Flux, questions, exclusion and compassion: collective learning in secondary care.

CONTEXT: Health care organisations are increasingly conceptualised as complex, indivisible entities made up of web-like networks of staff that connect to each other in changeable ways. This study draws on the theoretical framework of activity theory and the concept of knotworking to illustrate how health professionals improvise collaboratively to negotiate everyday challenges and contribute positively to patients' health priorities. OBJECTIVES: The aim of this paper is to contribute to evolving ideas about collective learning, change and improvement in secondary care by exploring how health professionals work and learn together and how this compares with earlier findings from primary care. METHODS: This study applied a constructionist methodology within the research paradigm of interpretivism. Qualitative data were gathered through 26 hours of observations and 17 field interviews within the natural environment of a working hospital over a 3-month period. The research site encompassed a medical receiving ward, a chronic ward, an out-patient clinic and the connecting corridors. Staff participants included a range of clinical, nursing, ancillary and clerical staff. RESULTS: The study found a recurring pattern of spontaneous team forming and interprofessional shared learning to respond to care needs within the hospital as they arise. These are presented in four analytical themes: motion, flux and the unpredictability of 'team spirit'; adaptive, responsive learning through seeing, doing and asking questions; the collective learning gap between doctors and other staff; and frustration, compassion and the desire for improvement. CONCLUSIONS: Health care professionals in the hospital setting both create and experience complex inclusion and exclusion behaviours that define who is empowered to act with professional authority in any given moment of care. This paper discusses issues of power, the particular exclusion of doctors from interprofessional knotworking, and the greater emphasis on questions as the pivotal aspect of shared collective learning when compared with primary care.

Research paradigms in medical education research.

CONTEXT: The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence. METHODS: This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research. DISCUSSION: This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice. CONCLUSIONS: This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.

Community nursing managers' perceptions and experiences of protected learning time: a qualitative study.

BACKGROUND: Protected learning time (PLT) is used to allow primary healthcare teams time to learn, protected from service delivery. Different occupational groups have different perceptions and experiences of PLT. Research has shown that community nurses have low rates of attendance at practice-based PLT (PB-PLT) in one area in Scotland. Nursing managers have considerable influence with PLT, as leaders of community nursing teams and as members of PLT steering committees. AIMS: To understand the community nursing managers' perceptions and experiences of PLT, and to explore their perceptions of the low rate of attendance by community nurses at PB-PLT. METHODS: Qualitative study involving two focus groups (six nursing managers) and one interview (director of nursing), in three community health partnerships in one NHS health board in Scotland. Focus group interviews and one in-depth interview were conducted, audio-recorded and then transcribed. Transcriptions were analysed using a grounded theory approach to data analysis. RESULTS: Participants recognised the potential benefits of PLT for community nursing and primary healthcare teams. They perceived low rates of attendance were because learning at PB-PLT was considered irrelevant by community nurses. They felt community nurses were not involved in planning and preparing PB-PLT, and that their learning needs were not incorporated into PB-PLT. Participants felt there were organisational differences between practices and the community nursing team, which acted as a barrier to learning. Participants had concerns about the learning arranged for practice nurses at PB-PLT. They considered that the new general medical services contract had been an initial barrier to learning. CONCLUSION: Nursing managers had perceptions of PLT that contrasted with those of their community nurses. There were similarities also. Primary healthcare teams need to improve mutual understanding, and need to work together to improve the quality of learning at PB-PLT.

Community nurses' perceptions and experiences of protected learning time: a focus group study.

BACKGROUND: Protected learning time (PLT) has spread quickly to primary healthcare teams in Scotland. Previous research has shown that PLT is generally well received, but that different professional and occupational groups have differing perceptions and experiences of PLT. Community nurses have low rates of attendance at practice-based PLT in NHS Ayrshire and Arran. It is not known why. AIMS: To explore and understand the community nurses' perceptions and experiences of PLT, and to discover the barriers to their attendance at practice-based PLT. DESIGN: Qualitative study involving four focus groups of 37 community nurses. SETTING: Three community health partnerships in one NHS health board area in Scotland. METHODS: Focus group interviews were conducted, audio-recorded and then transcribed. Transcriptions were analysed using a grounded theory approach to data analysis. RESULTS: Community nurses often had separate learning events at PLT, and were not involved in the processes of learning with the general medical practice. Chosen topics were often irrelevant to them and their attendance was low. Learning was often uniprofessional. Community nurses perceived they did not have adequate protection from service delivery during PLT. They felt that practice managers had a key role in the delivery of PLT, and that team working and team learning were important, and useful if done well. They considered that the new contract had had a negative impact on PLT. DISCUSSION: Community nurses need to be involved more in the learning process, if PLT is to be relevant and useful to them and the practice. Nursing managers may need to increase the service protection for community nurses in order to allow them to learn with the rest of the primary healthcare team. Those who organise PLT at primary care organisation level may have to consider using independent facilitators to effect changes.

'The unknown becomes the known': collective learning and change in primary care teams.

CONTEXT: The growing emphasis on teamwork within the National Health Service (NHS) has made it a priority to understand how health care teams learn together and cope with change. OBJECTIVES: This study aimed to explore how collective learning and change happen in primary care teams and how the process varies across the disciplines of general medical practice, pharmacy and dentistry. METHODS: This study reports on qualitative data gathered from 10 primary care teams over 1 year, by means of observational visits and 38 semi-structured interviews. RESULTS: Informal collective learning is a powerful team coping mechanism that develops through experiential, evolving and implicit learning processes. These processes are predominantly relational in that they rely on the extent to which team members know and understand one another as people. This makes shared learning an effective but 'messy' dynamic, the motivation for which is internally generated by the team itself. Teams report that if they cannot learn together, they cannot meet patient needs. CONCLUSIONS: These findings demonstrate that teams share their knowledge because they believe it has value, not because they are driven by external incentives or are monitored. This challenges the prevailing assumption that, to be effective, interprofessional learning should be externally managed. As health care develops, it will become increasingly important to consider how to support the internal learning processes of care teams as they navigate complex organisational changes and the shared learning experiences that characterise those changes. Those who support learning and development within the NHS should therefore focus on how relational processes, as well as educational content, contribute to a team's collective learning capability and the quality of care its members provide.

Delivering feedback on learning organization characteristics--using a Learning Practice Inventory.

RATIONALE, AIMS AND OBJECTIVES: Learning is recognized to be at the heart of the quality improvement process in the National Health Service (NHS). However, the challenge will be how to ensure that learning becomes embedded within the NHS culture. The aim of this study is to identify a robust feedback process and format in which practices could receive data on their responses to a Learning Practice Inventory (a diagnostic instrument designed to identify a practice's capacity for collective learning and change). METHOD: Five practices volunteered to test the instrument, and it was distributed to all members of the primary care team. A process was worked through to identify different formats for presenting scores within and between practices. The preferred method of data presentation was sought, and an evaluation gathered information on the preferred form of feedback, the usefulness of the data, the clarity of the questions and the level of interest in receiving further information. RESULTS: Eighty-five staff from five practices completed the questionnaire, and 61 individuals completed the evaluation forms. In most cases, there was a spread of scores by staff within practices and across the scale of 1-10. Medians were clustered at the learning practice end for all five practices. However, despite this skew, there were sometimes quite large differences between practices in their median scores. CONCLUSION: Our study suggests that a robust feedback process on collective capacity for learning and change can be identified that is useful and feasible. A key implication is that some form of educational support is required, and this work will take place as part of an ongoing programme of research by the authors.

CELT: a computerised evaluative learning tool for continuing professional development.

OBJECTIVES: To evaluate a computerised, evaluative learning tool (CELT) designed to encourage self-directed learning and help users make changes in practice following learning. The study aimed to evaluate how CELT was used and to ascertain user perceptions of the program. DESIGN: Qualitative analysis of interviews and quantitative analysis of entries made using the software. SETTING AND SUBJECTS: West of Scotland region, comprising six Health Board areas with a total of 2176 general practitioners (GPs), 39 of whom took part in the study. RESULTS: Of the 39 GPs who started on the project, 34 used CELT. Of these 34, 28 GPs sent in files and six did not. Of the 28 GPs who sent in files, 25 entered data and 76% (22/29) considered the program easy to use. The program was used 7 days a week during the day and night. It raised participants' awareness of the educational value of everyday experiences and led to increased thought about learning. In 41% (45/111) of entries there was evidence that some action had been initiated by users as a result of learning. CONCLUSIONS: CELT was designed to encourage self-directed learning and help users make changes in practice following learning. The study has shown that it can be used to deliver individual continuing professional development. It encourages a disciplined approach to learning, promotes thought about learning needs and increases the ability of GPs to learn from everyday experiences. In some instances, users were able to apply what had been learned.