The World Café was developed in the mid-1990s as an innovative approach to collaborative thinking (Brown, 2001; Brown and Isaacs, 2005; Schieffer et al, 2004). Brown and Isaacs (2005) describe the World Café as an informal relaxed conversation about questions that matter to the participants in an informal setting. By linking group conversations, World Café accesses shared knowledge that may not be accessible through traditional methods of collaborative work, providing an informal environment for table top discussions. Brennan and Ritch (2010) suggest that World Café is a specialist form of the focus group, capturing the narrative in written form and enhancing creative thinking, expression and communication (McAndrew et al, 2012; Wilkinson et al, 2012).
This article explores the literature related to World Café and presents a case example of the use of World Café in a teaching programme for midwives and student midwives about domestic abuse.
Literature review
Unlike traditional methods of active and reflective learning (Revans, 1998; Marquardt et al, 2009) World Café uses an appreciative enquiry approach as described by Cooperrider and Srivastva (1987). As such, World Café builds on positive aspects (Brown and Isaacs, 2005) rather than on problems or dysfunction (Stowell and West, 1991). Burke and Sheldon (2010) suggest World Café increases engagement and achieves success by learning from staff innovation, as groups engage in constructive dialogue (Fouche and Light, 2010; Shaw et al, 2012). From a social constructionists’ philosophy, appreciative enquiry takes the idea of the construction of reality to its positive extreme changing the way people view the world through structured discussion (Aldred, 2009).
World Café uses collective thought to gather information with the aim of producing productive change. Action research traditionally tries to solve a problem. In contrast, Word Café concentrates on purposeful, motivational questions that produce constructive responses, moving beyond participants’ receiving knowledge to having an active role in knowledge creation (Karvinin-Niinikoski, 2005; Aldred, 2009; Fouche and Light, 2010). World Café is recognised as an effective learning and change management tool (Schieffer et al, 2004; Brennan and Ritch, 2010) and a good method for focusing on complex social issues (Thunberg, 2011; Trainor et al, 2012).
The World Café is an increasingly popular approach to action research in health and social care (Burke and Sheldon, 2010; Thunberg, 2011; Fallon et al, 2012; McAndrew et al, 2012). However, only two studies were found to have examined its use with midwives (While et al, 2006; Nursing and Midwifery Council, 2012) and in midwifery education (Chenery-Morris, 2012).
The setting
The safeguarding study day was a non-mandatory day provided by the Trust to showcase some of the innovations that were taking place within the maternity unit. One of the authors was asked to host a 45-minute domestic abuse workshop on a safeguarding study day for midwives, including student midwives. She was concerned that she would not be able to cover something so complex in the short time allocated. Coincidentally, the author also was working on a project to develop an antenatal care pathway for women who experienced domestic abuse. The World Café format seemed ideal for facilitating the domestic abuse workshop and had been shown to be an effective health service development tool (Burke and Sheldon, 2010). It was also felt that the World Café would provide a good platform to exchange ideas and practises with midwives from other Trusts while gathering information for use with the domestic abuse pathway she was currently developing. There are seven design principles of World Café (Brown, 2001; Schiefer et al, 2004; Brown and Isaacs, 2005) that supported the preparation, presentation and evaluation of the workshop experience. These are: setting the contexts, creating a hospitable space, exploring questions that matter, encouraging everyone's contribution, connecting diverse perspectives, listening together, sharing collective discoveries.
The aim of the café was a reflective learning workshop, using structured conversation to brainstorm and exchange ideas (Trainor et al, 2012), turning collective wisdom and experience into learning (Emlet and Moceri, 2012). The World Café is based on the assumption that the knowledge and wisdom we need is already present in the room with intelligence emerging as people connect (Fouche and Light, 2010). By connecting midwives’ thoughts and experiences of domestic abuse issues from their practice it was hoped to generate ideas to better identify and support victims of abuse.
Evidence suggests that organisational barriers, problems with multi-agency working, midwives’ personal views and a lack of both pre- and post-registration training all contribute to the difficulties experienced with routine enquiry into domestic abuse (Table 1).
| Midwives views | Supporting evidence |
|---|---|
| Time constraints / workload / staff shortages / low staff morale | Stenson et al, 2005; Buck and Collins, 2007; Mezey et al, 2003 |
| Jeopardising the client–professional relationship | Buck and Collins, 2007 |
| Lack of confidential time with the woman / partner present | Stenson et al, 2005; Buck and Collins, 2007 |
| Language difficulties | Stenson et al, 2005 |
| Finding the subject difficult and challenging / feeling uncomfortable / do not know how to ask / lack of confidence | Lazenbatt et al, 2005; Stenson et al, 2005; Buck and Collins, 2007; Lazenbatt, 2010; |
| Uncertainty and frustration with how to proceed with the situation / inability to help if domestic abuse is disclosed | Stenson et al, 2005; Buck and Collins, 2007 |
| Fear of making the situation worse | Buck and Collins, 2007 |
| Gaps between knowledge and practice / lack of training | Bennett et al, 2001; Crisp and Lister, 2004; Baird et al, 2005; Barnett 2005; Stenson et al, 2005; Buck and Collins, 2007; Bull, 2008; Lazenbatt and Thompson-Cree, 2009 |
| Conflict between the role of caring for the woman and their child protection role | Buck and Collins, 2007; Wood, 2008 |
| No shared understanding of what defines the child protection role / not their responsibility | Crisp and Lister, 2004; Buck and Collins 2007; Wood, 2008; Lazenbatt and Thompson-Cree, 2009 |
| Lone working and practitioner safety, especially for those working in community | Price et al, 2007; Buck and Collins, 2007; Wood, 2008 |
| Personal experience of domestic abuse | Barnett, 2005; Buck and Collins, 2007 |
It was hoped that the workshop would highlight ways of improving services and experiences for both women and midwives, which the participants could take back and further develop in their own units. The World Café website (www.theworldcafe.com) was helpful in planning and carrying out the café as it contains a wealth of information and tools for guidance, providing useful pictures and resources to download.
It was expected that 12 midwives would be attending from five Trusts, and therefore, three tables were planned for this domestic abuse ‘café’. Brown and Isaacs (2005: 163) suggests that World Café may not be the optimal choice for less than 12 participants or a time allowance of less than 1½ hours; as only 45 minutes were allocated for this session, the author was anxious for the format to work. As the workshop was scheduled within a day-long study day and after a coffee break, it was decided to allow the participants to take their break in the ‘café’ room (it was a café after all!), which would save valuable time in terms of settling down and introductions. The session began with a short introduction to explain what was expected of the group, the objectives and World Café etiquette. This was followed by three 10 minute rounds of questions/discussions and 15 minutes at the end to come together as one group.
Creating a hospitable space
A key element of World Café is creating a welcoming atmosphere. Brown and Isaacs (2005) argues that creating a safe, inviting and informal space using the café environment encourages more generative and authentic conversation. Thunberg (2011) suggests that the morning coffee break or afternoon tea have always been a source of reflective learning therefore a World Café format would be a normal hospitable space for many participants. World Café uses naturally occurring networks of conversation and social learning through which we traditionally access collective intelligence (Brown, 2001).
The challenge was to transform a traditional classroom into a café. Following negotiation with the canteen manager in the hospital where the workshop was being held, the workshop facilitator was allowed to use her bistro style tables and chairs. Schieffer et al (2004) suggests that small tables facilitate a more intimate connection, drawing people closer together deepening the quality and depth of the conversation. The optimum number of people around each table is four, allowing intimacy with everyone participating in the conversation. Wall art was downloaded from the World Café website, table decorations were borrowed and ambience was created with ‘mellow jazz’ playing in the background. The tables were covered with chequered tablecloths and paper for guests to write on, coloured pens, pencils and crayons and a flower to complete the effect. With the aid of PowerPoint, the white board in the classroom was transformed into a large piece of art.
As the ‘guests’ arrived refreshments were served. A large welcoming message showed on the screen at the front of the room as the participants entered the café.
Exploring questions that matter
A challenging part of the preparation was developing the question. World Café is intended to open new possibilities for enquiry around questions that matter (Schieffer et al, 2004) paying particular attention to the phrasing, which may strongly effect the answer. The question is meant to be positively focused, encouraging participants to concentrate on what could happen, not what is happening (Carter et al, 2012). A powerful question is one that is simple, clear and thought provoking, producing positive constructive responses (Brown and Isaacs, 2005; Fouche and Light, 2010). The author sought an open-ended, stimulating question to prompt positive thinking and generate new ideas and eventually decided on:
‘How can we motivate midwives to routinely enquire about domestic abuse and better support victims?’
Encouraging everyone's contribution
The World Café challenges the structure and authority that normally is present within discussion groups. Brown (2001) claims that the World Café design creates psychological safety and lessens inappropriate grandstanding and individual attachment to points of view, features often present in group settings (Donovan et al, 2005).
In introducing and illustrating the World Café principles and etiquette at the beginning of the workshop, the following were highlighted:
Following this, three simple objectives from the author's perspective were shared with the group:
Ethical approval
Prior to the workshop the author approached the Trust's Research and Governance Department to discuss ethical considerations, around using this type of workshop with a view to publishing the findings. They informed the author that this was not a problem as long as attendees were all professionals, not patients and they were informed at the start of the workshop with no objections.
At the start of the World Café workshop, the author also asked the participants whether they objected to her using information gathered for a possible future publication. There were no objections. As the topic was an emotive one, the author also offered fall-back support for anyone who might want to leave or to discuss personal issues with our counsellor.
Methods
The first round of conversation began and after each 10 minute round, participants moved to another table sitting with different people to continue the conversation. As host, the author moved around the tables, prompting participants to write down their ideas on the paper table cloths to ensure nothing was lost (Schieffer et al, 2004). This approach appeared to work well with the room buzzing as the conversations warmed up.
Connecting diverse perspectives
A defining feature of World Café is the intentional cross-pollination of ideas as people move from table to table (Schieffer et al, 2004). Knowledge forms across the shifting groups (Wilkinson et al, 2012). As the discussion evolves, it forms a basis of further analysis in rounds of questions (Wilkinson et al, 2012). During these rounds differing perspectives are able to focus on common issues, encouraging new themes to emerge (Carter et al, 2012). Brown (2001) suggests that a shared knowledge base develops that is larger than any individual or group in the room.
Between rounds the author asked one of the guests to remain on each table to act as table host. The aim of this role was to share key points and inform new arrivals of the seeds of previous conversations. This enabled the conversation to avoid repetition. Instead, the subsequent conversations reached new depth and breadth. Table notes served to connect ideas (Schieffer et al, 2004).
Burke and Sheldon (2010) argue that the World Café engages all levels of staff encouraging equal participation and this seemed to be demonstrated at this café as experienced midwives and students equally contributed to the conversations.
Listening together
The World Café establishes an arena of dialogue which develops reflective learning through analysis of experiences (Thunberg, 2011). It yields valuable ideas for different communities united by common problems; providing a good platform for collaboration between different organisations (McAndrew et al, 2012; Trainor et al, 2012). Notes and doodles become transcripts that develop into themes (Emlet and Moceri, 2012). Four main issues seemed to emerge from the discussions (Table 2).
| Routine enquiry |
| Opportunistic enquiry |
| Information |
| Disclosure |
Routine enquiry
One of the main sub-themes was how to phrase the question in routine enquiry. Several suggestions were made including the need for guidance for midwives in notes related to undertaking routine enquiry. Another sub-theme was when to ask questions about abuse and the consensus was that the best time was during the initial appointment, while the social history is taken. This supported the guidelines that the author had written in line with guidance from the National Institute for Health and Care Excellence (NICE, 2010) and the Department of Health (DH, 2005). A third sub-theme was absence or presence of the partner during routine enquiry. Suggestions were made about what to do if the partner was present, including: sitting the partner further back and pointing to the question, have the woman fill in a form or take the woman out of the room. However, NICE (2010) states that women should be alone when asked about abuse. The pathway being constructed by the author offers all women a solo booking appointment.
Opportunistic enquiry
It was highlighted in the World Café that opportunistic enquiry should also take place later in the pregnancy, as pregnancy may trigger or exacerbate abuse (Steen and Keeling, 2012). The woman's body language or partner's controlling behaviour were identified by the group as possible indicators, and improved communication between accident and emergency departments and maternity would help identification of abuse.
Information
Another theme that emerged was how to provide information to pregnant women. Suggestions made by participants included displaying information in the ladies’ toilets, and having systems in place that allow the woman to discreetly signal if she wants to talk alone. Giving women small credit card sized safety information and emergency numbers that can be concealed was also raised.
Disclosure
There was discussion around the need for individual care plans and longer, more flexible appointments. It was suggested that on disclosure of abuse by a woman, the midwife should follow up her/himself rather than relying on other members of staff. It was suggested that the women may have difficulty trusting their midwife or a fear of the involvement of Child Protection creating reluctance to disclose. It was suggested that women should be asked what they want the midwife to do. Following disclosure, collaborative care and good communication were discussed, but not who should be collaborating and communicating with whom. The author perceived this as a potential gap in knowledge, which is discussed later in this article in the context of the end activity in the World Café when everyone came together as one group.
Sharing collective discoveries
Fifteen minutes before the end of the café, the participants at each table were asked to write down the main theme from their conversations, so that links could be made between the discussions to form one conversation. The final group discussion was limited due to lack of time and more could have been achieved with additional time.
Three main themes were identified from the final group discussion: pathway, time management and communication problems.
Pathway
The first table identified that staff needed a clear pathway of care for domestic abuse. This enabled the author to introduce into the final discussion the evidence-based antenatal pathway that she was constructing, including discussion on the importance of multi-agency collaboration and the roles of other statutory and voluntary expert agencies, such as Social Services, the Police and Women's Aid, as well as the role of the Multiagency Risk Assessment Conference (MARAC) for high-risk women. In the final discussion, the author highlighted the importance of the National Domestic Abuse helpline number, which enables contact with agencies and also responds to non-English speaking women. Several of the ideas and issues discussed at this World Café were features of the antenatal pathway for domestic abuse including:
Time management
There were concerns about dealing with these issues in busy clinics with others waiting to be seen. Suggestions offered in the discussion included seeing the woman again when there was time for more detailed discussion, possibly after the clinic or the following day, providing the woman was in no immediate danger. The group also discussed the fact that many women may have been living with the problem for some time and the importance of making suitable time to talk at length and not rush them.
Communication problems
One table in the café highlighted communication issues with non-English-speaking women. Problems with family members and partners acting as interpreters were also discussed. NICE (2010) states that only professional interpreters should be used and the group discussed ways of sensitively explaining to family members that their services would not be required, the possibility of using telephone interpreting and that it was not only partners who may be abusive but any family members in positions of authority and control.
Evaluation of the World Café
The World Café was evaluated through a participant questionnaire. In addition, the workshop was evaluated as part of the entire study day evaluation, of which the World Café was but one session. The results of the evaluation can be found in Figure 1.
The evaluation made no attempt to evaluate the student midwives’ experiences of the World Café from those of the qualified midwives. Despite students having less experience with the subject of the midwives’ role in domestic abuse, they made a significant contribution to the World Café. Indeed, the ethos of the World Café is to include all participants on an equal basis as the combination of different levels of experience add to the discussion; often those with less experience see issues from a different perspective.
The evaluation of the participants’ experience was unanimously positive, with two participants highlighting the World Café session as the most valuable part of the day. All participants indicated that they would recommend the World Café session to a colleague. The evaluations also showed that participants understood and referred to the antenatal pathway for domestic abuse and found it engaging and informative. They enjoyed exchanging ideas with, and gaining knowledge from, midwives from other trusts. However, it is important to acknowledge that these were highly motivated midwives prepared to fund and attend a study day in their own time. Less motivated participants may be less positive. Nevertheless, the objectives of the session were met, including some later evidence emerging about how participants went on to use what they learned from the World Café in their practice.
From the literature, the use of World Café has provoked positive feedback from a number of authors (Brennan and Ritch, 2010; Burke and Sheldon, 2010; Thunberg, 2011; McAndrew et al, 2012). However, Donovan et al (2005) found that it could be a negative experience when the conversation focused on barriers. The only negative evaluation received in the study presented in the article was lack of time, which had been predicted, and when the author uses World Café in future, she will request a 2 hour workshop as suggested by Brown (2001).
Conclusion
World Café is a powerful conversation process (Brown and Isaacs, 2005) with naturally occurring networks of conversation and social learning which access collective intelligence to create new knowledge (Brown, 2001). Its simple methodology yields valuable experiences for diverse groups united by common problems (Trainor et al, 2012).
Using the World Café for this domestic abuse workshop was successful and rewarding. The time and effort spent preparing the café to create a welcoming atmosphere proved worthwhile as the café evaluated to be an extremely good platform for exchanging ideas on the socially complex subject of routine enquiry about domestic abuse. Comments and suggestions made reinforced the necessity for a supportive framework and the continued development of the antenatal pathway for domestic abuse.