Doves and hawks: practice educators' attitudes towards interprofessional learning

The authors offer a critical account of interprofessional learning and working within the spheres of health and social care. The 'joined up' imperatives promoted by central government are compared to the somewhat contradictory findings of research exploring the effectiveness of interprofessional working. The role of practice educators in developing attitudes, learning and experiences around interprofessional working is heralded as an under-researched area while being of particular significance in the formation of professional identity. This paper uses the term 'practice educators' to capture the shared functions of nurse mentors and social work practice teachers. The authors draw on a small-scale piece of focus group-based research with professional practitioners from health and social care. The authors stress throughout the need to retain a localized approach to research in this area where differences emerged even among teams located closely to each other. The focus groups explored the experiences and attitudes of a variety of field-based practice educators within two profession-specific focus groups. The findings are coded, summarized and presented using a matrix. An analysis is offered which suggests that across both professional groups, two distinct categories of practice educators are emerging. The 'doves' appear to be more accepting of changes around professional boundaries where blurring is taking place. Although they do not ignore the potential conflict that can exist for themselves and their students, the doves largely seek to manage this conflict and look to a consensus approach. In contrast, the 'hawks' are more concerned with issues of professional erosion and look to develop more combative strategies around the maintenance of the existing boundaries and their current professional identity. It is argued that this approach has more of a conflict base.     

Technology and medical practice

Abstract One of the most significant developments in healthcare over the past 25 years has been the widespread deployment of information and communication technologies. These technologies have had a wide‐ranging impact on the organisation of healthcare, on professional practice and on patients’ experience of illness and its management. In this paper we discuss the ways in which Sociology of Health and illness has provided a forum for the analysis of these new technologies in healthcare. We review a range of relevant research published in the Journal; papers that address such issues as dehumanisation and emotional labour, professional practice and identity, and the social and institutional shaping of technology. Despite these important initiatives, we suggest that information and communication technologies in healthcare remain relatively under‐explored within the Journal and, more generally, by the sociology of health and illness and point to developments in cognate areas which may have some bearing upon the analysis of technology in action.     

Practice libraries: managing printed information and meeting the information needs of staff in general practice

Librarians and GPs share an interest in exploring different approaches to providing information to general practice and improving information management within it. Describing the aims, policy, collections, enquiries and services of three Practice Libraries in the Aylesbury area, this paper demonstrates that an information professional can make a significant impact on the management of printed information whilst facilitating access to external sources. A wealth of opportunities lie ahead for those willing to apply information handling skills to general practice. Medical librarians will need to strike a careful balance between providing direct access to sources and the development of information services tailored to meet the needs of primary health care workers.     

A questionnaire examining learning in general practice

Vocational training is a key element of professional development in general practice. Learner-centred approaches to teaching bring a need for greater understanding of the individual learning styles and preferences of trainees. This paper reports the findings of a pilot study undertaken to determine factors that may influence learning among general practice trainees. A questionnaire survey of 261 trainees in six regions in the UK was carried out to explore attitudes to a series of themes identified in semi-structured interviews with trainees at the end of their training. Six distinct subscales were identified using principal components analysis. These are named 'Learning from Patients', 'Openness to Criticism', 'Negative Attitudes', 'Desire for Clear Guidelines', 'Peer Support', and 'Academic Approach'. Males scored significantly higher on 'Academic Approach' (   P < 0.05  ). Each of the subscales reflects themes that permeate the atmosphere of general pratice training. Further work is required to establish relationships between the subscales and the outcomes of learning and to explore the implications for continuing professional development. The questionnaire is an instrument that may prove useful in the future investigation of learning in general practice.     

Organisational development in general practice: lessons from practice and professional development plans (PPDPs)

Background

Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care.

Results

Practice and professional development plans are hybrids produced by the combination of ideas from management (the applied behavioural science of organisational development) and education (self-directed adult learning theories) and, in conceptual terms, address the lack of effectiveness of passive educational strategies by making interventions relevant to identified system wide needs. In the intervention, each practice participated in a series of multidisciplinary workshops (minimum 4) where the process outcome was the production of a practice development plan and a set of personal portfolios, and the final outcome was a realised organisational change. It was apparent during the project that organisational admission to a process of developmental planning needed to be a stepwise process, where initial interest can lead to a fuller understanding, which subsequently develops into motivation and ownership, sufficient to complete the exercise. The advantages of introducing expert external facilitation were clear: evaluations of internal group processes were possible, strategic issues could be raised and explored and financial probity ensured. These areas are much more difficult to examine when only internal stakeholders are engaged in a planning process.

Conclusions

It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures. Existing systems are based on educational credits for attendance and emerging accountability frameworks (criteria checklists) for clinical governance. Moving to systems that are less summative and more formative, and based on the philosophies of continual quality improvement, require changes to be made in the relevant support systems in order achieve policy proposals.     

Linking assessment to learning: a new route to quality assurance in medical practice

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.     

A reflective analysis of medical education research on self-regulation in learning and practice

Medical Education 2012: 46: 71–79 Objectives In the health professions we expect practitioners and trainees to engage in self‐regulation of their learning and practice. For example, doctors are responsible for diagnosing their own learning needs and pursuing professional development opportunities; medical residents are expected to identify what they do not know when caring for patients and to seek help from supervisors when they need it, and medical school curricula are increasingly called upon to support self‐regulation as a central learning outcome. Given the importance of self‐regulation in both health professions education and ongoing professional practice, our aim was to generate a snapshot of the state of the science in medical education research in this area. Methods To achieve this goal, we gathered literature focused on self‐regulation or self‐directed learning undertaken from multiple perspectives. Then, with support from a multi‐component theoretical framework, we created an overarching map of the themes addressed thus far and emerging findings. We built from that integrative overview to consider contributions, connections and gaps in research on self‐regulation to date. Results and conclusions Based on this reflective analysis, we conclude that the medical education community’s understanding about self‐regulation will continue to advance as we: (i) consider how learning is undertaken within the complex social contexts of clinical training and practice; (ii) think of self‐regulation within an integrative perspective that allows us to combine disparate strands of research and to consider self‐regulation across the training continuum in medicine, from learning to practice; (iii) attend to the grain size of analysis both thoughtfully and intentionally, and (iv) most essentially, extend our efforts to understand the need for and best practices in support of self‐regulation.     

Is drawing a valuable skill in surgical practice? 100 surgeons weigh in

The author noted surgeons frequently drawing in routine practice. Literature review revealed no prior study of this activity. This research was conducted to examine the prevalence, purpose, and perceived value of this practice. Surgeons' experiences and opinions regarding drawing in surgical practice were canvassed via an online survey. One-hundred surgeons participated. 92% valued drawing routinely in practice. Utility was reported across domains of consent, communication, patient care, medico-legal, education, and planning operations. Free-text feedback is discussed, and learning points from this data were summarised. This paper establishes the collective professional opinion of 100 surgeons regarding the value of drawing, which plays a thriving role in current surgical practice. The utility of this skill transcends merely documenting visual information, allowing surgeons to quickly visualise simplified, dynamic representations of reality. This facilitates communication between professionals, and with their patients. The efficiency and availability of this medium allows drawing to maintain a distinct role in medical communication amongst other imaging modalities available. This paper is the first to document the prevalence of drawing amongst surgeons, substantiates an informed professional opinion supporting this practice, and demonstrates widespread enthusiasm for further training in these skills.     

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians’ learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients’ conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians’ learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.     

Simulation and clinical practice: strengthening the relationship

INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.     

In the eye of the beholder: student perspectives on professional roles in practice

Context Learning about professional roles in clinical settings is confounded by the gap between espoused theory and the professional practice of the workplace. Workplace learning is grounded in that which is afforded to learners and individuals’ engagement with those affordances. The meaning students make of the real‐world performance of professional roles and how this relates to formal professionalism frameworks remain unclear. Construal of experience is individual. Professional roles are enacted in the eye of the beholder. In their reflections, student subjectivities, intentionalities and engagement with workplace affordances are revealed. Our research question was: How do students’ perspectives of professional roles in practice, revealed through written reflections, relate to the formal professionalism curriculum? Methods Year 3 students (n = 108) wrote reflections during hospital and community placements. Thematic content analysis was performed. A priori categories based on the CanMEDS Physician Roles Framework were used to map content. Results A total of 107 students consented to the use of their reflections (n = 315). The CanMEDS roles of Communicator, Professional and Scholar predominated. Students were seen applying prior knowledge to new situations and reflecting on them. For some, the confirmation of previous learning was the outcome; for others, the mismatch between practice and the formal curriculum led to the questioning of both. The roles of Manager, Collaborator and Health Advocate were less frequently reflected upon. Differences between the affordances of hospital and community placements were seen. Means to address findings are discussed with reference to Billett’s duality of workplace learning. Conclusions Reflective narratives reveal how students construe professional roles in practice. Mapping the content of reflections to a competency framework confirmed the mismatch between the formal and enacted curricula. Billett’s duality of workplace learning provides a useful lens through which to identify means to address this, through the structural aspects of access and guidance, and through the promotion of individual engagement and reflection.     

Creating a professional development platform to transform social work clinical practice in health care

ABSTRACT

Since U.S. Congress’ 2010 passing of the Affordable Care Act and the creation of numerous care coordination programs, Mount Sinai Hospital’s Department of Social Work Services has experienced exponential growth. The Department is deeply committed to recruiting and developing the most talented social workers to best meet the needs of patients and family caregivers and to serve as integral, valued members of interdisciplinary care teams. Traditional learning methods are insufficient for a staff of hundreds, given the changes in health care and the complexity of the work. This necessitates the use of new training and education methods to maintain the quality of professional development. This article provides an overview of the Department’s strategy and creation of a professional development learning platform to transform clinical social work practice. It reviews various education models that utilize an e-learning management system and case studies using standardized patients. These models demonstrate innovative learning approaches for both new and experienced social workers in health care. The platform’s successes and challenges and recommendations for future development and sustainability are outlined.     

Reflection and reflective practice in health professions education: a systematic review

The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.     

Independent learning among general practice trainees: an initial survey

Self-directed learning is a natural way for adults to learn. Vocational training for general practice is a preparation for unsupervised clinical work that will be supported, in the main, by continuing medical education. This study uses the Self-Directed Learning Readiness Scale to investigate factors influencing readiness for such learning among a sample of general practice trainees. Three principal factors emerged from analysis: enjoyment and enthusiasm for learning; a positive self-concept as a learner and a factor suggesting the possibility of a 'reproducing' orientation to learning. These factors may reflect approaches to learning in general rather than these adopted for professional learning, but offer helpful pointers for the development of both vocational training and of continuing medical education.     

Reflection in professional practice and education

Reflection is a crucial process in the transforming of experience into knowledge, skills and attitudes. As such it is at the core of both learning and continually evolving professional practice. This article draws on literature from adult learning and medical education fields to present a theoretical framework for reflection and practical techniques for its application in general practice. It is directed toward the training of medical students and registrars on clinical rotations, but also for the established general practitioner.     

What is a 'learning organization' in general practice? A case study.

The focus of the research herein was to examine the main characteristics of a learning organization in a general practice. An ethnographic approach was taken. Blockage instrument, structured interviews and documentary evidence were used to establish the validity and the reliability of the research. Data were collected and analysed systematically. It is shown that the case study practice contains the characteristics of a learning organization and key management and organizational issues, such as policy making, practice management and performance management, are identified. Management strategies are offered and recommendations made both for the case study practice and generally for primary and secondary healthcare services. We hope that our research will guide further strategic planning in the case study practice, and that it will help other general practices and the NHS as a whole in the development of a learning organization.     

SHORT REPORT Technological dreams: The implications of new technologies for occupational therapy education and evidence-based practice

Computer technologies will change both occupational therapy education and practice. Technological optimists suggest that there will be positive benefits for distance learning and supervision, universal equal access to information and expertise, and positive cross-cultural exchange. However, technologies have inevitable and unexpected costs. In this report I explore the potential for future problems with professional induction, educational reductionism, cultural imperialism and deprofessionalization through a review of the literature. I suggest that early recognition of the costs as well as the benefits of computer-based education will be important to the development of international occupational therapy.     

Using theory and research to shape the practice of continuing professional development

As research has expanded in scope and diversity, application of new ideas to the programs that facilitate learning and change should have grown accordingly. However, the gap between the theories of how and why physicians learn and change their practices and the practical application of these theories appears to be wider. The research component of research and development in continuing professional development appears to be strong, but the development function appears to be weak. This presentation will describe some of the factors that have led to this gap between theory and practice and suggest some actions that may be taken to reduce this gap. Among the factors leading to the gap are the different perspectives of practitioners and scholars as to the purposes of research, the appropriate foci of studies, and the attributes of quality of studies related to continuing professional development. A traditional model of research is discussed and analyzed for its strengths and weaknesses as they relate to writing research that is relevant to practitioners. The role and function of the research problem and the conclusions of studies are described in terms of how these two parts of a research report can assist in the translation of theory and evidence into the practice. In order to illustrate how theory may be translated into practical tools and procedures, the application of the theory of change and learning to the assessment of readiness to change is reviewed briefly. Implications of this experience are described and steps that may be helpful in bridging the gap between theory and practice will be proposed. Finally, a system of research and development that can ensure a tighter link between research and practice is proposed. The next steps to achieve this kind of system are suggested in the conclusions.