Learning responsibility on the job? Exploring doctors’ transitions in the clinical workplace

1. Learning responsibility on the job? Exploring doctors’ transitions in the clinical workplace • Learning responsibility: Exploring doctors’ transitions to new levels of medical performance • Trudie Roberts, Medical Education Unit • Sue Kilminster, Medical Education Unit • Naomi Quinton, Medical Education Unit • Miriam Zukas, Lifelong Learning Institute • 2007/9 -part of ESRC-funded Public Services Programme • Sub-theme on medical regulation part-funded by GMC ESRC RES-153-25-0084

2. Doctors’ transitions to new levels of performance

3. Overall research questions • How are doctors’ transitions regulated, managed and monitored? • How is doctors’ performance understood by trainees, healthcare professionals, employers and regulatory bodies? • How do specific learning cultures support transitions?

4. Many agendas Patients want smooth, seamless and invisible transitions with well-qualified care from doctors GMC want quick and ‘scientific’ results about ‘performance’ with implications for practice; Participants want better and more welcoming learning cultures; Consultants want better-prepared and more agentic doctors; Nurses want junior doctors to take more responsibility … We want theoretical and practical understanding of transitions with a focus on learning;

5. Existing assumptions • Doctors can be prepared for new levels of responsibility • They need first to learn (acquire) knowledge, skills, values • Knowledge, skills, values are transferred to new situations • Knowledge, skills, values are then applied to those new situations, being modified through experience

6. Performance Transfer Learning, knowledge, values

7. In the mind Individually derived Socially derived In the environment • Information processing (Simon) • Cognitive constructivism (Piaget)  Situated cognition (Greeno)  Socioculturalism (eg Lave and Wenger) Epistemological positioning of learning theories Adopted from Alexander, 2007

8. BUT • BUT • But to what extent does this recognise the embodied nature of learning? • Does this recognise the distinction between knowledge and knowing in practice? • Can we separate individually derived concepts in the mind from socially derived activities ‘out there’? • Metaphor of transfer a problem – use transition to suggest ongoing process in which work activity and context, the individual and changes over time and through practice are significant

9. Apprenticeship (socioculturalism) – an alternative • Apprenticeship, situated learning and communities of practice • Emphasises practice as basis for learning • Learning is about participation – learning is a form of ‘becoming’ • Learning is engagement in legitimate peripheral practice under the guidance of old-timers • Learning knowledge, values, skills in practice – not as separate from practice • Socially derived understandings of learning within the work environment (Lave and Wenger, 1991, Bleakley, 2002, Dornan, 2005)

11. BUT … does it apply for doctors in practice? • No tight-knit community; • Instead intersecting (competing?) communities; • Often old-timers absent; • Practice transforming constantly (through regulation, technological transformation etc) • And what about changing dispositions and actions of the individuals concerned? • And what about the power relations operating within a community of practice? And the reproduction of practices and power relations?

12. Methodology • Participants • From medical student to foundation training (F1) and beginning clinical practice (n=10) – second or third rotation • From F2 (SHO) to Specialist Trainee (Specialist Registrars) - generalist to specialist clinical practice; at least 2 years (usually more) after graduation (n=10). • All working in elderly medicine; • Located in teaching and district hospitals

13. Data sources • Desk-based research (policies, protocols etc) • Interviews with doctors (beginning and end of transition if possible) • Focused observations • Interviews with other professions – nurses, pharmacists, physiotherapists etc and with consultants (ie seniors in charge of doctors’ learning)

14. Security passes

15. Patient records

16. Putting practice into values: two cases • Yeah, whereas if it had been the other consultant I would probably have started antibiotics … because he is for antibiotics so it just depends on who the consultant is, you have to know who you are working for. Caroline (F1)

17. Putting practice into values: two cases • He took us (two new specialist trainees) into a room – didn’t really tell us an awful lot but he did tell us that we shouldn’t do this – it’s a bit political – that we shouldn’t do blood cultures because they have an enquiry into every MRSA [a bacterial infection] which you have on the ward – this goes completely against any medical advice or you know what should be done and purely to save the Trust money. I thought it was really rather disgraceful …Charles

18. How do specific learning cultures support transitions? • Learning cultures – the social practices through which people learn – are important in transition learning (learning cultures before and during transition) • Social practices involve clinical staff, patients, technologies, protocols, organisational and institutional practices etc: • “cultures are constituted by actions, dispositions and interpretations and exist in and through interaction and communication” (Hodkinson et al, 2008, p 34). • This entails a two-way process of individuals being (re)produced by culture and cultures being (re) produced by individuals.

19. Dispositions and actions of the individual also highly significant • Hodkinson et al, 2008 – cultural theory of learning – horizons for learning taking into account inter-relationship between an individual’s dispositions and the learning culture; • Metaphor of learning as ‘becoming’ (after Lave and Wenger, 1991; Hodkinson, Biesta and James, 2008):

20. Tentative conclusions • Values and judgement are relational, embodied and inseparable from learning culture • Practices are relational, embodied and inseparable from learning culture • Learning culture exists in practice – not separately from practice • Transitional learning involves learning to make transitions as well as learning in transition