MARILYN HARTZEL: I'm Marilyn Hartzel, I'm from the Portland, Oregon LEND. And this is…

JIM BOGGS: And my name's Jim Boggs. I'm from Effective Arts and Interactive Drama Educational Company.

MARILYN HARTZEL: And we're doing an integrated discipline presentation. Primary to this group is we felt that communication is a set of skills that can be taught, should be done so explicitly, um, modeled, and should be laid out clearly within the LEND Program as a set of skills for people to learn, that this communication is across all audiences in, from our pediatric patients, parents and families, very key group we want to learn to communicate with effectively. The communities, the public, and even the media. We have for you seven skills. I'm going to name them, and that we're going to act them out. No we're not. We're gonna, we identified skill one, being able to assess your audience or learners' or collaborators' or listeners' information needs. Being competent at, with, in multiple modalities of communication. The skill of listening, which is a big skill area. Vision and storytelling is skill number four. Feedback is skill number five. We tapped into negotiation. We know we've invaded somebody else's territory. And the skill area of leading meetings and facilitating. On our first skill, assessing your audience learners' collaborators needs and information needs, we talked about the importance of being sensitive to who you're speaking to, what their needs are, and how they can best hear you. And we spent a fair time talking about being able to recognize at the information needs and the way those information needs and the way those information needs are conveyed from the audience.

A training experience that we thought would work is to set up an experiential workshop where you ask your trainees, dividing them into groups, to develop a presentation around a particular notion, perhaps asthma treatment. And that the groups have to arrange for presentations across different types of groups. Fourth-graders, parents of the media, and an agency head. And then let them debrief about how those presentations might vary.

JIM BOGGS: And then skill number two, being competent with multiple modalities of communication. So, there are, you know, obviously different ways that we can communicate. So different media, so face-to-face, through e-mail, PowerPoint presentations, all of that. And, just hard skills, hard skills on how to do those things. So, this should be pretty much a how-to section.

Marilyn Hartzel: Under listening, we thought a key training experience could be that we actually set up opportunities, explicit opportunities for trainees to go and speak with families, parents, and have the attempted to be able to reflect back to them what they heard them saying. So we would want to find some parents that are willing to engage in the activity, to see that trainees in fact can hear from the parents' perspective, knowing that at a young age, they may not know what they don't know, but are attempting to learn and will over time. We talked about humility in our group.

Jim Boggs: And so then on the vision and the storytelling elements, we found that that's very, very core, towards setting the context for anything basically. The context for leadership and, and that leaders should be able to tell stories powerfully. So, when I looked back and think of the session that we did with the eating disorders class, and we did the interactive drama scene on eating disorders, and that young woman came up after the presentation and said, “Thank you for your work. I know today what you are talking about. That's my lived experience.”  So, that as a story, actually brings something present in the room. You know, notice how everybody just got quiet. Okay, so that was actually a story that I just did, versus describing, “Oh, and then there was this woman that she just came up, and told me this thing,” right?  So I actually told a little story right then. The power of that as a leader, to set a context.

MARILYN HARTZEL: And his other main point is therefore inspire to action.

UNIDENTIFIED SPEAKER MALE 1: Okay, second workgroup is building constituencies. Oh, lots of paper. Good.

UNIDENTIFIED SPEAKER FEMALE 1: We're going to report in two sections. We found is to be a very difficult task. And, uh, having made the task myself, I'm feeling a lot of humility right now. Uh, but we thought constituency building was very important. It came across in many of the discussions today. And, we divided into some key skills, and or competency areas. And some of the training experiences that, uh, might go along with this. And, you want to introduce yourself?

ROCIO QUIONES: Sure. I'm Rocio Quiones. I'm at University of North Carolina, and I'm a pediatric dentist. So, our topic was building constituencies. And we were over time able to bring all of our thoughts together and develop eight different things that we felt were important in doing this. Um, we also felt that there was some overlap with other areas like management and negotiation. So we're going to briefly mention some of those, although we'll let other speakers speak to that. Our first one, which we spent probably the most time was, understanding language and the intent of meaning in the same language and culture. So, really what we're getting at there is making sure that we're understanding where all these different players are coming from, and their, different, let me just start again on that one. Their different perspectives. And in doing that, the real purpose of that was getting everybody to be on the same page so we can start at that same baseline and be able to move forward. And that would also, need to be framed in a certain context and that that was an important element. Our second point was the role of revision, and then spoke a little bit to what Dr. Joel Berg eloquently spoke to us today, and that was that we all have to share a vision, make that very transparent to everybody involved, and focus, make that a focus throughout the whole journey. Because without a vision, we wouldn't be able to, we wouldn't have constituency. Our third theme was, legitimacy and the importance of that. And we felt that there are three ways that one could acquire legitimacy.

The first one would be if you possessed it through experience of training. The second was you had resources to get it. That was financial means. And finally, you were given it. You are voted to do something or you were just overall given that responsibility. This, and, right. And the fourth theme was to delegate. And being able to give people responsibilities and authority. And part of that was going to require letting go and being able to do that. And, an important part of that we make sure that you were constantly re-evaluating and being flexible and changing things as you move through things with your constituents. Our fifth one was purposeful evaluation of your constituency building, meaningful feedback from different perspectives, and having the flexibility to change the time. Our sixth, dimension was determining all your stakeholders, and realizing that in doing this, you may really miss some people in the process. And that you needed to make sure that throughout the process, you're making sure that you're involving as many people that need to be involved. And you may offend some people in the process, but, you should try to embrace people rather than exclude them. Our seventh was being savvy and street smart. And I know Wendy's going to speak about how we're going to train some of these. And this, we thought was kind of hard to do. But, but really to really focus on what your limits are, and look for opportunities throughout the process. And finally was characteristics. That was being persistent getting to yes. And I know that the other groups may speak to this, and is also related to some qualities of an individual. Your ethics, your integrity, and the important of those elements that will sort of make the process go a lot more smoothly in building your constituencies.

UNIDENTIFIED SPEAKER FEMALE 1: And, we realize that we don't really give trainees opportunities and experiences in building constituencies, although it's a component of just about every leadership job that you take on. And we recognize that it was hard to do it, and maybe we have a few ideas, but one of the most basic things would be to share to ourselves, be transparent to our trainees, that we in fact as faculty go about building constituencies all the time, when we try and change programs and bring about new ideas. So pieces that would be part of this, in terms of understanding culture, perspective, and viewpoints of your other constituencies goes back to the interdisciplinary model. You know, it was good then and it's good now. And it needs to be set again because some of our programs are uni-disciplinary. And they're at particular risk. Pediatric dentistry is one of them. Because it's, you know, we're not always a set in, 13 disciplines like a LEND might be. And hopefully, you know, that's, changing a lot. So, interdisciplinary experiences. And then exposing them to faculty who themselves bring in different perspectives. And you might need to have, faculty there beyond your usual faculty. Community of faculty. Affiliates who have different shared experiences to bring to the trainees. And then by having some kinds of practical experiences out in the community, they will also learn from other perspectives. And then finally, the, requiring a meaningful product of this interdisciplinary experience. Not just like we sent into the interdisciplinary team for one-day a month for three months, but to either present a case or describe or write on some aspect of another discipline, taking turns being the case manager. I think we've, given that in some of the LEND Programs, and other kinds of experiences that truly challenge them to see things through other peoples' viewpoints.

Vision, one way to do vision is to share it, model it, and another way is to actually give a task, such as writing a strategic plan around some particular, case or, that might be appropriate, to whatever that area is, a public health program or an IEP, to actually go through an example, and to say, what is the vision, what's the outcome you want at the end of this. The second piece of this we thought related to the internal process issue, which is we have to mentor people to go inside. And some of that vision really has to have, has to do with your own sense of what you want to make happen. You can't build a constituency without a vision. You know, nowhere to go. Turnabout is fair play. One minute, Wendy. So, in terms of legitimacy, it needs to be pointed out to people that they will take their credibility and the legitimacy from these different areas. And that they understand what that's about. And also, legitimacy within is part of striving to be competent in your area. That's important, that's how you have credibility. Purposeful evaluation. This is part of a strategic plan. And you can also model this. And I think that same holds true for, street smarts and being savvy through particular case examples and through modeling. I think you could point out where these things are important. We did not set out the curricula for ethics and, integrity. We thought that was another area, but a very important one. And we aren't sure how you create the characteristics of flexibility and persistence. Humility and respect, except other than by mentor it, by modeling them and showing them that this in fact is very helpful. Thank you.

UNIDENTIFIED SPEAKER MALE 1: All right, the third group is cultural competency. Introduce yourself.

NOEL CHAVEZ: Sure. I'm Noel Chavez from the University of Illinois School of Public Health, MCH Program. And, our cultural competency group, kind of took at the end what seemed to be a, an approach that may seem a bit—not culturally competent. And I will certainly invite our group members to contribute if they feel like I've misrepresented things. One of the pieces that seemed to come out of our discussions was that the idea is that cultural competence needed to be integrated, into the other domains. It is not something that is separate. It's  something that is a part of all of them. And that that was something that we needed to, needed to incorporate it as, as Dr. Hayes said. You know, it's a core thing that's there. It's not, it's not an add-on. It's not something that you mark off that you've done. And I think that concept kind of tended to guide us in our, in our discussions. So, we would see cultural competence as a part of all of them, but not necessarily a separate one in and of itself. And, rather than have skills per se, we've described a series of combination of skills, values, and qualities that we felt that people who were culturally competent would have. Uh, one, that they would have respect for others, that they would be good listeners and communicators and follow through on what they heard. Excuse me. To begin where that particular unit was. Maybe it was a family, maybe it was, um, a community worker, maybe it was your boss. But you begin with where they are. And then take it from there as opposed to imposing your own agenda. You work to build trust within your relationships with others. You're self aware of where you are, what your own cultural box happens to be, realizing that culture is more than race or ethnicity, but includes a wide variety of things. But how is life within my culture, how does that move me toward or keep me from interacting with others?  People having good interpersonal skills and being able to, to have some humility, that we're open-minded and flexible and willing to think that there's not just one way to get things done. The fact that there was reciprocity and that both sides had something to give and to take from a particular interaction. To be responsive to, what the needs actually are, to leave assumptions at the door. And then, so those are some of things that we came up of, as skills or value areas.

Generally, the idea was that, we needed to get trainees kind of out, out there, in some sort of way. We had a, came up with a whole list of experiences that we would like to think of as more menu than a list of things that everybody must do to the same level. But, things such as enabling encounters with people from multiple cultures, looking at our own personal culture, and figuring out what do we have that actually contributes to a particular circumstance?  What do we have that takes away?  And how can we maybe choose to do something a bit different in this expansion of our self-awareness. And to try to provide support for students so that as a result of their educational experiences, they didn't become more insular, as opposed to more looking outward. We had, have people from different constituencies evaluate the program. Not just have the, our self-evaluation, but perhaps have the families evaluate the program. Create an organizational culture that enables the development of cultural policy. Cultural competence. And this whole issue of policy and having a policy that supported it. Having the policy isn't enough. You've got to live it. Simulations and role-playing's, experiences, having a diverse student faculty, combination of folks. Perhaps having shadowing people from the group, perhaps a visit to the food stamp office with someone from your population base, would be an example of experience that could help build cultural competence in the MCH Program.

Various exchange programs between facilities or different groups. The use of videotaping and standardized patients or circumstances for people to perform and then get feedback. Use of case studies, field projects, practice, visits to organizations, agencies, home visits, and the like. Involve our trainees in community-based research to learn about the issues of different cultures. Using reflective journaling. And, a greater exposure to what's going on globally. So, these were just some of the activities that we had. And but the whole idea that we needed to provide support, so that these were useful learning experiences as opposed to just saying, you will do these five things, and you be culturally competent, which we didn't think would fit all. So, the thing is, is that we, you know, we need to see that there are changes, and have students involved in making changes in policy and at the implementation level, to help make, so that in organization or an institution or an activity is culturally competent. And that's one that's a longer discussion than what we have now. And I think that will cover us for now. Its certainly keeps, kept us busy.

UNIDENTIFIED SPEAKER MALE 1: Thank you, Noel. Fourth group, negotiation conflict resolution. Here we go.

MARY SHROATH: Hi, I'm Mary Shroath. I'm from the University of Wisconsin, the other U.W., pediatric falminary center. And my group talked about conflict resolution and negotiation, which sort of, we blended together. There a lot of skills that are really universal to leadership that we discussed that I think everyone's going to bring up as they present from their group. Those including, listening skills, always having that vision in mind, and then the transparency of the vision. One of the things that was very interesting from our group, there were two main things that, I came away with. One was the decision-making process, which is involved in negotiation. In order to make a decision, you have to have some knowledge base. You have to understand sort of the science of decision-making. You have to be, mentoring of the application or consideration of how you're going to apply this, then the motivation to actually apply your decision, and then doing it. It's like when you teach someone how to do something, or when you have an adolescent in your clinic. Actually I like this example the best. If you have an adolescent in your clinic. Me for example, I take care of a lot of patience with cystic fibrosis. They can tell me why they take their medications or why they're supposed to take their medications, what the medications do, how they're supposed take them. But then never actually take them. So that's very important in the conflict resolution and management.

The other thing that came out that I thought was very important, or, new information under consideration was resiliency. Teaching our trainees about resiliency. How do you recover from a failure, which, the new generation is having less and less opportunity to do that. And working from failure. Because when you're in a conflict or, in a negotiation situation, it's not always going to be a win-win situation. And sometimes you fail. And sometimes you succeed. Hopefully you have more successes than failures. We spent quite a bit of time talking about different modes for conflict management such as avoidance. You know, a favorite of many people when you run into a conflict. Competing, which tends not to be, since we're in healthcare, that tends to be less one of our styles of conflict management and more so for the lawyers that are out there. Compromise, where it's a give-and-take situation. Collaborative, which I suspect is really the one that is, we use the most, where it's a win-win situation, and then accommodating. Am I getting it right? Okay.

The qualities that are involved in the different skills that we talked about, include having, having the ability to make those tough decisions. And having a passion. I mean what drives all of us to be here is that we're passionate about taking care of children. And then these abilities to integrate knowledge experience, having a self-awareness, and also, finding opportunities or creating opportunities, and the thing we struggled with probably the most was trying to identify how do we teach our trainees to manage conflict. And we can go through different skills, but there's, so we, we did not come up with any great recommendations, other than doing simulations. And none of us are great actors. So it's always harder, when you get into a simulation, there's much more stake when you're actually in the situation negotiating a conflict. So that's something that our group will need to explore some more. This is a very interesting couple of hours. Thank you. Thank you.

UNIDENTIFIED SPEAKER MALE 1: Group number five, group number five, uh, mentoring and modeling. Speaking now, Louise Uashi, LEND director from Hawaii.

LOUISE UASHI: Well, I was going to say, this is almost like being in Hawaii. We've been enjoying just wonderful weather here in Seattle, so I hope the rain doesn't come too soon. I'd like to acknowledge our group five. A diverse group of, of folks who contributed a lot during, the break. And we had folks from New Hampshire to South Florida, Tennessee, Iowa, Washington, etc. So, uh, I need to say. And we had programmed, representation from folks who were, mentoring, high school students for people who were mentoring for a five- or 10-year period. So I must say that we had a lot of discussion and we went all over the place, but I'm hoping that we came to sort of a consensus towards the end. Fundamentally, our feeling was that mentoring is a key. We fundamentally came down to the fact that mentoring is a key part of leadership training. And, you know, that was just a general consensus. And not confusing that with mentoring of trainees, but the fact that training trainees to become mentors was a fundamental part of a leadership role. We defined as that, the act of providing direction and guidance and nurturance and support in order to, in a planful way, provide, guidance to develop a plan and ultimately to make a difference in a person's life. So, we really sort made that generic, but wanted it to be something that could apply to a variety of programs. Because as I said, we had programs where people wore mentoring someone for five or 10 years, and others who wore mentoring over a six-week or a nine-month period. And it was quite diverse.

The skills we felt that would be identified, and again, since we felt it was so fundamental, we, in our sharing of our experiences, people were mentoring in a variety of ways. Trainees mentoring families, trainees mentoring each other, but no one in the group, in our group certainly, of nine of us, had actually formalized in mentoring curriculum and/or, sort of really thought through that, and there was discussing, is this really mentoring or is this role modeling, or is this coaching, and, and a variety of things. We decided to drop role modeling from the title because we felt that role modeling or conscious role modeling would be subsumed under mentoring, and so would coaching and some other strategies. So, mentoring would be sort of the title we would suggest or recommend at this time. Some of the, the skills we felt were generic in terms of relationship. Because the mentoring we felt was going to be a one-on-one relationship whereby developing trust and rapport, being able to get feedback, would be skill sets that will be incorporated in the curriculum. There would be a higher level of then developing personal professional goals. Because even if you're working with a trainee, you might also be working with a family, that goal setting and strategies for successful goal settings would also be part of the curriculum. Uh, we also talked a bit about the idea that having again the strategies of what is really conscious role modeling when you're looking at clinical expertise, associated with good teaching skills, associated with personal attributes, you know, that would come into package there. And trust me, I'm trying to make this very simple, but it was a very long discussion. And there was a real debate at times of whether those of us who are clinicians, and being the developmental pediatrician was more clinical, versus those who were in public health, and we're looking at more than humanism part. So I think there's a lot more to be teased out of it. Our feeling was that the key training strategy for this was, one, that all our trainees should have a formalized mentor, should have formalized mentoring opportunities. We didn't really feel because the programs were so diverse, you could, you wanted to put everyone in a niche, but there should be formalized in their training, mentoring opportunities and that there should be a mentoring curriculum that would be established, identifying the skills that will be prerequisite, to become a mentor as you became a leader. So, that's it.

 UNIDENTIFIED SPEAKER MALE 1: Having just completed reading a biography of Captain Cook in the South Seas and also Magellan, I can say we've come a ways on some of these issues. If you want to give some good examples of complete lack of cultural competence, and complete lack of negotiation of conflict resolution skills, look at those two books. Our sixth group is translating signs and evidence to practice. Peter Bosco, LEND director from OHSU.

Peter Bosco: We came up with, seven skills. And as I read through these, it's becoming increasingly clear about how much overlap there is in the, ideas notions we're talking about. The skills, as with everybody else, were kind of evolved from the stories. The stories in terms of evidence-based practice, came in two varieties. One is projects that people had done. But also, efforts to, translate scientific information to other, constituencies, like policymakers, the lay public, and so forth. So the first skill, information gathering. For example literature review, in terms of training that skill, we talked about bio-informatics courses, basically technical search techniques, mid-line, and stuff like that. Bio-statistics in epidemiology courses, and the various methodologies, involved in research. And, frankly just having a research project is a practical concrete way to figure out how to gather information. Second skill we talked about, background knowledge and experience. And we talked about this as a, as not only kind of fundamental to doing research, but also to, establishing your own legitimacy in credibility, really kind of a mirror edge of one of the recommendations your from Roseo and Wendy, where they talk, start out with legitimacy. What's the background or what's the basis for legitimacy?  Good clinical experience. So, how do you train that?  Well, good clinical experiences, interdisciplinary experiences, didactic teaching, case-based teaching, that sort of thing. And that we repeatedly talked about the interdisciplinary context for that training. Third skill, there were number of items that came under the heading of attitude. Open-mindedness, you've heard that before. Listening skills, negotiation, which is a whole topic. Basically a willingness to be open to different ideas. We talked about the, the method for doing that in terms of teaching people how to utilize focus groups, Delphi groups, modeling behaviors. For example, being willing to identify your own biases when you're talking about your approach to information, to evidence-based information. Collaborative techniques. Basically communication skills. Again, a whole domain. Fourth skill we talked about, critical literature review that is to say review of the scientific literature. And again, didactics, you can teach the rules of evidence.

Journal clubs. Other scholarly activities. Once again, having a research project is a very concrete way to teach folks out to review the literature. Number five, translation, to practice our policy. Teaching people that translate information into practice or into policy. Talked about teaching and modeling, interpretation skills. Giving people assignments to develop policies from, based on information, or to develop fact sheets based on literature information. We talked about distillation skills. That is to say the ability to take scientific information from, the literature or from whatever context, into a different audience, to distill it down to understandable level for an audience that's coming from a different perspective. Six is research acquisition. We identified this separately as the skill or the ability to appreciate other expertise, or other experts, or to find other experts, whether that be in a different discipline or in one's own discipline. So again in terms of training that clinical experience, modeling respect for other disciplines, modeling respect, modeling and open mindedness. And then lastly, we set one up. The seventh one was research mentality. Basically understanding the research method, but also, as Jeff described, having, what he called Equi-poise. That is to say, the ability to explain a research project to a participant in a way and again, this comes back to legitimacy I think and credibility, in a way that they could trust you, to participate in the project. That's it.

UNIDENTIFIED SPEAKER MALE 1: Now we're on to number seven, policy and advocacy skills. And I see Bruce coming forward.

BRUCE: We had a very unique group in two distinct fashions. First of all, there was nobody on our group from the University of Washington.

Unidentified Speaker Male 1: That was an oversight.

BRUCE: And, and the second was is that we actually had a trainee who joined us and gave us a sense of reality. But we had a comma a very interesting time. We recognized that there were two assertions that were made that represented the yin and the yang of the committee. First, that there was by human understanding the individual child and family. And second, that there was value in understanding policy and advocacy. And the test that we defined for ourselves, was, how do we bridge these assertions and bring the two cultures together. We felt that there was similarity in clinical, that there was similarity in clinical and policy advocacy processes, but there were different skill sets. And we felt that it was important to focus on the processes because it is hard to anticipate the skills that are required in the future. And some of us remember as part of our then UAP programs, teaching trainees how to use computers. And in the current era that's become superfluous because they picked up those technical skills long before they became LEND trainees. The process that we talked about included, problem identification. Problem refining, including, delineating our resources, what activities we wanted to, put to a problem. What the objectives of the problem were. And critical planning. The knowledge about things work, that is to say, how to effect change, and an evaluative component. We recognize that there are many factors that influence policy decisions, and that policy decisions are made in a context. And there are a number of contextual settings that we talked about. There was the social context, which range from the individual through the department, through the University, through the political jurisdiction through the larger society.

The historical context, how things came to be a particular institution program. And then a whole set of discussions regarding values. Including personal values, institutional values, and values of other stakeholders. We talked about the issue of timing that division versus reality, that these kinds of issues may lead to conflict. And that we needed to teach our trainees how to respect different values, as was evidenced by a very heated discussion of whether policy drove advocacy, or whether advocacy drove policy. We recognized that making these kinds of decisions for policy and advocacy may entail certain sacrifices and the sacrifices that we talked about is that, you might be adversely affecting your own academic career by focusing on policy and advocacy if it's, if these issues are not appreciated by your chair. And we also talked about prioritization, and that is that when you make a decision to embark on a certain course of action, there are other things that you're not going to be able to do.

A third major area that we talked about was the area of data. And we felt that we needed to teach trainees of how to define the rules, what are the different levels of evidence, how to recognize that many policy issues are decided on emotion versus evidence. And the term that somebody from this morning used, which was that frame trumps facts. And to that and, we felt that trainees needed experiences in educating various types of audiences. That they needed to know how to present their data in a way that furthered a particular point of view, and that how to use media including things like PowerPoint tape, video, to advance that point of view. And next to the last group that we talked about were issues of communication, and that include listening skills particularly to those others who have agendas, and that included your own personal agendas. The agendas of the consumers, the agendas of, all the people who are in charge of making the decisions, the agendas of your collaborators. We, recognize that trainees would need work in conflict resolution and negotiation, and we left those to the other groups to wrestle with. We avoided conflict. We also recognize that it was important, and when we were talking about communication, that we needed to understand how adults learn. Because presenting information to adults is somewhat different than more traditional kinds of approaches. And that some specific training in adult education would be useful. And then finally we, we talked about linkages and collaborations. And those included such things as how to enlist support, how to collaborate with other groups as an individual, how to collaborate with other groups as a group, and recognition that accountability is required for successful collaboration. I think that's about what we talked about.

UNIDENTIFIED SPEAKER MALE 1: And now we come to the big combined group, management skills and working with organizations and systems. And Joel Berg, from the UDUB here.

JOEL BERG: And Eric Ocada from UDUB Business School was my partner in this group, but I'll be presenting, 'cause I don't know anyone that can read my handwriting. I'm going to take the liberty in changing the presentation a little bit from what we discussed in the group. And, yeah. No, what I'm going to do is I'm going to talk about all the skills first, and then I'm going to talk about the training experiences. I think it will come across better that way. So, the skills that we came up with that we feel are necessary, oh, by the way, I should mention, we combined the groups, and we consumed the, group nine into management. We felt that management, included, yeah, it's the bigger, it's the broader issue. So the first skill, and we, I should mention that, we identified that some of these things aren't black and white. You know, it's not the skill that you have to learn this. But rather, we felt there are many of these management skills, that one had to learn where they reside or should reside along a continuum. In a different situation.  So we came up with several continua, for some of these. The first one was adaptation of oneself along the continuum of consensus building on one and two authoritative behavior on the other. So, where, where should you be?  And that, that's a skill that has to be learned.

The second skill was getting people to understand the theory of systems change. And that was part of actually the group nine. In other words, instead of just diagnosing a patient or a condition, making a diagnosis of the system, or a cultural, of a corporate culture within an organization, understanding and knowing how to deal with that given that assessment. The third one is also a continuum. It's the continuum of sticking to your vision versus amending it along the way. And we heard this morning a lot of people say, okay, you can be a group, you come up with a consensus, you have a vision. And the most important thing, as Don DePaula said, “Stick to that vision tenacious way, don't give up.”  But then you're going to have nay-sayers coming in, or people coming in late in the game and saying, “Yeah, but I didn't get the chance to get my input.”  Blah, blah, blah. Or I changed my mind. When do you stick to the vision, and when do you amend the division along the way?  And that's a skill that has to be learned, where you should reside along the continuum.

The next one is also a continuum. And it's selling an idea while setting expectations properly. Because, the reason it's continual is because if you sell something to somebody, you have to present a lot of evidence and show what you can do, and I can do this, and we can solve that. And then you don't want to set the expectations so high that you can't actually achieve it when it comes to deliverables. So, where do you, how far do you push on the selling side before you get into the delivery category. And then the fifth area—I've got a couple more. Stuck versus facile. So that's the continuum. Do you stay stuck, or do you keep doing what you're doing, or do you become flexible?  An example that I'll give is, one of the members of our group, in the area of nutrition, has been dealing with an area which is suddenly very popular on the public, on the public side. The consumer awareness is very high, nutrition and obesity. And so all of a sudden there is a lot of funding, a lot of other priorities that may be slightly different than yours. So do you respond to an immediate emerging need?  Yes you should. But how do you do that while maintaining continuity and sustainability of your original objective?  So that's kind of a continuum as well. And then, satisfying your constituents. That's a skill, when it comes to whether they be shareholders, stakeholders, stockholders, investors. Earning credibility. That's a skill. So you're appointed to a position, but you have to earn credibility. How do you teach skills to do that?  And, finally, convincing the consumer is this is an important need for them. So in other words, if we have a health care program we're implementing, it might be easier to present data to governmental agencies or other entities to get to support for this program, but how do you sell it to the people who need it. And, uh, so now will talk briefly, how much time to I have left?  A minute and a half?

UNIDENTIFIED SPEAKER MALE 1: Yep.

JOEL BERG: Okay. I just guessed.

UNIDENTIFIED SPEAKER MALE 1: Yes.

JOEL BERG: Some of the skills that have to be learned in the programs to obtain these management skills that are objected from the training experiences. So, uh, case examples are very good. You know, experience and management, self-awareness. Not much more important than that, and it was mentioned there are certain tests that tell you where you are on the awareness scale. The lead test, someone mentioned. Training and systems change. Training to understand that you're managing a process, and an organization. And not, it's not you personally at stake here. It's the process at stake. So to take yourself out personally, and that requires little bit of experience, not to take things personally. Modeling. Mentoring, which had been mentioned. Actually giving the trainees a project that's definable and small enough that they can manage it and gain some of these experiences. And it must be a project that is actually important to the organization, so it's a real life issue for the organization. Listening skills. Getting to know your group. This relates to the earning credibility. And this can be learned by modeling examples and observing your mentors engaged in this process. And then as far sustainability, we spent a lot of time in a few of these areas talking about sustainability of management, of engaging management objectives. And Erica, who's professor of marketing suggested, and we all agreed, that everybody should take Marketing 301 because, you know, we defined, we heard the definition of marketing is exchanging value, and then therefore making people aware of what the value is. So I think the basic understanding of those principles, what would be really essential for all, 'cause a lot of this isn't selling. A lot of this is showing off. A lot of this is engaging constituents. So it really is about understanding customers and marketing. So we felt, it wouldn't be a bad idea to get a good basic marketing course. Maybe design one that's adapted to our needs. So I'll stop there. Thanks.

UNIDENTIFIED SPEAKER MALE 1: And, The Internal Process of Becoming a Leader. Come right on up. Go ahead and introduce yourself.

ANGELA ROSENBERG: That's okay. I'm Angela Rosenberg from the University of North Carolina, and I co-facilitated with Gail Tekafer from University of Washington. And Joel, if you thought your group wasn't black and white, you should have been in our group. It was very Zen-ish. And I'm just going to read some quotes from the group as we started when Gail and I began to panic. Someone said “Awareness is understanding, and that really should be the skill.”  Someone else said, “The process is the outcome.”  And then, we talked about a dialectic, which, I'm still not sure we operationalized, but I think it's continuum, and I'm going to do with that. And then, one of the quotes at the very end, after of course we'd been working for a couple hours, was, “Aren't the internal processes really about the external factors?”  So, actually we had a great group. And we had some excellent discussion about the internal processes of becoming a leader. And let me tell you, it's all about balance. And as we went through our different skills, we really did decide, quite a bit that it is about a process, and it is about a continuum. So, we're going to capture that same concept here.

The first skill or process or understanding is that reflection and self-awareness are key. And that there is a continuum there between understanding of self and really going inside and getting in touch with your internal attributes. But the continuum is really looking at all the external factors that we all know influence that the process. And so that was our first skill. Secondly, we looked at the process of personal renewal. And that's, you know, taking a good vacation. But also just really taking some time out. And again, on a continuum, there are times when we all know that work is, of the essence. And really striving ahead and moving forward. And knowing when the time is to step back and, and take a break. And when that will make you more effective in whatever leadership role you're in. Thirdly we talked about retaining progress toward a goal. And really, you know, you could just take all the management stuff and just sort of put a meditations spin on it I think, because really, they mirror it beautifully!  And as I was listening to them, I thought, “My God!”  I mean, Gail and I both chuckled, but really retaining progress toward that goal while remaining flexible to the context one is in. And how to reflect on that and understand it and know it and not become so driven that one doesn't understand that that flexibility is key. And how to, how to go inside and really understand that process. Let's see. Number four was to seek, use, and integrate feedback from the other. I can't tell you how many people, as they recounted their personal stories, you know, with everything from talking to colleagues, getting information from a coalition, to talking to my mother, and really finding out what she thought about it. I mean, honestly, everyone relied on the other, and then we, we took that one step further and said, then we take that information and knowledge and really seek to understand it and go with it and really assess it in use it wisely. So again, that process of understanding that were not alone, and that internal processes aren't all about only self and, and solo, but they revolve around and involve other in context.

The fifth was to assess external environments, to move beyond a vision, to be able to identify a leadership style. What in the heck is this?  Let me rephrase that. And Gail, help me out. But it's looking at people versus situations, and really understanding the consciousness of getting that feedback and looking at the vision and being able to identify the leadership style, or what style you might need to tap into in your own personal reservoir, what's most appropriate at that time. So again, having that knowledge and understanding. And lastly, well, we had two more. Acknowledgement of the unique leadership trajectory. This is one we really bandy about, but there's a lot of discussion about the fact that sometimes, as we all move along our own unique trajectory, there are times when we need to step back, and it may be wise to do so. And that also there are periods in one's life that may call for, sort of heightened awareness and, knowledge of one's own leadership and where one needs to step up to the plate. But also the knowledge that one, one needs to step back from the plate. Something that I read not long ago from Jim Collins, that, when, I guess it was in his book, or I read it in the paper, just that he said, you know, when the new year rolls around, instead of looking at all the resolutions or the things that we have to do, it's knowing what not to do anymore, and when to take something off the plate. And having that self-awareness and reflection to do that.

And lastly, openness, readiness, and recognition of the opportunities, and knowing how to tap into the mentors and networks that will help us access the opportunity and move ahead. So I think all of these dovetail with a lot of things that have been said already, but it's putting sort of a unique internal spin on it, in how to really ready oneself for these types of opportunities and experiences. We talked about lots of different ways to do this. And I know time is, everybody's probably a little weary, but everything from case studies to community experiences, one of the first ones we said, and, we identify these by the skill, was really to, to stop and actually give trainees a specific time, maybe starting in their programs, to get this type of experience and begin this process of self renewal and understanding of self. And then also having some one-to-one mentorship throughout their traineeship. Not, not necessarily assigned, but I think everyone was of the agreement that, that mentorship should develop from those initial experiences and evolve. Thank you.

UNIDENTIFIED SPEAKER MALE 1: And now the group on critical thinking in problem solving.

CATHLEEN ROUNDS: Okay. I'm Cathleen Rounds. School of Social Work, that I direct the MCH social work training program at University of North Carolina at Chapel Hill. I was a member of a group that could be described as critical thinkers, critically thinking about critical thinking. And, that captures what was a fascinating discussion. Of course, we then followed the instructions. We changed things. But I will try to summarize best as possible and, and please those of you who are part of that group, speak up. I think one thing that we all agreed upon was that critical thinking is a very important component of training of students. And it should be embedded in the programs as opposed to having something talked separately on critical thinking. That said, we also felt that most of us are probably doing some type of teaching, or training on critical thinking, but were not acknowledging that or were not identifying it as such. And that we really need to specifically identify what we're doing, so that students understand how important critical thinking is, as well as, by explicitly labeling that we're teaching and training on critical thinking, we can then, focus on that, we can describe what were doing, and we can also, look at outcomes and begin to really, see if we are achieving those outcomes. In terms of practice skills or skills in critical thinking, we came up with a list, but this list is in no way inclusive and we did not prioritize these particular skills. So I'll just go through some of them.

One is the ability to question ourselves as well as others. Why are you doing this?  Why you practicing in this way?  In a non-challenging way, one that really emphasizes and encourages inquiry. The ability to understand and handle conflicting viewpoints. The ability to reflect and examine, to question one's assumptions and those of others. The ability to decide on what to believe in and why. And also to be able to explain to others why you believe what you do, and why you think the way that you do, and why you practice the way you do. I think that's something that's, really hard to teach students, to be able to actually identify whether, why they're thinking the way they are and why they're practicing the way they are. The ability to use and evaluate evidence, the ability to understand and examine context. That maybe the context of the situation, the context of the group, or the context of an individual that you're working with, if you're doing clinical work or of a family.

We also listed; we came up with examples of, of training strategies that we're using. A couple of these are having trainees present projects, so that they can be critiqued in a way that models critical thinking. Helping them become more and more precise about their presentations, and how they're thinking. Having trainees critique, our own projects—that is faculty projects. So internal projects, someone gave the example of a business plan, a clinical business plan and having trainees critique that. Having trainees do research on a topic where they're searching for evidence-based practice. I think the example that was given was on autism and vaccinations, and coming with some of the, looking for evidence for a research that's been done. Having trainees work with the data set to answer a question, doing issue-based data analysis, but not just doing the data analysis, but being able to under, to explain what their assumptions are, and the process that they're using in, in approaching the data. Using interdisciplinary case conferences, or having interdisciplinary discussions on specific topics. Someone gave the example of a discussion on the medical home, and if you have a, MCH person, a social worker, a businessperson, a therapist, an M.D. in the room, that you might have a very different, everyone might have very different views about what that is and, and how to approach it. Have trainees teach others about critical thinking and what, what it is, and about problem solving.

One example of a strategy was having people reframe the model, or use a different frame in approaching a question. I think example that was given was, having trainees do a survey, of parents with children with special healthcare needs, and asking them what they thought could have been done to prevent or enhance this child's life in some ways. And then, sharing that information with practitioners, and it really helps people think in a different way about the issue. Using a prevention model instead of a medical treatment model. And then finally having faculty really model critical thickening in their discussions. It's very helpful for students or trainees to see faculty disagree in a respectful way and really think out loud and front of them, so that they understand that that's what in fact people do.

Finally, two other things we talked about, one was developing an environment for critical thinking that we really need to do that in our training programs. Not just modeling, but making it okay to ask questions and in fact encouraging people to ask questions. And then we did spend a little time on talking about dispositions for learning critical thinking or characters—characteristics or character development, I can't remember what it was. But some of these being curiosity, humility, tolerance, cooperation, open-mindedness. And I think that was it. Any additions?

UNIDENTIFIED SPEAKER MALE 1: We seem to be holding everybody's attention. The last group, Ethics and Moral Commitment.

DAVID DEER: I'm David Deer, the Training Director for the LEND Program in Arkansas. And I just wonder, how the other groups managed to get one of their identified leaders to do the presentation? We're onto you. Poor leadership on their part. Okay. Felt like a sucker here. I will say that our group, I think we'll all plan to be here at 7:00 tonight because we got enough insight from what David Nash has to share with us that we want to be here. We really did have a good discussion on ethics and professionalism, and, he dropped enough pearls of wisdom in there among our discussion that we're anxious to hear what he has to say. We broke out knowledge and skills and attitudes as some of the core features of the area of ethics and professionalism. And incidentally, we talked about whether ethics was a better label for our domain, or professionalism, and we decided we were going to wait until we hear him speak tonight, and then we'll decide tomorrow.

UNIDENTIFIED SPEAKER FEMALE 2: Cop out

DAVID DEER: That's one of the things he's going to address. In talking about the knowledge that we felt was important in this area, and most of these things, unlike the skills and attitudes, are probably specific to this domain. They're not so cross-cutting as the others. We felt like one of the things was just a basic understanding of ethics, the framework out of which we develop our ethical models. Are we looking to principles, or are we looking at rules or ideals, are we basing it on legal issues, that all these probably factor in, we need to have, basic knowledge about each of those, but even more important, we need to have that understanding of what an ethical framework might look like, and what sort of framework are we using to develop our own ethical system. And also, we felt there were number of core current issues that change from time to time. A lot of very pressing issues that we're dealing with today were not issues 10 years ago. You know, the Genome project is spinning out lots of them, and we're going to be seeing lots of more in the very near future that come out of some of that work. So, then we talked about the skills that a person would need. And these would include ethical decision-making models. It's related to the, what we said before of the knowledge, but then, operationalizing those, applying those two are practice is a, would be a skill. And it involves critical thinking, and again, a lot of things we talked about, we heard overlapping with the other groups. Things that, that you talked about as well. We felt a really important part of ethical practice is empathic communication. And actually if you look closely, you'll see arrows going both ways. Because we felt that it was important to be able to communicate empathically, but also to be able to listen with empathy.

We felt that another important component was a self-reflection. The self-assessment, having the capacity to be self-critical. That, if we can't do that, then how do we step outside ourselves and apply ethical issues to others. We felt that one thing that really do both into the knowledge area and into the skills is informed consent. We had a good bit of discussion about that. That, we had a good bit of discussion about that. That's a key issue for all of us in our academic settings. So it's not only knowing what are the rules and requirements, but how do we apply that? How do we put it into practice? Sometimes we think we have everything lined up perfectly and it doesn't work out that way. We heard a very compelling story of, the way one of the workers was actually presenting this to the people in the study that, was having some very adverse effects. So operationalizing in informed consent would be a skill.

Conflict negotiation skills. We heard from the group that talked about that, but that's a key part to ethical issues a lot of times. Another member told an example of a school that had a child whose parents had a D & R order, and the school really had trouble dealing with that. So there was a lot of negotiation that went on between the school and the parents over that issue. And, then finally under the skills area, we talked about, it would be critical to have disciplinary clinical competency, upon which one builds. You need to know what's expected of your discipline in terms of a code of ethics, or, ethical practice, before we can start talking about it in an interdisciplinary setting.

The attitudes that we looked at were integrity or moral virtues, comfort with ambiguity. Empathy and compassion. And moral courage. That's, by moral courage, we meant, not only knowing what needs to be done, but having the courage to step forward and, and take action. And then finally, responsibility or accountability. Then, under the training, and we listened to Dr. DePaulo, when he said we need to think outside the box. So we did. We looked at training in the global sense, rather than tied to the specific skills and knowledges that we talked about. You've seen a lot of these before, but some of the things that we felt might work were didactic presentations, using reflective journals, case studies, or scenarios or problem-based learning, using mentoring, modeling, or shadowing. But we also felt that tying debriefing to that was important. It's not enough to just model, but we need to really tie that up for, with the trainees. Using role-playing, standardize patients, and I'd already talked about debriefing, tying that to the others. So, those were the things, anything missed from the group?

UNIDENTIFIED SPEAKER MALE 1: Well, that was a quick run-through. Everybody did very well. I appreciate it. Wendy, do you, running a little tight on time, but doing okay.