking too critically – to various ‘flags of
convenience’ such as ‘child/family centred care’, ‘holistic practice’, ‘partnership’,
‘collaboration’, ‘patient/parent expertise.’ However, blind, unthinking, convenient
allegiance is insufficient if we are to truly make a difference to the children and families
we come into contact with. If a problem-orientation explicitly or even subtly infuses our
thinking within these frameworks we are, I believe, not approaching our care in the best
possible way. A solution focused approach – as proposed by McAllister (2003) is a way
forward that is genuinely worthy of consideration.
Any paradigm shift naturally brings change and much change fails because it is costly,
requires new resources, or is seen as being remote and unnecessary. But being more
solution-oriented and appreciative does not need to cost anything. It just – albeit it is a big
‘just’ – needs us to use our selves differently. Thinking is free. Changing the way we think,
use language, co-construct discourse and dialogue with children and families is possible
without financial costs. The potential benefits are not remote; they are real and
achievable.
The problem/needs oriented paradigm we are currently ensconced in feels comfortable.
Being comfortable might seem to be fine; but it is a short step away from being complacent
or even unaware of some of the assumptions that underpin the way we are thinking and
working. The notion of a ‘comfort zone’ is, to some degree, indicative of a well-embedded
paradigm as paradigms themselves are normative. This normative thinking is, to an extent,
helpful as it can avoid long existential and epistemological considerations (Guba & Lincoln
1989). Changes to normative, paradigmatic thinking are usually talked of in terms of
revolutions (Kuhn 1970), whereas Erickson (1986: 120) perhaps more aptly and wryly
proposes that ‘paradigms don't die; they develop varicose veins and get fitted with cardiac
pacemakers’. If we are to avoid developing philosophical varicose veins (something likely
to bring out the Eeyore in most of us), we need to be considering new ways of thinking
with, engaging with and relating with children and their families. If we engage with them
solely through a problem-oriented approach we are in danger of seeing the problem not the
child.
Getting appreciative, getting solution-focused
For me my moment of dysjunction occurred was whilst developing a research proposal
when I serendipitously came across a research study which had used ‘appreciative inquiry’
(AI). The approach intrigued me and it started me thinking about how – despite using
participant oriented approaches – so much of my own and other people’s research (and
practice) was undertaken within a problem oriented frame (Carter 2006a). Since
undertaking that first AI project (Carter et al. 2004) I have found that much of my thinking
has been challenged and I have seen the potential that working and thinking appreciatively
has for children’s nurses.
Fundamentally, AI is a framework for thinking appreciatively with people about situations
and settings (Watkins & Cooperrider 2000; Van der Haar & Hosking, 2004). Most firmly
established within organisational change and management it is now becoming more
frequently utilised within academic research in the social sciences (for prison work see
Liebling, Elliott & Arnold 2001; Liebling, Price & Elliott 1999) and health (Lavender &
Chapple 2004; see Reed et al. 2002). Its impact on nursing practice is less well documented
but it has been used to consider issues related to ward staffing (Wright & Baker 2006) and
there are reports of it being used successfully as the framework for appraisal of nurses
(Klausen 2005) and other health care staff. Fundamental to appreciative inquiry is notion
that things generally work and they often work well. It is both pragmatic and aspirational
as it aims to try and build on existing successes and achieve an even more positive future.
It has the potential to address the discouragement felt by children and families when their
successes and achievements are overlooked and nurses focus on things that have not gone
so well.
Hammond (1998: 20-21) proposes eight assumptions about AI which I believe have
resonance for a solution-focused approach to children’s nursing.
1. ‘In every society, organisation or group, something works.
2. What we focus on becomes our reality.
3. Reality is created in the moment, and there are multiple realities.
4. The art of asking questions of an organisation or group influences the group in
some way.
5. People have more confidence and comfort to journey to the future (the
unknown) when they carry forward parts of the past (the known).
6. If we carry parts of the past forward, they should be what is best about the past.
7. It is important to value differences.
8. The language we use creates our reality’ (Hammond 1998: 20-21).
Each is important and can contribute to shifting to a solution-focused way of working. AI is
predicated on the belief that something always works; this is worth remembering as it is all
too easy for the focus to be on things that are not working rather than placing them in the
context of successes. It requires us to consider families expertise and knowledge as they
will know what works best for them. Accepting that what we focus on, the language we use
and the questions we ask creates reality/realities means that affirmatively framing our
practice, professional discourse and shared focus is likely to engender a more affirmative
lived experience for children. Accepting this means that we accept that the lived
experience of being ill/sick or caring for a child who is sick is created in each moment of
care or living. This requires us to be attuned to the diverse ways of experiencing things and
multiple ways in which nurses can care with families. It requires us to carefully consider
not only what we say but how we say it and the impact that our dialogue with children has
on them.
If all that AI was looking at was the ‘best of now’ it could well be accused of being both
complacent and smug; the very things I was aiming to shift our practice away from. But AI
is future looking and change oriented; the best of the past and present is important
because it can inform and create confidence about the future. AI also accepts the
importance of valuing differences. Parents and children can draw on their own past
experiences, their strengths and resourcefulness to help navigate a child’s current illness
and their future. This does not mean adopting a ‘let them get on with it’ approach, it
means exploring with families what their strengths are. It does not mean that we are
expecting children and their families to be extra-ordinary, although they frequently
astonish me with their capacity to deal with enormously challenging life experiences.
However, it does mean allowing them to perceive their own strengths and resources whilst
we act in a supportive and facilitative way.
I am not advocating that children’s nursing should wholeheartedly embrace AI since its
roots are in change management rather than in nursing practice. What I am suggesting is we
look to the principles of AI and consider using them to develop a solution focused approach
to nursing; McAllister (2003) has already shown us the way. This would not mean that we
would ignore children’s needs and problems; that would be the antithesis of good practice.
However, we should be focusing our practice in a way that is more affirmative, dialogic,
positive and relational (Carter 2004; Frank 2004). This would be infinitely more satisfying
both for children’s nurses and for the children and their families. Focusing on solutions
would inevitably create more opportunities for families to be active partners and would
ensure that practitioners gained a more genuine insight into the life-world of each family.
Attitude and energy: nursing-strong and living-strong
Children’s nurses who move away from being primarily problem-busters can develop more
creative, innovative practices as solution-supporters who help children and their families to
‘live well’ even if the child is sick. The notion of ‘living well’ despite chronic illness is a
relatively new concept that has emerged as societal attitudes and the dominant discourses
about chronic illness have shifted (Telford, Kralik, & Koch 2006). I want to push the idea
further and propose that we take a leaf out of the manifesto of the Lance Armstrong
Foundation ‘LIVESTRONG’ (Lance Armstrong Foundation - LIVESTRONG 2006) and see
children’s nursing as a way of helping children and their families ‘live-strong’
ii
. It would
create an entirely new and more positive approach to the way we relate as practitioners to
children/families. An excerpt from the opening lines of the Lance Armstrong Foundation
‘LIVESTRONG’ manifesto states:
We believe in energy: channelled and fierce.
We believe in focus: getting smart and living strong.
Unity is strength. Knowledge is power. Attitude is everything.
I’d genuinely like to see a manifesto for children’s nurses worded along the same lines.
Maybe something like this:
Children’s nurses believe in energy: channelled and fierce.
We believe in focusing with children and families on the things they can do: in
nursing smartly so they can ‘live-strong’.
True partnership is strength. Sharing knowledge and expertise creates
powerful relational practice. Attitude is everything.
I love the thought of ‘attitude’ in the way that Armstrong is advocating as being integral to
children’s nursing practice. I also love the notion of energetic, channelled, fierce (in the
sense of pro-active, dedicated, creative) children’s nurses working with children and their
families. Something along the lines of this approach should be inculcated into every
children’s nursing student. Maybe ‘nurse-strong’ will be the mantra of the future. It
certainly beats some of the professional but tedious standards and competencies that are
fundamental to registration but which often seem to miss the point of what nursing is all
about.
Strong moral arguments can be made about the potentially negative consequences of using
a problem-oriented approach to nursing children and their families (Bricher & Darbyshire
2004). At our best children’s nurses are creative, innovative, resourceful and expert. If we
add being appreciative and solution focused then we have a powerful set of attributes to
bring with us to nursing children.
However, being solution focused is not just a simple shift; it requires a commitment and
some of that ‘attitude’ and a repertoire of sophisticated skills. It requires practitioners to
shift from framing their world – and the child’s/family’s world - in terms of health care
problems and needs. Adopting this sort of perspective does not mean that we don’t think
problems exist or that they simply ‘problems’ disappear. This would be adopting a Peter
Pan approach to practice in which we believed that stubbornly saying ‘I don’t believe in
problems’ would make problems disappear.
In many ways reframing our thinking means we have to work harder and smarter as we
adapt to working in a solution-focused way. By aligning our mindset and approach our
practice in an affirmative, energetic, ‘live-strong’ way we have the potential to encourage
resilience, independence and strength in families. Adopting a solution focused approach
‘starts with accepting that if we explore with families their successes and achievements,
potentials and capacities, competencies and energies, resources and assets, positive
choices and strengths we are likely to discover what is already working and be able to move
forward and sustain their success(es)’ (Carter 2006b, in press).
Discovering, dreaming, designing and destiny: 4 D’s to take us forward
AI is structured around a four phase (4-D) cycle - discovering, dreaming, designing and
destiny. This cycle could be adapted and used to structure a solution focused approach to
working alongside children and their families to help them ‘live-strong’ (see Table 1). The
solution-focused cycle starts with the choice of where to begin and the right attitude is
critical. This affirmative choice needs to be negotiated between the child/family and the
nurse. The choice of starting point is crucial as it literally sets the ‘nursing’ compass and
direction of travel and, by default, what can be achieved.
Being solution-focused requires the best of our hands on ‘traditional’ nursing skills. It also
requires an enhanced repertoire of other skills including; critical and innovative thinking,
creativity, imagination, empathy, coaching, listening, respecting, holding back, sharing,
praising and constructive appraisal. Solution-focused children’s nurses, working in
partnership within a child/family centred approach to care, need a level of sophistication
in their reflexivity and decision making to ensure their work with each individual child/
family creates opportunities to ‘live-strong’.
Solution-focused nursing has the potential to create a climate where strengths are
acknowledged through affirmative dialogue rather than a reliance on professional
monologues (Frank 2004). Solutions can only be reached through collaborating with the
child/family and determining with them what is an acceptable and strong solution. It offers
a philosophical framework, albeit one which is still emerging, which can provide direction
and support to nurses who want to nurse differently, innovatively and with
children/families.
Conclusion
A solution focused approach to practice offers us an approach with ‘attitude;’ it entices us
with the chance to reframe our practice in a more affirmative, relational, boundary-
expanding and imaginative way. It is, as yet, a largely untried approach in children’s
nursing although solution-focused approaches to therapy and practice have been used and
reported as being effective in mental health (see for example, Iveson 2002; Wheeler 2001).
I’m offering solution-focused children’s nursing as a new(er) paradigm. At the very least I
would hope that some of the assumptions and approaches I have proposed would engender
debate.
A solution-focused approach means creatively thinking outside of conventional (often bio-
medically, problem, oriented) frames of reference. Many children’s nurses will already be
consciously or unconsciously be using a solution-focused approach. For those of us who
could do better, we should start to ‘think solutions’ and aim to help children and families
‘live-strong’.
At the very least it would kick the Eeyore in us into touch.
References
Bricher G and Darbyshire P (2004) ‘'I Know My Body, I've Lived In It All My Life': Therapy,
Surgery and Remediation Experiences Of Young People With Disabilities’, Contemporary
Nurse Journal 18(1-2): 18-33.
British Association for Community Child Health (BACCH) (2005( Community Child Health and
the Future. A BACCH discussion paper.
Carter B (2004) ‘Pain narratives and narrative practitioners: a way of working 'in-relation'
with children experiencing pain’, Journal of Nursing Management 12(3): 210-216.
Carter B (2006a) ‘'One expertise among many'-- working appreciatively to make miracles
instead of finding problems: Using appreciative inquiry as a way of reframing research’,
Journal of Research in Nursing 11(1): 48-63.
Carter B (2006b) ‘Working it out together: being solution-focused in the way we nurse with
children and their families,’ in Solution Focused Nursing: Rethinking Practice, M
McAllister (Ed.), Palgrave Publishers.
Carter B, Corby B, Cooper L, Cummings J, Martin L and Hooton S (2004) Appreciating the
Best: Multi-Agency Working Practice Project Report,
http://www.uclan.ac.uk/facs/health/nursing/research/groups/children/appreciating/in
dex.htm
DoH (2006) ‘What is an expert patient?’ London, Department of Health.
Erickson F (1986) ‘Qualitative methods in research on teaching,’ in Handbook of Research
on Teaching, 3rd edn, Wittrock MC (Ed.), Macmillan, New York, pp. 119-161.
Frank AW (2004) The Renewal of Generosity: Illness, Medicine and How to Live, University
of Chicago Press, Chicago.
Guba EG and Lincoln YS (1989) Fourth Generation Evaluation, Sage Publications, Newbury
Park.
Hammond SA (1998) The Thin Book of Appreciative Inquiry (2
nd
edn) Thin Book Publishing
Co.
Hawley K (2005a) Report on the EPP Parent Pilot Course, January 2004 - January 2005,
Department of Health, London.
Hawley K (2005b) Report on the Pilot of the Expert Patients Programme for Children.
January 2004 - January 2005, Department of Health, London.
Hill M, Davis J, Prout A and Tisdall K (2004) ‘Moving the participation agenda forward’,
Children and Society 18: 77-96.
Iveson C (2002) ‘Solution-focused brief therapy’, Advances in Psychiatric Treatment 8(2):
149-156.
Kirby P, Lanyon C, Cronin K and Sinlcair R (2003) Building a Culture of Participation
Involving children and young people in policy, service planning, delivery and evaluation,
DfES, London.
Klausen SH (4
th
October 2005) Personal Communication- AI and Appraisal.
Kuhn TS (1970) The Structure of Scientific Revolutions (2
nd
edn) University of Chicago
Press, Chicago.
Lance Armstrong Foundation – LIVESTRONG (2006) The Manifesto of the Lance Armstrong
Foundation. Accessed at Internet
(http://www.livestrong.org/site/c.jvKZLbMRIsG/b.736591/k.E20E/Manifesto.htm) on
26 September 2006.
Lavender T and Chapple J (2004) ‘An exploration of midwives' views of the current system
of maternity care in England’, Midwifery 20(4): 324-334.
Liebling A, Elliott C and Arnold H (2001) ‘Transforming the prison: Romantic optimism or
appreciative realism?’ Criminal Justice 1(2): 161-180.
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Punishment Society 1(1): 71-98.
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in England’, Children's Geographies 4(1): 9-17.
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Advanced Nursing 41(6): 528-535.
Reed J, Pearson P, Douglas B, Swinburne S and Wilding H (2002) ‘Going home from hospital
- an appreciative inquiry study’, Health and Social Care in the Community 10(1): 36-45.
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evidence and can we trust it?’ Children's Geographies 4(1): 19-36.
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studies’, Journal of Clinical Nursing 15(10): 1317-1323.
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Table 1: Using the AI 4-D cycle to guide Solution Focused Children’s Nursing (SFCN)
(developed from Carter 2006b, in press)
Discovery Phase
(the best of what is
or has been)
In this phase the nurse uses generative questions to trigger story telling
about past experiences, memories and values. This needs the nurse to
use careful listening and prompting skills. Amongst other things, the
nurse needs to inquire, explore and appreciate:
• what makes things work well for children and their families
• what helps them feel positive, happy, motivated
• what they already know about getting things right
This phase often includes the ‘miracle question’ in which the
child/family are asked to imagine what things would be like if a miracle
happened and the best was always happening.
Using these stories explores the child/family’s experiences and helps
make sense of them and builds a comprehensive view of each
child’s/family’s world as they understand and experience it.
Dream Phase
(what might be)
In this phase the nurse aims to explore with the
child/family ‘what
might be’ and to develop a strategic focus. In this phase ‘the interview
stories and insights get put to constructive use’
(Cooperrider and
Whitney, 1999).
The nurse works with the child/family to come up with:
• a vision of how things co
uld be better in the future. This is
encapsulated in ‘provocative propositions’ (statements that
realistically sum up ‘what could be’) created by the
child/family/nurse.
• a powerful reason for achieving that vision
• a strategic statement that identifies how this might be achieved
Design Phase
(what should be)
In the design phase the nurse and child/family focus on creating an ideal
way of living with and managing the child’s illness.
This needs to be done within the context of their own family.
This is ba
sed on grounded examples that have emerged from the
successes and achievements that the family have had in the past.
Destiny Phase
(what will be)
In this phase a solution focused approach has become embedded and the
child/family and nurse relate effecti
vely with each other and they
genuinely appreciate each other’s strengths and capacities.
This phase is focused on creating the networks and structures that
facilitate connections and the potential to co-create new ways of ‘living
well’ with the child’s illness.
i
For those of you mystified by references to Eeyore, Piglet and Kanga, then you should stop
reading this immediately and curl with a copy of A.A. Milne’s ‘The House at Pooh Corner’
and all will be revealed. (I’m also very fond of Eeyore).
ii
Lance Armstrong is a cancer survivor who went on to win one of the toughest bicycle races
in the world, seven times. Even more impressive than his cycling is his dedication, through
his Foundation, to helping people ‘LIVESTRONG’ and be affirmative in their new lives with
and post cancer.
