1. The trainee as participant observer Roy Wallworth

2. Overview Background Challenging questions Essential features of a GP NHS values Participant observation Reflective v Reflexive practice Structured teaching as a ‘reflexive space’

3. Background Thinking like a GP from day one. Preventing the trainee from ‘going native’ Francis report. – ‘ the trainees are invaluable eyes and ears in a Hospital setting’ –‘the trainees are less likely to be ‘infected’ by poor organisational culture.

4. Challenging questions How do we get the trainee to think like and observe the world around himself as a GP? How does a trainee recognise poor organisational culture and what it is that is wrong.

5. Being a GP Essential features Attitudinal Contextual Scientific

6. Attitudinal features Awareness of your own capabilities and values Delivering care with compassion and kindness Being able to identify the ethical aspects of your clinical practice Awareness of self: understanding that your own attitudes and feelings are important determinants of how you practise. Valuing and encouraging the contribution of others Being prepared to participate in service management and improvement Justifying and clarifying personal ethics Being aware of the interaction of your work and your private life and striving for a good balance between them

7. Contextual features Understanding the impact of the local community (including socio-economic and workplace factors, geography and culture) on your patient care Awareness of the impact of your overall workload on the care given to individual patients and the facilities (e.g. Staff, equipment) available to deliver that care Understanding the financial, regulatory and legal frameworks in which you provide healthcare both at practice level and in the wider NHS Understanding the impact of your personal, home and working environment on the care that you provide

8. NHS values Respect and dignity Commitment to quality of care Compassion Improving lives Working together for patients Everyone counts

9. Participant observation This is an anthropological or ethnographic approach to learning about cultures –Complete participant –Participant as observer –Observer as participant –Complete observer.

10. Participant observation Skills –Learn the language (jargon) –Be explicit as to what IS seen and heard not what is expected to be seen and heard –Maintain posture of apprentice (treat the rest of the group as experts) –Record observations (ideally daily) –Be aware of your own feelings and response to situations. –Avoid ‘going native’ (this is not observing but living)

11. Participant observation Etic approach –The respondent's behaviour is interpreted by the observer with reference to known behaviours and beliefs Emic approach –The respondent becomes an expert and gives meaning to behaviour and beliefs.

12. Reflexive v Reflective practice Reflective practice –Reflecting on action Consciously review, describe, analyse and evaluate past practice with a view to gaining insight to improve future practice –Reflecting in action Examination of experiences and responses as they occur.

13. Reflexive v Reflective practice Reflexive practice –Involves an internal conversation and is self referential. –Recognises that observations and interactions and meaning made of them are influenced by ‘self’

14. Modes of reflexivity Communicative reflexivity –Internal conversations need to be confirmed and completed by others before they lead to action, thus fostering normative conventionalism Autonomous Reflexivity –Internal conversations are self-contained, leading directly to action and characterised by instrumental rationality Meta-reflexivity –Internal conversations critically evaluate previous inner dialogues and are critical about effective action in society, in promoting value rational action. Fractured reflexivity –Internal conversations cannot lead to purposeful courses of action and only intensify personal distress and disorientation, leading (temporarily) to ‘passive agents’

15. Reflexive space and structured teaching Questions to explore –Questions about the world –Questions about my world –Questions about correspondences and contradictions between those worlds

16. WHAT I DO… Behaviours Biological functions Physical states BODY and ORGANISM WHY I DO… Intentions and beliefs Assumptions Emotions SELF and CONSCIOUSNESS WHY WE DO… Cultural beliefs Norms, worldviews Organisational culture CULTURE and WORLDVIEW WHAT WE DO… Social, political, economic… organisational structures, processes and systems. SOCIAL SYSTEMS and ENVIRONMENT Individual Collective Outer (objective) Inner (subjective)