Frame Attunement in Clinical Group Supervision

Paper submitted to the International Summerschool in Lifelong Learning

2nd to 12th of August 2005 at Roskilde University

By Helle Merete Nordentoft Ph.d.-student

at the Institute for Language and Communication

University of Southern Denmark in Odense.

This paper discusses how the members of a supervision group and the supervisors negotiate and clarify the nature of the problem when the original frame for the supervision sessions is challenged. The paper is based on data from the 4th out of 10 multidisciplinary clinical group supervision sessions in an outpatient ward. In this session it becomes evident that the group members expectations to the sessions have not been fulfilled. As a point of departure the supervision group is conceived as a community of practice (Wenger 1998). However, the paper is critical towards the vague conception of a community of practice Wenger presents in his book (ibid), so an interactional perspective is also persued to illuminate the analyses of the interactions in the group. This perspective is illustrated by Goffman´s frame analysis (Goffman1974), concepts from ethnomethodology (Garfinkel 1967 and 1981) and the conversational analytic tradition (Drew and Heritage 1992, ten Have 1999 and 2004).

The data comes from my Ph.d.-project, which examines the transformative impact of clinical supervision on interactions in an outpatient ward. The choice of data is inspired a major methodological strategy of ethnomethodology when trying to describe and capture the nature of common sense.In order to direct a focus at the ordinary practices in the ward a close study of sense-making situations is conducted, where the sense making has been especially noticeable. Such situations are those ”....in which sharp discrepancies, between on the one hand existing expectations and/or competencies, and on the other practical behavioural and/or interpretative tasks necessitate extraordinary sense making efforts by members” (ten Have 2004: 40). In this respect group supervision, being a meta-perspective on practice, contains a transformative potential in stimulating these sense making efforts and potentially an awareness of the “ordinary” everyday practices in the ward.

Introduction

As we enter new practices or social situations we need to learn the forms of talk and the ways of acting that are relevant to those practices – in fact that is what the practices are made up of (Peräkylä and Vehviläinen 2003). In order to become the kind of person that society expects one has to learn the accounting practices and the authoritative ways of making sense, which according to Shotter [1]constitute reality in their operation. Group supervision is a new practice to the staff in the outpatient ward, where all of the above has to be learned. The ambition of supervision is to be a stimulating metaperspective on practice where the employees have an opportunity to talk about and reflect on a situation or a problem from their every day practice. (Lund-Jacobsen 1996), Reflection means a critical examination over actions in order to become aware of the professional basis for these actions.

Thus supervision can be characterized as a learning context that builds on the knowledge, values and experiences of the members of the group. The role of the supervisor is not to be an expert in solutions but to be an expert on dialogue and help the employee develop new ideas and modes of action through a curiosity and inquisitiveness toward the situation in focus (Arvidsson 2000). Prescriptively speaking supervision should provide understandings of and possibly new knowledge on how the professionals can exercise their profession rather than telling them how it should be done. As such supervision is regarded as a process of change from practical experiences to new experiences, understandings and perhaps actions (Arvisson 2000).

Supervision can be done individually and in groups. The focus for this paper is an extract from a multidisciplinary group supervision session in an out patient ward, where most of the staff participates. In the paper a nurse called Maja (M) and a physiotherapist called Sara (Sa) will be referred to. Because of the size of the group it is supervised by two supervisors: Karen (K) and Birgitte (B).

The extract shows that the expectations of the staff have not been met until now, and in the paper I will try to show how the participants negotiate the nature of the problem and which contextual resources they use in their sense making of what goes on in the group.

The physical setting

According to Adam Kendon (1990) the surrounding physical environment and the member’s spatial orientations towards this environment play an essential role in the sense making process. The supervision sessions is taking place during the normal working hours in the same room where the weekly multidisciplinary conferences are held. Furthermore most of the staff is dressed in their uniforms and not private clothes. Considering these facts the tables have been moved out of the room and the members are sitting in a circle in order to create a different physical and close atmosphere than the staff is used to. The question is, however, if this is enough?

Garfinkel´s term ‘indexicality’ refers to the fact that all expressions are local and time-bound in short situational depending on the concrete situation the expression is a part of. Furthermore members understanding of their roles and each other- and this holds for both staff and patients – and their actions (verbally and non-verbally) reflected by the concrete situation so to speak reshape each other in a never-ending circle – and this is referred to as reflexivity by Garfinkel. Together with reflexivity the term accountability is used to explain the understandability and the expressibility of action as being sensible and at the same time an essential part of action.

Taking this theoretical line of thought into account it could be anticipated that the physical setting will influence the interaction in the group – the question is how?

According to ethnomethodology social reality is experienced as an organized orderly reality ”out there” but at the same time the individual must interpret this reality and make it meaningful by means of his common sense knowledge. The ethnometodological perspective (EM) has been chosen for this analysis since it seeks to uncover the dynamic properties of social life dealing with member’s cooperation, their capacities and activities, as they negotiate and try to create some kind of social order. Thus the term ethnometodology refers to the study of the common sense knowledge in a given context. The cooperation depends on the manner in which a certain situation is perceived based on a given contextual common knowledge – both of the physical setting and of the nature of the practices in the out patient ward. This knowledge is according to EM very pragmatic and it makes it possible to categorize and name the things we experience in order to understand what we are dealing with. Inspired by the phemenological philosophical tradition common sense knowledge is seen as made out of typifications or schematas of interpretation referring to typical aspects of a collection of objects, incidents or actions. They vary and change constantly depending on the situation the member is a part of, and which object out of many he chooses to focus on – in short the relevance, which is motivated by the situation.

The expressions of the staff is based on a common knowledge which can be seen as indexical of the time and place the group takes place: Consciously or subconsciously they may think: We are in the conference room: What are the differences or similarities between this session and the meetings we normally have in this room – namely the conferences? And as we shall see a bit later on in this paper the physical setting of the group supervision sessions certainly can be seen as having a major influence on the sense making processes of the staff. The staff does orient towards the institutional location and character and is also affected by it, which as mentioned is called reflexivity. Consequently I will argue that the relations between the actions and their senses can be said to be both indexical and reflective at the same time.

Communities of practice

Group supervision is considered to be an example of professional learning in practice. As point of departure for conceptualizing learning in practice the project is inspired by Wenger´s theoretical framework for social learning (1998). This theory emphasizes learning in practice as a situated activity and a negotiation of meaning based on participation and reification in communities of practice, and as such it provides a framework and a point of departure for understanding what goes on in the group.

Wenger says that a community of practice is ”neither a specifically narrowed activity or interaction nor a broadly defined aggregate that is abstractly historical and social” (Wenger 1998: 123). However, certain indicators that a community has been formed can be outlined and these indicators. These indicators can be compared to the notion of a mutual common sense knowledge as mentioned above and these indicators include ”knowing what others know, what they can do, and how they can contribute to the enterprise (...) shared ways of engaging in doing things together (...) specific tools, representations and other artefacts (...) sustained mutual relationships – harmonious or conflictual (...) jargon and shortcuts to communication as well as the ease to produce new ones (...) a shared discourse reflecting a certain perspective on the world” (ibid: 125-126) To sum up the group must experience a mutual engagement, understand and tune their enterprise and develop a shared repertoire in creating and recreating a community of practice. In other words communities of practice reflect shared histories of learning.

In this case the supervision groups mutual engagement and positive attitude towards creating a shared repertoire can be questioned. As we shall see later on in the paper the members of the group focus more on the past than the present and future in their sense making of the situation - instead they look for similarities. They do not look at possible differences between their past experiences and present. Consequently it can be questioned whether or not they are genuinely interested in being members of a new community of practice and negotiate a new - but different – shared repertoire.

Maybe this reflects one of the challenges or benefits for the supervision group, namely that it consists of the same people who are a part of the every day community of practice in the out patient ward. It could present a challenge because it may be harder to negotiate a shared repertoire, which is different from the repertoire that exists in the ”every day community”. This might be easier if the group consisted of people from different wards. On the other hand the negotiations might run more smoothly since the members of the group are well acquainted with each other. Also the two supervisors could be seen as a community within the community of practice of the supervision group. They know what can be said and done and what is inappropriate to say or do in supervision. They are so to speak role models until the group has learned what supervision is all about. In other words it can be said that there may be many communities within the community of practice – and Wenger does not specify what the significance of this fact might be in the production of meaning.

The complexity of learning has not decreased with Wenger´s book (1998) where he is introducing new concepts that are meant to clarify and capture the complex nature of learning and how it happens. Here I am thinking of ”nexus of multimembership” and ”trajectories” across different communities. The broadening of the scope does not make it easier to delineate the system of learning – the community of practice. Wenger introduces the concepts of boundary markers and brokers – but does not deal with the possible concrete impacts these aspects might have on his essential conception and delineation of a given community of practice. Ideally speaking a broker can make new connections across communities and ” enable coordination, and – if they are good brokers – open new possibilities of meaning” (Wenger 1998: 109). As we shall see later on, this is not the case in the extract that I have chosen for further analysis.

Maja´s problem

Prior to the 4th session Maja, the oldest of the nurses, told me that she had not written much on the sheet of paper the members of the group were handed to fill out after each session. The paper invites each member to reflect on the session asking him or her to answer the following two questions:

What made the biggest impression in you today?
What do you take home with you today?

”I did not know what to write because nothing new happened at the session” Maja told me. I replied that I thought that this was interesting. It made me think that there was a difference or a gap between the actions in the group supervision sessions and the expectations, which she now was making an account to me about.

So I asked her to reflect on what her expectations might have been. And furthermore I told her that I thought that her problem would be extremely relevant to discuss at the next supervision session. ”Is that possible?” she asked with a surprised voice indicating that she was not sure that her problem could be a potential issue to discuss – that this topic could possibly be part of the shared repertoire. I asked her if she had discussed this issue with any other members of the staff and she said no.

In the terminology of Lave and Wenger her reluctance to speak about her problem in the group could be explained in the following manner. Anticipating that the group had developed a shared repertoire, reflected in the contract for the group, this repertoire might be challenged by the introduction of her problem. The contract for the work in the supervision group, which was negotiated in the first session, emphasized that the sessions primarily should deal with the staffs experiences with patients. So in the 2nd and the 3rd time 2 patients, who had been especially challenging, were discussed. Consequently Maja´s uncertainty is understandable since might leave her with a feeling of marginality – or being in the periphery of the group.

According to Lave and Wenger (1991) the course of the negotiation process contribute to the notion peripherality for the group. Peripherality suggests that there are changing locations and perspectives, which are a part of the members learning trajectories and these trajectories can be signified by more or less engaged and inclusive ways of being located in the field of interaction. An indication of this is also the fact that she had not discussed her problem with anybody- Furthermore she had not been the most enthusiastic about getting supervision – it was okay for her – but other members of the staff had been keener about the project. As such it can be said that Maja is aware of the fact that meanings have various degrees of currency, participants have various abilities to make use of, control and perhaps modify meanings – which imply that the social nature of meaning also includes a competitive aspect i.e. how the issue of power is mastered by the community/group. In this respect Maja is not one of the most out spoken nurses in the staff. She is the oldest – probably the most pragmatic and least ambitious of the nurses. Maybe this explains why she talks to me and not her colleagues about her problem. Furthermore I am also in charge of the project and collects and uses the answers in my project.

Isolation - or the feeling of isolation is given meaning through the concept of participation. Participation reflects a wish to describe ”...the social experience if living in the world in terms of membership in social communities” (Wenger 1998: 55). In this sense it is: ” a complex process that combines doing, talking, thinking, feeling and belonging” (ibid: 56). Participation is one of two concepts Wenger introduces when explaining the negotiation of meaning. The other concept is reification and together with participation these concepts refer to a duality fundamental in this process. They advocate for intertwinement of action and connection, where participation in the context of the analysis in this paper – as the concept of community of practice – can be used as a broader broader framework to have a closer look at what actually happen in the interactions in the group.

In participation we aim to recognize ourselves in each other. In reification we project ourselves on to the world through various ways of giving form to our experience. We produce objects ”that congeal this experience into ’thingness’” (ibid: 58). These objects should be conceived in a very broad manner and is seen as a wide range of processes such as narratives, minutes, interpretations, designs and so on. The contract for the work in the supervision group is also reification. And all of these aspects of a practice are congealed into fixed forms and given the status of an object. Wenger claims that reification shapes our experience because having a tool to construct an activity will change that activity.

Lave and Wenger advocate for a non-reductionistic perspective on the concepts in the social learning theory given the complex and differentiated nature of the communities. They emphasize the dynamic character of concepts like for instance reification and participation and those they are not dichotomies. Because: ”...dichotomies cannot provide clean classificatory categories because they focus on surface features rather than on fundamental processes” (Wenger 1998:69). For instance reification is not merely an articulation of something that already exists, but it is creating the condition for new meanings. Both participation and reification are considered to be transformations and they provide a framework to understand the interplay between them. But how reification shapes our experience” is not expanded upon. Therefore Wenger´s and Laves framework need to be supplemented with concepts and methods such as Goffman´s framework theory, which elaborate more specifically on the importance of framing and how it can be described.