Becoming a doctor-The potential of a change laboratory intervention.

In a previous ethnographic field study, we found that newly graduated doctors (NGDs) found their first months of practice challenging and overwhelming. By including an organisational perspective (Cultural Historical Activity Theory), we were able to identify contextual factors within the hospital organisation, which influence the NGDs' challenges. This raised the question: What can be done about it? To address this, we designed a Change Laboratory intervention (CL), consisting of six sessions, involving NGDs, junior doctors, and consultants across eight departments (on average, 18 doctors participated in each session). Through the CL, the participants were able to get a mutual understanding across departments and develop two initiatives to support the NGDs: An NGD introduction day with a 'need-to-know' focus, where the NGDs meet their future collaborators, and are introduced to important work procedures, and are given the opportunity to establish a peer network. This is followed up by a monthly NGD forum with a 'nice-to-know' focus, where new topics are introduced, allowing time for reflections, and supporting the further strengthening of a peer community. The CL approach promoted agency among participants and the results show how CL offers a unique opportunity for stakeholders to challenge and rethink their work practices within the hospital organisation.

Expansive learning in medical education: Putting Change Laboratory to work.

This paper explores the purposeful use of conceptual and methodological tools provided by Cultural Historical Activity Theory (CHAT) to transform learning cultures and practices within and across diverse clinical learning environments. We describe how Change Laboratory methodology helped clinicians and others who support student, intern, and resident education to make changes collaboratively. A case study in undergraduate medical education shows how this created new forms of medical student placement and a postgraduate study shows how it addressed supervisors' undermining behaviour towards Obstetrics and Gynaecology residents. This empirical work illustrates ways of modifying the classical Change Laboratory process to fit local contexts, resources, and needs. We conclude with lessons learned and future directions for practitioner-researchers who wish to broaden the range of methodological tools they use to transform clinical learning environments.

Using activity theory to transform medical work and learning.

This article introduces key concepts of activity theory and expansive learning. Expansive learning builds on the foundational ideas of the cultural-historical activity theory (CHAT). It is a research approach designed for studying the complexities and contradictions in authentic workplace environments. Change Laboratory is a formative intervention method developed for studying workplaces in transition and for stimulating collaborative efforts to design improved patterns of activity. We present concrete examples of formative interventions in healthcare, where good patient care was compromised by the fragmentation of care and disturbances in collaboration between the healthcare experts. This implies that physicians are challenged to develop collaborative and transformative expertise. We present three spearheads into a zone of proximal development, representing opportunities for change of medical expertise: (1) reconceptualizing expertise as object-oriented and contradiction-driven activity systems, (2) pursuing expertise as negotiated knotworking, and (3) building expertise as expansive learning. While medical expertise needs to expand, medical education must also look for ways to evolve and meet the challenges of the surrounding society. We call for adopting an interventionist approach for developing medical education and intensifying collaboration with the practitioners in healthcare units, their patients, and target communities.

A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative.

Disrespectful and abusive treatment of women during childbirth is a worldwide problem. This research aimed to develop and implement a Mother Baby-Friendly Hospital Initiative (MBFHI) in an academic maternity hospital in Brazil and evaluate how change could be sustained. Change Laboratory principles guided a process of action research, which was conducted between 2017 and 2019. Clinicians and managers joined the researchers in discussion sessions to redesign routines and care pathways. Observation, interviews, focus groups, and historical and documentary analysis provided information about the existing activity system, which we analysed qualitatively using MBFHI criteria to identify themes. Evidence of inappropriate obstetric interventions and impersonal interactions between clinicians and patients stimulated us to devise innovative solutions. The challenges identified by this exercise included: poor infrastructure and ambience; difficulty adhering to evidence-based protocols; social and professional hierarchies; and clinicians being poorly educated about women's rights. Although challenges remained, positive changes included a friendlier environment, improved patient privacy, and fewer unnecessary procedures. Resources released by these changes allowed us, collaboratively, to track the further implementation and sustainability of change. We conclude that the Change Laboratory can help motivated clinicians and managers humanise patients' experiences, make care more evidence-based, and expand learning of mother-friendly maternity care. Tensions and contradictions between education and patient care reported here may resonate in settings other than maternity care.

Cultural Historical Activity Theory for Studying Practice-Based Learning and Change in Medical Education.

Cultural historical activity theory (CHAT) is a social theory which is useful as a methodological framework for the vital task of studying practice-based learning in complex learning environments. CHAT is an apparatus considering learning as occurring through practice, through collective activity, and mediated by culturally specific instruments. Because CHAT is increasingly drawn upon in medical education academia, it is necessary for medical educationalists to be familiar with this theory. This methodology article explains how CHAT theorizes learning in dynamic workplaces within an activity system comprising multiple practitioners engaged in activity, which is collaborative, multi-voiced, and bounded by a shared intended object. It provides an accessible overview of the central concepts within CHAT and a description of a methodological strategy (activity system analysis) to incorporate CHAT into one's own work. CHAT also theorizes where tensions lie within and between activity systems, causing difficulties in achieving the intended object, defining such tensions as contradictions. It is through the overcoming of past contradictions that activity has come to exist in its current form, abiding by social norms of the present time, and CHAT allows consideration of how practice within a system may be changed through resolution of contradictions. For example, the Change Laboratory is a contrived intervention where practitioners consciously contribute to developing and embedding new, improved ways of practicing using CHAT principles. This allows practitioners to have agency in improving their own areas of learning and practice. Throughout this article, examples are provided of how CHAT has been usefully applied to various aspects of medical education research, including undergraduate education, postgraduate education, and continuous professional development. By building on the introduction to CHAT provided in this article, the reader can start to use CHAT methodologically to describe complexity, identify practice-based contradictions, and develop improved forms of practice-based learning, in his/her own context.

The Development of Transformative Agency of Teachers in Teaching Research Activities in China.

Teaching research activities (TRA) in China are practical and reflective research of teachers on teaching. These required activities are meant to ensure quality education and facilitate the professional development of teachers. However, in TRA, teachers encounter many challenges such as low efficiency and weak team collaboration. These problems make it hard to achieve the expected outcomes. W Primary School reformed its activities using Change Laboratory, a formative intervention approach to workplace learning and development based on activity theory. The data collected included seven recorded meetings in the Change Laboratory. The conversations in the meetings were then transcribed into texts. A deductive method of content analysis was used to code the data, focusing on categorizing comments of teachers about the transformative agency. The findings showed the following: (1) There were five types of transformative agencies, namely, resisting, criticizing, explicating, envisioning, and committing to actions. Resisting and criticizing were represented less frequently, and taking action did not emerge as a type of transformative agency. (2) The comments about transformative agency about tools were more frequent than comments about other elements in the activity system. (3) There were some differences in the expression of transformative agency across participants. At the end of this study, the implications for the development of TRA are discussed.

Learning Platforms for Implementing Formative Interventions to Promote the Health and Safety of Workers in Brazil.

Formative intervention methodologies, such as the Change Laboratory (CL), are increasingly being used in work environments. However, the learning process entailed in the application of these methodologies has received insufficient attention and may be facilitated through the use of learning platforms. We examined the development of learning and training strategies for implementing formative interventions, drawing on the experiences of a research group focusing on workers' health. Information obtained from individuals involved in CL formative activities was analyzed and interpreted using Cultural-Historical Activity Theory and the theory of expansive learning. The process of learning to implement formative interventions unfolded gradually, beginning with the interventionists' initial exposure to abstract concepts that they subsequently internalized via various mediations and applied in concrete situations. Four key interventionist training strategies used to foster collective learning were identified: (1) promoting dialogues and exchange of experiences, (2) creating environments for continuous learning and permanent discussion (seminars and post-graduate courses and the use of communication technologies), (3) creating spaces for experimentation and the practical application of concepts (case studies and participation in interventions), and (4) the use of the double stimulation method during training programs.

Desafios da reabilitação profissional desenvolvida pelo Instituto Nacional do Seguro Social (INSS): uma perspectiva histórico-cultural / Challenges of the vocational rehabilitation developed by the Brazilian Social Security Institute (INSS): a cultural-historical approach

Resumo Introdução: transformações ocorridas na prestação do serviço de Reabilitação Profissional (RP) pelo Instituto Nacional do Seguro Social (INSS) fizeram emergir contradições entre seus resultados e o que se espera de uma política pública de inclusão social. Objetivo: compreender como tais transformações afetaram a atividade de trabalho e como o serviço de RP está lidando com as mudanças e problemas decorrentes. Métodos: realizada análise histórica das contradições entre elementos do sistema de atividade da RP em serviço do INSS localizado no interior do estado de São Paulo. Foram utilizados dados etnográficos e discursivos de intervenção baseada no método Laboratório de Mudança. Resultados: evidenciou-se que o objeto da RP foi historicamente reduzido à orientação e capacitação profissional. Foram identificadas dificuldades do sistema de atividade da RP em lidar com determinações judiciais, além da diminuição da capacidade instalada e acúmulo de tarefas que impactam no atendimento aos trabalhadores. Conclusão: a redução administrativa do objeto da RP, bem como o sistema de atividades apoiado em ações de atores externos à Previdência Social, sem articulação institucional e protocolos de cooperação entre os serviços, demonstra o descompasso entre o desmonte histórico da RP no INSS e a demanda social dos trabalhadores com incapacidades para o trabalho

Abstract Introduction: changes in the Vocational Rehabilitation (VR) service provided by the Brazilian Social Security Institute (INSS) led to contradictions between their results and what is expected from a social inclusion policy. Objective: to investigate how these changes affected work activity and how the VR service is facing the consequent issues. Methods: we conducted a historical analysis of the contradictions between the VR system elements based on the provision of this service by an INSS agency in the state of São Paulo. Ethnographic and discursive data were collected using the Change Laboratory method. Results: we evidenced that the VR service was historically reduced to vocational guidance and professional training. We identified the VR system had difficulties in addressing judicial orders, as well as there was a diminished installed capacity and task accumulation that hinder a proper assistance to workers. Conclusion: administrative reduction of the VR service, and the system of activities supported by social actors outside Social Security, without institutional articulation and cooperation protocols between services, demonstrates there is a gap between the VR historical dismantling and the disable workers' social demands.

Protagonismo para uma compreensão sistêmica sobre acidentes de trabalho e anomalias organizacionais / Protagonismo para una comprensión sistémica de accidentes de trabajo y anomalías organizacionales / Agency for a systemic comprehension of work accidents and organizational anomalies

Resumo As investigações de acidentes e anomalias organizacionais são tradicionalmente baseadas em consultorias, análises internas ou externas às instituições que geralmente não conseguem engajamento e participação dos atores internos tanto no diagnóstico como na construção de soluções. Objetivou-se analisar se o método intervencionista Laboratório de Mudanças, empregado na compreensão dos determinantes organizacionais e das condições latentes de acidentes de trabalho, promove agência (protagonismo) e aprendizado expansivo dos atores envolvidos e contribui para visualizar e construir possíveis alterações na concepção e desenvolvimento da atividade de construção de grandes obras. Foram examinadas seis sessões do Laboratório de Mudanças, a fim de identificar os microciclos de aprendizado propiciados pelas séries de dupla estimulação. As sessões resultaram no engajamento dos atores que criaram seus próprios artefatos ou se apropriaram de conceitos ou modelos, tais como linha do tempo da obra, círculo vicioso, sistema de atividade, identificação de contradições na origem das anomalias e indicação de soluções para obras futuras. O estudo evidenciou que o Laboratório de Mudanças se apresentou propício à investigação de causas sistêmicas de acidentes e anomalias, revelando que a metodologia é potente para o aprendizado organizacional coletivo, uma vez que o grupo se engaja na compreensão, na análise e na busca de soluções.

Resumen Las investigaciones de accidentes y de anomalías organizacionales son basadas tradicionalmente en consultorías, análises internas y externas que generalmente no alcanzan la participación de los actores internos con en el diagnóstico y la construcción de soluciones. Este artículo analizasí el método intervencionista Laboratorio del Cambio, utilizado en la comprensión de determinantes organizacionales de accidentes de trabajo, promueve la agencia (protagonismo) y el aprendizaje expansivo de los actores involucrados, contribuyendo a construir posibles mudanzas en la concepción y desarrollo de construcción de grandes obras. Fueron analizadas seis sesiones del Laboratorio del Cambio, a fin de identificar los microciclos de aprendizaje propiciados por las series de doble estimulación. Las sesiones resultaron en el compromiso de los atores que criaron sus propios artefactos o se apropiaron de conceptos o modelos, tales como, línea de tiempo, círculo vicioso, sistema de actividad, contradicciones en el origen de las anomalías e indicación de soluciones para obras futuras. El estudio evidenció que el Laboratorio del Cambio se mostró propicio al análisis de causas sistémicas de accidentes y anomalías, revelando que la metodología es potente para el aprendizaje organizacional colectivo, una vez que el grupo se compromete con la comprensión, con el análisis y con la búsqueda de soluciones.

Abstract Analyses of work accidents and organizational anomalies are traditionally based on external consultancy, or internal or external analysis, which generally fails in terms of the engagement and involvement of internal actors during the diagnosis or creating solutions. This paper aims to analyze if the interventionist method called Change Laboratory used in the analysis of organizational determinants and latent conditions of work accidents promotes agency and expansive learning of the involved actors, contributing to visualize/construct possible changes in the conception and development of the activity of construction of large buildings. Six sessions of Change Laboratory were analyzed to identify the micro-cycles of learning, facilitated by series of double stimulation. The sessions led to the engagement of the actors who created their own artefacts or appropriated the concepts or models, such as the timeline of the airport building, vicious circle, activity system, contradictions identified in origin of the anomalies and the possible solutions for future building projects. The study showed that the Change Laboratory can be used in systemic analysis of work accidents and anomalies. It is a powerful instrument for organizational collective learning when the group of actors becomes involved at comprehending, analyzing and creating solutions.

Processo de formação da rede municipal de saúde: análise sob a perspectiva da teoria histórico-cultural / Municipal health network training process: analysis under the perspective of the historical - cultural theory

Introdução: este estudo é parte do projeto Construção de cuidados em rede nos serviços públicos de saúde em Piracicaba que busca a integração dos recursos da rede municipal tendo como foco os trabalhadores acidentados, aplicando a metodologia denominada Laboratório de Mudanças Interfronteiras. A interface desse projeto e o trabalho que ora apresentamos, encontra-se descrita no texto principal. Objetivos: esta pesquisa tem como escopo aprimorar a construção da linha histórico cultural, analisar os marcos históricos como possíveis determinantes organizacionais para as mudanças na rede, identificar as contradições emergentes na rede e apresentar um diagnóstico situacional da Rede de Atenção de Piracicaba Metodologia: tendo em vista que o objeto da pesquisa é o processo de formação da rede de saúde municipal baseado na teoria da atividade histórico cultural de Vygotsky, o estudo tem caráter exploratório e descritivo de abordagem qualitativa. Valeu-se das fontes de informações documentais e históricas advindas de sessões do Laboratório de Mudanças Interfronteiras, gravadas e filmadas. Obteve-se, ademais, quatro entrevistas com pessoas fundamentais para a construção da rede pública de forma a complementar os dados das sessões. As entrevistas foram conduzidas por meio de um roteiro semiestruturado com o intuito de captar o processo de atendimento aos acidentados de trabalho. A totalidade dos dados foi agrupada na dimensão de estrutura e processos o que permitiu visualizar os fatos por décadas na linha do tempo, entre a fundação da Santa Casa até o ano de 2016. A partir dimensão estrutural criaram-se subcategorias sobre política e investimento; sujeito, mediação e objeto de trabalho e contradições. E a partir da dimensão processo, agruparam-se em subcategoria acesso e sistema de informação. Tomou-se como referencial teórico a teoria da atividade histórico-cultural de Vigotsky e como formação da rede de Atenção a Saúde, de Eugênio Vilaça Mendes. Resultados e discussão: produziu-se uma linha histórica por desenho gráfico do sistema de atenção à saúde local, com foco no atendimento ao acidentado de trabalho. Assinalaram-se os principais fatos por décadas, tendo como marcos a Fundação da Santa Casa, o advento do Sistema Único de Saúde e as suas transformações até 2016. No que se refere ao aspecto estrutural, a evolução histórica exibe, aparentemente, uma estrutura boa em rede com distribuição tecnológica em três níveis de atenção. Houve sucessivas investidas persistentes pela oferta de atendimento às urgências, de 80 até a implementação de Unidades de Pronto Atendimento, fortalecidas com a linha de financiamento advinda do governo federal. A demanda em excesso criou um distúrbio na conformação da necessidade das Unidades de Pronto Atendimento em detrimento do cuidado longitudinal previsto para a atenção básica. Essa dualidade é visível a partir de 2000, com o aumento abrupto de unidades de atenção básica que busca, aparentemente, a melhoria de atenção longitudinal do indivíduo e das famílias. A expansão da rede significa um aumento da divisão de trabalho e requer ferramentas de articulação entre serviços, elemento que se constatou ser frágil quanto à natureza organizacional. Por isso, em mediação e atores buscou-se discutir as lacunas na comunicação interinstitucional como uma das consequências da divisão de trabalho. Neste sentido, não se organizaram necessidades básicas de formação e capacitação dos profissionais com vistas à emergência do objeto coletivo que requer múltiplos cuidados. A realidade do Núcleo de Apoio de Educação em Saúde identificado na estrutura encontra-se totalmente alienada desse processo, mostrando-se contraditória à política pública de Educação Permanente. A centralidade administrativa é uma característica clara na formação histórica, o que contrapõe á diretriz organizacional do Sistema fundamentado na descentralização das decisões e de ofertar serviços coerentes aos perfis epidemiológicos da população. Quanto ao dispositivo de sistema de informação disponível, o Relatório de Atendimento aos Acidentados de Trabalho (RAAT) teve capilaridade e potencial produtor de informação qualificada. Conclusão: confere à estrutura local hegemonia hierárquica para reproduzir e reiterar problemas, no entanto, de sem melhorar a competência organizativa para potencializar os recursos investidos. A estrutura ostenta perspectivas positivas de que desenvolvam meios organizativos de coordenação da rede de forma a reconhecer o objeto coletivo e sua capacidade instituinte de cuidado coletivo. Embora se tenha constatado o potencial colaborativo de cada trabalhador, nota-se que o profissional se encontra subsumido a uma organização hierárquica difusa, mas centralizada sem o subsídio das diretrizes políticas.

Introduction: This study is part of the project Networked construction in the public health services in Piracicaba, which seeks to integrate the resources of the municipal network, focusing on injured workers, applying the methodology called Interfrontier Change Laboratory. The interface of this project and the work presented here is described in the main text. Objectives: This research aims to improve the construction of the cultural historical line, to analyze the historical milestones as possible organizational determinants for the changes in the network, to identify the emerging contradictions in the network and to present a situational diagnosis of the Piracicaba Attention Network Methodology: Since the research object is the process of formation of the municipal health network based on the theory of cultural historical activity of Vygotsky, the study has an exploratory and descriptive character of qualitative approach. He relied on sources of documentary and historical information from Interfrontier, Recorded and Filmed Laboratory sessions. There were also four interviews with key people for the construction of the public network in order to complement the data of the sessions. The interviews were conducted through a semistructured road map with the purpose of capturing the process of attending work accidents. The totality of the data was grouped in the dimension of structure and processes, which allowed visualizing the facts for decades in the time line, between the foundations of Santa Casa until the year 2016. From a structural dimension, subcategories on politics and investment were created; subject, mediation and object of work and contradictions. And starting of the process dimension, they were grouped into subcategory access and information system. The theory of Vigotsky's historical-cultural activity and the formation of Eugenio Vilaça Mendes's network of Attention to Health were taken as theoretical references. Results and discussion: a historical line was produced by graphic design of the local health care system, with a focus on attending work accidents. The main events for decades were marked by the Santa Casa Foundation, the advent of the Unified Health System and its transformations until 2016. As far as the structural aspect is concerned, historical evolution appears to have a good structure in network with technological distribution in three levels of attention. There were successive investees for the provision of emergency care, from 80 until the implementation of Emergency Care Units, strengthened with the line of financing from the federal government. The excess demand created a disturbance in the conformation of the need of the Ready Care Units, to the detriment of the longitudinal care provided for basic care. This duality has been visible since 2000, with the abrupt increase of primary care units that seemingly seeks to improve the longitudinal attention of individuals and families. The expansion of the network means an increase in the division of labor and requires tools of articulation between services, an element that has been found to be fragile as to the organizational nature. Therefore, mediation and actors sought to discuss the gaps in inter-institutional communication as one of the consequences of the division of labor. In this sense, basic needs for training and qualification of professionals were not organized with a view to the emergence of the collective object requiring multiple cares. The reality of the Health Education Support Nucleus identified in the structure is totally alienated from this process, which is contradictory to the public policy of Permanent Education. Administrative centrality is a clear characteristic in historical formation, which contrasts with the organizational guideline of the System based on the decentralization of decisions and of offering coherent services to the epidemiological profiles of the population. As for the available information system device, the Report of Attention to the Worker's Casualties (RAAT) had capillarity and potential producer of qualified information. Conclusion: it confers on the local hierarchical structure hegemony to reproduce and reiterate problems, however, without improving the organizational competence to potentiate the invested resources. The structure has positive perspectives to develop organizational ways of coordinating the network in order to recognize the collective object and its institutional capacity for collective care. Although the collaborative potential of each worker has been verified, it is noticed that the professional is subsumed to a hierarchical organization diffused, but centralized without the subsidy of the political guidelines.