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.

Collective learning, change and improvement in health care: trialling a facilitated learning initiative with general practice teams.

RATIONALE, AIMS AND OBJECTIVES: Many patients, families, health care professionals and politicians desire for quality improvement within the UK National Health Service. One way to achieve this change is for health care teams to work and learn together more effectively. This research aimed to design and trial a facilitated learning programme with the aim of supporting general practice teams in fostering the characteristics of learning organizations. METHODS: This is an action research study. Qualitative data were captured during and after the trial from 40 participants in two multi-professional general practice teams within different Scottish health boards. Data were gathered using observations, semi-structured interviews and written learning notes. RESULTS: Taking part in the LPP was a positive experience of learning together as a practice and enhanced communication within the team was a particular outcome. External facilitation helped provide focus and reduce inter-professional barriers. Teams found working in small, mixed role discussion groups particularly valuable in understanding each others' perspectives. The active learning style of the LPP could be daunting at times but teams valued the chance to identify their own quality improvement goals. Teams introduced a number of changes to improve the quality of care within their practice as a result of their participation. CONCLUSION: This trial of the learning practice programme shows that, with facilitation and the appropriate input of resources, general practice teams can successfully apply learning organization principles to produce quality improvement outcomes. The study also demonstrates the value of action research in researching iterative change over time.

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.

'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.