Learning through health care work: premises, contributions and practices

CONTEXT

Learning through work has long been important for the development of health care workers' occupational competence. However, to effectively utilise this mode of learning, its particular qualities and contributions need to be understood and optimised and its limitations redressed.

CONCEPTS

Optimising the experiences health care workplaces provide, augmenting their potential for learning and promoting workers' engagement with them can, together, improve workers' ability to respond to future occupational challenges. Importantly, such considerations can be used to understand and appraise workplaces as learning environments. Here, the concepts of practice curricula and pedagogies, and workers' personal epistemologies (i.e. what individuals know, can do and value) are described and advanced as practical bases for optimising learning in and for health care workplaces now and for the future.

CONCLUSION

Such bases seem salient given the growing emphasis on practice-based provisions for the initial preparation and on-going professional development of health care workers' capacities to be effective in their practice, and responsive to occupational innovations that need to be generated and enacted through practice.

Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program

BACKGROUND

Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme.

MAIN TEXT

To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience.

CONCLUSION

The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.

Interns' participation and learning in clinical environments in a New Zealand hospital

PURPOSE

To explore factors that encourage interns to participate actively within clinical rotations. Encouraging their participation in workplace interactions and activities during their clinical rotations is central to effective development of clinical practice.

METHOD

In 2002-03, individual interviews and a focus group were conducted to gather data about interns' experiences in clinical rotations within a New Zealand hospital setting. A model for planning and organizing clinical learning was drafted and refined by iteration with other learners and more experienced peers.

RESULTS

The findings resulted in a model for participation in clinical settings where two critical components were identified: the tasks of patient care and engagement with the clinical team. These two components are further divided into two aspects: initiation and maintenance. The outcome of all four factors working well is a reinforcing cycle of activities that promote and encourage effective participation and learning.

CONCLUSION

This model could provide a framework and best-practice guide that could be used for faculty development and thereby allow both supervisors and learners to gain confidence and satisfaction.

Sociogeneses, Activity and Ontogeny

Understanding relations between the social and cognitive contributions to thinking and acting has become a pressing goal for psychological theorizing. Central to understanding these relations is the negotiation and construction of knowledge that is comprised of the inter-psychological processes that engage both cognitive and social experiences. This paper proposes that these processes can be understood through a complex of relations among different sociogenetic sources and between those sources and individuals’ agency as constituted by their life histories or ontogenies. Rather than a single sociogenetic source, the social contributions are held to have historical-cultural and situational geneses. However, through inter-psychological processes these contributions are mediated by individuals’ unique and socially shaped cognitive experiences. Findings from an investigation of the same vocational practice (hairdressing) conducted in four different work settings are used to identify tentative relations between the sociogeneses of the goal-directed activities that individuals engage in, and how these individuals represent their knowledge in memory. Together, these findings tentatively elaborate particular sociogenetic contributions to individuals’ thinking and acting, and relations between particular elements and phases of goal-directed activities and, hence, their impact on cognitive change (development).

Journeying through clinical placements--an examination of six student cases

INTRODUCTION

How student nurses are permitted to participate in healthcare settings during placements is central to their skill development, formation of occupational identity and retention in nursing. Novices' participation and learning was mapped through their clinical experiences from student to graduate, as part of a multi-method longitudinal study examining nurses' workplace learning.

METHODS

Twenty-nine second and third year nursing students participated in a series of interviews over a two year period. Six students, representing a cross-section of a student cohort form the basis of this case study. Interviews were transcribed verbatim and thematically coded.

RESULTS

Four themes encapsulating the participants' journeys through clinical situations were identified; (a) creating learning opportunities, (b) gaining independence, (c) becoming part of the team and (d) generational differences. The themes reflect the development of novice nurses and the nuances of the workplace as a learning environment.

DISCUSSION

The cases highlight the importance of supportive placements that comprise openness with opportunities, tolerance of inter-generational differences and invitations to become part of the nursing team. The challenge for nurse educators is how to best prepare students for the complexities of the social, cultural and political arena of clinical practice.

The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers

AIM

To identify what motivates individuals to engage in a nursing career.

BACKGROUND

Recruitment and retention of nurses is a worldwide concern that is associated with several compounding factors, primarily the high attrition of its new graduates and an ageing workforce. Given these factors, it is necessary to understand why individuals choose to nurse, what keeps them engaged in nursing, and in what ways healthcare systems can support career development and retention.

METHOD

This paper presents initial interview data from a longitudinal multi method study with 29 undergraduate student nurses, 25 registered nurses (RNs), six Nurse Unit Managers (NUMs) and four Directors of Nursing (DoNs) from four hospitals across a healthcare organization in Australia.

RESULTS

Thematic analysis yielded four key themes that were common to all participants: (1) a desire to help, (2) caring, (3) sense of achievement and (4) self-validation.

CONCLUSIONS

These themes represented individuals' motivation to enter nursing and sustain them in their careers as either nurses or managers.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers need to be cognisant of nurses underlying values and motivators in addressing recruitment and retention issues. Strategies need to be considered at both unit and organizational levels to ensure that the 'desire to care' does not become lost.

Resilience in Healthcare (RiH): a longitudinal research programme protocol

INTRODUCTION

Over the past three decades, extensive research has been undertaken to understand the elements of what constitutes high quality in healthcare. Yet, much of this research has been conducted on individual elements and their specific challenges. Hence, goals other than understanding the complex of factors and elements that comprises quality in healthcare have been privileged. This lack of progress has led to the conclusion that existing approaches to research are not able to address the inherent complexity of healthcare systems as characterised by a significant degree of performance variability within and across system levels, and what makes them resilient. A shift is, therefore, necessary in such approaches. Resilience in Healthcare (RiH) adopts an approach comprising a comprehensive research programme that models the capacity of healthcare systems and stakeholders to adapt to changes, variations and/or disruptions: that is, resilience. As such, RiH offers a fresh approach capable of capturing and illuminating the complexity of healthcare and how high-quality care can be understood and advanced.

METHODS AND ANALYSIS

Methodologically, to illuminate what constitutes quality in healthcare, it is necessary to go beyond single-site, case-based studies. Instead, there is a need to engage in multi-site, cross-national studies and engage in long-term multidisciplinary collaboration between national and international researchers interacting with multiple healthcare stakeholders. By adopting such processes, multiple partners and a multidisciplinary orientation, the 5-year RiH research programme aims to confront these challenges and accelerate current understandings about and approaches to researching healthcare quality.The RiH research programme adopts a longitudinal collaborative interactive design to capture and illuminate resilience as part of healthcare quality in different healthcare settings in Norway and in five other countries. It combines a meta-analysis of detailed empirical research in Norway with cross-country comparison from Australia, Japan, Netherlands, Switzerland and the UK. Through establishing an RiH framework, the programme will identify processes with outcomes that aim to capture how high-quality healthcare provisions are achieved. A collaborative learning framework centred on engagement aims to systematically translate research findings into practice through co-construction processes with partners and stakeholders.

ETHICS AND DISSEMINATION

The RiH research programme is approved by the Norwegian Centre for Research Data (No. 864334). The empirical projects selected for inclusion in this longitudinal research programme have been approved by the Norwegian Centre for Research Data or the Regional Committees for Medical and Health Research Ethics. The RiH research programme has an embedded publication and dissemination strategy focusing on the progressive sharing of scientific knowledge, information and results, and on engaging with the public, including relevant patient and stakeholder representatives. The findings will be disseminated through scientific articles, PhD dissertations, presentations at national and international conferences, and through social media, newsletters and the popular media.

Mimesis

This article proposes that human resource development (HRD) practitioners need to reconsider the potential of workers’ learning through every activities and interactions at work. It holds that the majority of learning across working lives likely occurs outside of being mentored, taught, or guided through training programs by others (e.g., teachers or experienced coworkers etc.) and their predetermined intentions for what is to be learnt. Yet, many, and perhaps most, explanatory and procedural accounts emphasize these kinds of intentional interventions by others (e.g., educational and training programs), more than workers’ actions as learners in and through their everyday work activities and interactions. Therefore, it seems important for HRD that these everyday learning processes be understood more fully. Here, an account is advanced of how workers’ learning through everyday work activities and interactions, both remote from and when engaged with others, arises through mimetic processes (i.e., observation, imitation, and action).

"It's yours to take": generating learner feedback literacy in the workplace

Feedback can improve students' learning and performance on clinical placements, yet students are often dissatisfied with the process. Attempts to improve feedback frequently focus on faculty development programs without addressing learners' capabilities to engage with feedback. For feedback to be effective, students need to understand its processes and to translate this into practice. Developing student feedback literacy may enhance feedback engagement and, therefore, learning outcomes. This qualitative interview study aimed to problematise student feedback literacy in the healthcare setting, from the learner's perspective. Before commencing placements, 105 healthcare students at an Australian teaching hospital participated in a feedback literacy program. After their placements, 27 students engaged in semi-structured interviews to explore their feedback experiences. Informed by workplace learning theory, interview transcripts were analysed using the framework method of qualitative analysis. Students reported reframing feedback as a process they could initiate and engage in, rather one they were subjected to. When they took an intentional stance, students noted that feedback conversations generated plans for improvement which they were enacting. However, students had to work hard against orthodox feedback expectations and habits in healthcare. They privileged intraprofessional supervisor feedback over interprofessional practitioners, patients, or peers. Findings suggest that student engagement with feedback can be augmented with focussed retraining. However, further research examining the structural and cultural influences on students' capacity to be active in workplace feedback is warranted.

Use of a think-aloud procedure to explore the relationship between clinical reasoning and solution-focused training in self-harm for emergency nurses

Self-harm is a risk factor for further episodes of self-harm and suicide. The most common service used by self-injurers is the emergency department. However, very often, nurses have received no special training to identify and address the needs of these patients. In addition this care context is typically biomedical and without psychosocial skills, nurses can tend to feel unprepared and lacking in confidence, particularly on the issue of self-harm. In a study that aimed to improve understanding and teach solution-focused skills to emergency nurses so that they may be more helpful with patients who self-harm, several outcome measures were considered, including knowledge, professional identity and clinical reasoning. The think-aloud procedure was used as a way of exploring and improving the solution-focused nature of nurses' clinical reasoning in a range of self-harm scenarios. A total of 28 emergency nurses completed the activity. Data were audiotaped, transcribed and analysed. The results indicated that significant improvements were noted in nurses' ability to consider the patients' psychosocial needs following the intervention. Thus this study has shown that interactive education not only improves attitude and confidence but enlarges nurses' reasoning skills to include psychosocial needs. This is likely to improve the quality of care provided to patients with mental health problems who present to emergency settings, reducing stigma for patients and providing the important first steps to enduring change - acknowledgment and respect.

Developing junior doctors' prescribing practices through collaborative practice: Sustaining and transforming the practice of communities

Prescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors' prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists' contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors' prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.

Learning to prescribe through co-working: junior doctors, pharmacists and consultants

CONTEXT

Learning to prescribe is challenging for junior doctors. Significant efforts have been made to improve prescribing education, especially in view of the high rates of prescribing errors made by junior doctors. However, considerations of educational options often overlook the fact that learning to prescribe and prescribing practices rely on practice-based interactions with informed practitioners, such as pharmacists and consultants. Pharmacists have long made important contributions to developing prescribing capacities.

OBJECTIVES

The present study examines the potential of everyday co-working between junior doctors and pharmacists, in conjunction with consultants, as an accessible means of developing effective prescribing practices.

METHODS

A qualitative interview study was conducted in an Australian tertiary hospital using thematic analysis to explore junior doctors', pharmacists' and consultants' perspectives on how co-working supports learning to prescribe in an acute tertiary hospital setting. Participants included 34 practitioners, comprising junior doctors (n = 11), consultants (n = 10) and pharmacists (n = 13). The thematic analysis was informed by workplace learning theory.

RESULTS

Learning to prescribe was found to be a highly interdependent process. In particular, junior doctors were dependent on co-working with consultants and pharmacists. Three interrelated themes related to co-working and learning to prescribe in the workplace were identified: (i) prescribing readiness of junior doctors; (ii) need for guidance, and (iii) the challenges of pharmacists co-working as outsiders.

CONCLUSIONS

Co-working with pharmacists and consultants contributes positively to junior doctors' prescribing practices. However, co-working is complex and is influenced by differing understandings of prescribing practices. These insights assist in informing how co-working can be enacted routinely in hospital settings to promote safe and effective prescribing practices. Consideration should be given to when and how co-working between junior doctors and pharmacists is initiated, including during medical school. In clinical settings, strategies such as having pharmacists attend ward rounds and adopt a role of learning facilitation rather than error identification may augment everyday opportunities for co-working and learning.

A bridge over troubled water? - Exploring learning processes in a transition program with newly graduated nurses

Successful preparation of newly graduated nurses (NGN) is a critical concern for the healthcare sector. This study explores the learning processes enacted in a transition program with NGNs implemented in hospitals in western Sweden. Group interviews with NGNs and ward managers were conducted, with the data analyzed using qualitative thematic analysis. The following themes were identified as the learning processes secured through the program: Recognizing the NGNs' role as novice practitioners, Emphasizing newly graduated nurses as learners, and Progressing towards a comprehensive nursing role. To support these learning processes, the program should provide opportunies to consolidate and reconcile NGNs' experiences as novices in healthcare environments where effective performance is crucial. If NGNs are supported in these ways, the program can make salient contributions to develop the knowledge bases of their occupational expertise.

Using video-reflexive ethnography to understand complexity and change practice

CONTEXT

A range of research methods have been used to understand effective workplace learning in the health professions. The impact of findings from this research usually requires knowledge translation activities in the form of faculty development initiatives, such as supervisor workshops. Far rarer, but with greater potential, are research approaches that concurrently seek to understand and change practice through empowering clinicians to refine aspects of their practice.

METHODS

In this methodological article, we describe video-reflexive ethnography (VRE), a collaborative visual research approach that seeks to capture, illuminate and optimise in situ work and education practices. Video-reflexive ethnography usually has three phases: (a) initial familiarisation with practice through field observations; (b) video-recording of practice, and (c) reflexive sessions about the edited footage with participants and researchers. Drawing on our own experiences as researchers using VRE, we discuss four key principles of VRE: (a) exnovation; (b) collaboration; (c) reflexivity, and (d) care.

DISCUSSION

Although VRE has been used to illuminate and understand health professionals education, its potential for changing clinical education practices has yet to be realised. Video-reflexive ethnography enables observation of the social and relational interactions in health care practice and allows individual (and group) perspectives to be articulated and analysed. The approach can prompt fresh perspectives and insights into health care education and practice for researchers and clinicians through shared deliberations about how practice might be reimagined and enacted.