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

Doctors transitions to new levels of performance

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?

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;

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

Learning, knowledge, values Transfer Performance

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

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

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)

Practice LearningValuingBecomingKnowing

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?

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

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)

Security passes

Patient records

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)

Putting practice into values: two cases He took us (two new specialist trainees) into a room – didnt really tell us an awful lot but he did tell us that we shouldnt do this – its a bit political – that we shouldnt 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

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.

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 individuals dispositions and the learning culture; Metaphor of learning as becoming (after Lave and Wenger, 1991; Hodkinson, Biesta and James, 2008):

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