Use of an Appreciative Inquiry Approach to Enhance Quality Improvement in Management of Patient Care


 Background

Different approaches are available to facilitate employees’ motivation, involving them in decision making and participating in different activities. Due to changes and the widespread of dissatisfaction with the management of the current South African health system, various approaches to enhance quality improvement in management have emerged. However, their effects on the quality of care have been unsatisfactory. This article describes how an appreciative inquiry was used to facilitate motivation and promote organisational quality improvement in the management of patient care.
Methods

The AI approach which comprise of an appreciative topic and acting on this theme through the 5-D cycle: namely Definition of the affirmative topic, Discovery, Dream, Design and Destiny was used.
Results

An appreciative inquiry approach offered employees an opportunity to reflect on the existing strengths within their practice situation, leading them to discover what is important and enhance quality improvement in the management of patient care in South Africa. Furthermore, AI is reported to have significant transformational as it has shifted the focus form problems to be solved to discovering and building on what works well within an organisation and used that as the starting point for implementing change.
Conclusions

New approaches such as AI have the potential to improve patient care and enhance individual and group motivation by changing the way participants think about, approach, and imagine the future.


Background
The Appreciative Inquiry was originated by Cooperrider and Srivastva in the 1980s (1). This paper describes the use of appreciative inquiry (AI) approach by the managers to enhance quality improvement in managing patient care. Different approaches are available to facilitate employees' motivation, involving them in decision making, team work, and participating in different activities. Due to changes and the widespread of dissatisfaction with the management of the current South African health system, various approaches to enhance quality improvement in management have emerged. However, their effects on the quality of care have been unsatisfactory. This needed nurses who were motivated to do their work and because the challenge is still continuing, it is imperative that nurses be continuously motivated. According to (2), it was revealed that a nurse manager should advocate for both the patient and the nurses to promote quality care.
The AI is an action research method and organisational developmental, as rst described by Cooperrider (3). In addition, AI was used to enhance quality improvement in management thereby promoting a positive work environment. Cooperrider and Coghlan (4,5) stated that presently, AI gained prominence and is practiced globally, and its popularity is still growing. The positive and transformational impact of AI on persons, groups, organizations, and multi-stakeholder collaboration is widely recognised and documented.
It is an approach that facilitates positive change in organisations, hence, improved quality care. Frankel and Moorer (6,7), emphases on what works well and bring positive results not changing person.
According to Cooperrider (8) the approach involves the 5-D cycle that consists of ve phases, namely De nition), Discovery, Dream, Design and Destiny. The study conducted by (9) emphasise that AI assists to strengthen relationships in an organization and increase positive emotions into what people appreciate. Appreciation has to do with recognition, valuing and gratitude and is de ned as recognising "… the best in people and the world around them" (3). The perception of things which provide life, strength, liveliness and excellence to living human systems (7). "It implies a quest for new possibilities, being in a state of unknowing, wonder and willingness to learn. It implies an openness to change" (10).
In addition, AI is a fully participative approach which mainly focuses on how best practices could be developed and maintained in an organisation (1). After recognising the highest level of energy and investment attached to the stories of success and good practice, Cooperrider (1987) chose to focus on these in developing a research process that adds value to organisations based on a constructionist orientation to meaning and reality. Furthermore, AI is meant to co-construct and drive in a desired reality built on participants' experiences and aspirations rather than to discover pre-existing truth but rather (9). It works from the premises that whatever is being "looked at" becomes magni ed and that a focus on problems is unlikely to result in their reduction. Con ning reactions to positive behaviour principle are applied in behaviour modi cation techniques that extinguish unwanted behaviour (11). Appreciative Inquiry rooted its methods on the initial set of four principles (1). The original method illustrated that the inquiry into the social potential of a social system should begin with appreciation, should be collaborative, provocative and applicable. Furthermore, it clari es intended outcomes and organizational signi cance using constructivist, simultaneity, poetic, anticipatory and the positive principle (9).
The rst principle distinguishes that organizations are socially co-constructed realities. Therefore, AI should involve as numerous stakeholders as possible in the inquiry into desirable collective futures. The principle of simultaneity is based in the belief that inquiry is intervention, that as we inquire into human systems, we change their behaviour. "The seeds of change -that is, the things people think and talk about, the things. All elements and considerations are signi cant to bring up the organizational change (3).

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Fitzgerald (12) common critique is that AI's focus on positive, high-point issues of organisational life might overshadow most of the negative experiences by participants and again imperative expressive discussions that could take place. A number of practitioner critiques pointed out that the 4-D model omitted an important rst step in the AI process of identifying the focus of the inquiry itself. Bushe (13), stated that inquiry into "the best of what is in order to imagine what could be" denoted by the Clergy Leadership Institute in the United States and others as 5-D model. In addition, the nal phase of the 4-D Cycle (also referred to as Destiny). Although, Cooperrider's dissertation called this the "a rmative topic" and many models have retained that label. How exactly that topic is de ned has not been well articulated but is generally regarded as essential to the overall success of the effort (3).
In Figure 1.1 the ve stages of the 5-D cycle (14) are illustrated.
Signi cance of the study An AI approach may also be used when formulating policies in rural hospitals as it encourages individuals to look for positive actions that can lead to positive solutions. Further research may be conducted to add to the body of knowledge and education of nurses as to what actions should be taken to motivate nurses effectively in rural hospitals. In education AI may be used as a research methodology which refrains from problem orientation to focus on positive inquiry.

Aim of the study
The purpose was to describe how an appreciative inquiry was used to facilitate and promote organisational quality improvement in the management of a rural hospital.

Research question
Is AI approach a possible change management technique to enhance quality improvement in management of public rural hospitals?
Objective of the study To improve the management techniques by using an appreciative inquiry approach to enhance quality improvement in management of public rural hospitals.

De nition of Terms
For consistency and for a better understanding, the de nitions of the key concepts, as applied in the current study, are presented.

Appreciative Inquiry
Appreciative Inquiry is the co-operative search for the best in people, their organisations, and the world around them. It involves systematic discovery of what gives life and is utmost active and pro cient in the economic, ecological and human terms in an organisation (4). In this current study AI refers to the positive way of soliciting the best practice that could be harnessed to improve quality care in a rural hospital.

Quality improvement
Quality improvement refers to the system in which the quality of health service is formally monitored and assessed to improve the quality of the service provided. It implies putting quality into practice (15) in the pursuit of providing the best possible service within the constraints of certain circumstances. In this study quality improvement refers to opportunities for improvement identi ed and mechanisms provided to bring about and maintain improvements.

Rural hospital
A rural hospital is a facility or structure in the countryside and not in a town or city where people who are ill or injured are given medical treatment (16). In this study rural hospital refers to hospital in an underdeveloped area in the Limpopo Province of South Africa.

Assumptions
Assumptions are "embedded in thinking and behaviour and therefore in uence the development and implementation of the research process" (17). In addition, (18) stated that an assumption refers to "a basic principle that is believed to be true without proof or veri cation". The current study was guided by the following question embedded in naturalistic assumptions.
Ontology: What is the nature of reality?
The researchers based this study on the AI assumptions of (19). Accordingly, the following eight basic AI assumptions which guided the study.
In every society, organisation or group, some of the factors work. The researchers believed that there were some aspects in rural hospitals that worked well.
What we focus on becomes our reality. The researchers believed that if one focused on the positive aspects in rural hospitals and worked towards a positive work environment in this hospital it would become a reality.
Reality is created in the moment and there are multiple realities. It was the researchers' belief that all stakeholders involved in managing rural hospitals could use the available intrinsic and extrinsic factors towards creating a positive work environment.
The act of asking questions about an organisation or group in uences the group in some way. The researcher believed that by asking positive questions relating to the intrinsic factors and the extrinsic factors that in uence the nurses' motivation relating to the intrinsic and extrinsic factors in a rural hospital, the stakeholders would become more positive towards both these sets of factors and would collaborate to work towards a positive work environment.
People have more con dence and comfort to journey towards the future when they carry forward parts of the past. It was the researcher's belief that not everything in rural hospitals was bad. It was her assumption that there were certain aspects that people felt proud about and would like to carry into the future.
It is important to value differences. The researchers believed that individual differences should be valued and appreciated because it brings more views and possibilities.
The language that we use creates our reality. The researchers believed that negative thoughts brought about negative ideas while positive thoughts resulted in positive ideas. For this reason, if nurses thought positively about their challenging work environment, it would turn out to be a positive work environment.
Epistemology: How is the inquirers related to those being researched?
The researchers in this current study believed that the participants needed to be actively involved in sharing their perceptions regarding the extrinsic and intrinsic factors that worked well for them. She obtained in-depth information by allowing them to talk freely and telling her what should be done to in uence the achievement of a positive work environment.

Methodology: How is evidence best obtained?
The naturalistic paradigm is best utilised by seeking an exploration and description of rst-hand information; thus, obtaining data from the original personal experiences of the nurses rendering patient care in rural hospitals (20,21). A qualitative method was used to collect the data. In this current study the researchers used an AI to pose a question to nd out what motivated nurses to render quality patient care in a rural hospital. The issue of human complexity was dealt with by exploring it directly (21). For example, the researcher allowed the participants to re ect on their perceptions through the AI. The data analysis and data collection processes were done concurrently.

Methods
The appreciative inquiry was used. Individual interviews were conducted using an exploratory, descriptive and contextual design to explore and describe the perceptions of nurses with regard to the intrinsic and extrinsic factors that motivated them to render quality patient care in rural hospitals despite the challenges. The aim of this methods was give participants time during the interviews to relate their views, options and feelings regarding their responses on the asked questions to illustrate how their hospital would, according to them, be its best and on how it should become. They reshaped (designed) what they had by understanding that they could bring a positive change in their hospital. The participants felt free to narrate their views and interviews assisted them to give in-depth information in their context.

Research design
A qualitative AI was employed based on the 5-D cycle that involved asking positive questions to a group of stakeholders (nurses who directly rendered patient care) in order to craft and implement action plans towards excellence (22). The research design assisted the researcher to execute the study in such a way that the trustworthiness of the ndings was maximised.
Appreciative Inquiry approach For this study an AI approach was employed based on the 5-D cycle which involved asking positive questions to a group of stakeholders in order to craft and implement action plans towards achieving excellence. The ve stages of the 5-D cycle employed in the three phases of this study are brie y described.

De ning stage
During the de ning stage the researcher clari ed the topic of the study. In this study the topic of inquiry was to explore and describe the perceptions of nurses with regard to extrinsic and intrinsic factors that motivated them to render quality patient care in rural hospitals in spite of the challenges. The background and problem statement were clearly described to explain the extent of the challenges being addressed. In this stage the researcher also developed the AI approach interview to guide questions.

Discovery stage
In this section, the design and method for Phase 1 were outlined. A descriptive qualitative research design was used (23). Qualitative research is a way of gaining insight through discovering meaning or a sense of people's perceptions and "the world in which they live" (24).
Using an AI approach assisted the researcher to make use of words to explore and describe the perceptions of nurses with regard to factors that motivate them to render quality patient care in a rural hospital. For this study semi-structured interviews were conducted with the nurses in the selected institution.
The discovery stage involved an assessment of the intrinsic and extrinsic factors nurses deemed as essential to motivate them to give their best. Appreciative Inquiry approach questions were asked to allow nurses working in a rural hospital to appreciate the positive aspect of what they were currently enjoying in their work and what kept them going. The intrinsic as well as the extrinsic factors were determined from what the nurses themselves voiced. Researchers allowed the participants (nurses) to share their positive experiences through interviews regarding who they were and who they wanted to be (14). Furthermore, the participants were asked to discuss the best intrinsic and extrinsic factors that worked well for them.
The participants working in a rural hospital were also discovering for themselves what the core extrinsic and intrinsic factors were that motivated each of them. It bene ted the participants in that it allowed them to encourage one another to realise their strengths so that they would participate positively and be actively involved in the change process. It allowed the participants to consider new possibilities; thus, the nurses' motivation to render quality patient care in a rural hospital was facilitated. The discovery stage assisted the participants to continue with the next stage which entailed "dreaming about what could be.

Dream stage and Design stage
During the dream stage the participants, working in the speci c rural hospital, dreamt about "what could be" (14). Based on the positive experiences of the discovery stage, participants began to dream about possibilities (intrinsic and extrinsic factors) that could motivate them. During interviews, when the discussions proceeded, participants perceived and understood things in a different way. The AI approach questions such as what progress and growth nurses would like to see in the following four years and what opportunities for personal growth, achievement and recognition should prevail in the work environment, were asked.
The design stage involved reshaping the future through dialogue (25). The main reason of this stage was to create a supportive environment for conversation and interaction. A process of common ideas was sought through sharing the intrinsic and extrinsic factors that motivated participants in their work environment in a focus group. This step involved all the participants of the group to co-construct the core intrinsic and extrinsic factors that should prevail in their work environment and how they should be implemented.

Destiny stage
Results of the dream stage and what had been planned in the design stage were implemented. The feasibility of implementing the dream and the design stages in the operational plan (or the work plan) was evaluated. This involved transforming the design stage into more speci c sets of tasks or activities to be put into action. Implementation and monitoring are essential parts of this process. The implementation of these intrinsic and extrinsic factors needed to render effective results that would bring about change in the de-motivation and negative behaviour, thus facilitating the motivation of nurses in a rural hospital. All inputs that were given by the participants, regarding the intrinsic and extrinsic factors that motivated them, the most were translated into reality and their beliefs were put into practice. The plan of action will be presented to the supervisors, managers and nurses so that they could be empowered to promote a positive work environment.
In Phase 1 of this AI study, the researchers followed a qualitative research approach using an exploratory, descriptive and contextual study design to explore and describe the perceptions of nurses with regard to the intrinsic and extrinsic factors that motivated them to render quality patient care in a rural hospital.
The participants were given the opportunity to describe their perceptions regarding the factors that motivated them to render quality patient care in a rural hospital during semi-structured in-depth interviews (26,21).

Data collection procedures
Semi-structured interviews were conducted in phase 1 using an interview guide. Questions asked were; what are the intrinsic factors which motivate you to render your service each day? what are the extrinsic factors which motivate you in your hospital? how best do you think your manager could motivate you to work willingly and effectively?
In Phase 2 focus group interviews were conducted again using a new interview guide with the following questions: what motivated you most in the past and now in the current situation that can motivate others in the future?, what could be the motivating factors towards a positive working environment for your hospital what would they be? What do you think are the most core intrinsic and extrinsic factors for success in your work environment that could be used in the future?

Data analysis
The semi-structured interviews were audio taped and transcribed verbatim in typed format for the data analysis. The transcribed data were subjected to an analysis modelled on an approach of Tesch (23). The six steps of (23) were used during the thematic analysis. Coding ensured that a small number of themes or categories were generated which were in line with Herzberg's two factor theory (27), as it concerns intrinsic and extrinsic factors. For this study the themes appeared as major ndings and were stated under separate headings in the ndings (23).

Phase 2: Dream stage and Design stage
In Phase 2 the researcher conducted a workshop during which the AI approach was used. The researcher used positive AI approach questions to initiate transformative discussions with nurses in the speci c rural hospital to dream about the factors that might enable them to render quality patient care. Based on the experiences shared during the discovery stage, the nurses began to dream about possibilities (intrinsic and extrinsic factors) that could motivate them. During the focus group interviews, and as the discussions continued, the participants saw and understood things in a different way.

Design stage
The third stage involved determining what should be (19). In this stage participants engaged in making plans for the future (19). During this stage the participants had the opportunity to build their future. The researcher looked at the practicalities needed to support the vision that had to be in place for the dream to take place.

Data analysis
Similarly, to in Phase 1, the interviews were transcribed verbatim for analysis. In this phase the obtained data were in the format of group report scripts. The discussions were analysed by using the approach of Tesch (23). The open-coding and analysis technique of Tesch (23) was used to analyse the focus group discussions for themes (26).

Phase 3: Destiny stage
Nurses tend to respond better when we seek to see the best of one another (28). In this stage the consensus was reached on the factors that ranked as the most need to improve quality of care.

Summary Of The Findings
"What are the changes that nurses would like to see in their work environment.

Results
According to the ndings the need to achieve professional growth was ranked number 1 with a total score of 97 (38.34%). The participants indicated the need for an education and training strategy to gain more knowledge and skills; to learn about new developments so that they could render quality patient care with competency and con dence. The researcher is of the opinion that nurses should be accommodated better in this context with regard to their professional development to improve quality patient care.
The need to teach others was ranked number 2 with a total score of 82 (32.41%). The ndings showed that teaching others motivated them because they shared their knowledge. This knowledge sharing does not need to be forced but the nurses' interest in sharing knowledge should be acknowledged and accommodated; if not, it could become a burden. The ndings revealed that there were nurses who enjoyed transferring knowledge to others and who did not wait to be allocated by their managers to teach others. When they felt that the manager trusted them, they felt more motivated to teach.
The need for responsibility was ranked number 3 with a total score of 74 (29.25%). The ndings revealed that nurses wanted to be given responsibility for activities undertaken to own the processes. They felt more motivated when they were responsible for planning the patient's care. The following strategies were recommended for the nurses to sustain their responsibility to stay motivated when rendering quality patient care: See attached; Figure 1

.2: Numerical intrinsic factors
According to the ndings, recognition for good work was ranked number 1 with a total score of 315 (12.09%). The ndings revealed that nurses needed to be recognised for work well done.
The need for positive feedback was ranked number 2 with a total score of 291 (11.17%). The ndings showed that nurses needed positive feedback for their extra efforts. Positive feedback played an important role in creating positive change in the hospital that in turn would result in enhanced quality patient care.
Salary and other bene ts were ranked number 3 with a total score of 289 (11.09%). The ndings revealed that it was important for managers to take notice of bene ts that the participants found motivating. It further showed that nancial incentives could increase nurses' motivation when provided effective care on time.
Work conditions were ranked number 4 with a total score of 274 (10.51%). The ndings indicated that work conditions could increase nurses' motivation provided that it was favourable. It was also revealed that nurses in a rural hospital rendered quality patient care while utilising the minimum resources available to meet their patients' needs. As seen in the ndings, nurses could become highly motivated when they rendered services and had su cient resources.
Interpersonal relations were ranked number 5 with a total score of 264 (10.13%). The ndings revealed that good interpersonal relations were pivotal in bringing about positive changes in a rural hospital.
Adequate technical supervision was ranked number 6 with a total score of 255 (9.79%). The ndings showed that nurses needed adequate technical supervision. It was further revealed that supervisees listened to managers who were friendly because it was then easier for them to follow the managers' instructions. It was also important for managers to be role models to their supervisees to bring about the positive changes that could enhance quality patient care.
Effective communication was ranked number 7 with a total score of 249 (9.55%). The ndings indicated that managers should be aware of how they interacted with nurses. It was shown that managers should make sure that their instructions were clear. They needed to spell out explicitly and in the simplest form what was required. Managers should be speci c when informing nurses about expectations and behaviours. Nurses should be given time to acknowledge what had been said to make sure that they understood the communication correctly. An effective communication strategy is essential to bring about positive change in a rural hospital. Effective communication will maximise all the nurses' morale positively when rendering quality patient care.
Rewards and incentives were ranked number 8 with a total score of 241 (9.25%). The ndings revealed that rewards could be one of the strategies adopted to bring about a positive change in a rural hospital. It was further found that for rewards to be meaningful to nurses it was essential to be linked to performance. The element of recognition should be in place. The ndings showed that when nurses received rewards it made them feel good when they were being appreciated. Involvement in decision making was ranked number 9 with a total score of 238 (9.13%). The ndings revealed that involving nurses in decision making motivated them and they worked wholeheartedly if owning the processes, making sure that they sustained the good reputation of their institution. The ndings further showed that nurses wanted to use their own discretion when rendering quality care. When they were allowed to use their judgement, they felt honoured and became highly committed to make decisions; hence, they were highly motivated to own the processes.
The need for personal security was ranked number 10 with a total score of 190 (7.29%). The ndings indicated that nurses were happy about job security. However, there was a signi cant need for personal security.
See attached Figure 1.

3: Numerical extrinsic factors
The ndings revealed that nurses would like to see the following changes in their work environment: Upholding the standard of professionalism in terms of how they are doing their job and ensuring that they are ful lled as far as their job is concerned. To develop in their career. To be responsible for accomplishing added activities related to quality patient care. To be involved in decision making and be empowered at an early stage to ensure that they take ownership of all processes. To share their knowledge by teaching others and ensuring that they are capacitating each other for the improvement of quality patient care.
Furthermore, nurses would like to see the following changes implemented by the managers.
Recognition for good work to be done immediately to have meaning and value. The managers might fail to provide adequate resources due to processes in place, but should learn to say, 'Thank you' and encourage nurses for further development. Government should provide nurses with a decent salary in relation with the in ation of the country and the managers should ensure that all necessary documents are signed and submitted so that allowances are paid within a reasonable period. Nurses should be respected, and the government should maintain their status by recognising their skills and knowledge.
Individual feedback should be provided so that nurses could change from being negative and to being positive.
The employer should increase nurses' salary scales to be in line with their quali cations. The employer should pay Organisational Speci c Dispensations to all categories of nurses. Tight hospital security in all strategic risk areas should be provided. The employer should provide rural allowances to lower categories of nurses as they are currently not receiving it and they are committed to rendering quality patient care in a rural hospital. Achievements should be rewarded as soon as possible because it would prevent confusion about why a nurse is being rewarded. Recognition of all post-basic courses for payment. Not only a few should be selected since all knowledge and skills nurses acquire are also bene ting the patients in rural hospitals. Revision of salary scales in a rural hospital on completion of their studies for those who are developing themselves and obtaining degrees.
Ensure that there are trusting and supportive relationships. Create a culture of respect and dignity for all team members. Display interest in the work of supervisees. Exemplify respect and warmth to supervisees. Show supervisory behaviour that indicates friendship and mutual trust. Role modelling by the supervisors.

Phase 3: Destiny phase
The managers should give nurses an opportunity for self-improvement and let nurses understand that managers want them to be better than they are. Nurses should be given enough work to do; not too much and not too little.
Reasons why respondents wanted to continue working in the rural hospital The ndings showed that despite the challenges, nurses faced they valued working in their rural hospital.
The factors that motivated nurses to stay in the rural hospital included:

Discussion
The objective of this study was to explore and describe the perception of nurses with regard to what it is that motivate them to render quality patient care in a rural hospital. It was envisaged that a better understanding of the perceptions of these nurses regarding what motivated them would provide insight into the current motivational factors that drive these nurses to render quality patient care in a rural hospital.
Routasalo and Suominen (30) state the question about employee motivation has played a pivotal role in management practice and theory since 20th century.
They reported they can become more motivated if they are sent for different training programmes that are either initialised by the Government or, alternatively, if they are given the opportunity to advance themselves. The "self-motivated learning experience can be transformed into a way of life once motivation and a re exive learning process are in place" (31).
The ndings revealed that participants are motivated by the following factors: love for their patients, ful lling patients' expectations, empathy and patriotism. It was indicated in the ndings that the participants are highly motivated to render good, quality patient care despite the challenges they encounter in their rural hospital. The ndings of this study con rm the Appreciative Inquiry (AI) assumption that in every society, organisation or group" something works" (32). The ndings of the current study are in line with those of the study conducted by (33,34) that emphasises participants described their work as a "calling" and expressed that they love helping others and being satis ed with their job.
The ndings revealed that access to and support for training, education and having opportunities to learn new skills seem to motivate nurses to render quality patient care in a rural hospital. These ndings are similar those of (35, 36) who corroborate that the nurses' need for achievement is derived from initiatives or discretions exhibited in the way they work which, in turn, encourages them to like the kind of job they are doing. The training was described by (34) as a way to gain necessary information to perform their job as a factor that increases motivation.
The ndings further reveal that the moment the participants are part of decision makers they own the processes and become committed and clear about the objectives of the hospital. This nding concurs with that of (37) who found that participants re ected they could be interested in becoming involved in decision and policy making in their work place. Oppollo et al. (36) and (38) agree that it is important for the nurse managers to work closely together with the nurses' union representatives and their nursing staff to develop strategies that make rotation work more palatable.
All the participants shared the need to be recognised, praised and rewarded because it motivates them to develop goal-directedness, take ownership, encourage active participation and involvement, and enhance the realisation of the institutional goal and sustainability in rendering quality patient care in their rural hospital (39). Furthermore, the ndings denoted that performance nancial incentives such as salary increases, non-nancial incentives and other bene ts play a vital role in motivation. The nding of this study revealed that nurses are keen to be recognised for work well done. Researchers such as (39) and (40) found that nurses acknowledge that they perceive recognition as the most effective factor for work motivation. Motivation is encouraged in nurses as it can result in rewards as recognition for good job performance and in this way nurses' job satisfaction can be enhanced.
The ndings in the current study further revealed that the participants seemed to be happy and experienced a personal sense of safety and security because they provided a service that was much needed in their community. Similar ndings are described by (35) in that the participants in their study reported they felt safe because they rendered an essential service in a politically stable area where their personal safety was ensured in the rural health facilities.

Original Contribution
One of the main contributions of this study was to involve the participants in different stages of AI where they were given opportunities to identify their strengths, opportunities and aspirations in their own environment and learned to appreciate what they have. An opportunity to dream and design was also a major contribution as the participants also learned about aspects of this methodology for doing research such as using AI and the steps to be followed. Another contribution was that the participants learned that what they could focus on could become a reality despite the challenges that they might be experiencing; if they focus on the positive aspects in their rural hospital and work towards creating and maintaining a positive work environment it would become a reality. The participants further learned to see things in a positive way as opposed to seeing it in a negative manner.
Furthermore, the study contributed to the body of knowledge and the AI approach offered employees an opportunity to re ect on the existing strengths within the practice situation, leading them to discover what is important and enhance quality improvement in management of rural hospitals in the Limpopo Province.
The AI approach might be used to conduct research studies to add to the body of knowledge and education of nurses as to what actions should be taken to enhance quality improvement in the management of rural hospitals in other developing countries.

Limitations
The limitation of this study was that the research was conducted in only one hospital, a secondary hospital in the Limpopo Province, one of nine provinces in South Africa and did not involve more comprehensive rural hospitals. There might be risks in using Al because it is di cult for some people to maintain a positive stance. In addition, the exible nature and lack of methodological consistency and thoroughness might also be viewed as a limitation of the AI model.

Trustworthiness of the study
The validation of this study was ensured by means of establishing its trustworthiness. The term trustworthiness was used to indicate how the researcher enhanced the validity of the ndings using the model of Guba and Lincoln as described by (29). To ensure the trustworthiness of the ndings the following criteria were used: credibility, transferability, dependability, conformability and authenticity.

Ethical considerations
The ethical clearance was granted by the Research Ethics Committees of the Faculty of Health Science of the University of Pretoria as well as the approval to conduct the research by the Limpopo Province Department of Health and permission by the hospital at which the research was conducted.

Conclusions
The researchers built on the best ideas and used the practice already existing in this rural hospital. The researchers adopted AI as an approach for making positive hospital changes. The AI also served as a foundation for the strength-based approach to strategic planning which entails placing emphasis on strength, opportunities, aspirations and results (SOAR). AI provides a way forward to implement change without force in organisations allowing management, and employees the opportunity to positively in uence the work, design and management of health care.

List Of Abbreviations
AI-Appreciative Inquiry

NGT-Nominal Group Technique
SOUR -strength, opportunities, aspirations and results

Declarations
Ethics approval and consent to participate Ethical clearance was granted by the university of Pretoria ethics committee. Protocol number is (65/2013) Consent was given by the participants before data collection.

Consent for publication
Consent for publication was obtained from the participants.

Availability of data and material
The datasets generated and analysed during the current study are not publicly available. The researcher agreed with the participants that all information given will be con dential between the researcher and the participant's promoters, independent coder where it was necessary.

Competing interests
Authors declare that they have no competing interests

Funding
The researcher was supported by University of Pretoria research funds to pay tuition fees Authors' contributions TR, FM and DR conceptualised the study. TR collection data. TR, FM and DR analysed and interpreted data and TR was the one writing manuscript. All authors read and approved the nal manuscript  Numerical extrinsic factors