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

Abstract

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 outpatient clinic and the connecting corridors. Staff participants included a range of clinical, nursing, ancillary and clerical staff. RESULTSThe 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.

Socio-material perspectives on interprofessional team and collaborative learning

“…Bunniss and Kelly illustrate this type of collaborative learning in one primary health care setting: ‘[T]eams described an implicit aspect of their shared learning that was highly relational: that is, knowing each other well allowed them to “know what the other one is thinking”.’ As a result, these team members could anticipate each other's movements and even potential oversights, which they found critical in providing good care. As a point of contrast, Bunniss and Kelly also describe a hospital setting in which the complicated dynamics of inclusion and exclusion resulted in more limited forms of collective learning, mostly by asking questions of people within the same profession. Another factor that limited learning in this setting was the relative impermanence of teams: ‘[T]he interprofessional team did not necessarily share years of professional history and therefore would not expect to predict what colleagues will think and do.’…”

“…As a point of contrast, Bunniss and Kelly also describe a hospital setting in which the complicated dynamics of inclusion and exclusion resulted in more limited forms of collective learning, mostly by asking questions of people within the same profession. Another factor that limited learning in this setting was the relative impermanence of teams: ‘[T]he interprofessional team did not necessarily share years of professional history and therefore would not expect to predict what colleagues will think and do.’…”

“…To explain this latter finding, Bunniss and Kelly draw upon the CHAT concept of ‘knotworking’. This concept is used to explain how practitioners based in different professional activity systems each contribute their own distinctive thread of activity to the collaborative care of a patient.…”

Enhancing patient-engaged teamwork in healthcare: an observational case study

“…The concept of Knotworking (e.g. Bleakley, 2013;Bunniss & Kelly, 2013;Engeström, 2005;Lingard et al, 2012) suggests that clinical and educational interventions need to be developed that highlight the dynamic nature of each therapeutic encounter, and that identify the ebb and flow of the relationships involved including the role of nonanimate objects, such as telephones, pagers, computers and electronic patient records (Latour, 2007). Low or high fidelity simulated learning experiences can make these complexities and the fluidity of situations explicit (Liaw, Zhou, Lau, Siau, & Chan, 2014;Sawyer, Laubach, Hudak, Yamamura, & Pocrnich, 2013).…”

“…Collaborative teamwork allows healthcare professionals to address the multiple physical, psychological, social/ cultural and spiritual needs of patients with complex and chronic health issues (Hall, Bouvette, Heillman-Stille, & Weaver, 2012). However, some issues linked to professionalization, such as professional fragmentation, traditions of individualism, hierarchical authority and diffuse accountability create a daunting challenge to teamwork in healthcare (Bunniss & Kelly, 2013;Reeves, Lewin, Espin, & Zwarenstein, 2010;Varpio, Hall, Lingard, & Schryer, 2008). In addition, while care providers may be expected to work collaboratively, existing team-based research does not consistently address the involvement of the patient as a contributing team member (Casimiro et al, 2011;Martin & Finn, 2011).…”