Phase 2 Anaesthetic action learning group

This phase followed the scoping interviews with the four anaesthetic trainees where four themes emerged: they were all involved in teaching, teaching was mainly within the workplace, teaching was mainly opportunistic, and they had received no ‘training’ in workplace teaching.

This phase of the study had two main sections. The first section was to build a picture of how the anaesthetic trainees learn and teach within the OR. While the interviews had given some indication, these were memories and covered issues in general. In order to explore what happens in the OR, more detailed and in depth illustrations were needed. These descriptions needed to encompass the breadth of teaching to include episodes that demonstrated good practice and those that were less successful. The second section used the analysis of how the trainees taught and learnt, in the OR, to identify areas where they might change their practice. In addition there was an opportunity for the trainees to put these changes into practice.

I considered a number of options to capture examples of teaching and learning in the OR. Observation of the trainees teaching was considered, particularly as this approach was used successfully by Lyon and Brew (2003) when they looked at medical student teaching in the OR. This was rejected for several reasons. The observer would need to be supernumerary, as all the members of the OR team are actively engaged in patient care. This would involve complex ethical issues involving consent from the patient, all members of the OR team and the learner. Furthermore the cost of employing such an observer would be prohibitive as there were no monies for this study. The use of videos and recording was also considered but this also involved ethical and consent issues. I took the approach of asking anaesthetic trainees to document their teaching and learning experiences. This was achieved by asking them to keep diaries of their experiences. This was different to the interview approach because they would

be identifying the teaching in real time and be able to document it soon afterwards. Thus the teaching episodes would be contemporaneous.

This approach produced problems of its own. The act of identifying and writing about their teaching had the potential to change what they were doing because they would be viewing their teaching from a different perspective. I decided to utilise this problem by including the trainees in identifying changes they might want to try in their practice. I approached this by setting up an action learning group (ALG) with a small number of experienced anaesthetic trainees. This enabled the trainees to discuss their experiences with peers and identify common areas of excellence or concern. This then fed into identifying changes that each of them might make as individuals to their teaching. In addition the group offered suggestions and support for other members of the group. This meant that the ALG acted as an educational intervention.

This was an innovative approach to gathering data, identifying areas for change, and

providing an educational intervention for anaesthetic trainees. The direction the study would take was uncertain as was the expectation of success. In order to track the progress and the reasons for the direction the study took I kept a diary, including reflections on the process which formed part of the data collection.

In summary this phase took the form of a case study using an action learning group of anaesthetic trainees, drawing on the principles of action research. The overall structure is summarised in Figure 1. I identified and approached suitable participants and invited them to an introductory meeting. The participants then documented teaching and learning episodes in their diaries for discussion at four subsequent meetings. I explore the methods used in more detail in the following sections.

Figure 14 Summary of the design for Phase 2

Action Learning Group

Central to this phase of the study was the establishment of the ALG. Action learning is:

‘…a continuous process of learning and reflection, supported by colleagues, with an intention of getting things done.’ (McGill and Beaty, 1995, p.21)

This definition has several terms that relate directly to my study. There is an intention to improve the trainees’ teaching in the OR, there will be the support of colleagues in the form of a group, and there will be reflection on their teaching. The purpose of an ALG is to help the individual reflect and to suggest ways of moving forward. It was hoped that meeting in a group would facilitate this, as we often do not find the time for reflection in everyday life. However, it is still the individual who changes as a result of this group process. The individual has the opportunity to speak and think aloud. It is not so much that the group

Participant selection Diary entries Action Learning Group meetings 1 - 4 Disbanding Recording Transcription Analysis Preliminary meeting

members select a solution to a problem as they help the individual to find the solutions for themselves. It is about real issues and resolving real problems. However, the individual has to want to develop and learn.

Novel or painful experiences encourage or even demand reflection. However there are all those other mundane experiences which never quite demand reflection. Action learning is one approach to encouraging reflection on the less dramatic but still important experiences of life. The process is cyclical in that it starts with experiences, which may be novel or problematic. These experiences are shared and discussed by the group members to understand the issues and formulate plans for the individual to try. The individual implements the plan and then brings the ‘results’ back for further discussion.

This integration of experience, reflection and action include aspects of Kolb’s (Kolb et al., 1971) experiential learning and Schon’s (Schon, 1983) reflection as discussed in the literature review. Indeed tracing back these three themes shows they converge at the seminal work of Kurt Lewin (1946). At the time Lewin was looking for ways to improve race relations in the USA. He brought together a group composed of individuals who worked together, despite widely different beliefs, because they were ready and willing to face difficulties realistically, fact find and work together to overcome them. Lewin (1947, p.12) describes the relationship between fact finding, action and how its investigation may influence change:

‘Individual perception or ‘fact-finding’ – for instance, an act of accounting – is linked with individual action in such a way that the content of the perception or fact-finding depends upon the way in which the situation is changed by action. The fact-finding in turn influences or steers action.’

The ALG consisted of a small number of anaesthetic trainees and me, to lead the group, from a single university hospital.

Participants

The sample was selected from the anaesthetic trainees attached to a university hospital between February and August 2003. They needed to have completed at least two years as an anaesthetic trainee and have passed their final anaesthetic examinations. In addition those trainees who were within six months of completing their training were also excluded because their energies were concentrated on acquiring a consultant post and this research study would not be completed in time. This left a total of seven potential individuals.

I approached all of the individuals personally face to face. I explained the purpose of the study and that it was to form part of my thesis into investigating how anaesthetists learn to teach. I emphasised that it was voluntary and that they could withdraw at any stage without reason. Furthermore all data would be treated confidentially and when presented or published it would be aggregated so that individuals or individual institutions cannot be identified. There would be no references to individual patients or members of staff.

Five of the seven potential individuals were keen to participate. The two who did not volunteer to participate had not worked at the hospital before, did not know me and seemed wary of the study. Out of the five who volunteered, two had already completed an educational module with me and one of these was already part way through a Postgraduate Certificate in Medical Education. Two had previously approached me about how they might improve teaching, one of whom was about to start a Postgraduate Certificate in Medical Education. The gender mix of the group was three female and two males.

Diary keeping

Reflective diaries or journals have been suggested as an effective tool to undertake a systematic look at one’s own practice (Holly, 1989). Diary writing is a powerful way for teachers to explore their practice through the discipline of documenting their action. The act

of writing helps to construct and reconstruct their experiences so that reflection can take place. Diaries for reflection have much in common with research diaries which can be used as companions to the research process (Altrichter et al., 1993; McNiff, 2002). These diaries often contain notes of observations made and ideas for new research questions. They can act as a record of the researcher’s development and as a historical document.

Edwards and Talbot (1999) view diaries as a conversation with oneself. They suggest the entries might include an indication of what one intended to do on the day or during the

session (in detail) and why. This is extended by recording one’s perceptions of what happened and reflecting on the targets set or the questions explored. Moon (1999a; 1999b; 2004) has undertaken an extensive review of the literature on various uses of diaries, journals and logbooks. She considers they have a use in reflection while at the same time appreciating that not everyone finds them easy to use.

The use of reflective writing in logbooks now forms part of the UK postgraduate medical training scheme (Foundation Programme Committee, 2005, p.30). The use here is related mainly to the effects on the patient and the trainee:

‘Describe interesting, difficult or uncomfortable experiences. Try to record both positive and negative elements.

1. What made the experience memorable? 2. How did it affect you?

3. How did it affect the patient? 4. How did it affect the team?

5. What did you learn from the experience and what (if anything) would you do differently next time?’

Preliminary meeting

This took place on April 16th 2003 with four participants and myself. The fifth was unable to attend because of work pressures within the department. I met later with her individually. However she failed to make any of the meetings or contribute any diary entries due to other work pressures.

The meeting started with a detailed explanation of the study. I gave an introduction to the principles of the research methodology and explained how it can be made reliable and valid. I gave a verbal introduction on how to keep a reflective diary. In order to be able to illustrate this I had kept a reflective diary of my OR teaching for the previous four weeks. This was supplemented with a comprehensive handout including a brief literature review of keeping reflective diaries and action research (Appendix 5 and 6) and some background reading on situated learning.

The suggested guidance for the diary entries included: • Recording the date and location.

• Recalling events as written recollections as soon as possible. • Trying to include descriptions, your responses and how you felt.

• Recording questions that arise to be tested in practice or against current understanding. • Recording implications for future actions, future practice and intentions.

• Leaving a blank space for later reflections which may be revisited to back up continuous themes evident elsewhere in the diary.

ALG meeting one

This took place as scheduled on 4th June 2003 with the same four participants as for the

preliminary meeting. The meeting lasted for about 90 minutes and was recorded. At the end of the meeting we agreed a number of areas that we might concentrate on changing within our teaching in the OR. A further meeting was scheduled for the 6th September.

ALG meeting two

This took place as scheduled on 6th September 2003 with the same four participants as the meeting one. This meeting only lasted for 20 minutes because they had little opportunity to teach in the OR. This was mainly due to the pressure on the service over the summer holidays. The meeting was recorded and transcribed. We revisited the main areas for concentrating on changing with our teaching and then rescheduled to meet on 17th October 2003.

ALG meeting three

This took place as scheduled on 17th October 2003 with three participants. One of the male members had forgotten. This meeting lasted for about 90 minutes and was again recorded. The group agreed to meet again during the spring of 2004 to review their progress. I sent transcripts of the meetings to the participants and invited them to check and return comments and observations.

ALG meeting four

This took place in March 2004 with the same three participants present at the meeting three. The format was similar except there was no expectation of further diary keeping other than as a personal choice. The meeting was recorded and transcribed. The last section of the meeting focused, by design, on series of targeted aspects which included:

• Have you kept up your diaries? • Has it changed your job satisfaction?

• Have you talked about ‘learning’ to each other individually or as a group, either formally or informally?

• Have you spread your learning or experiences any further? • Would you be prepared to facilitate your own group?

Process of Analysis

I transcribed the recordings of the group meetings and gave copies to the participants so that they could check them for accuracy and withdraw aspects if they wished. They did not make or request any changes. As in the analysis of the interviews, I utilised NVIVO as my record keeping tool for the ideas and themes and used a similar approach to analysing the data as with the interviews. The data were analysed from two perspectives relating to the two

questions addressed in this phase of the study. The first considered the teaching delivered and experienced by the participants as an extension of the data collected in the interviews. The second explored the areas participants identified for possible changes in their teaching, and their success or otherwise in achieving these changes. Throughout this analysis there was frequent movement between the transcripts of the four interviews and the four anaesthetic group meetings.

The ideas, themes and transcripts were shared and discussed with my two supervisors and critical friend. In addition, one of the participants reviewed the initial ideas and themes with a detailed reading of the full transcripts. This was undertaken after the final group meeting in March 2004. As part of their involvement in this analysis, the participant looked particularly at the changes effected through the process and was first author for a poster presentation at AMEE 2005.