This article was downloaded by: [Kathryn Winterburn] On: 03 October 2012, At: 05:55 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Action Learning: Research and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/calr20 A mirror in which to practice using action learning to change end-of-life care Kathryn Winterburn a & Fiona Hicks b a NHS North of England (Yorkshire & the Humber), Leeds, UK b Leeds Teaching Hospitals NHS Trust, Leeds, UK Version of record first published: 26 Sep 2012. To cite this article: Kathryn Winterburn & Fiona Hicks (2012): A mirror in which to practice using action learning to change end-of-life care, Action Learning: Research and Practice, DOI:10.1080/14767333.2012.722361 To link to this article: http://dx.doi.org/10.1080/14767333.2012.722361 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Action Learning: Research and Practice 2012, 1 9, ifirst article ACCOUNT OF PRACTICE A mirror in which to practice using action learning to change end-of-life care Kathryn Winterburn a and Fiona Hicks b a NHS North of England (Yorkshire & the Humber), Leeds, UK; b Leeds Teaching Hospitals NHS Trust, Leeds, UK (Received April 2012; final version received June 2012) While action learning is a familiar tenet of much management and leadership development activity within the NHS it is not commonly utilised within the education and development of doctors where didactic methods remain the preferred mechanism to impart factual knowledge necessary to fulfil the autonomous practitioner role. Within the specialism of palliative medicine, the implementation of a national end-of-life (EoL) care strategy will challenge this predilection. The new strategy seeks to enable more people to die in the place of their choosing as such it requires clinicians outside the speciality of palliative care to make it a routine part of their practice. Since doctors are trained to cure or extend life, the strategy requires specialists to change their practice, behaviour and communication to engage the patient and family in decision-making and planning for the EoL. An intensive development programme utilising action learning methods is currently being piloted in two acute hospital settings to equip a small group of specialist senior clinicians to deliver the required changes. This paper describes the use of action learning within this context to explore its utility with an uninitiated and sceptical audience. Keywords: action learning; behaviour change; education; leadership development; palliative care; end-of-life care Introduction As life expectancy has increased, the number of people living with and dying from long-term conditions has also increased and will continue to do so. Modern medicine has created systems designed to intervene and treat illness with care predominantly taking place in the hospital setting and patients entering a system of diagnosis and treatment. Many people have multiple admissions to hospital in the last year of life and it is all too easy for the dying person to become a patient and lose control over their life at this critical stage. Therefore, it is incumbent upon the medical profession to address the question of Corresponding author. Email: kathryn.winterburn@yorksandhumber.nhs.uk ISSN 1476-7333 print/issn 1476-7341 online # 2012 Taylor & Francis http://dx.doi.org/10.1080/14767333.2012.722361 http://www.tandfonline.com
2 K. Winterburn and F. Hicks how to define and deliver good care at the end of life (EoL). Indeed, it is a question that can no longer remain within the speciality of palliative medicine, but needs to be addressed by the medical profession in its entirety (Hicks 2012). Action learning is a familiar tenet of much management and leadership development activity and widely used within this domain across the National Health Service (NHS). The benefits of experiential learning integrated with the challenges of real work are widely recognised. Despite its prevalence within the NHS, action learning is less commonly utilised within the education and development of doctors where didactic methods remain the preferred mechanism to impart knowledge and fact. By nature, medics are educated and socialised to be autonomous agents possessing the technical knowledge and skills to fix and cure. The specialism of palliative medicine in end-of-life care (EoLC) runs contrary to this predilection. In 2008, the Department of Health implemented a national EoLC strategy which seeks to enable more people to die in the place of their choosing. Such a strategy requires medics outside the speciality of palliative medicine to make it a routine part of their practice. Since doctors are trained to cure or extend life, the EoLC strategy requires a significant cultural shift on the part of specialists enacted through changes in practice, behaviour and communication so that they are able to engage the patient and their family in the decision-making and planning for the EoL. An intensive 12-month development programme utilising action learning methods is currently being piloted in two acute hospital settings to equip a small group of specialist senior clinicians to deliver the required changes in practice. The following paper describes the use of Action Learning against this context and its use as a learning methodology to address the challenges and changes that might be required in medical practice. The paper begins with a brief description of the pilot programme, its structure and describes the rationale for utilising action learning as a developmental method within it. Currently, at the half-way stage of the pilot programme, the paper offers an opportunity to surface and reflect on the early emergent learning of the four senior clinicians responsible for delivery of the pilot and myself as their action learning facilitator. It is worth noting that since the programme is only at its halfway point, the reflections within this Account of Practice can only be initial observations and general emergent themes. The EoLC pilot development programme for senior clinicians Before describing the EoLC pilot development programme and the use of action learning within it, there would seem to be utility in providing a brief background to the necessity of its conception which is a result of a national EoLC strategy initiated by the Department of Health in 2008. Approximately half of the annual 600,000 deaths in England occur in acute hospitals and yet research suggests that hospital is not the place where most would choose to die. Enabling people to die in the place of their choosing requires
Action Learning: Research and Practice 3 individuals and their families to know that they may be approaching the EoL, to be involved in the decision-making and planning for the EoL and for appropriate community-based care and support to be put into place (Hicks 2012). Therefore, the national strategy aims to encourage senior clinicians outside the speciality of palliative medicine to engage with it more deeply and make it a routine part of their practice and promotes multiple procedures to do so. The EoLC pilot development programme (hereafter referred to as the Pilot) as described is one such approach and is specific to two acute hospitals. The hospitals were chosen for their contrasts in terms of size and complexity, with one being a very large tertiary centre and the other a smaller district hospital with Foundation Trust status. The aim of the Pilot is to work with a small group of senior clinicians to equip them to lead their own colleagues to deliver better EoL care via the delivery of intensive development interventions focussed upon communication and culture change. The main protagonists delivering these interventions are four experienced palliative medicine consultants, who act as trainers to colleagues within other sub-speciality areas. The four trainers share their technical expertise, facilitate action learning and are supported in their own action learning set that is facilitated by an OD practitioner from within the NHS. Responsibility for the Pilot programme belongs to the authors and component elements are:. Identification of motivated sub-specialist consultant colleagues.. Intensive one-to-one work with sub-specialist colleagues. Attend ward rounds, shadowing, impart technical knowledge via e-learning, recommended reading, joint problem solving, reflective journals, etc.. Action learning sets bring sub-specialists together to reflect on individual learning, surface and resolve problems, share and consolidate learning. Recruitment to the larger site began during the summer of 2011 (Figure 1), drawing eight participants from the specialities of cardiology, respiratory medicine, stroke, medicine for the elderly, diabetes, oncology, vascular surgery and Figure 1. Pilot elements and timeline.
4 K. Winterburn and F. Hicks general practice. The Pilot formally commenced in September 2011 with individual meetings for each specialist to scope their participation and complete a training needs analysis specific to EoLC. The smaller site began recruitment in September 2011, with their programme commencing in November 2011 in the specialities of respiratory medicine, cardiology, gastroenterology, diabetes, renal medicine and general practice. Why action learning? As a member of a clinical leaders network, Fiona had previously experienced action learning within a leadership context and had recognised its value to her own learning. She had been put in touch with Kathryn for professional development support to the design of the pilot. Within early scoping discussions, it became apparent that the specific aims of the programme might be effectively served through experiential action learning. Enabling more people to express and achieve their preferences about care at the EoL requires a major shift in the culture of healthcare provision. Doctors are still largely trained to cure and when cure is not possible, to extend life. Death may still be seen as a failure of medical care both by the professional and the public and yet we all die (Hicks 2012). Confronting such issues requires a safe environment for the clinician:...my nurse colleague thought the programme should be multi-professional, but I really thought that if we were to change behaviour by helping people to confront some of their fears about EoLC, we needed the safety of a peer group of consultants. Creation of a supportive but challenging learning environment via action learning sets offered a safe space for participants that might mitigate some of the inherent risks of dealing openly with the subject matter. Honest conversations about the limits of medical care and the likely outcomes must become routine if patients are to be given time to consider their choices. The challenges for senior doctors to address such issues, both practically and behaviourally, are indeed significant. The programme design, therefore, seeks to be sympathetic to these challenges. One factor that has influenced the design is the assumption that when looking to challenge and change existing practice and behaviours senior doctors are likely to learn best from their clinical peers. The counter-intuitive nature of this particular learning content (where death may equate to failure) requires a safe and contained learning environment where practitioners can raise problems, dilemmas and fears in a supported but challenging manner. Action learning sets facilitated by other senior clinicians offered a means of creating such a space for the participants.
Action Learning: Research and Practice 5 Action learning sets were also considered a relevant method within the pilot since by their very structure they might offer a safe place to practice some of the very communication skills that an interaction around EoLC might require. Strong communication techniques, feedback, surfacing difficult issues within a supportive relationship are all skills that the specialist requires to effectively discuss the issues of death and dying with their patients and the patient s family. Assumptions and influences In being asked to provide developmental advice and guidance to this Pilot, I was immediately interested by its aims and able to understand the necessity of changing practice. The guidance I have offered has been drawn from numerous professional influences and development interventions in an attempt to create a learning environment that is supportive of the programme aims. Action learning had been discussed and agreed as a method within the overall component elements. My original remit had been to provide some internal training for the four palliative medicine consultants who would become the Pilot trainers. This initial workshop (held in November 2011) provided action learning theory and an introduction to some tools and questioning techniques that might assist the trainers to facilitate action learning sets with their recruited participants. While the theory introduced did indeed refer to the work of Revans, it was in fact, the work of Mary Parker-Follett that seemed to have significant resonance for this particular programme. As such, it is recognised that the action learning as delivered may not be recognised in a pure classical tradition. Parker-Follet s commentary and exploration of the teacher/student relationship does however hold relevant amplification of the ambitions for the Pilot. Unlike action learning in the context of management and leadership development where the problem that the action learner presents may not necessarily have a right or wrong answer, the nature of the Pilot does necessitate the teaching of some content. However, to achieve changes in cultural and behavioural practice, the defining feature of the Pilot rests in the application of that explicit knowledge as well as a host of issues that do not have right or wrong answers. It was my theory that the effective achievement of both is possibly different to other areas where action learning has been applied and as such necessitated a different approach to achieve traction. It was against this context that Parker-Follett s work offers a useful theoretical base that could illustrate teaching in an experiential context and expose the parallel processes that might surface among the Pilot s four educator/learners. Parker-Follett suggests that the purpose of the educator is to make the student experience-conscious that is aware of things of significance. Once aware, the educator encourages experimentation or action from the student followed by reflection to surface the significance and meaning and finally organise the experience or integrate with other experiences. Finally, Parker- Follett advocates collective learning through the use of joint thinking as
6 K. Winterburn and F. Hicks learners (Parker-Follet 1970). It is acknowledged that while Parker-Follett s work is not action learning in a purist sense, her approach offers an experiential basis that would appear to be particularly relevant to the aims of the Pilot. In addition to Parker-Follett, my practice here has also been influenced by Argyris and Schon, single and double loop learning theory. For me, these influences coupled with the by now atypical interest in the aims of the Pilot, led me to offer an additional component to the overall design. During the November workshop, it became apparent that there might be added benefit for the trainers to regularly come together as trainer/learners in a facilitated action learning set of their own. Within the generic process of the action learning set, I have utilised techniques drawn from executive coaching practice, appreciative enquiry and prototyping to stimulate reflection and learning. As such I have attempted to model practices that the trainers might offer with their clinical colleagues. Emerging themes The following section describes some of the early learning that has manifested within the first six months. In presenting these early observations, this paper does not seek to claim any specific conclusions and certainly recognises its limitations in relation to general application. Any such conclusions will be developed over time. Instead this halfway point offers an opportunity to reflect upon the programme; to take stock of what is happening and observe any patterns or themes that are developing which might be researched in detail later. The observations as presented here have surfaced within the action learning sets that I have facilitated with the four trainers. Thus, they are my observations in relation to their experience and my second-hand interpretation of their reported experience either in the action learning set or taken from their reflective journals which have been shared with me. While it is still early in the Pilot, I have noticed there would appear to be some parallels between the experience of the learners in relation to action learning as a methodology and the general approach to EoLC that the Pilot seeks to address. Fear of the unknown what is action learning? Part of the programme that probably worried me even more than that was this idea of action learning sets, which I had never heard of before. This quotation describes the general sense of anxiety among the trainers at the start of the programme and is later echoed by the wider group of participants who reportedly do not understand what action learning is and are feeling like we felt at the first session. In introducing the use of action learning to the programme, I was prepared that we were attempting something different and the audience would be uninitiated. I was not, however, prepared for the level
Action Learning: Research and Practice 7 of discomfort that its use would create. One trainer reflects: I m not sure how I feel about all this deep questioning! Indeed, there is some evidence that this discomfort actually interfered with the learning. Where I believed that I had spent a considerable amount of time explaining the generic process and structure required to facilitate a set certainly one individual did not easily recognise the amount of structure inherent within the process: I am still struggling with the lack of definite structure, would have been more in my comfort zone if I was leading a series of tutorials or something. In contrast, where participants could be offered something tangible such as participation in an Advanced Communication Skills course (prescribe a cure to fix the issue at hand), the relief is palpable. What is increasingly interesting, however, is how quickly both the trainers and wider participants have experienced the benefits of action learning: Talking about different learning styles was interesting and I guess kind of based on what I knew and common sense but it is still really interesting to think of it in that way because I think when we do teaching we get ourselves into formal ways of doing things and don t always sit back and think. Actually this is the best way of approaching the particular audience to which this teaching is aimed. The second action learning sets have been described at as: Really encouraging, with members of the group helping each other...learning from and with colleagues in a very open way. A gap in the working day, time to stop and think and they realised they were going to get something positive from it. This is not to say that there is any less scepticism by the participants at this stage, rather it is submitted as evidence of how different the collective learning experience is for senior clinicians whose traditional methods of learning as they become more senior and specialised tend to become narrower. The Pilot appears to be demonstrating the benefits of collective learning with colleagues outside their normal clinical silos and a real appetite for learning that takes place in a different environment. Proclivity to control am I doing it right? Some of the trainers and participants are demonstrating discomfort as they begin to realise that in terms of experiential action learning there is uncertainty and they are not working with finite circumstances. This has surfaced a number of times. Following the first set meeting it was observed that we all feel somewhat concerned that outcomes are not easy to define or measure and that feels uncomfortable for us at present.
8 K. Winterburn and F. Hicks Another trainer states; I fear that we are actually a quarter of the way through this project and it has gone really quickly and I m not sure quite what we ve achieved or even that I am clear I know where I m going. The concept that there is a right outcome to be delivered by the Pilot is implicit within the following view expressed by one of the trainers: This particular doctor may not be able to deliver what the pilot set out to do...i feel I need to show her what good looks like. In relation to running action learning sets, there certainly is a view that there is a correct formula: I m not sure we really stuck to the official action learning set line...and It felt impossible to manage the time without appearing rude. Although I am the perceived expert facilitator, these uncertainties are ones that I too have experienced as I have worked with the group. Arguably, the only advantage I possess is that having been in this position previously I do have the benefit of experience on which to draw and that enables more trust in the process of action learning. Indeed, most recently this trust was rewarded as one of the trainers described where they were in relation to the Pilot: I m beginning to reach a place where I don t have to own it and realise it s not all my responsibility to make this work. Relationships really matter and it s difficult to talk At the last action learning set with the trainers a new theme started to emerge around the importance of relationships. This may be one to watch going forward as increasingly the language revealed a collective desire to maintain and nurture relationships: I don t want to come across as being too critical of her, she would be sensitive. I will find her difficult. All of the participants want to know how to deal with difficult colleagues. My issue is about how I am getting on with them. It is difficult to understand at this stage if this inclination to tip toe around colleagues is a result of wanting to facilitate action learning in what is perceived to be the right way; How much can we be directive, which might influence the results of the Pilot? or if there are deeper motives at play. Certainly
Action Learning: Research and Practice 9 when working with senior clinicians within the health service, the subject of dealing with difficult colleagues is one that surfaces again and again. Of particular interest here is the fact that the reticence to address relationship issues is precisely the same problem that the Pilot was established to tackle. Concluding comments This paper has attempted to describe the elements of the Pilot Development Programme for Senior Clinicians in two acute hospital settings. Specifically, it has focussed on the use of action learning within the Pilot which is at the half way point. The paper began to explore some of the themes that have emerged thus far and in doing so has started to surface patterns of parallel processing that are mirrored in the barriers clinicians display in relation to death and dying. This early paper offers a means of tracking progress within the Pilot additionally, it identifies potential areas for further exploration in particular the utility of experiential action learning as an effective learning methodology for senior clinicians in a clinical context. Notes on contributors Kathryn Winterburn works as an Internal Organisation & Leadership Development Consultant in the NHS based at NHS North of England (Yorkshire & Humber Strategic Health Authority). Fiona Hicks is a Consultant in Palliative Medicine at Leeds Teaching Hospitals NHS Trust and Senior Clinical Lead for End of Life Care in Yorkshire & Humber Strategic Health Authority. References Hicks, F. 2012. Avoiding emergency stops in end of life care. Clinical Medicine 12, no. 2: 106 7. Parker-Follet, M. 1970. The teacher student relation. Administrative Science Quarterly 15, no. 1: 137 48, (Transcript of speech given by Parker-Follett at Boston University in 1928).