Designing narrative for professional development: A programme for improving international health care practitioners’ cultural competence

To maintain and improve skills for practice, health care professionals across all disciplines need to engage in ongoing professional development. However, helping clinicians learn and apply new knowledge in practice can be challenging. This article reports on a purpose-designed professional development programme targeting experienced practitioners of a particular music therapy, focusing on their cultural competency. The author conceptualised a workshop format with a relevant clinical scenario at its centre. She describes how she developed the programme, which she subsequently delivered to an international community of 57 practitioners attending professional development conferences. To capture participants’ reactions and evidence of their new thinking applied to an everyday clinical practice, she used Brookfield’s Critical Incident Questionnaire (CIQ). Her analysis of the data, which provided feedback on the training scenario and structured group discussion materials, found that this continuing professional development training workshop was effective in challenging clinicians to think differently, and to plan the application of their newly acquired knowledge to their everyday practice. This paradigmatic case study contributes new knowledge towards the current reform of health systems, where achieving person-centred health care depends on the ongoing professional development of established health practitioners. Replacing traditional health care, where the patient receiving treatment is accorded a passive role, person-centred health care engages patients’ active participation in their therapy. Practitioners who have graduated a while ago therefore need to change some of their ingrained practices and approaches in treating their clients and patients, which will then lead to improved health outcomes.


Introduction
In line with current ecological approaches to health, the human being is seen as both an individual and holistic being (mind-body-spirit) and at the same time is influenced by the social determinants of health such as family, community, environment and culture (AFMC 2014; Short 2019a). Whilst many health practitioners have been trained in individual care, a broader and deeper understanding of how individuals interact with and are influenced by their ecological context may be slow to be fully understood (McCormack et al. 2011;Golden and Earp 2012). Further, current models of person-centred care assume both initial and ongoing skills development of 1 3 Designing narrative for professional development: A programme… health practitioners across the span of their working life (King et al. 2021;Bogdanova et al. 2017). Such ongoing and lifelong education is typically taught by advanced practitioners within a professional development model, supporting increased evidence-based practice and ongoing reflective knowledge development across the specific profession.
In fact, ongoing continuing professional development is increasingly required across all health fields (Burke et al. 2016;Herold et al. 2005;McArdle and Ackland 2007), but engaging established clinicians in training and getting them to put their newly acquired skills into practice can be challenging (Berkhout et al. 2017;Kristensen et al. 2016). In fact, health services around the world typically invest considerable resources in efforts to improve practical implementation of new knowledge. Application difficulties are commonly known as the "research-practice gap" or the "evidence-practice gap", and many implementation science researchers 1 actively work to embed clinical knowledge at service provider level to improve client care with established (i.e. tried and tested) best practices (Burke et al. 2016;Mick 2017;Ploeg et al. 2014).
For some health professions, recognition within a therapeutic discipline is linked to certification of ongoing professional development. This is the case for music therapy (Edwards 2015;Register 2002;Wheeler 2015), which is the focus of this article. Often working in private practice, music therapists using the psychotherapeutic method of Guided Imagery and Music (GIM) must engage in regular continuing education activities to maintain clinical skills (Grocke 2019). International accreditation for GIM practitioners and this specialised method of music therapy is provided by the Association for Music and Imagery (AMI), the Music and Imagery Association of Australia (MIAA) and the European Association for Music and Imagery (EAMI).

Guided imagery and music (GIM)
Guided Imagery and Music (GIM) therapy started off in the early 1970s, as relaxation and a prepared tape of music selections had begun to bring surprising results. Therapeutically meaningful imagery was evoked by careful application of classical music, and this approach was sometimes more effective than the longer, more intense drug sessions (Bonny 1994, p. 70).
Initially conceptualised in the United States by American music therapist Helen Bonny (Bonny and Savary 1973), and further developed since, the GIM method has meanwhile gained international acclaim (Bonny 1994;Grocke 2019). Using predominantly Western classical music, GIM is an inherently culturally bound genre (Short 2019b). Despite the music being conceptualised by Bonny as broadly "archetypal" in nature, many instances of unexpected cultural specificity have been noted 1 3 anecdotally in GIM practice. Examples of imagery associated by some clients with particular music include a black swan (Australia) or the music of "Greensleeves" signalling the mobile ice-cream van in some cultures (Short 2003(Short , 2006. It stands to reason that Western classical music is unlikely to suit the therapeutic purpose of relaxation and imagery generation for patients/clients from all cultural backgrounds. Moreover, with a global increase in migration, the number of patients/clients seeking help from a GIM practitioner in a country/culture of differing ethnicity is likely to rise.
So far, no studies have investigated how professional development activities can be uniquely developed for and applied by these specific health professionals. In this article, I use a case study research approach to track and evaluate the development of learning materials and the implementation of these materials within professional development training. The research questions guiding me in this endeavour were: • Can tertiary-level education techniques of using a purposely designed scenario and worksheet with small group class activities be applied to engage a specific group of practitioners in professional development training? • Can this unique approach be effective in challenging clinicians to review their everyday practices and in promoting critical thinking aimed at applying this new knowledge in their individual ongoing practice?
To answer these questions, I explored the pedagogy of continuing education, narrative scenario-based learning, real-world learning and educational problem-solving approaches and their potential to assist with applying new knowledge into everyday practice.

The pedagogy of continuing education
Across the literature, there is scant evidence about the process of devising and implementing continuing education (professional development) training for health care practitioners, despite the undoubted need for specific training. Since clinicians already have at least one first academic degree, professional continuing education for this group of health care personnel can typically be informed by a higher education (tertiary-level) approach to teaching. Many practitioners have left the higher education context many years before settling into work in the health industry. Therefore, engaging these learners in continuing education requires additional effort to deliver relevant materials with a view to improving their practical and applied professional skills (Berkhout et al. 2017;Jackson et al. 2019;McArdle and Ackland 2007). Experienced practitioners may be leery of formal lectures and textbook knowledge. However, these learners typically respond well to clinical case reflection and practiceoriented approaches to professional skills development, since reflective practice is integrally related to the critical thinking skills needed by all health care practitioners in everyday practice (Duchscher 1999;Mantell and Scragg 2019). Within the higher education context, the increased use of groupwork, questioning and dialogical techniques supports reflective practice and critical thinking in 1 3 Designing narrative for professional development: A programme… engaging with learners (Di Stefano et al. 2019;McArdle and Ackland 2007;Oelofsen 2012;Tummons 2019), extending well beyond formal lectures. The traditional lecture format is limited by a lack of feedback about students' learning progress, the promotion of students' passive learning, limits to teaching higher-order thinking 2 and "unreasonable demands on student attention", all of which contribute to making the lecture format less effective than active approaches (Cashin 1985, as cited in Butler et al. 2001Freeman et al. 2014). Whilst the lecture format inherently provides more material (in terms of many facts and the lecturer's detailed research experience), student retention rates may be low, with suggestions that students' attention span is typically 10-20 minutes (Christopher 2003). Since knowledge is individually constructed by each learner (Biggs and Tang 2011), much of this process happens in response to social interactions with other human beings. Likewise, optimal learning occurs via doing and engagement, not just watching and listening (Christopher 2003;Taylor and Parsons 2011).
Principles of adult education apply to the learning and teaching context both at university and beyond; students bring their own experiences and prior learning from a wide range of sources to the educational context. Mark Tennant and Philip Pogson (1995) argue the need for building on and extending the previous experiences of adult learners' prior experiences by carefully linking their teaching materials to these experiences. This is picked up through experiential learning, fostering even more learning via reflective practice processes (Tennant and Pogson 1995;Vann 2017), thereby supporting lifelong learning.
The concept [of lifelong learning] implies that an individual's life course can no longer be divided into a period of preparation followed by a period of action, rather that learning extends across the whole lifespan in different life phases. The concept also implies that learning takes place not only in formal schooling and training settings but also in diverse learning spaces, and that learning can be provided through a variety of means and pathways (UIL 2022, p. 17).
In continuing professional development, the concept of lifelong learning is evident across many professions, linked to movements such as the University of the Third Age (Jarvis et al. 2003;Jarvis 2014), and has behavioural, cognitive, social and experiential foundations (Jarvis 2014;Jarvis et al. 2003).
The social and interactive context of learning is important for education. Key theorist and researcher John Biggs (1999, andBiggs andTang 2011) suggests involving university students taught in a typically large class context in collaborative learning and knowledge construction by way of social learning groupwork strategies and active questioning techniques. Karen McArdle and Aileen Ackland use dialogical approaches within communities of practice within their learning and teaching approaches (McArdle and Ackland 2007). Breaking up a formal lecture to apply an active learning activity increases engagement and motivation for students to attend class (Butler et al. 2001), with students reporting that this helped them absorb the learning material (ibid.). Enthusiasm on the first day of class is promoted via engagement practices (Eskine and Hammer 2017), linking to class attitudes and motivation. Interactive learning within lectures comprises "orderly brainstorming in which students generate ideas in response to a question or prompt" (Christopher 2003, p. 85). In interactive lectures, "the instructor not only presents materials, but also elicits questions and comments from students, stopping periodically to pose questions for student consideration" (ibid., p. 86). The amount of information presented is reduced to promote retention and effectiveness compared to a traditional lecture format.
Interactive lecturing has been applied to many health disciplines, promoting active involvement, increased attention and motivation, higher-order learning and problem-solving, increased feedback for both the teacher and the student, and increased satisfaction for the student and the teacher (Preetha et al. 2019;Ratelle et al. 2017;Steinert and Snell 1999). The materials presented in interactive health care teaching have typically been real-life case studies sourced from everyday practice (Nilson 2016), but such case studies often carry extraneous peripheral and irrelevant materials distracting the learner. Nevertheless, relevant examples of practice are important for scaffolding adult learning and ultimately promoting practice change.

Narrative scenario-based learning
Stories are fundamental to the creation of meaning, linking to identity and adult development (Easton 2016;Rossiter 2002).
The most effective way to reach learners with educational messages is in and through these narrative constructions. Learners connect new knowledge with lived experience and weave it into existing narratives of meaning (Rossiter 2002, p. 1).
In higher education and professional development, narrative and story are connected via case studies, scenarios and critical incidents (Moon 2010). Stories are used to facilitate learning in different forms; scenarios are particularly selected to promote deeper understandings. They are personal or fictional stories that "lift a selected situation out of the 'here and now' for special attention" (ibid., p. 125), and storybased learning promotes critical thinking to enrich and enliven teaching and learning processes. For Brian Pentland (1999), stories are enacted rather than simply told, with typical features of narrative text being (1) sequence in time, (2) a focal actor or actors, (3) an identifiable narrative voice, (4) "canonical" or evaluative frames of reference, and (5) other indicators of content and context. He states, "to the extent that stories play an active role in shaping our interpretations, expectations, plans and actions, they are a particularly salient factor" (ibid., p. 720). The way in which we use, tell and structure stories is important for learning and communication, thereby informing scenario development for professional development training.

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Designing narrative for professional development: A programme… Narrative material used in the learning context must be appropriately tailored for the student learning experience, and it is of vital importance how a case study is devised to function as a case scenario addressing the learning aims and context. The conceptual framework for developing new teaching cases put forward by Sara Kim et al. (2006) is based on reviewing 100 studies across many disciplines, with subsequent applications to health contexts (for example, Gupta et al. 2018). Kim et al. (2006) see case studies as needing to be (1) relevant, (2) realistic, (3) engaging, (4) challenging, and (5) instructional (see Figure 1).

Intrinsic effects: real-world learning and educational problem-solving
Stories' intrinsic effects on learning include promoting elements of problem-solving, addressing educational issues, understanding real-world applications, and fostering disruptions in thinking. Narrative scenarios used for teaching promote learning outcomes in several ways within the learning context (Alinier 2011;Jonassen and Hernandez-Serrano 2002). First, they form instructive examples. Second, they are used as problem cases to be solved, and third, they function as advice in approaching similar stories or cases. David Jonassen and Julian Hernandez-Serrano comment: Because stories are essential to solving complex, everyday and professional problems, we believe that stories should form a basis for learning how to solve these problems (Jonassen and Hernandez-Serrano 2002, p. 76).
Stories inherently promote interaction with the listener; likewise, shared stories link people together through common discussion and shared engagement, supporting the educational endeavour.
The concept of educational engagement has rarely been studied in detail (Bryson and Hand 2007), with the debate over the nature of "engagement" focusing on Conceptual framework for developing teaching cases (from Kim et al. 2006, p. 869). both the behaviour and the orientation of the learner. In terms of scale and context, engagement may be seen to occur within a classroom or task, a particular module, across a programme of study, and/or within the entire focus of (higher) education. Lack of engagement may result from "our curriculum design, implementation, or weak alignment between sought outcomes and teaching delivery" (ibid., p. 360).
Student engagement is strongly influenced by providing a "natural critical learning environment" (Bain 2004, p. 18), and in health education, "real-person" interactions serve to build rapport and understanding (Ross 2013). For experienced practitioners, engaging with story-based learning as a realistic simulated "real-patient" scenario can provide a critical learning environment. Setting up a "disruption to thinking" and a "disorienting dilemma" as a catalyst for critical reflection is important for the learning process, forming a "critical incident" to stimulate the learning situation (Gilstrap and Dupree 2008, p. 409). Such critical incidents are facilitated by the use of case scenarios with built-in ambiguity as "messy" problems (Tallent 2016, p. 1), challenging the learner to respond and think in new ways.
The project presented in this article developed and implemented a narrative scenario specifically devised to match the materials to be taught and stimulate participant discussion. I had been invited to hold a keynote professional development seminar for GIM practitioners during the 22nd biennial conference of the Association for Music and Imagery. I developed a professional development workshop for GIM practitioners, which I conducted in Canada in 2013 (as the keynote of the conference) and repeated this workshop in Australia in 2014.
This documented case study focuses on how the training provided during two iterations of that workshop was developed and implemented to shape the narrative case to fit the needs of the learning group of experienced practitioners. This article tracks processes of decision-making and development of the training materials for delivery. It also reproduces some of the attendees' responses to the implementation of the training, captured using a critical thinking tool which anticipates changes to practice.

Method
The case study presented here aims to create an educational initiative to address the learning needs of established health care practitioners relating to the specific issue of cultural competency, thereby influencing future practice. It explores the principles used for the development and application of a learning workshop which attracted established international practitioners. This was subsequently evaluated to determine the engagement, reflection and critical thinking of the participants and investigate the influence of their learning experience on evidence-based practice.

The case study approach
The case study methodology addresses the complexity of multiple streams of data with a depth and richness of discussion within an applied real-life context (Alpi and Evans 2019). This particular project forms an instrumental case study (Wolf et al. 2017;Stake 1995), emphasising the specific development of a scenario approach for professional development education. An instrumental case study focuses in particular on "the dynamics of the topic" rather than an individual or unique case (Wolf et al. 2017), and the purpose of the current case study is descriptive in nature (Wolf et al. 2017;Yin 2009Yin , 2018, describing and clarifying responses to the training within the professional development learning context. Rich detail results from delving into issues around professional development training with a specific group of health professionals across two iterations of the same training with a similar cohort. None of the practitioners attending these trainings had engaged in interactive learning experiences with a similar methodological approach before, therefore all participants formed a naive sample, and this case study may be considered a paradigmatic case with "prototypical value" (Flyvberg 2006, p. 232).

Context/participants
The workshop featured in this case study built on a peer-reviewed article I had published earlier on cultural dimensions of music and imagery (Short 2006) and was prompted by my being invited to hold a keynote professional development seminar at the premier worldwide conference for the GIM method. 3 The resulting workshop focused on training one specific health care professional group in cultural sensitivity. Using identical materials, I conducted this workshop with two international groups of practitioners in both Canada (Short 2013) and Australia (Short 2014) as part of their professional development activities. GIM practitioners from around the world who had chosen to attend either of these two professional development workshops formed the entire cohort of participants (N = 57) being considered in this case study. Attendees were from Australia, Canada, Colombia, Greece, Hong Kong, Ireland, Mexico, South Africa, South Korea, Spain, Sweden, the UK and the United States.
My keynote seminar was underpinned by the recognition that the predominantly Western classical music originally conceptualised for GIM was somewhat culturally biased, and that there was a clear need for addressing and expanding cultural sensitivity in GIM practice (Short 2013). In this seminar, I was able to harness my own pre-existing interprofessional health and practice and cultural studies knowledge (Blignault et al. 2004;Sheikh et al. 2011). Minorities exist worldwide within multicultural communities, making the issue of culture a "hot topic" for GIM therapists' preparation for understanding and addressing clients from diverse cultural backgrounds (Short 2019b).

Conceptualising the workshop
Conceptualising the workshop, I explored frameworks for teaching cultural sensitivity and competence in order to effectively teach cultural understandings for everyday practice. The resulting Embedded Scenario Training -Cultural Practice (EST-CP) professional development workshop was specifically designed for GIM practitioners, seeking to advance their cultural competence in a way they would be able to embed easily into their applied practice. Culture affects many aspects of health, ranging from client willingness and capacity to accessing services and adopting knowledgeseeking behaviour (Blignault et al. 2004;Sheikh et al. 2011); cultural issues in health are considered important in many health and therapy contexts (Coyne 2001;Fang and Wark 1998;Lo and Fung 2003). Frameworks can guide practitioners in dealing with cultural issues with their clients. Such frameworks include the two models I selected for my workshop: The ETHNIC and the CRASH models (see Table 1). ETHNIC stands for Explanation, Treatment, Healers, Negotiation, Intervention and Collaboration (Levin et al. 2005(Levin et al. [1997; Levin et al. 2000;Kobylarz et al. 2002). CRASH (or CRAASSH) stands for Culture, Respect, Assessment, Affirmation, Sensitivity, Self-awareness and Humility (Rust et al. 2006).
I conceptualised the Embedded Scenario Training -Cultural Practice (EST-CP) professional development workshop to be credible and acceptable to experienced GIM practitioners, comprising a workshop with an embedded specific scenario narrative to fit the educational goals. Scenario and storytelling techniques have been used and explored in cultural training (Sell 2017). Successive drafts of the developing scenario narrative were reviewed by several practitioner advisors as key informants. The aim of the EST-CP concept was to devise a sufficiently open-ended and ambiguous narrative scenario requiring participants to think hard clinically, thereby presenting disruptions to thinking and disorienting dilemmas as a basis for encouraging critical thinking (see Gilstrap and Dupree 2008). The narrative scenario needed to meet criteria of being relevant, realistic, engaging, challenging and instructive (Kim et al. 2006). It was important that the scenario narrative was sufficiently "bland" without cultural indicators (name, picture) giving cultural clues to cultural identity. An iterative development process was  (Levin et al. 2005(Levin et al. [1997; Levin et al. 2000;Kobylarz et al. 2002) (Rust et al. 2006) 1 3 Designing narrative for professional development: A programme… linked to the proposed teaching application of the CRASH and ETHNIC frameworks, with training materials adapted to meet reflective norms in the professional group. This included using art and musical materials as stimuli for discussion/activities related to their experience and practice.

Development of the training materials
The development of the training materials for the EST-CP workshop was influenced by my own advanced knowledge, gained through a graduate certificate course in University Learning and Teaching, which I completed at the University of New South Wales (UNSW) in 2012. This included gaining experience in specifically creating narrative scenarios for teaching (Short 2011). In addition, I was also able to build on practical skills and experience about frameworks and acronyms, acquired through several years of regular and ongoing teaching of medical students within a Cross Cultural Communication subject (UNSW). Finally, the development of the training material was further supported by additional knowledge I had gained from multiple culture-related research projects (Blignault et al. 2004;Folagbade et al. 2008;Sheikh et al. 2011). Conceptualised with integrated learning tasks -underpinned and extended by lecture materials, worksheets and challenging questions -the workshop was devised to relate to scenario-based teaching for professional development. The whole package was designed to be credible, relevant and accessible for GIM practitioners, and the embedded scenario specifically developed for teaching them about cultural competence (see Table 2) aimed to stimulate participants' critical thinking skills and prompt a collaborative learning experience.

Scenario
A young woman, called Noor, phones you asking for a GIM appointment. She is a friend of one of your other clients, and has not long been in your country. Her friend comes with her and waits outside the door.
She is reluctant to say much about herself. She often has her head down and averts her eyes, but keeps looking at the mandala art materials and so you offer that she could use these.
She accepts. You give her some time, and she draws a flower.
She smiles when she has finished, and you ask her about the picture. She says it reminds her of where she used to live, and then bursts into tears. You ask about how she is feeling, but she shakes her head and says nothing more.
You keep trying to project a soothing and calm attitude, and after a while she seems more settled.
You notice that she is shaking and has become pale. You offer her a glass of water but she refuses.
You wonder how to start moving to the music and relaxation part of the session, given that she has told you so little about herself. And you wonder what music would be suitable. How can you use cultural communication to address the needs of this person? introduction to space and sequence of activities throughout workshop 2 Engagement with non-verbal expression through visual arts Creating own reflective image for further use later in workshop Create own drawing of a flower, using provided oil pastels and paper 3 Introduction to scenario Familiarising participants with presented scenario ("Noor"; see  (Lo and Fung 2003), followed by presentation of ETHNIC and CRASH models 7 Synthesising activity: juxtaposing scenario and new knowledge Working in small learning groups to integrate the scenario with the knowledge frameworks to promote higher order critical thinking. Role modelling within and between groups for peer learning Form small groups to tackle worksheet based on the "Noor" scenario and applying ETHNIC and/or CRASH models. Facilitator circulating to support the small groups. Followed by large group discussion, including discussing the reasons for the symptoms displayed by Noor (which could be physical not only emotional)

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Designing narrative for professional development: A programme…  Brookfield 1995Brookfield , 2007Brookfield , 2015 and place them in box at back of room

Notes:
The scope and sequence of this participant-engaged workshop learning strategy included informal ongoing assessment of learner needs and their skills and abilities.
A wide range of contextual experiences, examples and additional questions were provided by the facilitator as required, in order to support and challenge participant learnings within the workshop. Key components in terms of activity, learning focus and the example learning activities are presented in chronological order

The workshop as such
The workshop was presented within a 2-3 hour timeslot using a combination of lecture format presentation, small peer group discussion with worksheet, large peer group discussion, and other feedback, and the use of music and art were incorporated into the learning materials (see Table 3). I began the workshop with a formal lecture-based explanation of the two frameworks (ETHNIC and CRASH). Next, I presented the narrative scenario and handed out an EST-CP training worksheet, which provided open-ended questions designed to compel the participating practitioners to think deeply and critically. The worksheet questions included: (1) How can you use cultural communication to address the needs of this person?; (2) What further issues could improve cultural communication highlight in relation to music therapy practice?; and (3) How would you decide what music to use with Noor?
Overviews of the two frameworks (ETHNIC AND CRASH) were printed on one side of the worksheet, and the scenario with questions on the other, necessitating repeated page turns supporting enhanced memory of the acronyms as learners completed the task.
A few verbal "snapshots" from the workshop are included in the "Results" section below.

Evaluation materials
Since the one of the purposes of this professional development training was to induce GIM practitioners to take what they had learned during the workshop on board when they returned to work, an important part of this training, indeed providing the data for its evaluation, was participants' feedback. To obtain this, I used the tertiary education Critical Incidental Questionnaire (CIQ). This single-page tool served to evaluate the participating GIM practitioners' responses to my purposely designed narrative teaching approach (Brookfield 1995(Brookfield , 2007(Brookfield , 2015Hessler and Taggart 2011;Jacobs 2015;Phelan 2012), collecting their views and perspectives about their process of learning (Brookfield 1995(Brookfield , 2007 during the workshop. The CIQ is designed "to assess student critical thinking and subsequently reflect on these findings as a source of professional development by teachers" (Gilstrap and Dupree 2008, p. 410). It involves a brief introduction followed by five questions: (1) At what moment in the class this week 4 did you feel most engaged?;

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Designing narrative for professional development: A programme… (2) At what moment in the class this week did you feel most distanced from what was happening?; (3) What action that anyone (teacher or student) took in class this week did you find most affirming and helpful?; (4) What action that anyone (teacher or student) took in class this week did you find most puzzling or confusing?; and (5) What about the class this week surprised you the most? (This could be something about your own reactions to what went on, or something that someone did, or anything else that occurs to you) (Brookfield 1995, p. 115;2015, p. 34).
The use of the CIQ as part of the educational process, where a feedback sheet is normally expected at the end of professional training, was approved by the continuing education convenors of both the AMI and MIAA. All participants were informed that the evaluation was optional and anonymous, and were given time to complete the CIQ near the end of the workshop and place it in the relevant box at the back of the room; it was observed that most participants completed the feedback sheet.

Data collection and analysis
Following data entry, I proceeded with analysis of the CIQ using qualitative coding and a thematic analysis (Braun and Clarke 2006) by coding textual responses and grouping units of meaning as an iterative process. Given an emergent high level of repetition in the data, I further engaged descriptive statistics to summarise the data numerically, based on previous approaches where patterns or regularities in data were described and counted mathematically (Lambert and Lambert 2012;Maxwell 2010;Sandelowski 2000).

Results
Participants represented a mix of ages (ranging from 25 to 72 years across the entire cohort), gender, ethnicity and experience levels in both locations, with both groups similarly trained in the GIM clinical method. Since visual scanning of the results from each of the two workshops indicated a broad homogeneity in the responses between the two groups, I pooled the results into a single data set (N = 57; n = 47 in Canada and n = 10 in Australia). Participants spontaneously identified the most engaging aspects of the workshop as "learning through group discussion" (75%) and, with reference to the embedded scenario, "case study" (33%). Below, responses to each CIQ question are addressed individually with a combination of summary statements and participant quotations to encapsulate answers, in line with standard qualitative research reporting approaches. Participants are labelled according to workshop attendance (AMI or AUS) and an assigned participant number.

Q1: At what moment in the professional development workshop did you feel most engaged?
Participants generally responded that they had felt especially engaged during the small group worksheet discussions, with some also finding the formal presentations, the problem-solving and the artwork aspects most engaging. Many participants said the workshop was engaging throughout, including the balance/range of activities, the story of Noor, the group discussions and the speaker's style (AMI-47, AMI-08, AMI-18, AMI-45). As one participant said: "I was engaged throughout -it was a good balance between class lectures, the group discussions, the use of visuals on the screen" (AMI-05).
Participants primarily indicated their most engaged moments were related to the case study, small group work and larger group discussions (AMI-34, AMI-04, AMI-46). As one participant said, the "group discussions were very rich" (AMI-35). Another said, "during the Case Study Discussion about Noor -useful to have a case study as a springboard for discussion, thinking about cultural communication" (AMI-07). Some participants found the presentation/lecture materials most engaging, commenting on the new information, lecture materials and the theoretical underpinning (AMI-11, AMI-38). As one participant commented: "The topic was most interesting so I was deepened with the ETHNIC and CRAASSH diagrams, perhaps as these were the crux of the presentation!" (AUS-07).
Other participants found applied critical thinking and problem-solving the most engaging, including brainstorming how to work with Noor (AMI-32, AMI-43), discussing varying techniques (AMI-01), consideration of music choices (AMI-31) and applying the presented models (AUS-01). They highlighted "Aha moments where info struck home -e.g. the 'Ramadan' example" (AMI-20) 5 and applied personal aspects of "hearing feedback to questions from others who live in different [sic] culture from me" (AMI-21). Some participants reported they had found the integrated art/music activities most engaging, commenting on music listening (AMI-06, AMI-15) and "the initial drawing and thinking about cultural orientations and biases" (AUS-08). In summary, reported engagement in this workshop largely followed expectations that learning via small group worksheet discussion tasks would promote active engagement.

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Designing narrative for professional development: A programme…

Q2: At what moment in the professional development workshop did you feel most distanced from what was happening?
Many participants wrote that they had been engaged all the time, that nothing had distanced them, said "zero", or simply left this question blank. Reports about distancing related to the room space and overhearing conversations of others (AMI-07, AMI-34), external issues such as the acoustics in the room, other conference duties (conference planning), the need for a break or refocusing due to the break, jetlag, feeling hungry and feeling tired. A few participants reported the lecture materials as being distancing (AMI-31), and a few others mentioned the small and group activities as distancing. One participant commented, "small group -although good to discuss ideas in 'private' I felt stuck -unsure how to proceed with task" (AUS-04). Some participants indicated that their sense of distancing had changed across the time of the workshop: "At the beginning of the first group discussion -but then I got warmed up and engaged" (AMI-05).
In summary, any distancing reported appeared to be mostly due to individual and situational factors.

Q3: What action that anyone (teacher or student) took in the professional development workshop did you find most affirming and helpful?
Participants reported affirming and helpful actions within group discussions, the leader's facilitation style, their own insights and problem-solving, and the narrative scenario. They viewed group discussion and sharing as affirming and helpful, for example: "I enjoyed the comments and sharings from the audience. You have a nice way of eliciting comments and thoughts from the audience" (AMI-05).
The leader's (i.e. my own) responses and affirmations were seen and described as listening, supportive and respectful (AMI-14, AMI-15, AMI-37), "teacher's related and open way" (AMI-41), and "encouraging students to self-process" (AMI-01). The gaining of insights and their engagement in problem-solving was seen by participants as affirming and helpful in terms of the models presented (AMI-13, AUS-02), of engaging in "the experience of 'not knowing'" (AMI-18), of finding small group members' insights "wise and prudent" (AMI-34) and of "admitting to difficulties with certain cultural groups" (AMI-46).
Extending the narrative scenario with further relevant stories was seen as most affirming and helpful in terms of discussing the case example (AUS-10), personal stories and experiences extending the content (AMI-19, AUS-03, AMI-47), the leader's (i.e. my own) life experiences and professional stories (AUS-09, AMI-21), and using these stories to reflect on participants' own experiences (AMI-21). Affirming and helpful activities reported by participants highlighted the facilitator's (i.e. my) approach, learning engagement activities based on scenario and group discussions, problem-solving, and further reflection related to personal stories and experiences.

Q4: What action that anyone (teacher or student) took in the professional development workshop did you find most puzzling or confusing?
Few participants responded to this question, and of the responses received, many refuted the question, such as, "Not at all. The presentation including questions and answer/feedback was well-facilitated and coordinated" (AUS-03). Most responses indicated that any confusion was resolved during the unfolding training workshop. The obviously challenging "disruption to thinking" (Gilstrap and Dupree 2008) was an inherent part of the workshop, and some sense of puzzlement and confusion occurred within the purposeful reflective learning situation. Other unexpected elements included the use of music during the workshop to create practitioner empathy (AMI-11), unlike typical workshop presentations of music as a new resource directly applicable to clinical practice. As one participant said, "at first the Australian string quartet puzzled me; when the teacher suggested our (therapists) using it to develop empathy re client, I got it." (AMI-34).
Participants reported experiencing initial challenges with assimilating the theoretical concepts (AMI-41), puzzlement in answering questions around the scenario of Noor (AUS-08), but also indicated that the handouts had been useful in understanding the theory/frameworks (AMI-30). In general, it seemed that when participants were puzzled or confused, this was typically resolved within the workshop. The experience of one participant feeling "puzzled and awkward in identification of my own cultural sensitivity" (AMI-04) clearly laid the foundation for further learning and growth.

Q5: What about the professional development workshop surprised you the most?
The sense of surprise experienced and reported by workshop participants included emotional responses, finding out about unknown cultural issues, being challenged into new ways of thinking, finding out about their own cultural prejudices and discomfort, and experiencing a new and different way to undertake a professional development workshop with attendees' active participation. Participants reported surprise about individual actions or elements embedded in the workshop, reporting tears in eyes and feeling moved by the initial acknowledgement of Indigenous people and their ancestors (AMI-33) and surprise at what they had learned about cultural competence related to GIM practice (AMI-35, AMI-36, AMI-32, AMI-46). Other specific incidental surprises included the existence of black swans in Australia (AMI-08). Many participants were astonished how little they knew about cultural differences (AUS-01) in reviewing 1 3 Designing narrative for professional development: A programme… their own cultural relationships (AMI-01) and openness to scenarios such as Ramadan (AMI-02). One participant highlighted humility, the "H" of CRASH: "I was surprised by memories that surfaced about leading GIM trainings in different countries -moments when my assumptions were overturned -the importance of humility" (AMI-14).
Some participants were surprised that many of their peers went straight to standard GIM music as an intervention (AMI-46), "that we have so little reflections/insights into music alternatives for other (non-Western) cultures!" (AMI-09). Another participant said, "the topic is huge, because of the global civilisation we are part of! Nevertheless, I would love more examples, such as Ramadan, such as both feet on the floor, to raise my awareness of what in the world I might encounter" (AMI-34). One participant indicated surprise "when I heard that one small group only discussed using traditional Western music from GIM programmes with Noor and hadn't considered that, (1) a GIM session might not be appropriate at this time, (2) the client might not have a relationship with Western music" (AMI-15).
Some participants also became aware of their own prejudices, deficits and discomfort relating to their understandings of other cultures (AMI-23, AMI-31, AMI-13). This was seen as linked to living in an isolated community (AMI-21) and an awareness of "my own possible 'blindness' in relation to culture e.g. re Noor and Ramadan" (AUS-06).
A small number of participants expressed surprise about the workshop's learning and teaching delivery style, which apparently overthrew their personal expectations, with some participants surprised about the amount of group input (AMI-41, AMI-22, AMI-11). Others had expected more standard/typical GIM music to be presented. A few participants reported being surprised by the specific uses of music and visual art in the workshop (AMI-17, AMI-18, AMI-37), even though using the arts is fundamental to GIM practice. Despite challenges to participant expectations, one participant said, "Thanks Alison, loved the way you used drawing, music, small groupwork etc. Kept me very alert" (AUS-06), and another said "really enjoyed the lecture style of case study, reflection, discussion, theory! Very engaging!!!" (AUS-04).
"It made us engage with the material very differently. I'm also impressed you are asking us those questions in this form. No wonder you are such an excellent and respectful person! Congratulations and thank you!" (AMI-15).
In general, it was obvious that the aspects of the professional development workshop which surprised participants most were actually the carefully planned and facilitated learning activities, with the reported surprise linked to active learning and critical thinking activities.

Discussion
I embarked on this project aiming to change understandings and practices related to issues of culture via an educational approach developed and implemented as a specifically designed professional development workshop. This approach bridged the research-practice gap (Berkhout et al. 2017;Kristensen et al. 2016), and my evaluation of the participants' feedback contributes evidence towards initiatives which are successful in improving everyday practice (Burke et al. 2016;Mick 2017;Ploeg et al. 2014). This narrative educational approach was effective in engaging with the clinicians, encouraging them to position themselves within their clinical practice decision-making (Berkhout et al. 2017;Jackson et al. 2019;McArdle and Ackland 2007) and challenging them to approach cultural issues in new ways. Despite some confusion over my subversion of a traditional lecture approach, and the requirement for participants to think and engage in their own learning, these same participants appeared to "get with the programme" and clearly were able to engage with reflective practice and critical thinking around a challenging topic (Duchscher 1999;Mantell and Scragg 2019).
Narrative-based case materials are clearly conducive to engaging with these adult learners. However, original case material can be too long and complicated, potentially causing disinterest and disengagement. Therefore, this study created a purpose-designed scenario which clearly aligned to the focus of the teaching materials, with design characteristics guided by Kim et al. (2006). The narrative of Noor (see Table 2) was effective in engaging with participant learners, leading to reported "Aha" moments within an apparent gradual change of attitudes and opinions based on reflection and discussion. The created scenario for the culture-oriented workshop was designed to deliberately hide subtle cues which might have led to cultural assumptions, thereby reducing cultural stereotypes and hidden assumptions in the interpretation of words and actions, and promoting increased cultural competence.
Participants clearly highlighted the importance of sharing stories and learning collaboratively in the professional development workshop. This sharing and discussion about the ambiguous case scenario assisted with the "reality" of the situation, helping them to apply what they had learned to their work context. Their feedback demonstrates the (desired) effect of setting up a disruption to thinking and a disorienting dilemma as an ambiguous, messy learning problem requiring critical thinking skills for resolution (Gilstrap and Dupree 2008;Tallent 2016).
Implemented with international GIM practitioners, the EST-CP professional development workshop changed participants' learning expectations by reducing the emphasis on the formal lecture format and increasing active engagement activities. Engagement was sought via a practice-related scenario prompting applied groupwork discussions, underpinned by a deep theoretical basis and linked to the ETHNIC and CRASH cultural frameworks. Participants were challenged to think critically and practise decision-making in relation to the scenario, using peer learning to engage in supporting discussions and insights about broader practice issues. The further effectiveness in shifting critical thinking to embrace cultural aspects of professional practice is demonstrated by a subsequent invitation I received to contribute a book chapter, "Cultural considerations in GIM practice, training and research" (Short 2019b), to the second edition of Guided Imagery and Music: The Bonny Method and beyond (Grocke 2019), the foundational resource for this clinical method.
The current case study confirmed that using the teaching technique of a purpose-designed scenario with a discussion worksheet could be applied to effectively engage a specific group of university-educated practitioners in theoretical and social learning around cultural competence. A wealth of comments demonstrated learner engagement with the case study and small group work. Many participant responses indicated an inner shift in understandings about themselves and others during the workshop, including a sense of their own cultural "blindness". Self-reported statements from this workshop showed that new knowledge was being applied, evidencing insights and deep engagement in problem-solving related to these practitioners' own clinical practice. Clinicians clearly began to think differently and envisage applying their new knowledge in their practice as a result of this workshop. Discussions were observed to take place beyond the professional development workshop, extending across lunchtime and the subsequent several days of the conference.
The importance of creating the "right" case/scenario for the teaching and learning context was underpinned by ensuring its characteristics were relevant, realistic, engaging, challenging and instructional (Kim et al. 2006). Without a well-developed purposeful scenario, the workshop would have been unlikely to prompt participants to reflect critically on their own practice and open them up for change in their own attitudes and beliefs. Such reflection is essential for the growth and development of expert practice; it is important that clinicians are challenged to think afresh and not just "do what they have always done". Creating a disruption of "assumptions and habitual practices" (Gilstrap and Dupree 2008, p. 409) provided further learning opportunities within the scenario and group discussions, which was clearly achieved with this professional development workshop.
Engagement with critical thinking processes is necessary in order to be effective and drive change, but the acceptance and embedding of practice change with practitioners is known to be challenging across many applied clinical settings. This article outlines a case study which effectively approached this issue via the purposeful development of a well-integrated scenario within the EST-CP professional development workshop, suggesting that such an approach could be used across many other clinical groups and training topics in the future.
Integration of theory and practice is necessary for excellence in pedagogy and curriculum development. Although this workshop was designed for a particular niche professional group, it serves as an informative case study to draw out applicable lessons of relevance to professional development activities across all health professions.
As an instrumental and paradigmatic case study, this project explored the dynamics of the topic in rich detail from the development of the learning materials into the context of implementation, data collection and participant feedback, gaining insights at every point. The prototypical nature of these insights may be extrapolated to other health professional continuing education contexts, especially where health treatment 1 3 needs to be adapted to the treatment of an individual client in a person-centred approach within a critical thinking focus. The rising importance of health professionals' delivery of person-centred care has been outlined as a global shift by Maria Santana et al. (2018) and underlined by the World Health Organisation (Nolte et al. 2020). The education of health professionals is seen as a driver for systemic change: The move to person-centred care has considerable implications for the training of health and care professionals and how this needs to be adapted to enable professionals, organisations and systems engaging in a true partnership with individuals as service users and the wider public to provide the support appropriate to their preferences and needs (Nolte et al. 2020, p. 100).
The question remains -how best to (continuously) educate established health professionals via a standard and acceptable but at the same time effective professional development process? It has long been understood that student-centred selfmotivated adult learning practices are analogous to person-centred health practices (Brown et al. 1976). Therefore, it is important to maintain a client-centred approach to teacher development programmes, including input from the teachers themselves (Nunan 1989). In developing curriculum, learning approach and resources, it is important to engage with experienced practitioners in the field to take critical reflections into account within the curriculum development process, including situational challenges requiring renewed perspectives about professional development applications (Burnett and Lingam 2007).
This project has focused on the usefulness of narrative scenario-based learning approaches in the health sector, which is supported by knowledge about professional development contexts in the education sector, where teachers become learners (Nunan 1989). The importance of narrative relating to the clinical context in nursing education has been highlighted by Mary Kirkpatrick et al. (1997), where stories form an important communicative technique, enhancing motivation and the process of learning human sensitivity skills needed within the context of multidisciplinary health care.
The importance of a context-based curriculum has been highlighted in engaging with adult learners, especially in relation to intercultural learning (Abu-Nimer and Smith 2016). Embracing cultural diversity as a quality dimension for education and learning can stimulate personal knowledge development, and enhance interpersonal relationships (Alidou et al. 2011). Using a critical incident/scenario as a learning tool demonstrates the importance of reflective and creative practices in addressing cultural learning needs (ter Avest 2017).
The work culture embedded in graduate training (e.g. internships) has a significant influence on post-graduation practice behaviour. It forms the basis for the relational and communication skills essential for person-centred care of/ with patients as the learner moves from university training into everyday practice (Kosunen 2008). Further, Elise Kosunen suggests that a "hidden curriculum" of role-modelling exists within the clinical workplace. Given that person-centred care requires all disciplines to work well together for the benefit of the person, good role-modelling with reflection and mentoring is of vital importance to support cultural change, in the context of current interprofessional educational approaches (Rosewilliam et al. 2020;Thistlethwaite 2015). Santana et al. (2018) point to the fact that for systemic change to happen across multiple sectors, person-centred health care approaches must be effectively implemented. Challenges include improving interactions between patients/clients and caregivers, and Santana et al. (2018) specifically note that a "cultural shift in practice" is required (Santana et al. 2018, p.437). The nature and application of educational initiatives seeking to engage with practising clinical professionals is clearly of great importance to improving care within health systems around the world.

Conclusions
This case study of an educational initiative has outlined the learning and design issues in creating a programme which is relevant and acceptable for established health care practitioners, effectively assisting them in changing their ingrained attitudes and assumptions. In this instance, the target focus was on issues of culture, for a group of international practitioners using the original Western-based music approach of the psychotherapeutic method of GIM, irrespective of the cultural background of their patients/clients. This case study explored how to engage learners with narrative-based new materials to promote reflective practice and critical thinking, thereby leading towards necessary changes in their practice to become more culturally competent.
The staged processes by which the narrative-based learning materials were developed and applied are clearly outlined in this article and are expected to be potentially applicable to further learning topics and groups of practitioners in other contexts. Awareness of contextual factors within the work culture and engagement with relevant professionals within the curriculum development process are essential in developing an effective training format. The success of this approach with the GIM practitioners who participated in the EST-CP workshop has been demonstrated by participants' feedback using Stephen Brookfield's CIQ (Brookfield 1995(Brookfield , 2007(Brookfield , 2015, a tool known to be ideal for gathering data about enhanced critical thinking in an educational context. Designing, implementing and evaluating a professional development workshop such as the EST-CP provided the capacity to foster improvements in evidence-based practice in this specific profession, in turn setting the stage for improving client care via potential fundamental shifts in practitioner attitudes as initiated by active and engaged learning experiences.
Funding Open Access funding enabled and organized by CAUL and its Member Institutions.
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