Abstract
Keywords
Overview: a case study of the complexities of visual reasoning in interprofessional working strategies
Whilst much attention has been devoted to the development of visual methods, including the importance of power relations within the creation and interpretation of them, (Banks, 2001; Pink, 2015), this article focuses on how visual interpretations are always already part of communication, particularly in making sense of complex social interactions. Our article makes a significant contribution to articulating the underlying conditions of research interviews within the social policy sphere. Being attuned to metaphor is a crucial component of standard discourse analysis practice whether this is text based (Fairclough, 2008) or speech based (Gee, 2014; Rampton, 2009). However, actively engaging key stakeholders in articulating their choices of visual imagery and comparing these to the parallel process researchers use within analysis brings a novel approach that further excavates the issues at play and their ramifications. We do this within the specific research focus of interprofessional working across health and social services.
Several drivers in technology and governmentality are changing the landscape of professional development (Jandric et al., 2019). Across international contexts, public policy integration has implications for professional education, supervision and practice (Vestergaard and Norgaard, 2018). This requires professionals increasingly to work together to meet multiple goals more holistically so that problems are prevented rather than addressed once they have become entrenched and expensive, often needing to work across specialisms in more efficient and coordinated processes (WHO, 2010). Because of this, problem solving is becoming more complex and collaborative, and yet, higher education preparation for interprofessional working remains partial and under-theorized (Evagorou et al., 2015; Cross and Cheyne, 2018; Trede et al., 2012). In this context, the role of visual reasoning, particularly where programme models are condensed into diagrammatic figures, is of increasing importance, as it can speed the process of professionals orientating their work together, whereas lack of agreed interpretation of visuals can create stumbling blocks that lead to systemic failures. This article looks at the role of visual reasoning through interviews with health and social care policy managers tasked with increasing the efficacy of interprofessional working in Scotland. Although the work takes place in Scotland, researchers on the team have experience working internationally across a range of contexts in Sweden, Australia, South Africa and the USA and have found similar issues at work there. This experience is brought to bear on the iterative reflexive process the research team undertook to think through how to interpret the visual language that arose within the interviews. Comparing interpretations of data is often listed as a key step in qualitative research; however, this often remains a black box with little insight into the reasoning that takes place within this step. Here we open up some examples of how visual language can be scrutinised. We conclude with a discussion of how researchers and educators can work more creatively and effectively with visual reasoning to prepare professionals entering arenas of complex systems change (Walton, 2016; Westhorp, 2013).
Disparate views at cross purposes: the theoretical landscape
To date, visual communication and the reasoning done with it have received much less attention beyond specialist disciplines and thus its potential is underutilised (Ligita et al., 2022; Tversky, 2014). Whilst there is an appreciation of metaphor (Eisner, 1991) and a rich vein of research that draws upon it (Pink, 2015), the kinds of thinking done with metaphor as distinct from diagrammatic thinking lack analytic clarity. As Weber (2008) argues, the understanding and use of visuals’ efficacy is dismally under-tapped and undervalued in the humanities and social sciences, in part ‘because visual language research occurs in several different communities, largely unaware of each other’ (Marriott and Meyer, 1998: 2). As Lunenfeld (2010) observes, there is much weaker academic engagement about visual design. Design has traditionally had a very technically focussed discourse. Digital forms of discourse are driving a reconsideration of design: Yet, even with this rise, the wide swath of contemporary humanities scholars pays little attention to design as a creative endeavour and distilling agent. As the humanities digitize, the academy is not introspective enough about the tools it picks up, the aesthetics that these tools encourage, and the ways in which certain aesthetics become defaults. Deeper engagement with design on personal and disciplinary levels can change this. (Lunenfeld, 2010: 153)
Digital modes of communication increasingly require professionals to use design, production and decoding skills and with that comes a duty to subject these new processes to critical literacy scrutiny for the power relations and norms they encode. Science studies do incorporate an analysis of how visual language as one form of semiotic tool is used to construct scientific knowledge (Latour, 1987; Lemke, 1998); however, this scrutiny is a minority voice within qualifying degree programmes that rely on scientific constructs. As Ervagorou et al. (2015) argue, much less use of visuals as “epistemic objects” is made. As a result, there is less opportunity to open up discussion of the power dynamics within representations and their constructions (Galman, 2009). Despite critical works that demonstrate the power of visual texts, Galman argues visual texts still struggle to be recognised as valid in academic arenas because of bias built into the ‘deep grammar’ of academic disciplines and habits of problematisation (2009: 201)
Making this task even more demanding is the reality that visual literacy requires an understanding of very different kinds of visual thinking and the ability to orientate and navigate across a wide range of uses. At one end of a spectrum is the aesthetic or evocative use of visuals to prompt expansive exploration through metaphoric thinking of multiple correspondences and interpretations, and at the other is the use of visuals to map information precisely and to effectively communicate strategies based upon this to aid convergent thinking around a blueprint for action with clarity (Figure 1).
Images and the work they do as a spectrum.
Many practitioners and educators may be unaware of the implicit role this spectrum of visuals plays within communication and within policy development and implementation. Schön (1994) argues that a fundamental reason for the lack of progress in addressing many problems professionals face is not a matter of problem solving, but of problem setting, that is, using the wrong metaphor or schematic frame to understand the problem in the first place. He goes on to argue this happens because schematic frames are often adopted uncritically and even unknowingly without first attempting to expand the possible range from which we choose or examining the criteria that should inform choices. A lack of awareness of the spectrum of visual design choices and the language to talk about this, we argue, contributes to this oversight. In other words, we lack the discourse practices (habits/resources/impulse/courage) to use the artistic side of visual reasoning to choose the best frame and because of this lack of reflection, unwittingly design or have designed for us frames that are then poorly and variably understood.
One example from a recent policy initiative that has met with difficulty can illustrate the problem. A complex synthesis of innovations within child development and children's rights underpins the development of Getting It Right for Every Child (GIRFEC) (Scottish Government, 2014), Scotland's integrated children's services policy. An attempt to depict this within the practice model led to a graphic consisting of a wheel to represent the range of factors holistic diagnosis requires, a triangle to emphasise assessment of contextual factors, a standard
Getting it right for every child practice model.
However, within research into implementation of GIRFEC among health practitioners, it emerged that a range of professionals from front line delivery through to policy makers lacked the information or visual literacy skills to read the directional cues in each separate element of the practice model. The fundamental theoretical concepts they represented or how each component contributed to the overall approach to effect culture change was also often lacking (Cross and Cheyne, 2018). One practitioner summed up the bewilderment many expressed: ‘It looks like a baby gym.’ Could it be that the GIRFEC practice model is a particularly bad design or one that left out adequate explanation of key shifts in operating principles that it sought to represent? Or is it symptomatic of a larger problem?
Thus, we examine here how key policy makers engaged with visual diagrams within interprofessional practice across health and social care sectors. We also excavate what metaphoric imagery is embedded in their policy expertise, as knowledge may be encapsulated in metaphors whether we are conscious of this or not (Lakoff and Johnson, 2003). We found tensions between different forms of visual reasoning. Metaphoric visual reasoning was embedded within policy makers and managers’ strategic reflection and analysis; however, they did not readily identify this as part of what they were doing. What they did identify is that the use of diagrammatic visuals designed to clearly communicate consensus on policy implementation was highly problematic for a number of reasons. In the following pages, we examine in detail instances how these visual issues arise. We argue that central to them is a lack of language to talk about abductive reasoning. Thus, it is important to first theorise abduction and its role in our methodology.
Theoretical background: abductive reasoning at the interface of divergent and convergent thinking
Whilst there has been a decisive turn to visual methods (Scott Metcalfe 2020) for their ability to depict subtle and overlooked sensibilities, and make tangible lived realities (Liebenberg, 2009: 445), less attention has been paid to visual reasoning. Weber argues: . . .this ability of images to convey multiple messages, to pose questions and to point to both abstract and concrete thoughts in so economical a fashion . . . make image-based media highly appropriate for the communication of academic knowledge. (2008: 43)
As Lacković and Oteanu further specify, ‘An . . .image acts as a reminder of worldly materiality, spatiality and granularity (unlike verbal linearity)’ (2021: 12). And yet, the range of visuals deployed and the distinctly different kinds of reasoning and thinking they call upon need delineating to begin to understand the problem at hand. The working definition of visual reasoning we use is that it is the process of manipulating one's mental image of an object in order to reach a certain conclusion. Visual reasoning is a complex form of reasoning that involves abduction. In contrast to induction, reasoning from the particular to the general, and deduction, reasoning from the general to a specific, abduction is a kind of model-based cognition (Magnani, 2014) that occurs when hypotheses are derived from comparing a stored series of previous similar experiences. It is what we use to process messy data (Law, 2004). Grupen and Knepper (2019) have likened it to ‘intuitive physics’. Visual adduction plays a crucial role in recognising, not just individual attributes or factors, but the pattern in which they come together and cohere. It is the process whereby we distinguish a face we know in a crowd from all the others we do not. Visual abduction is particularly important in recognising patterns within complex situations and devising complex patterns of response, and thus particularly important to interprofessional policy and practice.
We argue that visual reasoning is particularly relevant within advanced professional learning that professionals need to do within interprofessional collaboration. Schema theory holds that expertise functions not by processing single lines of inquiry and assessment but by recognising more complex patterns or schema of related strands of assessment (Kohls and Scheiter, 2008). The role of visual abduction, that is, the process of scanning several possible patterns and identifying the most appropriate or relevant, within professional discernment processes is central to interprofessional expertise and to the development of sharing that expertise. To do this, professionals need to be better at discerning how visual design draws on the spectrum of visual resources at their disposal. This discernment would mean visuals could more easily enrich and clarify abductive reasoning within discussions amongst professionals from different disciplines, leading to qualitatively improved teamwork and enabling practice models to be read as more than ‘baby gyms’.
Distinguishing between diagrammatic and metaphoric visuals
In professional contexts there are a range of uses of visual from metaphoric to diagrammatic. It is important to first clearly distinguish between these very different kinds of visuals and the very different kind of reasoning they entail. The diagrammatic use of visuals is the simpler and easier to articulate, and, thus, we begin by defining this. As Kress and Van Leeuwen (1996) have articulated, there is a visual grammar to diagrammatic design, which rests upon assumed basic orientations:
That what is central is content rich and what surrounds it on the periphery provides ways to examine, manipulate or choose amongst the focus of that central content. That as one goes from top to bottom, there is either a descending order of priority or a sequential development of process. That content displayed from left to right will denote progress or causality as is the case for text-based communication.
These conventions are most evident in diagrammatic visuals such as flow charts and models where the visual frame is used specifically to represent processes, chains of causality and relationships (Bravington and King, 2019). However, unlike icons that are universally agreed upon, there is no overt stated agreement and much variety in design and interpretation of diagrams, which leads to the ‘baby gym’ problem described in the introduction. The common use of mind mapping to represent a number of possibilities laid out with no use of spatial direction to imply relationships or priority confounds reader's capacity to read visuals even further (Ernst, 2015). However, Ligita et al. (2022) argue concept maps can illuminate the process of analysing data if time is taken to clarify units of analysis and embed features that make clear the visual literacy conventions being used. Bravington and King (2019) in their work on graphic elicitation argue that consideration of the bigger picture is needed in order to choose the kind of diagramming that will work well for the research focus in mind. Their work underlines the prevalence of under-theorized use of visuals and the need for further thinking through of kinds of visual conventions it is possible to draw upon.
In contrast to this diagrammatic mode of visual reasoning, the use of evocative images to prompt metaphoric thinking opens up all these rule and conventions to provocative subversion. Metaphoric visuals invite exploration of possible models that Schön (1994) argues are important to consider before designing a specific programme or strategy. For instance, should centring children within interprofessional working be pictured as placing children at the hub of a wheel, at the centre of wedges of a pie? Perhaps on a pedestal at the centre of a forum? Even at the centre of the lens of a microscope? Thinking more widely, are children sandwiched in the middle? Perhaps in the midst of rope climbing apparatus common in play spaces with several connecting routes around them? If we turn to organic images we could consider, are they at the centre of a web, the fork of a tree, the core of an onion, the nursery of a hive or the heart of a blossom? Each of these metaphors suggests a different approach, different relationships of care and control and foregrounds certain activities whilst marginalising others. These metaphors are also symbolic of distinctly different power relations, and educational and psychological traditions (Serpell, 1995). When we use visuals to think in this way, we turn them around in our minds viewing the approaches and relations they suggest from perspectives. The metaphors glossed above have rich connotative meanings and an immediacy with the contexts from which they are derived. Their connections to lived experience are likely to be layered and numerous. As Hurdley draws on Appadurai to argue, visuals have a ‘social life’ (2007: 356). Attending to them, as we detail below, pulls at threads connected to deep ontological and epistemological commitments that may not surface in the short confines of research interviews without this invitation to the ‘pluri-sensory’.
As Brown asserts, what is involved in metaphoric thinking is a comparison of perspectives, which is the basic function of metaphor: ‘metaphors are our principal instruments for integrating diverse phenomena and viewpoints without destroying their differences’ (1977: 79). Metaphors often encapsulate stories and invite possible interpretations and re-combinations of how stories stand in for reality. They require not only a tolerance for ambiguity, but a playful pursuit of it, for the options such ludic musing throws open (Nind and Vinha, 2016). Within this kind of visually aided reasoning, qualities that suggest the metaphor as well as aspects of it that are incidental to it are opened up for investigation. Attending to metaphors enables the multivocal, contradictory layers of meanings to be examined. Ted Hughes, in a seminal essay on creativity in education, likens metaphor to ‘a fragment of the story . . . by which the whole story's electrical circuit is switched into consciousness and all its light and power brought to bear’ (Hughes, 1988: 32–33). He uses the metaphor of the ‘Crucifixion of Hitler’, to illustrate the connections to stories, even cannons of them, that metaphors can ignite. Hughes argues that not being able to understand this metaphoric imagination imbalances our discernment of how the inner and outer imagination work together. This results in an inability, individually and collectively, to make decisions that are both wise and accurate.
If we reflect on which of these two very different kinds of visual reasoning predominate in policy implementation, it is evident that diagrammatic visuals and the convergent thinking they facilitate predominate. Illustrative visuals more often serve a decorative function that only indirectly prompts divergent thinking or metaphoric comparison. Our examination below of how images are used uncovers some of the inherent flaws of this stasis.
Methodology for inquiry into visual reasoning
To explore the use of visual reasoning within professionals’ strategic thinking, the study began by an immersion in an extensive literature review on interprofessional working and interprofessional education and engaging in dialogue across our professional perspectives. In this task we benefited from previous literature review work (Cross and Cheyne, 2018) we had conducted on the role of culture in systemic change towards interprofessional practice. This served as a sensitising precursor to interviews with policy makers, policy managers and educators purposively sampled to explore participants’ experience of interprofessional working and education, their views on challenges and barriers and their recommendations for more effective culture and system change. Interviews were conducted, recorded and transcribed in two rounds punctuated by an analysis session as a team to compare coding and initial analysis to allow testing of emerging hypotheses about areas of congruence and discord within the data (Dicicco-Bloom and Crabtree, 2006). Fourteen interviews conducted across health, social work and children's advocacy sectors were conducted in total. At the close of interviews, the research team came together again for another reiterative cycle of examination of texts and images. The research concluded by bringing interview participants together for an away day where emergent findings and their implications for practice were further explored, giving participants an opportunity to scrutinise and revise our interpretation of data. On the day, we juxtaposed key visuals and texts, gave participants time to reflect, wander and write before coming together in a more discursive format. The interviews, research team's analysis days and the participants’ co-analysis day in total comprise four iterations of analytic scrutiny.
Our project went through the standard ethical clearance process for our university. As well as gaining informed consent at the outset of each interview, we continued to monitor assent as we progressed through the cycles of inquiry. Throughout the process, ethical principles, particularly those of confidentiality and transparency of research process, were kept uppermost in mind (UWS, 2019).
The interviews were designed to invite participants to think across increasing levels of complexity and scale from specific examples of practice to models of systems, to problem solving across sectors and the interface of systems (Kvale and Brinkmann 2009). We were curious what role visuals might play in this process, and to resource this, we began interviews by laying on the table a range of visuals as depicted in Figure 1. The visuals varied from practice model diagrams (flow charts, the GIRFEC practice model), to iconic images used to front policy documents (images of clean, smiling professionals walking forward together) to more subversive or diverse images that might serve a metaphoric purpose in questioning or problem posing about interprofessional working (a mess of wires, cogs and wheels, spiralling galaxies, a nest). We began by inviting participants to comment on the range of images, using a common form of visually aided interview technique (Bagnoli, 2009). We then left the visuals on the table as a resource that participants could use throughout the interview as they saw fit without further prompting by the interviewer. This provided an opportunity for participants to use images to illustrate concepts or orientate themselves within the interprofessional discussion. Our strategy is closely related to Rose’s (2001) auteur theory as we sought to peel back the layers of thought which visuals might play a role in constructing. Cognisant that a key problem in interprofessional working is that key terminology can be used with very different working models in mind, we paid particular attention to the associations that participants made between images and concepts. We were interested to know if participants would offer their own models or concept maps and towards the close of the interview invited them to do so. An interesting finding in itself is that participants did not do this. Throughout all subsequent steps of analysis and on the participant away day, the original set of images was accessible to continue to think with.
Analysis of findings
Transcripts were analysed to identify the function visual images played in developing participants’ perspectives and the arguments they built upon them. As we analysed, we kept the visual images on the table as a reference point and reflexively examined our own understanding of the images as we worked to interpret that of our participants. We followed standard sociolinguistic transcription practice (Rampton, 2009) of retaining the lines of speech as spoken as this can give insight into the sense-making done whilst speaking.
Diagrammatic visuals
What was clearest in the interviews concerns visual reasoning with diagrammatic visuals. When presented with a range of visuals, both illustrative and diagrammatic, policy makers singled the diagrammatic ones out as problematic. Many were critical of a diagram's ability to convey information clearly and in some instances saw them as counterproductive. They were seen as clunky and not indicative of how processes really happened. There was a sense that people assumed they knew what they meant without actually reading them carefully. As one policymaker observed, ‘practitioners just look at the shapes and don’t read the text’. A flavour of their critique is evident in the quotes below: 19. P7: This type of flow chart, is probably the least helpful 20. That's not how clients, families, professionals 21. That is NOT how people function in the Real World 22. That just gives us a methodology to process them. (Sr. Policy Officer in SG) 11. P3: this, that kind of diagram 12. often people pay more attention to the shapes than what's going on in them (Children's Rights Advocate)
Metaphoric visuals
In striking contrast, visual metaphors were drawn upon to refine or emphasise meaning or provide summative or systemic perspectives. Some participants were drawn to the metaphoric visuals we provided immediately; others either seemed ambivalent or sceptical. However, with the visuals available on the table, at significant points in conveying their views, participants made use of visuals in order to illustrate experience and to compare experiences through metaphor, using them as ‘reminder notes’ as Liebenberg (2009) reports participants doing in her study. They returned to them unprompted throughout the interview to clarify or illustrate particular points and to talk about the contrasts or contradictory dimensions of work. To illustrate the role visuals played in interviews and their methodological significance, we focus on what work images did to progress participants’ reasoning about the complex policy contexts in which they work in two contrasting interviews.
One participant, a senior oncology nurse, started by critiquing the iconic image of health professionals in crisp clean uniforms all facing forward. She contrasts this pristine image to examples of the communication issues within teamwork and the structural and personal factors that contribute to them. As the conversation reaches a conclusion, she picks up the image of the spidery strands of a galaxy. She speaks about the complexities of interprofessional interactions, and, referring to the emblematic phrase ‘the child at the centre’, she points out that the centre of the spiral is empty space and comments that the child can ‘fall right through’ such a centre. This image prompts the participant to think of specific factors, and her subsequent reflections clarify how she is using this image to think through the interprofessional dynamics of her work context: 169. and I would say my [tool] is listening 170. Absolutely 171. of course it is (picks up galaxy image) 172. Lots of energy mixing 173. but not really 174. and somewhere right in the middle of that swirl 175. is the patient. 176. That caught my eye right away, 177. kind of mixing, 178. but not entirely Interviewer: and is that a good thing? a bad thing? 179. I think it's’ a great thing 180. but sometimes it's awful and the patient falls straight through . .. 181. I think there are a great deal of factors 182. how many other patients you have to care for 183. how willing patient is to be a partner 184. so there is this wheel within a wheel.
What is ‘great’ may be the images’ capacity to capture the dynamic nature of collaboration as well as its dangers. To further contextualize her reflections, she draws on another image that is patterned, fluid and systemic: 188. The reality of the NHS is like a tide 189. Sometimes you do your best but it's not– 190. Sometimes it gets swamped when the waves are too big. (Sr. Oncology Nurse)
There is a reasoning process at work here that uses one image, that of the wheels, to spur an examination of factors that yields a more apt image that of tides, as both inductive and abductive reasoning are drawn upon to reflect on her experience.
It is worth noting that the participant who manages front line care articulates that the image she uses to summarise the discussion is one of the first images she saw. That she draws on it in the concluding lines of her thinking through of practice suggests that it may have been in the background of her thoughts throughout the discussion. Here, it can be argued, is evidence of how abductive thinking is at work. The picture of the complex strands of a galaxy is one possible model that she has recognised as relevant. It is as if she has kept it to one side as a possible thinking tool she might employ and brings it in at the most effective moment to encapsulate how she understands the different aspects of interprofessional working that she has delineated individually.
If we contrast this thinking through visuals to that of a senior policy advisor's, a similar strategical process seems at work. When the photos are first introduced, this participant shuffles through them quite quickly, almost as if conducting a triage exercise. He quickly eliminates as unhelpful both the diagrammatic ones and the iconic images. They were rejected as too neat and tidy in words similar to the oncology nurse. The participant laid the other photos down without comment, but as the conversation unfolds, imagery from them begins to be drawn upon. One of the images was a black and white photo of large cogs interconnecting and turning smaller cogs. From line 96, the participant begins to use imagery that could be associated with this image. 96. Cultures are changing and they are 97. But they unfortunately are changing in different ways 98. at different rates in different organisations. (Sr. Policy Advisor)
An important aspect of cogged machinery is that they turn in such a way that their rates of turn are coordinated in order to maximise efficiency. The question he poses here draws directly on the functional aspect of the photo sitting on the tabletop as the conversation continues. He, again, uses similar language a few minutes later to describe change: 114. So there is that type of culture which is slowly turning to an understanding. (Sr. Policy Advisor) 185. Schools have huge freedom to do what they wish 186. individual schools, which is great in some ways 187. but it means it's very very difficult for organisations 188. to interact consistently 189. which actually then reinforces that the health service, 190. well, we just do this, 191. because we’re dealing with ten secondary schools 192. within our local authority area 193. who do 194. all sorts of slightly different things. 195. So there is that sort of balance of how do you– 196. I see you have this picture of wheels and cogs here– 197. Well, do they fit together? 198. And, you know, can you actually work together, 199. do you have different sizes and different shapes 200. which can all work together– 201. but do they work together as a 202. one partnership area? 203. Or are we not quite working together, 204. which means we are working individually 205. contributing to perhaps common goals, which is fine, 206. of improving health and well being 207. but not really maximising the benefits of that 208. because we’re not able to actually function together. (Time Elapsed: 16:59-18:05) (Sr Policy Advisor)
In this passage, the policy manager paints a quite complex picture of relations amongst health, social work and education entities; he then uses the image of the cogs to represent this complexity, drawing on its connotative associations to focus a set of questions that interprofessional managers and educators would do well to address. In this passage, we see wide ranging experience encapsulated in the picture of the cogs in such a way that the image acts as a catalyst that refines the process of examining the relationships upon which interprofessional working depends.
Analysis of the research team's process of interpreting metaphoric data
Examining our own interpretations as a research team gave us further insight into how visual reasoning is part of the communicative process and in what ways it could help researchers gain clarity about each other's perspectives. Aware that we ourselves constituted an interprofessional team, we took the step of recording and transcribing our analysis conversations so that we could interrogate them as instances of interprofessional working as part of our commitment to reflexivity within research. We came to the analysis each with professional work experience in the different sectors that make up the interprofessional ensemble of children's services, but importantly also as educators with experience teaching for interprofessional working.
In the first of our meetings to compare emerging themes, we accessed the same images as our participants used to observe how they might enrich the process of comparing perspectives arising within the interviews. We stepped back from the data in a reflective exercise to look at the images that we felt visualised important dimensions of the messages coming out of the interviews and shared with each other what underlay our choices of images and the juxtapositions of them. In the terms of the theory we propose in this article, we first took an abductive approach to thematic exploration. This process brought out deeper meanings and a wider range of possible interpretations of both the interviews and the practices of which they spoke. One could say this drilled down to the visual level within reflexive thematic analysis (Braun and Clark, 2019).
What emerged were four distinct collages, each of us choosing some similar images and some different ones and juxtaposing them differently. As we talked about why we had chosen and arranged them, we referenced the interviews we had transcribed and reflected on the participant's interpretation of images that we were working with. As we explained our choices to each other, we articulated the qualities the visuals illustrated and in doing so were able to see the differences in the qualities each of us foregrounded. Using images in this way allowed for multiple meanings to emerge much like Mason's (2018) layering approach (Figure 3).
Differing collection of images that different researchers chose to represent issues arising within interviews, with rose positioned differently.
As we talked about the images, aspects that had formed our abductive recognition of their importance became easier to articulate. The discussion in its entirety spanned 4 h in which many different images were inspected alongside the transcripts. The analytic discussions about one of the images most commonly chosen by interviewers, that of a rose blossoming against a dark background, illustrate the process of our analysis. Our discussions drilled down further into how the image encapsulated values and aspirations. This image was used by participants to encapsulate a sharp contrast between organic and mechanised processes within systems, and between the aspirational as opposed to the dysfunctional aspects of professionalism. The rose depicts many petals coming together. The words that arose to describe this were ‘nestling’ or ‘nesting’ and with that a sense of security: Research Team Member 1 (RTM1) 571. : The moment of transformation 572. Where 573. You see relationships between professionals 574. Nestling together in a way that holds the focus (Professor in Child Health)
This moment of detailed analysis of the features of the image of the rose quickly gave rise to critical questions in terms of how it related to practice aspirations: RTM2: 622. So it's a real contrast between 623. organic and mechanistic processes 624. which are always there. 625. Do we ever have 626. just organic moments 627. or just mechanistic moments 628. within interprofessionalism? (Community Educator/Social Work Practitioner) Research Team Member 3 (RTM3) 1772. : Are we saying 1773. With the rose 1774. It's been allowed to form naturally 1775. And it's perfect 1776. Whereas what we are creating 1777. Are imperfect systems 1778. Like with so many policies and procedures and 1779. . . . And its not been allowed to evolve into a working system? (Sr. Lecturer, Nursing)
We noticed in our away day with participants at the close of the project that the image of the rose as a nested held centre was of particular resonance in contrast to the child being at the centre of a wheel as the practice model depicts, which is actually an exposed scrutinised position. As one researcher observed, if practitioners’ support can be seen as the petals, then there is an ambition for interactions to resemble what a rose visually depicts: RTM2 1839. I actually would like us to get to this place 1840. .. . . that we had something to share 1841. And that it held a core 1842. That our relationships to each other were like these nestling petals 1843. And that there was 1844. That core (Community Educator/Social Work Practitioner)
This investigation of the implications of the rose metaphor transformed our understanding of the relationality within interprofessional working. In particular, the overlap of petals to form the rose drew us to observe that professionals have unique skills to bring to a team but could share relational and communicative skills so that there is a strong overlap of approach. Being a child at the centre of professional care conceptualised as the nested petals of a rose differs markedly from a conceptualisation of it as galaxy with spaces to fall through, or the hub of a cog with fixed rigid modes of interaction. It draws attention to the overlap that may well be essential to the desired culture change the term ‘child at the centre’ seeks to effect. Examining the rose in this way helped the team articulate to a much greater degree the affordances of this metaphor as well as some of its potential drawbacks in comparison to other centres as depicted in Figure 4.
Example of thinking with visuals.
In the theoretical section of this article, we suggest that looking at images as possible metaphors for practice allows one to turn the image around in our minds, viewing the connotations and relations they suggest from different perspectives. In doing so, we may come to see not only the intended qualities or relations that the image contains but also unexpected connotations that may suggest constraints, tensions and problems. In Figure 4, some of the affordances and limitations are shown. Whilst annotating the rose, a realisation occurred: whilst conveying a sense of comfort, might rose-based practice also seem claustrophobic? It raises the question that professionals could usefully bear in mind as they work, when is it time for the petals to fall back so the centre can fruitfully develop? In comparing the rose to the pie with wedges, a question of uniformity was explored – do they need to fit together? This image seems to preclude overlap. This prompts the question, should some aspects overlap, such as a shared understanding of issues, strengths and strategies, whilst other aspects remain clearly designated, such as professional expertise? The wheel prompted yet another set of questions. Spokes convey a sense of clear distance between professionals involved. The image is held together at the periphery – which leads to the question, what management at the periphery ensures coordination? Can peripheral coordination be effective? One could look at the same image and see either a wheel with distances between spokes or wedges with contiguous borders that professionals share as they work. Does it matter if professionals read the same model in these different ways? Visual reasoning prompts these questions to a greater degree than mere text analysis. Finally, our collaging and thinking together took this question of differences further. Thinking about what the child might see, there is a very real possibility that, given differences across professions, it is very likely that children might see a strange amalgamation as they look out from the centre, with some professionals working together like petals whilst others relate to them along straighter lines or spokes. This diversity may not be a weakness. Teams can be made up of different components. However, for a team to work together, there does need to be some understanding of how those differences work together, and what to do when they don’t. Teams around the child may do well to make conversations about teamwork more open and more inclusive of both parents and children as part of that team. Thinking with images may facilitate this. One of the outcomes might be that children have different images they’d like to be part of and may see their place as somewhere other than the centre. As Balmer's (2021) work illustrates, this collaborative work can be enriched by not just accessing visuals but creating them.
For interprofessional communication to be effective, a common grounding is required. A collective process through which all parties plausibly reach enough of an understanding so that there is workable ‘mutual knowledge, mutual beliefs, and mutual assumptions’ (Clark and Schaefer, 1989). We argue this needs better thinking with visual tools. The question this investigation of images raises is, do we as educators prepare professionals to take enough time to explore abductive reasoning capacities so that the hinterland from which knowledge, beliefs and assumptions arise can be articulated as part of professional practice? The responses of the interview participants would seem to suggest this is not a graduate skill widely developed. They relate that the diagrams of practice models are problematic precisely because practitioners do not have a shared vision of what the boxes and circles within them actually entail. The use of diagrams may be problematic precisely because not enough prior work of a metaphoric nature has been done. To return to Schön's (1994) observation, our analytic discussions raise the concern that there is not enough consideration of metaphoric exploration within interprofessional education to make development, negotiation and use of diagrams content rich. Within specific work settings, agreed ways of reading diagrams will become entrenched (Dane, 2018), but, without the skills to metaphorically engage with a wider uses of visual tools, the flexibility and creativity to adapt diagrams when working with other professionals in complex situations will remain impaired. In the workshop with research participants, they underscored this need for time to explore the visual hinterland. They voiced a need to ‘step out of role’ in order to explore the models they worked with and the images that underlie their understanding of them.
Exploring findings as educators
Given the ways visuals can be embedded in professionals discourse and the subtle clues visuals provide about the intricacies of strategizing in complex settings, it was important as a research team to reflect on implications both as researchers of public sector change and educators responsible for developing that professionals who will enact that change. For both research methods and education, we came to some important points to consider:
Complex professional contexts require not just one way of doing things but the coordination of strands (Walton 2016). Visualising the coordination process can be extremely helpful. This requires becoming sensitised to abductive reasoning. In Higher Education, much more stress is placed explicitly and implicitly on inductive and deductive reasoning. Opportunities to become aware of abductive reasoning skills and practice using them need a higher profile in action research with professionals, Continuing Professional Development and professional education. A key facet of moving from novice to expert is this ability to recognise patterns and adjust accordingly (Dane, 2018; Lacković and Oltenau, 2021). Case studies and professional reflection practices that do this, drawing upon visuals, could potentially cut through much of the miscommunication that seems to perpetually stymie efforts to coordinate across sectors or to effectively research complex policy implementation.
By becoming more aware of their own use of abduction, researchers and professionals develop a second crucial capacity, that of being better able to hear others’ embedded visual language use. If we are more proactive about following the clues that those we engage with embed in their explanations, curiosity about the underlying metaphors can foster deeper conversations. The benefits for interprofessional research and working are manifold.
Exploration of the creative elements of visual reasoning is also needed. This research project relied on pre-selected images. Research design, which involves participants in actively sourcing and creating images and collage and layering (Balmer 2021; Mason 2018) activities with them, increases the understanding and innovation possibilities significantly.
Looking forward, the need for more coherent understanding of visual literacy as different forms of visual representation interact is only increasing and as it does, glotto-centric construals, that is, text-based forms of knowing, learning and teaching are coming under reconsideration (Lacković and Olteanu, 2021). Text is having to relinquish its primacy of place. This is being driven by very disparate developments. One only has to consider the diverse visual cues one engages with when playing first person shooter games, where one reads a map, one's health scores and the interactive terrain all at the same time, to get a sense of how digitally immersive cultures are changing the affordances we interact with. The disjuncture between visuality as experienced in recreational lives and professional lives is quite stark.
More importantly, decolonising research and curriculum, rightly so, will intensify the need to question the metaphors that for far too long have maintained Euro-centric views as normative (De Sousa Santos, 2017). Acknowledging and dismantling stances that dismiss indigenous forms of embodied knowledge practices and the place of visual literacies within these are vital to any genuine commitment to anti-racist practice (Mills and Dooley, 2019). We have much to learn to see again differently.
We hope this study holds resources for further curricular and research developments that more explicitly draw on visual reasoning. As Lunenfeld argues, we need to ‘build in more running room for the imagination’ (2010: 151) if the humanity of our endeavours is to match the complexity of our challenges.
Footnotes
Acknowledgements
Declaration of conflicting interests
Funding
ORCID iD
