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CONTESTING THE FREEDOM TO LEARN: Culture and learning in a British General Practice. An ethnographic study of the culture and learning process in a British General Practice. Dr. Paul Milne April 2007

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Page 1: Paul Milne Thesis

CONTESTING THE FREEDOM TO LEARN: Culture and learning in a British General Practice.

An ethnographic study of the culture and learning process in a British General Practice.

Dr. Paul Milne April 2007

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Table of Contents Title Abstract…………………………………………………………….I Acknowledgements………………………………………………...II Contents page………….…..………………………………………III Table of contents…………………………………………………..IV List of figures and photographs…………………………………… V List of abbreviations and acronyms…….………………………….. VI Chapter One-the research questions and their context 1. Introduction………………………………………………………….Page 1 1.4 The Research Questions Justification…………………………… …Page 4 1.8 Context of research. General issues…………………………………Page 8 1.11 Context of research. Local issues, the practice and its history…… Page 11 1.13 Development of new premises…………………………………..... Page 13 1.13 Photograph new practice premises…………………………………Page 14* 1.15 Quality, practice and personal development……………………… Page 15 1.16 Informants’ profiles-Practice nucleus team………………………. Page 16 1.21 Informants’ profiles-Extended primary care team………………... Page 21 1.24 The author’s profile………………………………………………. Page 24 1.25 Overview of the chapters…………………………………………. Page 25 Chapter Two-Literature Review 2.1 Introduction…………………………………………………………….Page 1 2.2 The National Health Service-the 1990s………………………………Page 2 2.3 The National Health Service-1998-2003……………………………..Page 3 2.5 Postgraduate general practice medical education…………………….Page 5 2.6 The Practice and Professional Development Plan……………………Page 6 2.8 Working together-Learning together. Lifelong learning for the NHS...Page 8 2.10 Work based learning………………………………………………...Page 10 2.13 Activity theory………………………………………………………Page13 2.17 Activity theory and power…………………………………………..Page 17 2.19 Complex adaptive system theory…………………………………….Page 19 2.22 Application of Complex adaptive system theory…………………….Page22 2.27 Communities of Practice…………………………………………….Page 27 2.31 Individual learning and the organisation…………………………….Page 31 2.37 Learning and the environment……………………………………….Page 37 2.37 Social Capital………………………………………………………...Page37 2.40 Summary……………………………………………………………..Page40

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Chapter Three- Methodology 3.1 In search of a Voice………………………………………………….Page 1 3.1 Justifying the research methodology………………………………...Page 2 3.2 Ethnography………………………………………………………….Page 2 3.4 Data collection……………………………………………………….Page 4 3.5 Ethnomethodology and the Developmental Research Sequence…….Page 5 3.6 Locating and interviewing informants……………………………….Page6 3.8 Timeline of data collection…………………………………………..Page 8 3.9 Making an ethnographic record…………………………………… Page 9 3.11 Other data sources…………………………………………………...Page 11 3.12 Asking descriptive questions /asking structural questions / Making a taxonomic analysis /asking contrast questions………… Page 13 3.14 Method of analysis and emergence of ‘key informants…………….Page 14 3.16 Examples of the use of a domain work sheet……………………….Page 16 3.20 Making a componential analysis and discovering cultural themes…Page 20 3.21 Discovering cultural themes………………………………………..Page 22 3.22 On reading this research: Agency, Validity, Reflexivity and Reliability ……………………………………………………..Page 20 3.22 Agency…………………………………………………………….. Page 22 3.23 Validity –the interview……………………………………………. Page 23 3.25 Validity-reflexivity…………………………………………………Page 25 3.26 Reliability…………………………………………………………..Page 26 3.28 Validity-the researcher’s sense of esteem…………………………..Page 28 3.29 Summary…………………………………………………………….Page 29 Chapter Four- Organisation, Notes and the Computer and Meetings Organisation 4.1.1 Organisation……………………………………………………….Page 1 4.1.2 The practice manager……………………………………………...Page 2 4.1.6 The receptionist……………………………………………………Page 6 4.1.10 The doctor………………………………………………………..Page 10 4.1.13 the practice secretary……………………………………………. Page 13 4.1.15 Summary………………………………………………………….Page15 4.1.16 The practice and its relationship with external bodies…………..Page 16 4.1.23 Discussion: Boundaries and the internal practice team…………..Page 23 4.1.24 Organisation and the extended team. View from the other side of the boundary……………………….Page 24 4.1.26 Comment…………………………………………………………Page 26 4.1.26 Sorts of meetings…………………………………………………Page 26 4.1.28 The place of leadership within Organisation……………………..Page 28

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4.1.30 Leadership and ‘keeper of the flame’…………………………….Page 30 4.1.31 Summary Keepers of the boundaries……………………………..Page 31 Notes and the computer 4.2.1 Introduction……………………………………………………..Page 1 4.2.2 Notes and the receptionist……………………………………...Page 2 4.2.4 Transformation of knowledge and reception………………….. Page 4 4.2.5 Notes and the practice manager………………………………...Page 5 4.2.7 Notes and the partner…………………………………………...Page 7 4.2.7 Comment………………………………………………………..Page 7 4.2.8 Concept map Notes……………………………………………..Page 8 * 4.2.9 The computer and the practice………………………………….Page 9 4.2.11 The receptionist’s view………………………………………...Page 11 4.2.12 Concept map Computer and the receptionist…………………..Page12 * 4.2.12 The computer and the practice manager……………………….Page 12 4.2.13 The computer and the partner………………………………….Page 13 4.2.14 Templates and the partner’s learning…………………………..Page 14 4.2.15 Template Headache 1…………………………………………..Page 15 * 4.2.16 Template Headache 2………………………………………….Page 16 * 4.2.17 Comment ………………………………………………………Page 17 4.2.19 Concept map Relationship between notes and computer………Page 19 * Meetings, formal and informal; their rituals and roles: maintaining the boundary 4.3.1 Introduction……………………………………………………..Page 1 4.3.1 Sorts of Meeting………………………………………………...Page 1 4.3.2 Informants and meetings………………………………………..Page 2 4.3.3 Extended primary care team and meetings……………………..Page 3 4.3.4 Meetings and their content……………………………………...Page4 4.3.5 Comment………………………………………………………..Page5 4.3.6 Diagram Flu vaccination meetings and learning………………..Page6 4.3.7 Meetings and the practice and professional development plan…Page7 4.3.9 Before the PPDP development meeting………………………...Page9 4.3.12 The PPDP development meeting………………………………Page 12 4.3.13 Photograph Metaphor 1………………………………………..Page 13 * 4.3.14 Photograph Metaphor 2………………………………………..Page 14 * 4.3.16 Photograph Metaphor 3………………………………………..Page16 * 4.3.19 Subsequent meetings…………………………………………..Page 19 4.3.20 PPDP and the informants………………………………………Page 20 4.3.23 Comment PPDP………………………………………………..Page 23 4.3.24 Socialization: Function and dysfunction……………………….Page 24 4.3.30 Summary……………………………………………………….Page 30

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Chapter Five: Hierarchy and Power 5.1 Introduction………………………………………………………Page 1 5.1 Leadership power and hierarchy, reflections on dissonance…….Page 1 5.2 Author’s esteem………………………………………………….Page 2 5.3 Concept map Author’s esteem 1…………………………………Page 3 * 5.3 Leadership style………………………………………………….Page 3 5.4 The partner and leadership……………………………………….Page 4 5.5 The author as ‘keeper of the strategy’……………………………Page 5 5.6 Leadership, power, micro politics and the practice nucleus team. Page 6 5.8 Concept map Authors esteem 2…………………………………..Page 8 * 5.8 The partner’s perspective on power………………………………Page8 5.9 The practice manager’s perspective on power……………………Page 9 5.12 The senior receptionist and power………………………………Page 12 5.13 The extended team and power and hierarchy……………………Page 13 5.15 Power hierarchy and learning-considering other influences…….Page 15 5.17 Summary Power and hierarchy………………………………….Page 17 5.18 Power hierarchy and trust………………………………………..Page 18 5.20 Professionalism………………………………………………….Page 20 5.24 Diagram summary of ‘being professional’………………………Page 24 * 5.28 Power and the practice building…………………………………Page 28 5.31 Responsibility, accountability and being professional…………..Page 31 5.32 Diagram Responsibility and accountability……………………...Page 32 5.32 Summary…………………………………………………………Page 32 Chapter Six Learning in the practice-informal and formal 6.1 Introduction………………………………………………………Page 1 6.1 The partner’s learning……………………………………………Page1 6.3 Templates and learning…………………………………………..Page 3 6.5 Concept map partner’s learning………………………………….Page 5 * 6.6 The partner and the politicisation of her learning………………..Page6 6.8 Reflections on the partners’ informal learning…………………..Page 8 6.10 Concept map Author’s learning-external agencies…………… Page 10 * 6.11 Recording informal learning…………………………………….Page11 6.12 Discourse and solving problems………………………………...Page12 6.14 The practice manager and his learning………………………….Page 14 6.17 Concept map Practice manager’s learning……………………...Page 17 * 6.17 The practice nurse and her learning ……………………………Page 17 6.18 Concept map practice nurse’s learning…………………………Page 18 * 6.20 The practice secretary and her learning…………………………Page 20 6.21 Concept map Practice secretary’s learning……………………...Page 21 * 6.21 The receptionist and her learning………………………………..Page 21 6.26 Concept map Receptionist’s learning……………………………Page 26 * 6.27 Multidisciplinary learning and the building……………………..Page 27 6.28 The staircase……………………………………………………..Page 28 6.29 Photograph: The practice staircase………………………………Page 29 * 6.32 Good conversations………………………………………….......Page 32

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6.33 Other influences on informal learning………………………......Page 33 6.34 Learning and the extended primary care team………………......Page 34 6.34 The Health Visitor and her learning …………………………….Page 34 6.37 Concept map Health Visitor’s learning …………………………Page 37 * 6.38 The physiotherapist and her learning……………………………Page 38 6.40 Concept map Physiotherapist’s learning…………………………Page 40 * 6.41 The community district nurse and her learning………………….Page 41 6.43 Concept map Community district nurse’s learning……………..Page 43 * 6.44 The McMillan nurse’s learning……………………………….....Page 44 6.47 Concept map McMillan nurse’s learning………………………..Page 47 * 6.48 The community psychiatric nurse’s learning…………………….Page 48 6.49 Concept map the community psychiatric nurse’s learning……….Page 49 * 6.50 Summary: Learning and the extended primary care team……….Page 50 6.50 Discussion………………………………………………………..Page 50 Chapter Seven: Discussion- empirical findings, their synthesis and validation of a social learning theory 7.1 Introduction……………………………………………………………..Page 1 7.1 The themes and their relationships……………………………………..Page 1 7.3 Concept maps…………………………………………………………...Page 3 7.4 Concept map the partner………………………………………………...Page 4 * 7.6 Concept map the practice manager……………………………………...Page 6 * 7.7 Concept map the practice nurse…………………………………………Page 7 * 7.8 Concept map the receptionist……………………………………………Page 8 * 7.9 Concept map the district nurse…………………………………………..Page 9 * 7.9 Boundaries and organisation…………………………………………….Page 9 7.12 Notes and the computer………………………………………………...Page12 7.14 Informal learning……………………………………………………….Page 14 7.15 Space and learning……………………………………………………..Page 15 7.17 Leadership an informal learning……………………………………….Page 17 7.17 Professionalism……………………………………………………….. Page 17 7.18 Meetings……………………………………………………………….Page 18 7.19 Practice and professional development plan………………………….. Page 19 7.20 Initial considerations, inter thematic relationships…………………….Page 20 7.24 The relationship between the research findings and social learning Theories…………………………………………………………………Page 24 7.24 Activity theory and the empirical findings……………………………..Page 24 7.26 The computer-templates as an electronic zone of freedom………… Page 26 7.27 Diagram Computer template and activity theory model……………….Page 27 * 7.28 Activity theory, geography and spatial relationship…………………. Page 28 7.32 Activity theory and boundaries………………………………………. Page 32 7.32 Synthesis of concept maps……………………………………………..Page 32 7.34 Informants’ concept maps and their synthesis…………………………Page 34 * 7.35 Venn diagram Informants activity systems and interrelationships…….Page 35 * 7.36 Comment Activity theory ……………………………………………..Page 36 7.37 Complex adaptive system theory, practice organisation and its learning……………………………………………………………..Page37 7.38 Complex adaptive system, organisation and ‘simple rules’…………..Page 38 7.42 Communities of practice and the research findings………………… Page 42 7.44 The role of social capital and the research findings…………………..Page 44

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7.47 Table Trust using Sztompka’s model…………………………………Page 47 * 7.48 Summary of empirical findings and their analysis……………………Page 48 7.49 Diagrammatic summary of practice cultural themes…………………Page 49 * 7.51 Synthesising the social learning models………………………………Page 51 7.55 Diagram of synthesis of social learning models using empirical findings……………………………………………….Page 55 * 7.56 Spatial influence and complexity……………………………………..Page 56 7.59 Interaction between activity systems and learning……………………Page 59 7.60 Potential criticisms and generalisability………………………………Page 60 Chapter Eight: Conclusion 8.1 Introduction………………………………………………………….. Page 1 8.1 Thesis summary……………………………………………………... Page 1 8.2 Thesis contributions…………………………………………………. Page 2 8.2 Methodology………………………………………………………… Page 2 8.2 The practice culture…………………………………………………. Page 2 8.8 Generalizability and validity of the synthesised learning model……. Page 8 8.10 Implications for the professional development of the primary care team…………………………………………………..Page 10 8.12 Summary……………………………………………………………Page 12

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Chapter One-The research questions and their context Introduction This thesis explores the relationship between the culture of a general practice in the United

Kingdom and the processes it uses to learn. The research focus is an ethnographic study of a

general practice culture and the empirical findings are used to explore and validate a synthesis

of sociocultural learning theory.

This chapter describes the formulation of the research questions and their importance to the

development of general practice and primary care education. It sets out the context of the

research at both national and local perspectives and, at the individual level, it summarises the

informants’ biographies. The practice building and its developmental history is also described

so as to contextualise the physical setting for the research.

Before pursuing the development of the research, I wish to outline and discuss the notion of

culture within the overall context of government health policy and then its use in relationship

to the etymological derivation of culture.

Culture has entered the discourse of modernisation of the National Health Service (NHS). A

search of the Department of Health website (www.dh.gov.uk) gives a score of two hundred

‘hits.’ A change in culture (my italics) is implied in relation to learning. This is outlined in the

Department of Health document ‘Working together, learning together’ (2001) and to be

operationalised through a change in the organisation.

‘Delivering this vision means that all NHS organizations and those with a contractual relationship with the NHS, need to develop and foster a learning culture (my italics). Investment in learning benefits the organisation, patients and carers, local communities, society more generally and individuals. To be effective, lifelong learning also depends on a strong relationship between individuals and their immediate world of work and on shared values and skills. If the basic building blocks of induction, appraisal, personal development plans and the learning culture are not in place, it will be difficult to develop and sustain this relationship.(Pg.21, Working together, learning together 2001)

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The point is made and in a broader sense in relation to quality of care in the Government

paper ‘A First Class Service 1998, Action for Quality’,

“Para 5.6 The point has been made repeatedly to us that achieving meaningful and sustainable quality improvements in the NHS requires a fundamental shift in culture, to focus effort where it is needed and to enable and empower those who work in the NHS to improve quality locally.” (Culture used in italics in original document).

Learning and culture are linked in policy change within the NHS. Implicitly, government

recognizes the importance of this relationship and the need to derive a positive process in the

dynamic between culture and learning. In other words, learning is meant in the sense of the

process of acquisition of knowledge and the development of a learning culture. Learning in

this sense embraces the wider notion of socio- cultural factors and to make it distinct from the

organizational process of education.

Learning in this research is concerned with the processes that are used ‘to acquire knowledge

of (a fact); to become acquainted with or informed of (something); to hear of, ascertain

(facts)’ (Oxford English Dictionary 1989).Therefore in the context of the NHS and its

modernization, the relationship in terms of process between learning and culture is of interest

in terms of research.

At this point I consider the etymological derivation of culture. This is pertinent given the

words widespread use in NHS policy and some discussion of its derivation enriches the

understanding of its use in this research. As a noun culture appears in the English language in

the late 15th century. The Oxford English Dictionary’s definition ‘the action or practice of

cultivating the soil; tillage, husbandry’ reflects the increasingly organized and agricultural

society. The subsequent definitions reflect the industrialization of human society and the

subsequent intellectualization of society. The definitions of culture therefore become

‘The training, development, and refinement of mind, tastes, and manners; the condition of being thus trained and refined; the intellectual

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side of civilization’, and ‘the civilization, customs, artistic achievements, etc., of a people, especially at a certain stage of its development or history’ (OED 1989, 19th and 20th century definitions)

Using the 15th century etymological derivation of culture, this metaphorically suggests the

process that would enable the proposed changes in the NHS with regard to a ‘learning

culture’. Eagleton (2000) uses a quotation from Francis Bacon to emphasize the relationship

between culture’s agricultural derivation and learning when he writes ‘the culture and

manurance of minds’ (Francis Bacon in Eagleton 2000 pg.1). It is the ‘cultivation’ of a

learning process that will enable the health professional to feel confident, creative and curious

and therefore empower the development of a positive learning culture.

Eagleton (2000) describes ‘culture’ as ‘one of the two or three most complex words in the

English language’ (pg.1 2000) and as above, derives the etymological relationship with the

word ‘nature’. Subsequently this relationship has evolved into specialized uses in modern

society and closes this brief discussion of culture with the socio-anthropological definition to

be used in this thesis. Culture is the

‘complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of society’(E.B. Taylor in Eagleton 2000 pg. 34).

However culture as a word is complex and within its use in society has the scope to reflect the

desire to achieve an ideal through the development of a culture. As noted previously, this

concept of an ‘ideal’ culture is reflected in the modernisation literature of the NHS. Returning

to Eagleton, he cites a quotation from Schiller’s ‘Letters on the Aesthetic Education of Man

(1795)’. The quotation summarises the internalisation of the idealism by the individual and

the notion of responsibility needed to promote that concept by government.

‘Every individual human being, one may say, carries within him, potentially and prescriptively, an ideal man, the archetype of a human being, and it is his life’s task to be, through all his changing

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manifestations, in harmony with the unchanging unity of this ideal. This archetype, which is to be discerned more or less clearly in every individual, is represented by the State, the objective and, as it were, canonical form in which all the diversity of individual subjects strives to unite’(Eagleton 2000 pg.8).

The individual ‘idealism’ of the health professional in the NHS and its relationship within the

NHS as an organisation would be aligned and synergistic. Perhaps this explains the pre-

eminence of culture and ‘change in culture’ as a word or phrase in the NHS by its political

masters. However this idealistic synergy between the individual and the organisation and its

promotion by the State is a strained relationship. Individuals and organisations have different

agendas. How individuals and their organisations attempt to make sense of that relationship is

through the development of cultural norms and values. It could be postulated that some of

these are used culturally to cocoon the individual in their micro organisations. This research

explores the processes in that relationship.

The Research Questions

Justification

The formulation of the research questions took place at a time of change of government. New

Labour came to power in 1997 and with it the hope of “of national renewal, a country with

drive, purpose and energy” (Tony Blair, Labour Manifesto).

Within the changes for the NHS, the internal market was abolished and there was the promise

of increased spending and “primary care will play a lead role”. The overall thrust was a

modernisation of the National Health Service. The research interest stemmed from the change

in emphasis for postgraduate general practice medical education within the modernisation of

the National Health Service. Amongst these changes was the introduction of the professional

development plan (PDP) for general practitioners and for the practice, the practice and

professional development plan (PPDP). These were significant changes in terms of learning

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method for general practitioners. Until the introduction of the PDP and PPDP learning had

been focused on pedagogic methods. These encompassed a variety of approaches. General

practitioners attended courses and lectures which inherently generated passivity in terms of

their learning. The courses and lectures were held in postgraduate centres which were located

in local district general hospitals. Meetings were commonly sponsored by pharmaceutical

companies and were used to promote their products. A variation on this was for a general

practitioner to be invited for a meal by a pharmaceutical representative together with other

colleagues at a local restaurant where a talk would be given by a hospital consultant. The

related literature to these changes is explored in the literature review chapter.

This change in emphasis in learning method appeared important. As a newly appointed GP

Tutor the changes highlighted several challenges for my role. This shift in educational

strategy intuitively would be viewed with suspicion and anxiety by ‘front line’ general

practitioners. Their anxieties would be about ‘how to do this?’ and ‘how am I going to find

the time to do this?’ In addition, in 2001 just after the introduction of the PDP, the General

Medical Council, the licensing body for UK doctors had proposed an appraisal system for

general practitioners and that this would form part of a revalidation process for GPs. The

challenges for the introduction of the PDP and PPDP were therefore compounded by the

suggestion that the appraisal and the practitioner’s PDP would be used in a summative

process when their principal purpose was to be formative. This difficulty was subsequently

explored by van Zwanenberg (EdD thesis2002) with a conclusion that recommended the

separation of appraisal from revalidation.

At the time of the formulation of the research questions I was also a GP trainer for one of the

local vocational training schemes. I had held this role for several years. A GP registrar was

assigned to the practice for six months by the training scheme and during that time had

regular formal tutorials with me and with other members of the primary care team. The GP

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registrar became part of the practice team during that time. I had noted that the registrar learnt

large amounts of codified knowledge and that we often met informally over coffee or in

different parts of the practice to discuss ‘cases’. In addition I was a group leader for the

vocational training scheme and during these sessions registrars would swap stories about

whether a practice was a ‘good or bad’ practice in which to do their training. Through these

informal observations it became apparent that this ‘informal’ method of learning was

important and furthermore the context of the learning was relevant.

These methods of learning contrasted with the formality of the tutorial and provided a

different perspective to the learning required for the registrar’s summative assessment. The

knowledge and skills required for these assessments appeared divorced from the context in

which the knowledge had been learnt. A similar observation might also be applied to the

Membership of the Royal College of General Practitioner’s (MRCGP) exam.

In 1998 the idea of culture or a change in culture entered the NHS rhetoric and shortly

afterwards the learning culture as described above. These then were the drivers or prompts

for the research questions. The drivers were to consider the interrelationships between

practice culture(s), the practice and professional development plan (PPDP) and learning.

Initially, I considered the possibility of exploring several practice cultures but it became self

evident that this was an impractical project in terms of time.

The research was important for two reasons. First there was a pressing need to understand

how the PPDP would be used in practices. Secondly the change in postgraduate education

policy in general practice to a more self directed and reflective method highlighted the need to

gain a greater understanding of how general practices undertook their learning. As might be

anticipated the introduction of PDPs and appraisal generated anxieties for general

practitioners. Little research has been undertaken into how general practices function in terms

of their learning and this was of direct relevance to this strategic change in postgraduate

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educational policy. For the individual practitioner, there is a need to find the right educational

model which encourages reflective practice and in a strategic setting where multidisciplinary

learning is encouraged (Howe A 2000). Newman and Peile (2002) call for the

acknowledgement of the ‘mature doctors’ wider experience and use of that experience in their

learning. In this research I seek to provide an understanding of the processes that mature

doctors and other health professionals use to learn and therefore inform the process of the

mentoring of these doctors.

Indirectly, the research is of importance with the change in undergraduate medical education

which now has its emphasis on the delivery of the medical curriculum in the community and

Modernising Medical Careers in which all year two junior doctors will gain experience of

general practice. Overall, in this context there is a need to develop many more ‘teaching

practices’ and for these practices there will be inherent pressures to develop as ‘learning

organisations’.

In addition, at the time of writing, the government has introduced ‘Practice Based

Commissioning’ which will drive practices to collaborate in the provision of quality assured

services. This collaboration will require significant inter and intra professional discourse and

with it a learning process. Overall, the outcomes from this research will contribute to and

inform national policy with regard to the development of the concept of a learning

organisation in the National Health Service.

Following a period of thought and reflection, the initial research questions therefore became

1. What is the relationship between a general practice’s culture and its learning?

2. What is the role of the practice and professional development plan in the practice

culture?

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A third research question follows from these. This relates to the theoretical area of learning

theory. The research lends itself to exploration of social learning models. The third research

question becomes

3. To what extent are the social models of learning validated by the empirical findings?

Context of research

General issues

The research was undertaken at a time of low morale for the general practitioner workforce.

In part this had a historical perspective. Stange (2001) titled his editorial in the British Journal

of General Practice ‘The best of times and worst of times’ and quoted the Collings report of

1950

‘The overall state of general practice is bad and still deteriorating. The deterioration will continue until such time as the province and function of the general practitioner is clearly defined, objective standards of practice are established, and steps are taken to see that these standards are attained and maintained’

Collings report was a descriptive narrative of a wide range of practices in England and

Scotland in the 1950s and in many ways stimulated the subsequent improvements in

professional practice from the establishment of the Royal College of General Practitioners

through to the changes proposed in the NHS Plan. As Stange noted there have been marked

improvements in general practice since then but once more general practice morale was poor.

The British Medical Association survey in 2001 reflected this unease with 56% of general

practitioners prepared to offer their resignation unless there was an improvement in their

contract (Beecham L 2001). General practitioners felt overworked and perceived that there

was little support. Their pay was lower in relative terms to other professions.

In July 2002 The Audit Commission published a report which gave an overview of general

practice. The report was published prior to the introduction of the new contract for general

practitioners (A Focus on General Practice in England 2002). The report rehearses the

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historical development of general practice and the rise of group general practice. The average

general practititioner list size was 1778 (Audit Commission pg.50, 2000).

This report acts as a useful focus in which to outline the state of general practice at the time of

the research. The Audit Commission found little data to support the contention by general

practitioners had an increased workload. Significantly, it acknowledged that the data available

did not reflect the increasing complexity of the problems presented to general practitioners

and that it was now possible to do more to help resolve and solve these problems. The

workload was also influenced by the increasing shift of care from secondary to primary care.

This is summarised in the report’s statement as

‘Evidence from focus groups of GPs convened by the Audit Commission supports the

increased complexity of caseload and ‘decision density’ in general practice’ (pg.41) and is

encapsulated in the following diagram.

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Diagram 1: Pressures on General Practice (pg.42 Audit Commission Focus on General Practice in

England 2002)

The diagram highlights the multiple demands on the general practitioner and the primary care

team. These are all embedded in the incoming government’s desire to improve quality as

enshrined in the NHS Plan (DoH2000) and the new NHS modern and dependable

(DoH1997). This complexity is summarized by the audit commission as

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Diagram 2 (Audit commission report pg.13, 2002)

The diagram highlights the multi disciplinary nature of primary care. The general practitioner

is just one of many health professionals with the patient at the centre of care. The diagram

does not illustrate how the professionals inter relate.

The overall tone of the report is positive but it does note the challenges of general practitioner

recruitment and the difficulties in providing quality care to increasing list sizes. The public

have a high degree of trust in general practice with a survey undertaken by the audit

commission showing 80% satisfaction.

Since the publication of the Audit commission report, a new contract was agreed with general

practitioners. As foreshadowed by the NHS Plan and the overall modernisation of the NHS

the new contract’s emphasis is on quality of care. The new contract addresses the issues of

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improving GP salaries through linkage with performance based targets. It is too soon to

comment on the long term implications for recruitment and morale. This then is a brief

overview of the context in which this research was conducted. In the next section I describe

the local issues and history relevant to the practice.

Local issues. The Practice and its history

The practice was a two partner training practice situated in the North East of England. Its list

size at the time of the research was 3,200 patients. The practice was accredited as a training

practice for general practice registrars from one of the regional vocational training schemes.

The practice also taught medical students and on a less regular basis other health professionals

such as practice nurses in training. Demographically the practice patient list had an above

average percentage of patients aged over 75years.

The practice was situated in a large village and, relative to other areas of the North East,

unemployment was low. Farming was the only local industry and the population commuted to

Newcastle and Durham. The research practice was the largest practice with two other

practices having branch surgeries in the village.

The practice had a long history with some of the older patients in the practice giving accounts

of the doctor doing home visits in his horse and trap. The practice had always been single

handed and relatively isolated. When I joined the practice the premises were sited in a large

house which also served as premises for the local rural council. The premises at that time

were cramped and unsuitable for modern general practice and hence at an early date I had

decided to build new premises.

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Development of new premises

I joined the practice in 1987. Following a protracted period of negotiation with the local and

parish councils I was successful in obtaining land to build new premises close to the original

premises. The design of the new premises was placed with architects who had previous

experience of designing purpose built premises. My broad instructions were in terms of

maximising available light and room for teaching. At that time funding for the premises was

available via a ‘cost rent scheme’ in which the health authority paid a ‘rent’ to the practice

which to a certain extent offset the mortgage payments. Additional cost rent was available if

the practice had additional rooms such as a treatment room. It was anticipated that the

building would fulfil a variety of roles and that it would offer a wider range of services.

However in terms of training and teaching there was no additional funding for additional

space. Thus the first floor of the building was financed without cost rent support. This placed

financial pressures and subsequent constraints on the practice. However, a building emerged

which for that period of change within the NHS was progressive and was more than adequate

for providing GP services.

Thus through the purchase of the land, the designing and the development and physical

growth of the building both literally and metaphorically confined and shaped space and the

aspirations of the practice.

The new building was completed in 1991 and gave renewed impetus to the need to pursue

quality. The planning and building of the new building had created a new beginning for the

practice team and the opportunity the need to pursue quality. This quest was lead and driven

by me and at that time supported by my partner. Sadly, during this time the partner developed

an illness which led to her leaving the practice. My wife joined the practice as the new partner

in 1994.

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The new practice premises

Quality of care was both a personal ideal and important in business terms for the practice. The

‘ideal’ was driven by personal values that were based on patient centred care and reflective

practice.

General practitioners in the UK are independent practitioners. They contract to provide a

range of services for the NHS and are in effect small businesses. The practice was sited in a

village where it was difficult to expand the list and therefore in order to improve the practice

income there was a need to capitalise on the practice’s interests and strengths in teaching.

Quality of care was therefore paramount in my vision for the ‘new practice’ as enshrined in

the new building and to be able to demonstrate it against an external standard.

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Quality, Practice and Personal Development

The Royal College of General Practitioners has developed several quality frameworks in the

last two decades. These are designed to assess a general practitioner or practice against a

range of performance criteria. These frameworks are the Fellowship by Assessment (FBA),

the Quality Practice Award (QPA) and the Quality Team Development award (QTD).

In 1996 I applied to do the FBA and therefore committed the practice and myself to

demonstrating excellence as defined by the RCGP across a wide range of activities within the

practice. The FBA criteria are described by the RCGP as the ‘ultimate audit’ and cover a wide

range of activities including an assessment of a video of patient consultations. The practice

willingly engaged with FBA and in 1998 we were successful in obtaining the award. The

assessment and the visit by the external assessors was a demanding time for everyone and

gaining success created a pride and confidence in the practice staff thereafter. This was still

evident when the partner and I left the practice in the summer of 2003.

The FBA reflects quality of care as measured against external standards. These can only

provide a limited insight to the perspectives of culture and learning in a practice. The practice

worked to achieve an outcome defined by an external organisation. Although there were

echoes from that achievement over the succeeding years, FBA does not describe the inherent

culture and learning processes in the practice. The FBA does not reflect how the group of

people who come to work each day in their areas of the building interact and learn. The

development of the building and the commitment to a quality agenda mainly reflects the

vision of the practice leadership and cannot describe the practice culture and the embedded

learning processes. Thus practice culture and its learning are dimensions that are not explored

or understood through the assessments currently used by training schemes, primary care trusts

and ,as in this case, the Royal College of General Practitioners.

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Informants’ profiles

In this part of the introduction my purpose is to outline the profiles of the informants. This is

to enable the reader of this research to gain insight into the informants’ backgrounds. These

biographies are derived from the informants’ transcripts. Each of the interviews began with

the informant giving an account of their life history. I have included them in the introduction

since this helps to contextualise the research in a similar manner to the discussion of the

general and local contexts of the research. Each profile gives a short biography and describes

the informant’s role in the practice or as a member of the extended primary care team.

There were twelve informants in the study. Their inclusion and emergence of the key

informants is described in the methodology chapter. ‘Key’ informants were the members of

the team that I sensed as being the most likely to give insight into the practice culture. I start

with the group of people whom I refer to in the text as members of the practice nucleus team

to distinguish them from the extended primary care team members. The practice nucleus team

consisted of the two doctors (the partner and me), the practice manager, the practice secretary,

the practice nurse, a senior receptionist, and three part time receptionists. The extended

primary care team was the district nurse (DN), the health visitor (HV), the McMillan nurse,

the community psychiatric nurse (CPN) and the physiotherapist. The midwife and dietician

were excluded since their professional contacts with the practice were only once per month.

The Partner

The partner (both in business and as my wife) joined the practice in 1992. She was from the

North West of England and had done her undergraduate training in London. She qualified in

1976 and in her early medical career had trained part time as an anaesthetist before pursuing a

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career as a general practitioner. She had trained part time to combine mother hood and

medical career. At that time in the early 1980s this was not easily done.

As a doctor she had several biomedical interests. These were in diabetes, lipidology and

rheumatology. Within the practice she was a full time partner. Her roles apart from the

clinical commitments were as clinical governance lead and an interest in developing the use

of the computer in the consultation. She had a preference for care of the elderly. As a partner

in the business she played a full part in the development of the practice. She disliked the role

of leadership and preferred the role of “being in the background”.

Outside the practice at various phases during her time in the practice she held clinical

assistantships at a district general hospital in lipids, rheumatology and diabetes.

The Practice Manager.

The practice manager was born and had lived all his life in the North East of England. His

career path had been both in the private and public sector. He had initially trained as a tax

officer, then as a quantity surveyor in the building trade and then subsequently joined the

National Health Service to become a manager in a Health Authority in the North East. During

this time he studied for qualifications as an accountant. At the time of the research he had

been with the practice for 7.5 years.

His role in the practice was to maintain the financial well being of the practice. This was both

in the management of the practice accounts but also in the negotiation of the contracts for

community fund holding. He was also responsible for the production of the annual reports

required by the health authority, regular financial reports for the partners, health and safety,

and general ‘handyman’ around the practice. The practice manager was the lead for the

updating of the clinical computer software. These updates were important and commonly also

caused the system to ‘crash’. He collected the various item of service payments, checked the

capitation payments, and ensured that the different fees for private insurance forms and

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medicals had been paid. He had an important role in reading and commenting on the many

changes in the NHS regulations that related to the practice and primary care.

The practice manager had frequent informal daily contact with the partners and more formally

on a monthly basis for a meeting with the partners. Each month the practice manager chaired

the practice meeting. In terms of role the practice manager formed the interface between the

practice and the outside world. In the practice his office was sited on the first floor of the

building. He was a key informant in this research

The Practice Nurse

The practice nurse had been in post for many years and preceded my appointment in 1987.

She had trained at one of the local district general hospitals. Her career had taken her from

‘cadet nurse’ to sister of a ward. She had been appointed as a practice nurse by my

predecessor in the practice. She recounted how her role had changed and blossomed over the

years. Initially her role had been to take blood pressures, giving injections and ear syringing.

Subsequently, she was given the role of doing most of the practice cervical smears and was

involved in helping coordinate the practice cervical smear recall. In more recent years she had

taken on more chronic disease reviews (ischaemic heart disease, diabetes and obstructive

airways disease). She was taking ECGs, assisted me with minor surgery sessions and led on

travel advice and vaccinations

Her main place of work in the practice was in the treatment room. She entered the data from

the chronic disease clinics on the computer. She attended the practice meetings, the protected

learning time sessions and the monthly primary care team meetings. She was a key informant

in this research

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The Practice Secretary

The practice secretary had held several similar posts before joining the practice. She had been

a school secretary and then had worked in the county council health department and as

personal secretary to the treasurer at county hall. At the time of the research she had been with

the practice for eight years.

In the practice she was responsible for the word processing of the referral letters. These were

either on Dictaphone or had been hand written. She liaised with the hospital secretaries and

also dealt with telephone referral queries by patients. She kept the minutes of the monthly

practice meetings using shorthand. She also attended the protected learning time sessions. She

organised the annual diabetic review day in which all the practice’s diabetic patients attended

for retinography and podiatry checks. The secretary needed to coordinate the various

appointments with the practice nurse and receptionists. In general she linked with all the

practice nucleus team but her main role was the administration of the referrals NHS and

private and the various private medical examinations done by the partners.

The Receptionists

At the time of the data collection there were three part time reception staff and one full time

receptionist. The latter was known as the senior receptionist. One of the part time

receptionists did not take part in the research. In the analysis I have not differentiated between

part time receptionist 1 and part time receptionist 2. The senior receptionist was one of the

key informants.

Part Time receptionist 1

Part time receptionist 1 had been to school at one of the local area schools. After leaving

school she worked in the hotel trade as a receptionist in several hotels in the UK. She pursued

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this career for several years before she became an office administrator and manager for one of

the large North East shipping businesses.

At the time of the research she had been with the practice as a receptionist for four years. She

worked twelve hours per week. Her role was to make appointments for the patients. This

involved a lot of telephone work and using the computer. She worked behind the reception

desk and therefore was also answering queries at the desk. She recorded telephone messages

in the practice ‘day book’ and like the other receptionists administered the repeat prescription

system. She attended the monthly practice meetings and the protected learning time sessions.

Part Time receptionist 2

Part time receptionist 2 was born and grew up in one of the neighbouring former mining

villages. She went to the local village school and then the local secondary school. She enjoyed

her school years and mentions she became deputy head girl. At the end of her school years

she had a period of prolonged illness which in hindsight she felt thwarted her ambitions.

Her working life began as a school secretary followed by receptionist and secretarial work in

various companies in Newcastle. She was then appointed as receptionist in a single handed

practice in her home village. She worked there for several years.

She had worked in the research practice for approximately eight years. Initially she had

worked full time but during the initial months of this study had reduced her hours. Her role

was similar to part time receptionist 1. She had participated in and had been instrumental in

suggesting various improvements in the reception area. Part time receptionist 2 was the most

vocal of the receptionist group. She attended the monthly practice meetings and protected

learning time sessions. During the research period she had set up a local bereavement group.

She was a close friend of the practice nurse and both were involved in amateur dramatic

productions.

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The Senior Receptionist

The senior receptionist was born in North Tyneside. Her family then moved to a mining town

close to the research practice area. She attended the local secondary school. After leaving

school she had worked in the Prescription Pricing Bureau for ten years. In this job, she had to

code all prescriptions written by doctors so that each item on the prescription could be priced.

She left this post as there was little prospect of promotion to work as a receptionist in a group

practice. She had joined the research practice as a receptionist three years ago.

She worked full time hours and her role was the same as the part time receptionists. Her full

time role provided continuity in that area of the practice. Like the other reception staff she

attended the monthly practice meetings and the protected learning time sessions. In this

research she was a key informant.

Members of the Extended Primary Care Team

These informants were the health professionals who were employed by the local health

authority and were tasked with providing care for the patients registered with the practice. For

most of these health professionals they also worked with other general practices in the area.

The informants in this research from the extended team were the district nurse, the health

visitor, the community psychiatric nurse, the McMillan nurse and the physiotherapist. The

district nurse was the key informant from this group. She visited and worked with members of

the practice nucleus team on a daily basis.

The District Nurse

Like the other informants the district nurse was a ‘local girl’. She attended a local secondary

school and then did her nurse training in Newcastle. She did her district nurse training at

Newcastle polytechnic and then worked in the Newcastle West end for seven years. She

described her nurse training as consisting of a lot of lectures in anatomy and physiology and

assessed through exams at the conclusion of the course. She said she learnt by rote. Her

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training as a community (district) nurse at Newcastle polytechnic included theoretical work in

the social sciences.

She had been in this post for four years. Her role as a district nurse was diverse. The role

ranged from undertaking complex nursing assessments through to giving injections and taking

blood samples. Her workload was high. She visited the practice on a daily basis in order to

collect messages. This was often used as an opportunity to discuss patient care with the

doctors. She attended the bimonthly primary health care team meetings.

In the locality she met with the other members of the community nursing team. These were

district nurses and nursing and auxiliary nurses. They met as a team on a twice daily basis

(lunchtime and at 4pm). These meetings were to discuss patients referred to as ‘the case load’.

The discussion was task orientated and aimed to utilise all the skills in the nursing team. She

had a clinical supervisor and had supervision sessions on a three to six monthly basis.

The Health Visitor

The health visitor was the oldest member of the primary care team and at the time of the

research was nearing retirement. She had done her nurse training and then midwifery training

at one of the local district general hospitals and then worked in Carlisle. Her work load and

type of work had changed over the years. Overall her work had been in welfare clinics. These

were run by welfare committees. Now her work was mainly in general practices which she

visited on a regular basis. This varied from one per week to once every two weeks. Her

responsibility was age limited to all children under the age of five years. She undertook

regular developmental examinations of these children and provided advice to their parents.

She worked with community medical officers in the early years of her professional life and

then with consultant community paediatricians. The development clinics were held in the

general practices in her locality often in conjunction with a general practitioner. As a Health

Visitor she also had a role in the care of the elderly but given the time constraints in her post

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she was not able to fulfil that role.She attended the practice’s primary health care team

meetings and outside the practice she met with other health visitors on a regular basis.

The Community Psychiatric Nurse (CPN)

The CPN grew up in a village in County Durham. After leaving school at sixteen years she

went into nurse training as a cadet followed by a period as a nursing assistant. The teaching

was by lecture in classes and then by shadowing and working with a staff nurse. At this time

she entered psychiatric nursing. Like other members of the extended primary care team she

had a line manager and she also had supervision sessions.

She attended the research practice once per week in order to do a clinic. In the clinic she

would see three patients per week. Each patient had a 45 minute appointment.

The CPN attended the primary health care team meetings but this was less frequent than

other members of the team.

The McMillan Nurse

Like the many of the members of the primary care and practice nucleus teams she grew up in

a town close to the research practice and attended local schools. She did her nurse training at

the local district general hospital. This was followed by training in Intensive Care nursing,

midwifery and then as a district nurse. During this time she developed an interest in cancer

and palliative care. There was no service in the locality until she was appointed. He had

worked as a McMillan nurse in the locality for twelve years.

The McMillan nurse was a frequent visitor to the practice to discuss palliative care for

practice patients. She also attended the primary health care team meetings.

The Physiotherapist

The physiotherapist was a private practitioner who was contracted by the practice to provide

weekly physiotherapy sessions. She had a similar contract with other practices in the locality.

The sessions were held in the treatment room.

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She had grown up in Jarrow and then Hebburn near Newcastle. She had gone to a grammar

school and then Liverpool University to do her physiotherapy training. She had moved back

to Newcastle to work at the general hospital and then in the community. During this time she

became disillusioned with NHS physiotherapy management and had left to do agency work

and then with another colleague had set up her own business.

The physiotherapist provided a weekly or occasionally twice weekly service. She did not

attend the primary health care team meetings since these meetings clashed with her working

at another practice.

The author

I was born in Yeovil Somerset and after a grammar school education went to the Royal Free

Hospital Medical School University of London. After pre registration house jobs I constructed

my own Senior House Officer General Practice rotation at Northampton General Hospital. I

joined a group practice on the Isle of Man as a partner in 1980. The partners also undertook

intra partum care for the island with consultant cover. In 1987 I moved to the North East of

England to a single handed practice. I joined as a partner and I then succeeded the doctor on

his retirement in 1990. Subsequently the practice became a permanent two partner practice.

In terms of educational development I sat and passed the MRCGP exam in 1983 and obtained

FRCGP (Fellowship by Assessment) in 1998. I became a vocational trainer in 1990 and a

member of the panel of examiners (MRCGP) in 1992. I was also a group leader for the local

vocational training scheme from 1992 -1998 and GP tutor for a locality from 1998 to 2003.I

left the research practice in 2003 to become Senior Lecturer in General Practice at the

University of Central Lancashire, Preston.

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Overview of the chapters

This section gives a brief overview of the content of the chapters.

Chapter two considers the learning theories which were of relevance to the research questions.

In this chapter I consider the literature drawn from the NHS which acted as a stimulus for the

research questions and the social theories of learning. The theories considered are activity

theory, communities of practice, and social capital which are then amplified and supported

through complexity theory.

Chapter three describes the methodology for the research. The research method employed is

based on ethnomethodology.

Chapter four to six describe and consider the results from the research. These chapters are

themed as organisation, hierarchy and power and learning in the practice. Within each of the

chapters there are sub themes. In the organisation chapter I consider the data related to

meetings and ‘notes’ and the computer. The hierarchy and power chapter considers leadership

and the role of the practice building. The learning in practice chapter considers the

relationship between informal and formal learning for the informants.

Chapter seven (discussion) summarises and reviews the findings from the analysis and

discusses them in relation to learning theory. The chapter explores the relationship between

the results of this empirical study and the learning theories discussed in the literature review.

In its final section the discussion proposes a synthesis of these theories which arises from the

research findings.

In chapter eight I summarize the work presented in this research and return to the research

area and questions described in chapter one so as to consider the contributions made. I

consider the extent to which the analysis answers the research questions and make

suggestions for future research.

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Chapter Two – Literature review

Introduction

In this literature review I consider whether there is any one theory that gives an overall

epistemological explanation for this research setting. Philosophically, learning theory has a

propensity towards a Cartesian model with the individual –social separation which in turn

reflected Descartes’ view of theoretical physics which was causal and mechanical. This

model can be expressed as an assumption that knowledge or knowing has a degree of

certainty and that the knowledge is held within the individual and that ideas emanate from

within the individual. A counter argument to this position is expressed through the Kantian

view that learning is intersubjective. Toulmin (Engeström 1999) summarises this

philosophical change away from Cartesian dualism through the writings of Wittgenstein.

‘Wittgenstein’s arguments not merely rejected but discredited the ideas and impressions that were the starting point of 17th Century epistemology, both rationalist and empiricist. If all our knowledge, concepts, and judgments are in principle intersubjective [as the philosopher Immanuel Kant acknowledged], there is a reason. All such units of understanding obtain their meaning by entering language not via the minds of single individuals but within ‘forms of life’ ... that are essentially collective. As a result, the origins of any individual’s questions and judgments are defined by the current state of the art in the relevant field of inquiry’ ... (pg. 55, emphasis in last two lines added. Toulmin in Engeström 1999).

Social learning theories reflect this philosophical view and within these, there is a range

of perspectives. These are explored in this chapter. The chapter is organised into two parts.

In order to provide context and to situate these theories, I start with the literature which

relates to the changes within primary care and postgraduate medical education for general

practitioners in the NHS and the wider NHS organisational influences on the practice at

the time the research was conducted.

Two papers, ‘A review of continuing professional development in general practice a

report by the chief medical officer’, and ‘Working together –Learning together A

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framework for lifelong learning in the NHS’ were of importance to the NHS workforce

educational strategy in the late 90s and early part of the 21st century. These are discussed

in detail with supporting literature because of their importance to the research and, in

themselves, played a part in the formulation of the research questions.

The chapter then examines the socio-cultural theories of communities of practice, social

capital and activity theory, which are then amplified and supported through complexity

theory.

The National Health Service –the 1990s

I begin with a short description of the contractual relationship between general

practitioners and the health service. Everyone living in the UK is registered with a general

practice. At the time of the research the registration was with an individual general

practitioner. (In 2003, this changed to registration with a general practice.)

In terms of their contract general practitioners in the National Health Service are regarded

as independent practitioners and are essentially small businesses. Typically they will own

their premises and will be the employers of a wide range of staff. They will work

alongside and together with community staff such as district nurses, health visitors. These

staff are employed and managed by the primary care group or trust. General practitioners

at the time of the research had the option to work with one of two contracts. The first and

most commonly the general medical services (GMS contract) or alternatively a primary

medical services contract (PMS). The latter type of contract was attractive to general

practitioners working in areas of deprivation and where it was difficult to attract staff. The

GMS contract that existed in 1997 financially rewarded practices with large list sizes but

did little to reward practices that wished to deliver quality services.

By contrast, a PMS contract defined negotiated quality local services for a practice’s

patients. The services to be delivered were negotiated between the primary care group and

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the practice. These contracts attracted financial reward for providing a quality service. In

general they were more flexible in terms of the staff skill mix. For example, for a practice

that served a population with high deprivation it was possible to receive reimbursement for

the costs of employing health professionals to set up drug addiction clinics. In this

research, the practice was in an area of high unemployment and also an area that had a

relatively high elderly population.

Together with other small or single handed practices, the research practice negotiated a

physiotherapy service which was practice and community based. The practice’s PMS

contract also included various quality markers for clinical care. The advantage to the

practice and its patients was that it provided a more focused response to the patients’ needs

as sensed by the practice team. The financial advantages were that funding from the PMS

contract could be used more flexibly as illustrated with the contract negotiated with the

private physiotherapy service and subsequently the employment of a salaried general

practitioner.

The National Health Service 1998-2003

I start with an overview of the changes that were proposed for health professionals

working within primary care in the National Health Service between 1998 and 2003 at the

time of the data collection and which in themselves influenced the formulation of the

research questions.

In 1997 the government published its white paper to reform and modernise the National

Health Service (The new NHS- Modern and Dependable DOH 1997). Its vision was to

‘offer high quality treatment and care when and where patients needed it’ (The new NHS –

Modern and Dependable Executive Summary 1997 pg.4). The internal market was

abolished and a plan was set out to provide integrated care with a strong emphasis on

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target driven performance (A First –class service: Quality in the NHS DOH 1998 page 4

para.5.13).

The ‘internal market’ established by the Conservative government in 1989 refers to a

market within which there were purchasers and providers. The purpose of this was to

control costs and rising demand. Broadly speaking, the purchasers were general

practitioners and the providers were hospital consultants. General practices that wished to

engage with the internal market concept were delegated a purchasing budget for their

patients. Fund holding led to various innovations within the provision of service in the

community (e.g. consultant colleagues held outpatient clinics in GP premises, the

development of minor surgery services). These types of innovations produced reductions

in waiting times for hospital services but also created a two tier service. Patients served by

large practices benefited from fund holding. Small practices or practices that did not want

to pursue fund holding indirectly disadvantaged their patients.

By 1998, 55% of the English population were covered by some form of fund holding

arrangement. The incoming Labour government signalled the end of fund holding by 1999.

The practice in this research had been a community fund holding practice and held a

budget for services such as physiotherapy. Fund holding had led to many general practices

needing to go through a period of internal reorganisation. The internal market and the

allocation of budgets brought a degree of collaboration between practices through their

combined purchasing power.

Postgraduate general practice medical education

The chief medical officer’s report (CMO) in 1998 (A review of continuing professional

development (CPD) in general practice a report by the chief medical officer 1998, CMO

1998) made recommendations for change in the continuing professional development in

general practice.

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The report defined CPD as

‘a process of lifelong learning for all individuals and teams which enables individuals to expand and fulfil their potential and which also meets the needs of patients and delivers the health and health care priorities of the NHS’ (CMO report 1998pg.6).

This definition attempts to fuse the individual’s learning needs and development with the

development of the NHS. This raises the question of whether the learning and

development agendas of individual and the organisation are necessarily the same as

recognised by Cornford (2001).

As the CMO’s report discusses, there is little evidence that attendance at courses and

lectures produces changes in practice for the benefit of patients (CMO’s report, 1998

pg.3).The evidence for the effectiveness of CPD in medicine had been reviewed by

Stanton and Grant (1997) as a precursor to the CMO’s report. The report discussed

different models of CPD and their learning outcomes. In their concluding comments,

Stanton and Grant concluded that no one method of CPD had been shown to be most

effective but did conclude that more attention needed to be given to the

‘conditions for effectiveness of CPD activity,…..that is by establishing process and culture rather than specifying particular educational experiences or types of education’(Stanton & Grant 1997pg.34,) (my emphasis).

The report highlights the lack of coordination in terms of use of the resources available for

CPD and in particular the lack of focus. The postgraduate educational allowance (PGEA),

available as a financial incentive for general practitioners’ educational development, was

criticised for failing to show any change in medical practice which would benefit patient

care. General practitioners were able to claim this allowance by attendance at courses and

lectures. Postgraduate meetings for general practitioners were often consultant led and

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encouraged passive learning. Their educational content was influenced by pharmaceutical

company sponsorship and little consideration was given to any quality agenda.

The Practice and Professional Development Plan (PPDP)

The CMO’s report recommended the introduction of the Practice Professional

Development Plan (PPDP) within general practice. This would attract the same funding as

the PGEA and the two educational systems would run ‘in parallel’. The report describes

the purpose of the plan as providing a framework which would

‘develop the concept of the whole practice as a human resource for health care; increase health authority involvement in the quality development of practices; be professionally led at all levels and be monitored through peer review’(CMO report 1998 pg.18)

Its content would be based on an amalgamation of individual practice team members

professional development plans and the service development plans of the practice. These

plans in turn would be influenced by local assessment needs and objectives. Emphasis was

placed on the use of clinical audit data, clinical governance and practice based learning

methods.

The introduction of the PPDP with its emphasis on practice based learning was a

significant change for general practitioners. This change was met with an ambivalent

response, reflected in Tudor Jones and Elwyn’s survey study of 202 general practitioners

(2003). This was a mixed quantitative and qualitative study and the general practitioners

responses are summarised in the box below. The study noted the practitioners’ resistance

to the offer of external facilitation and the difficulties expressed by the general

practitioners to engage with multidisciplinary team learning.

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Box 1 Quotations for obstacles to PPDP Time `Personally my time is already well catered for. To take on something new, something ``old’’ would need to be passed to some other provider.’ `The explosion of clinical and administrative demand for GP time in the last ten years without a corresponding increase in the resources to manage this demand has created a disillusioned, resentful profession.’ `The PHCT is so wide that to get all of us to a meeting at the same time is close to impossible. All our timetables are full what do we drop to go to meetings?’ Funding `Money to finance locums or overtime payment for staff.’ `If members of the PHCT feel they have an educational need, there may be a financial input required by the practice in order to allow them to e.g. attend courses to fulfil that need.’ Process `A PPDP process would not work unless all professional groups were in agreement that this process was ``the way to go’’. I can envisage problems with less than 100% compliance.’ `Motivation doing it because we had to rather than because we wanted to.’ Leadership `I am not sure I would have the skills to facilitate such a project, or the time.’ `I feel that a lot of GPs still feel threatened by entering into true teamwork and to relinquish the ``team leader’’ tag.’ Employment status or allegiance `Lack of (resources and) support from outside agencies such as other employers of team members.’ Change `I am unable to keep up with continuous organisational changes of (the) NHS which only satisfy the parties in power- and power/influence-hungry medical intellectuals.’ `Make up your mind whether it is going to change again as we have seen so many changes come and go in a very short period of time.’ PPDPs: a survey of GPs’ views 29

Tudor Jones, Glyn Elwyn et al (2003)

The tensions highlighted by the general practitioners in this study were replicated in

McEwen’s qualitative study of general practitioners attitudes to their professional

development plans (PDP) (McEwen, 2003). At the time of this study the General Medical

Council had just introduced revalidation and the use of the PDP in this process. In her

study McEwen found a mixed picture. General Practitioners could see the purpose of the

PDP in terms of acting as an educational framework and satisfying the needs of clinical

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governance. However as in Tudor Jones’s study there were barriers relating to ‘finding

time’ and feeling threatened by the link between PDP and revalidation.

Cornford writing in 2001 critiqued the assumptions within the concept of the PPDP in

terms of the underpinning learning theory (Cornford 2001). His view was that the PPDP

attempts to fulfil several functions and that these did not always have a synergy in terms of

its overall purpose. He recognises the inherent political tension in the PPDP between the

learning needs of the individual and that of the institution. The concept of the PPDP

highlights the difficulties inherent in multidisciplinary learning. Cornford recognises the

inherent weakness of the application of androgogic learning theory which underpins the

PPDP. This theory suggests that individuals are self directed and their learning is problem

based. This is not contested, but the PPDP also seeks to measure outcome and, as

Cornford observes, this could lead to only measuring outcomes which are easily measured.

This leads to the important but ‘softer’ areas of learning in the workplace being ignored.

Cornford exemplifies these through the learning influences of the social contacts that

health professionals make during externally facilitated educational courses. Implicit within

Cornford’s paper is the politicisation of the PPDP which distract from its educational

purpose as a developmental tool. As already noted in Tudor Jones’ and McEwen’s work

there were significant tensions as to the underlying purpose of the PPDP. This political

subtext is further highlighted in McKee and Watt’s (2003) evaluative study of PPDPs in

East Anglia where their main finding was that the PPDP was seen as ‘the growing threat to

the freedom of professional learning as education is seen as a means of managing

compliance to national performance targets.’

Working together –Learning together. Lifelong learning for the NHS

In 2001the Department of Health published ‘Working Together –Learning Together. A

Framework for Lifelong Learning for the National Health Service (DOH 2001). This

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document outlined how lifelong learning was to be embedded within the National Health

Service with an emphasis on helping staff ‘realise their potential’ and take ‘advantage of

wider career opportunities’. There is an expectation that NHS staff will ‘take responsibility

for their own development’ (2001pg.vii). The document sets out the development of the

NHS University (NHSU) and ‘skills escalator’ approach to staff development. The latter

envisages NHS staff will have the necessary support and opportunities to progress their

career. There is particular emphasis on the provision of training opportunities for those

who traditionally have been omitted from educational opportunities in the NHS. Example

of these employees might be health care assistants, clerical and catering staff.

‘Working Together –Learning Together’ was significant for its emphasis on lifelong

learning and its vision for the NHS as a learning organisation. Lifelong learning is

contextualised in terms of providing an improved service to the NHS through enabling the

individual to ‘fulfil their potential’. The document recognises the ‘fast moving pace of

change in health care’ and the need to improve ‘access to learning in the workplace’ (page

1).

The notion of a learning culture is encouraged as its authors acknowledge.

‘Delivering this vision means that all NHS organizations and those with a contractual relationship with the NHS, need to develop and foster a learning culture. Investment in learning benefits the organisation, patients and carers, local communities, society more generally and individuals. To be effective, lifelong learning also depends on a strong relationship between individuals and their immediate world of work and in shared values and skills’ (pg.6)

The learning culture is to be embodied within the NHS as a learning organization. The

purpose of developing the NHS as a learning organization is to enable the recruitment and

retention of NHS staff and ‘support them through high quality employment practices

including the provision of lifelong learning opportunities’ (pg.11).

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This development is structured through utilizing the ‘Improving Working Lives’ standard.

This standard requires the employer to use modern employment practices. Amongst these

is the provision of ‘personal and professional development and training opportunities that

are accessible and open to all staff irrespective of their working patterns’ (pg.12). The

learning organization is given further structure in terms of all health professional having a

professional development plan (PDP) and that the ‘effectiveness’ of a NHS organization

will be enhanced by having a learning strategy and a system of appraisal for all staff. This

will be achieved through the use of a ‘variety of development methods- coaching on the

job, mentoring, learning sets, secondments, project work, sabbaticals as well as formal

education and training’(pg.14). This places an emphasis on work based learning in the

NHS and it is this I discuss in the next section.

Work based learning

A report published in 2002 (Work related learning-key influencing factors Caley 2002)

considered the influencing factors in work based learning in the NHS and reflects the

conclusions made by Stanton and Grant in 1997. The report summarises the outcome of a

series of workshops with NHS managers in primary and secondary care settings. The

emergent factors emphasised the need for long term planning for learning within an

organisation and that informal learning should be facilitated in the workplace so that

experience can be shared. These factors were recognised as requiring development of the

infrastructure in terms of financial and technological support and that the overall culture in

an organisation should promote openness and sharing.

Learning in general practice and the research of culture in general practice has received

some attention. Rutherford and McArthur (2004) used a qualitative phenomenological

approach to explore the ‘lived experience’ of team learning among professionals’ across

several general practices. Their research reflected the issues related to team learning and

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especially the existence of true team working. Their results were similar to those of Tudor

Jones and Elwyn and in particular, the issues of hierarchy, leadership and trust were

prominent in their informants’ narratives. Sylvester (2003) used a survey method to

measure general practices as learning organisations and by extrapolation ‘diagnose’ the

practice culture. This study was from an organisational management perspective. The

study was undertaken in North Tees PCT and the questionnaire was sent to a sample of

staff working in the North Tees Primary Care Trust. Although this was a flawed study in

terms of its sampling and the broad definitions of the areas surveyed, it underlined the

need for trust so that the ‘characteristics of creativity, seeking and valuing feedback’ can

be enabled. The study did not explore how practices described or created their culture.

The CMO’s report and ‘Working together –Learning together’ are significant in terms of

strategic change for learning in the NHS and emerged at a time when there was an ongoing

debate related to the declining morale among doctors and a change in the ‘psychological

compact between the professions, employers, patients and society’ (Edwards N, Kornacki

MJ, Silversin J, 2002 , Ham C, Alberti KGMM, 2002, Smith R, 2001) and the

deprofessionalisation of doctors (Pereira Gray D, 2002) The compact change relates to

government bringing the medical profession under control through ‘the use of guidelines,

protocols, audit, regulations and inspection’ (Edwards N, Kornacki MJ, Silversin J, 2002)

and as a result a change in job expectations.

With this change in relationship the culture and regulation of doctors came under scrutiny

leading to changes in the regulation and registration of doctors and the composition of the

General Medical Council with increased lay representation (Irvine D 2001, Times editorial

16.2.01) There is therefore also a change in the relationship of trust between the parties

and this is a theme I return to later in this chapter.

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Comment

The CMO report on continuing professional development and ‘Working together –learning

together’ were published at a time of uncertainty for the National Health Service. For

health professionals it was another phase of reorganisation as outlined above. These

reports in some part reflect that uncertainty through their inconsistencies. The PPDP

appears to have multiple influences acting upon it. Principally these are political and this is

reflected in the studies described. Amongst these political influences is the control that

government wishes to exert on the professions. The purpose of the PPDP as an

educationally formative and developmental tool for the practice team is lost or distracted

by these pressures. Similarly ‘Working together –Learning together’ sets out worthy

aspirations for the NHS as a learning organisation. However, and cynicism is not intended

here, the NHS could be said to be moving through constant change. This leads to

uncertainty and militates against the sharing of knowledge and reflectivity as envisaged by

Senge’s ideal in the ‘The Fifth Discipline’ (1992). The learning organisational change

proposed in the NHS delivers changes through a top down hierarchical process. The

opportunity to develop learning in the organisation through a more bottom up or horizontal

process is lost. ‘Working together- Learning together’ reflects the NHS’s central

organisational desire to control in a mechanistic approach to the development of the

learning organisation. This ignores the fact that the NHS is a huge organisation and it

appears unrealistic to expect it to uniformly subscribe to and achieve the ideals of the

learning organisation.

The CMO’s report in 1998 and its implications for postgraduate education for general

practitioners is situated in a societal setting which has had its professional status

diminished through central control. In addition the wider NHS organisation is being

encouraged to become a learning organisation. This then has implications for how general

practitioners and their teams will learn. For a theoretical insight into how this might take

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place I turn to the socio cultural theories of learning and then for an organisational

theoretical basis I consider their relationship to complexity theory

Activity Theory

Activity theory and its close relative sociocultural theory are derived from the school of

Russian psychology developed by L.S. Vygotsky, A.N. Leont’ev and AR Luria.

Developed in the early part of the 20th century and in a Marxist tradition, this has

subsequently been developed by various workers (e.g. Engeström Y 1999, Wertsch 1991)

in the West who have a research interest in understanding how learning and development

take place in a cultural setting.

Activity theory places activity itself as being central to this understanding and similarly in

sociocultural theory this is primarily mediated through speech (e.g. Wertsch 1991). The

main focus in this discussion relates to activity. Its central tenet is the role of artefact in an

organisation and its influence on social learning.

There is a dialectic between the internalisation and externalisation of knowledge for the

individual and that artefact, be it through physical object or through regulation, mediates

this exchange. Daniels (2004) recognises the need to research the relationship between

sociocultural historical context and artefact. Historically, artefacts reify events past and

present to their users and within the social setting, artefacts help the understanding of the

process of social learning. Artefacts can be considered as mental models which mediate

activity. They can be internalised from the culture in which the person is taking part and

externalised by their use and development in the person’s environment. Engeström has

developed this concept through the activity theory model. In its simplest form mediation

by an artefact is expressed in diagrammatic form as (Daniels 2004)

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To clarify the diagram, subject refers to the unit whose actions are ‘the focus of analysis’

(Daniels 2004). The unit can be a person or an organisation. The object is ‘the focus of the

activity’ (Daniels 2004). Engeström then develops this model further into ‘second and

third generational’ models. These have been reproduced below from Daniels (2004). The

variables within the activity system are ‘rules and regulations that are both internal and

external to the organisation, division of labour, and community. The latter comprises the

people that the individual works with or for an organisation other organisations.

Engeström gives the relationship between the ‘variables’ a dynamic interpretation and I

have added arrows to the model to represent this.

Artefact Subject S Object O

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Mediating artefact

subject

outcome

rules communityDivision of

labour

Learning/meaning

With the addition of arrows which symbolise the dynamism of the system and the

introduction of an additional activity system then the overall complexity of interaction

intra and inter activity system can be seen. Activity is a ‘goal directed endeavour’ (Illeris

2002 pg.48) and an Activity system ‘has as its minimum elements the object, the subject,

mediating artefacts, rules, community and division of labour’ (Engeström1999 pg.9).

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Mediating artefact

Mediating artefact

subject Object 1 Object 1

rulesCommunity

Divn oflabour

rulescommunity Divn

Oflabour

subject

Transformation leading to new sense and meaning

(Adapted from Engeström 1999 and Daniels 2004)

The interplay between these two imaginary systems not only produces new knowledge as

individual systems but has the potential to generate new knowledge through the interaction

of the two systems. The communication between each facet of the system (e.g. rules –

subject-community) is at any point in time a mediational process which will have implicit

tensions and contradictions. In turn, these will be mediated by the other facets and power

and hierarchy within the system or organisation. Engeström considers an organisation to

have ‘multilayered network of interconnected activity systems and less as a pyramid of

rigid structures dependent on a single centre of power’ (Engeström et al. 1999 pg36). The

individual in learning a new activity internalizes until competence is obtained and

externalisation is seen in the form of innovative activity. When considering the interaction

between individuals, Engeström (1995) develops a theme that learning new knowledge is

generated from the interaction between individuals. This is described as knowledge having

an ‘emergent and interactive quality, as if it were hanging in the air between actors and

their artefacts, wanting to be further tested, modified and discussed’(Engeström 1995) .

Learning in Engeström’s view happens at a ‘horizontal level’ with workers crossing the

hierarchical boundaries. In his research in a factory, health centre and primary school

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artefacts facilitated the boundary crossing. Tacit knowledge emerges when the boundary

is crossed and new domains are explored by the people involved.

Activity theory and power

This observation leads to a consideration of the concept of power within an activity

system. Although I do not intend to explore in depth Foucault’s thinking in relation to

power it does serve to emphasise the social dynamic that power brings to an organisation.

Foucault envisages power being generated from within a micro group through activity.

Fox (2000) explores Foucault’s concepts of power in relation to communities of practice

and this would seem similarly applicable to activity system theory. Foucault considers

power as

‘……as the multiplicity of force relations immanent in the sphere in which they operate and which constitute their own organisation.’

‘……. The moving substrate of force relations which, by virtue of their inequality, constantly engenders states of power, but the latter are always local and unstable

…….because it is produced from one moment to the next, at every point, or rather in every relation from one point to another. Power is everywhere, not because it embraces everywhere, but because it comes from everywhere (Foucault 1984 pg 93 History of Sexuality Vol 1 and cited in Fox S. , 2000 pg7, my italics)

Fox amplifies this with ‘the self or subject acts upon itself, uses force upon itself and does

so on the basis of self knowledge’(Fox 2000 pg. 7)

Although Engeström has developed a theory at the macro level to account for the facets of

social learning, an activity system may also be conceived on a micro level, within small

groups working in an organisation. At the level of the individual other learning theories,

both behavioural and cognitive begin to impact which, if we reverse the flow of

understanding then influence the ‘objectification’ of artefacts. (Bakhurst 1995 in Daniels

2004 pg 125)

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In terms of practical application, activity theory has been of research interest in human

computer interaction. Mwanza (2002) has suggested an operational model which utilises

Engeström’s framework. She describes an eight step model for analysis of a second

generation model. I have tabulated the model below. The model is of interest since it

provides a potentially useful practical model. However it avoids engagement with the

overall concept of culture and the inherent complexities between activity systems.

Activity theory is persuasive but it might be critiqued for its inability to give an overview

of a system over a period of time. It describes learning at a moment in time and lacks the

perspective of a system as a dynamic process. A practice is a complex organisation with a

multiplicity of professional learning backgrounds. However to leave the level of thought

and understanding of learning as ‘complex’ is of course to give no insight into the

substance of the complexity. The proponents of the social learning theories discussed all

allude to the complexity of the process being described and hence in this research I seek to

The eight-step model for analysis of a second generation activity system (Mwanza 2002) 1 Identify the activity of interest: what sort of activity am I interested in? 2 Object of activity: why is this activity taking place? 3 Subjects in this activity: who is involved in carrying out this activity? 4 Influence of artefacts on the activity: by what means are subjects carrying out this activity? 5 Rules mediating the activity: are there any cultural norms, rules or regulations governing the performance of this activity? 6 Role mediating the activity: who is responsible for what, when carrying out this activity and how are the roles organised? 7 The community in which the activity is conducted: what is the environment in which this activity is carried out? 8 Outcome: what is the desired outcome from carrying out this activity? (cited in Sandars J 2005)

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use complexity theory and its derivative complex adaptive system theory and their

components as a social metaphor.

Complex Adaptive System Theory

Interest in complexity theory as applied to ‘knowledge generating’ organisations has

gathered momentum in recent decades (Stacey 2001pg.22). In developing his complex

responsive theory Stacey gives a fluidity and dynamic to knowledge generation. His

perspective is to discuss in what way is knowledge generated between two ‘human

bodies’. This is conceptualised as ‘knowledge cannot be managed, and there is no need to

manage it, because knowledge is participative self –organising processes patterning

themselves in coherent ways’ (Stacey 2001pg5). He situates the role of human agency in

the generation of knowledge as being one part of a complex system of interrelationships

between the individual and their social group. Stacey’s viewpoint (and is a logical

extension of Engeström’s view) is that ‘human agency is processes of interaction between

human bodies and those processes perpetually construct themselves as continuity and

potential transformation’ (Stacey 2001pg.5)

Complexity as a social metaphor gives an insight into how organisations develop. For the

purpose of this research, complexity theory is introduced since there is intuitively a

relationship between social learning and organisation. An organisation such as the general

practice in this research can be considered to be a 'complex adaptive system'. By this I

mean the agents within the practice interact between themselves and their environment

which lead to emergent novel behaviour.

From an educational theoretical perspective, in a series of articles relating to complexity

and health care ( Plsek & Greenhalgh , Fraser & Greenhalgh 2001), the authors rehearse

the increasing complexity of care that is delivered within a General Practice and the

multiple dynamics that arise from the various contacts with Primary Care Team members.

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Fraser and Greenhalgh consider that education within the NHS should aim to help create

an NHS that is ‘ever safer and constantly up to date’ and ‘challenged to enable not just

competence but also capability’ (ibid 2001).

Capability can be defined as ‘the extent to which individuals can adapt to change, generate

new knowledge and continue to improve their performance’ (ibid 2001). Fraser and

Greenhalgh’s viewpoint is that the NHS documents ‘Continuing Professional

Development: Quality in the NHS, Welcome to the NHS Learning Network, Promoting

Clinical Effectiveness’(Fraser and Greenhalgh 2001) implicitly accept the concept of

complexity theory.

Using Stacey’s model (Stacey 1996), they describe a zone of complexity in which learning

takes place. The ‘relationship between items of knowledge is not predictable or linear

neither are they frankly chaotic’. In the following diagram the arrow from competence to

capability is shown as a straight line. However in passing through the ‘zone of complexity’

although the trajectory remains linear, the emerging outcome in terms of capability

remains uncertain due to the multiple influences upon it within the zone of complexity.

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(From Fraser and Greenhalgh 2001).

Developments within the NHS have included plans for a “University for the NHS- NHSU,

Working Together Learning, (NHS Exec 2001). Overall these programmes aim to develop

capability by providing a framework within which participants have the opportunity ‘to

engage with unfamiliar and uncertain contexts in a meaningful way’ (Fraser and

Greenhalgh 2001, Price J. in Kernick D, 2004 pg227).

Thus for Fraser and Greenhalgh, process is all important in improving capability. Process

is exemplified by the arrow in the diagram and includes learning methods which centre on

non linear methodologies such as Significant Event audit, case discussions and small

group learning. (The learning done within a group has the potential to be greater than the

sum of the parts).

Environment unfamiliar Capability Tacit knowledge Explicit knowledge Competence zone of complexity Environment familiar

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By approaching learning through multiple methods over a period of time, it allows an

understanding of the underlying behaviours (or referred to as ‘Attractors’ in complexity

theory) and will permit discovery of what work best for groups and individuals.

Application of complex adaptive system theory

Within an organisation

Complex adaptive systems give insight into the organisation and interrelationships within

the practice. As will be seen, the practice had a flat hierarchy with devolution of

responsibility to the members of the practice nucleus team. In terms of complexity theory,

this social system can be viewed as a complex adaptive system. These systems are

characterised by numerous elements that interact and have ‘(re)iterative feedback loops’.

These feedback loops can be either positive or negative and hence outcomes from the

system are uncertain.

Complex adaptive systems are sited within other systems as in the case of a general

practice situated within the much larger system of the National Health Service. Other

properties of complex adaptive systems are that they have indeterminate boundaries and

that they always have a history. Finally, a complex adaptive system can be seen as more

than the ‘sum of its parts’. No one agent within the system can know the whole and the

resultant behaviour of the parts at a local level (in this case the practice) evolves from the

interaction from the parts without direction from external organisations or from internal

control (Kernick D 2004).

As will be seen later in this chapter there are synergies here with Wenger’s social system

theory of communities of practice and his theoretical stance is frequently used by

complexity theorists.

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Emergence and self organisation

Complex adaptive systems have certain features. Principally, these are of emergence and

self organisation. These will be briefly described and from these derive an understanding

of phase space and attractors.

Emergence relates to the development of unpredictable patterns that cannot be predicted

from knowledge of the individual parts of the system at a lower level. Thus within the

practice although the individual has a well defined role, their behavioural outcome from

their interactions is different from that anticipated from knowledge of their individual role.

Stacey adopts the term ‘autopoiesis’ to describe the generation of knowledge within the

system where each part interacts to help transformation of the other parts and in doing so

is itself self generating and self organising (Stacey 2001pg.34).

Complexity and organisational change

The complex behaviour that is witnessed within a biological system often results from

following simple non linear equations or rules. Everyday examples of this are flocks of

birds or shoals of fish. In these systems there are three simple rules, creating great

complexity. These are ‘move to the centre of the crowd, maintain a minimum distance

from your neighbour and move at the speed of the element in front of you’ (Kernick D

2004, Sweeney and Griffiths 2002) Organisational change is better understood if the rules

that guide a system can be understood. For example, Pampling (1998) describes the simple

rules for the NHS and considers these in relation to the fact that although there has been

considerable structural change, there has been little change in the underlying behaviours

within the NHS. She lists these current simple rules as ‘I am responsible, can do should

do, doing means treatment’ and suggests that these rules derived from simple rules

analysis could become ‘I am responsible with others in partnership, maximize the health

gain for the population within available resources, doing takes place within a broader

social action’.

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Attractors

Attractors in complex adaptive systems relate to a point towards which a system will

always moves or at which it stays. An example of this is a swinging pendulum which after

a time settles into repetitive pattern of movement in a given space. To develop this further,

if the pendulum is placed between two or three magnets and the magnets are now the

attractors the pendulum’s swings neither through a predictable point nor through a repeated

loop. The pendulum describes a complex but clearly ordered shape. This system in

complexity terminology is referred to as a ‘strange attractor’.

Within education, complexity surfaces as a metaphor to help elucidate the nature of

professional development (Knight P. 2002). Knight discusses complexity in terms as

outlined above emphasising the non linearity of non formal learning and its lack of

appreciation within an organisation. In common with other complexity theorists, the focus

should be on the ‘ingredients of processes’ in a successful piece of continuing professional

development (Knight 2002) and not the outcomes. For an organisation, the importance is

in reproducing the successful ingredients or processes. (Fullan M.1999 in Knight 2002).

Attractors and predicting outcome

Arrow et al. (2000) uses dynamic process theory to look at whether it is possible to predict

behaviour within a group. Arrow takes the view that it is not possible to use

chaos/complexity theory to predict behaviour within a group since it is difficult to map

complex dynamics and random behaviour. However within a system where there are single

variables, it is possible to predict a given range of variables, any values of the variables

will ‘gravitate towards the attractor’ (Arrow 2000 pg.155). Outside the variable range the

dynamic system will move towards chaos and unpredictability. Any small changes in

these variables can produce a larger effect elsewhere in the system.

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Knight (2002) emphasises the importance of a small change in process or many small

changes which produce a large one. Knight cites the work of Huberman, and in school

settings (Nias, Southworth and Yeoman1992) where small changes in process enhanced

school curriculum development.

Comment

Complexity theory and in particular complex adaptive system theory bring fresh insight to

the reflective practice techniques such as significant event audit and small group learning

in which the ‘outcome’ for the individual and the organisation are uncertain. In terms of

theory this is attractive given the observation that there is little evidence of learning using

the more traditional ‘linear’ methods (CMO report 1998).

As a theory of learning, complexity theory or more strictly learning as an emergent

property of a complex adaptive system relies heavily on metaphor. It does give a different

perspective to learning as it avoids an over reductionist view point and gives fresh insight

into the reality of how a group or organisation functions. Byrne (1998) as an advocate of

complexity theory as applied to social systems is even more ‘upbeat’.

‘Every PhD student in everything should get to grips with the “chaos/complexity” programme, not for reasons of fashion or even legitimate career building but because this is the way the world works and we need to understand that’ (Byrne, 1998pg. 161).

However as seductive as complex adaptive systems would seem, there is a risk of over

attribution. Gatrell (2003) in reviewing complexity rehearses the debate as to where it fits

ontologically. It could be viewed as modernist through a reductionist perspective or

through bringing together ‘macro, micro, agency and structure’ (Gatrell 2003pg.8,) it is

post modernist. This then raises the issue of the use of metaphor in complexity. Stewart

(2001) critiques the use of metaphor within a general discussion that current complexity

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theories are not sufficiently robust to explain the multiple complexities within a social

system

‘The concepts and the poetic imaginary of complexity theories may indeed at times throw light on social process; however, whether ..(there is).. a universal social attractor must be determined by social debates and research rather than by complexity’ ( Stewart 2001pg.332,)

Stewart is also critical of the viewpoint that social phenomena can be predicted through

the application of mathematics. Instead there is a reminder that the social histories and

their interactions within an organisation cannot be explained mathematically but through

the ‘codes of the discourses’ (Stewart 2001). This is amplified as

‘Social contexts have particular physical histories, environmental histories, and human histories, which together produce a unique set of boundary conditions in each context; add to this the boundary conditions created by actual people attempting to act reflexively on aspects of the context. The heterogeneous set of boundary conditions shaping real-world contexts is best described through codes or discourses that are able to retrieve aspects of these contextual histories or, to state it differently, that are able to retrieve the templets of the boundary conditions themselves.’ (Stewart 2001pg.332,)

Gatrell (2003) discusses the application of scientism to social theory. He concludes that ‘a

key issue, therefore, is whether we need the language (from chaos theory) of strange

attractors, dissipative structures, fractals, and the like to inform our understanding’

(Gatrell, 2003pg.10).

For the purpose of this research I take the viewpoint that complexity theory does produce

useful insights into the organisational interrelationships between the emergent themes

through the use of complexity terms. The language of complexity provides a perspective

on the energy or dynamism within an organisation. It enhances the understanding of the

social discourse of an organisation but in itself is not an overarching explanation for

learning in a social setting. This would be in keeping with Gatrell’s concluding position

that through complexity theory, ‘there may be some fruitful lines of enquiry, and it would

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behove us to look seriously, though sceptically, at the literature emerging from this area of

contemporary social science’ (Gatrell, 2003pg.22).

Ultimately, complexity theory in this research is used to help understand the social

complexity implicit in this research and is therefore useful as a metaphor.

Communities of Practice (COP)

I turn next to Wenger’s social learning theory and communities of practice (COP) .As will

have been observed there are commonalities between all these theories. Equally there are

difficulties with aspects of these theories in terms of their applicability and I address these

in the final part of this chapter.

Wenger (1998) develops various themes under the rubric of a ‘Community of Practice.’

This is described as a ‘characterization of the concept of practice, to distinguish it from

less tractable terms such as culture, activity or structure’ and defines it as a ‘special type of

community’ The word 'Practice' is given three dimensions in its relationship with

'Community'. These are ‘mutual engagement, a joint enterprise and a shared repertoire’.

These dimensions are explored further and each has several subsets. Within joint

enterprise, learning arises from the inherent negotiation of meaning for a group of

employees (Wenger 1998).

Here Wenger acknowledges the complexity of these settings and that their sense of ‘being’

has a multifaceted relationship with external influences.

‘It is the result of a collective process of negotiation that reflects the full complexity of mutual engagement. It is defined by the participants in the very process of pursuing it. It is their negotiated response to their situation and this belongs to them in a profound sense, in spite of all the forces and influences that are beyond their control’ (Wenger 1998 pg. 77).

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Wenger discusses the relationship between a Community of Practice and external

organisations. Wenger’s position is that a COP does not develop independently of other

organisations. Wenger writes that

‘even when the Community of Practice is profoundly shaped by conditions outside the control of its members ,as it always is in some respects, its day to day reality is nevertheless produced by participants within the resources and constraints of their situations’ (Wenger 1998 pg.79).

He acknowledges that the Community of Practice ‘responds to conditions in ways which

are not determined by the institution’. (Wenger 1998 pg.79)

This is similar to the point of view taken by Hargreaves (1994) in ‘Changing Teachers

Changing Times’ when reflecting on the changing working environment for teachers in a

post modern world. He describes various forms of ‘teacher culture’. The most intriguing

and engaging is that of the ‘moving mosaic’ in which the boundaries of school

departments are blurred and there is trust, a willingness to take risks and responsiveness to

outside agencies or change. To return to Wenger’s concept of joint enterprise he concludes

that

‘Members produce a practice to deal with what they understand to be their enterprise; their practice as it unfolds belongs to their community in a fundamental sense’. (Wenger 1998 pg. 80)

Participation and reification

When considering how the enterprise is negotiated Wenger introduces two important

terms. These are participation and reification. Participation is the ‘process of taking part

and also to the relation with others that reflect the process’(Wenger 1998 pg.55)

Reification is used in the sense of conveying the idea ‘that what is turned into a concrete

material object is not properly a concrete material object’ (ibid pg.58).Examples used are

terms such as justice, health, economy.

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Reification is an important concept since a Community of Practice will produce many

symbols and will hold a narrative history. There is a constant interplay and tension

between the two terms.

In terms of learning, Wenger uses participation and reification to describe the process. The

level of participation will vary as employees join and leave the Community of Practice

which will engender feelings of continuity and discontinuity. In turn the discontinuity will

engender new learning of skills and techniques. These will become reified through the

telling of stories and histories.

The introduction of new ideas or new tools as exemplified by the Professional

Development Plan would be an example where something new within the practice would

require the negotiation of meaning and for the dynamics between participation and

reification to be played out. Wenger conceptualises this as the politics of participation and

reification.

Here it is the issue of power and who holds it, and indirectly alludes to the concept of a

hierarchy within a Community of Practice. Politics for Wenger is expressed as ‘friendship,

ambition, trust, personal authority’ (pg.91).

Learning in Wenger’s terms is the result of the dynamic process between ‘mutual

engagement, understanding and tuning their enterprise, and developing their repertoire

styles and discourse’ (pg.95). Learning therefore takes place at across multiple perceptual

boundaries and this complexity is recognised by Wenger and which, in Wengerian terms,

is the resultant behaviour from the outcome of the negotiation of meaning.

It is apparent that Wenger and the proponents of complex adaptive system theory have

similarities if expressed in the different languages of their disciplines when considering

learning in the workplace.

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Wenger considers the relationship between reification and participation as important in the

process of learning. Wenger would argue that the concepts of reification and participation

have histories and that there is a dynamic process between these concepts. For reification

an object or artefact will have had different meanings for employees over time. The

process of change is continuous. Participation will have memories for employees;

‘identities of employees’ (Wenger) will have been created over time within a workplace.

The interplay between reification and participation is seen as creating learning and Wenger

asserts that employees do not see their job as learning, that what they learn is their

practice. (My underlining)

‘Learning is the engine of practice, and the practice is the history of that learning’ (pg.96).

Learning takes place through the interaction between participation and reification and in doing so causes Wenger to invoke the concept of complexity when he considers learning as an ‘emergent structure’

‘Learning involves a close interaction and chaos……practice is neither inherently stable or inherently unstable’ (pg.97)

Comment

Overall, although giving an understanding of how learning takes place for a community of

practice, Wenger’s concepts do not give us an understanding of how learning for the

individual and the production of knowledge takes place. This appears to be implicit within

the concept of the community of practice but is not described. In the next section I discuss

the relationship between the individual, the organisation and their learning. This

discussion also considers the inherent moral issue in their interrelationships.

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Individual learning and the organisation

For learning at the level of the individual, knowledge has been classified as ‘procedural,

propositional, practical, tacit, skills and know how’ (Eraut 1994). For the purposes of this

discussion I propose focussing on propositional and tacit knowledge.

Tacit knowledge has been defined as ‘that which we know but cannot tell’ and

propositional knowledge as knowledge about ‘skills and procedures but excludes the

practical know how needed to perform the procedure’ (Eraut 1994). There is a distinction

between knowledge gained at medical school in the lecture theatre or from books to the

knowledge gained in medical practice (Eraut in Coffield F. Informal Learning 2000pgs.

12-30,). This has also been described as ‘Big K and little k’ (Williamson B, personal

communication) where little k is the knowledge that the individual acquires to help ‘make

sense’ of their working environment. There is an interaction between the two with

modification of both.

Barnett takes this a stage further and explores the relationship between working and

learning. He uses the phrase ‘Work is learning, and learning is Work’. He rehearses the

complexity of the world and its relationship with ‘work’ calling it ‘Super complexity’ This

he justifies since

‘We live in an age in which our very frameworks for comprehending the world, for acting in it and for relating to each other are entirely problematic. We live in a world characterised by contestability, challengeability, uncertainty and unpredictability’. (Barnett R 1999 pg.29).

Thus, he generates a world of ‘super complexity’ which in his view inevitably work has to

become learning and learning has to become work. This appears to beg the question what

is learning in a complex society? Eraut would suggest that learning should only refer to

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‘significant changes in capability or understanding and exclude the acquisition of further

information when it does not contribute to such changes (cited in Coffield F 1997).

Barnett describes ‘effective learning is where learning is undertaken separate to the

working environment and which interacts with working done during the job’ i.e.

knowledge obtained how to do a task should relate to propositional knowledge done

elsewhere but also recognises the influence of other forces.

‘Learning is no longer just a matter of inward experience and challenge but is a matter of confronting multiplying expectations, standards and expectations which stand outside of oneself’( Barnett 1999 pg. 37)

However the sense of externalisation is soon lost. Eraut and Barnett equally ignore the

interaction between knowledge needed to do a task and knowledge gained either elsewhere

which is superfluous to do a task, or superfluous knowledge gained doing a task. Barnett

blends formal and informal learning saying that ‘learning is work because it is challenging

and that it creates uncertainty, thus formal and informal learning constitute work’ (Barnett

1999 pg. 36).

Inevitably there is a moral tension between the concepts of learning and work. This

Barnett recognises as ‘work can be over burdensome and threatening, so too can learning

especially if learning is imposed on individuals and if they are poorly supported’ (ibid pg.

37).

This moral issue is elucidated and discussed by Fenwick (1999) in terms of the ‘Learning

Organisation’. Organisations make the assumption on behalf of the employees that there is

an overriding need for learning to happen to ensure the well being of the organisation. She

echoes Edwards and Ushers (1996) view that Learning Organisations have a ‘rampant

moralism subordinated to overarching order, the systems totality’. The debate lies in the

assumption that the organisation is the individual’s world and that there is a potential

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mismatch between the individual’s perception of learning and learning model and that of

the organisation. This has further relevance when considering the individual’s capacity to

create new knowledge and to what extent this is possible or permitted within the

organisation.

In terms of the Activity theory paradigm, this could be viewed as the influence of rules and

division of labour. Fenwick cites her work (1996) in which

‘Workplace learning varies dramatically according to their intentions, the disjunctures, their positionality and relations in the workplace community, their values of knowledge and views of themselves’ (2001. pgs 74-88).

Organisations may therefore ‘appropriate for itself’ (i.e. an individual’s learning) the most

private aspects of an individual’s world’. This is stirring stuff especially if we also take the

view of Usher and Edwards (1989) that the emphasis on ‘team dialogue’ within a learning

organisation is ‘to surrender the last private space of personal memory to the public space

of workplace control’. Coffield when considering the rhetoric of learning organisations

also takes the view that the ‘Learning Organisation’ could be considered to be a form of

social control (Coffield 1999).

The moral issue here appears to be to what extent an individual’s learning can be

autonomous? Edwards goes for the moral high ground quoting Moore (1983)

‘Individual learning is a mode of education which reflects and also promotes the very values which give our society its meaning, for ultimately it is the well being and growth of each individual which is the purpose of, and justification for the democratic state’(in Paechter et al 2001pg 43)

However the concept of the ‘Learning Organisation’ holds considerable sway with its

power and political undertones. Edwards senses this interplay of ‘power’ linked with

learning for both the individual and the organisation

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‘The needs of the individual may be met (i.e. through adult learning and identification of learning needs), but the hidden agenda is the reproduction of the status quo’ (pg 43).

It would therefore seem that at this interface there is an important theme. As a

consequence of the interaction between power, knowledge, and organisational culture, the

resultant ‘potent mix’ produces a self consciousness that produces the desire (or not) for

learning. Indeed the morality of learning for the individual within the working

environment is unspoken and implicitly holds the ability to attract or distract from the

learning process.

Contrast the above with the NHS Executive document ‘Working Together, Learning

Together’ which says that

‘Right across the NHS and related health care services, people work and learn together everyday, but the value and application of the learning to improvements in patient care is not always recognised, or as systematic (my italics) as it could be’

‘The NHS invests over £2.5 billion in education and training every year. We need to ensure it is used effectively’ (Foreword, Working Together, Learning together 2001).

The role of the organisation and management will be discussed later but as can be seen the

‘outside world’ of the NHS will have considerable importance and influence on the

individual professional.

As I have begun to indicate the interactions at the boundaries within self, the community

of practice, both inter and intra, are of importance and a cause for creating resonance in the

process of promoting learning. Wenger describes boundaries as being internal and

external. Boundary encounters are ‘meetings, conversations and visits’. A Community of

Practice will have its own internal boundaries which for an outsider may be hard to break

through and hard for insiders to break out. For Wenger it is at the boundaries that learning

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takes place but also iterates the dimensions of learning and develops a design or

framework for learning.

The dimensions for learning in Wenger’s design are all embracing. These are listed as

‘Learning is first and foremost the ability to negotiate new meaning Learning creates emergent structures Learning is fundamentally experiential and fundamentally social Learning transforms our identities Learning constitutes trajectories of participation Learning means dealing with boundaries Learning is a matter of social energy and power Learning is a matter of engagement Learning is a matter of imagination’(pg.226-227)

Wenger describes the relationship between these although he does not appear to consider

the relationship between them in detail in terms of their complexity and in relation to a

temporal dimension.

Wenger’s neglects the inner interface or boundary, much of the description and thought is

given to the group of individuals and their learning and indeed the relationship between

groups. The personal construct of individuals is not interwoven with the group’s

perceptions.

In terms of learning for the individual, there is a tension between a theoretical basis

through cognitive theory and constructivist theory. Palinscar and Sullivan (1998)

acknowledge the influence of constructivism on cognitive theory and indeed ultimately

there is some difficulty in differentiating between the perspectives because of the dynamic

of internalisation and externalisation.

The phrase and rhetoric of the ‘Learning Society’ is all pervasive but it does raise the

issue of the tension between formal and informal learning. Eraut writing in ‘The Necessity

of Informal Learning’’ (ed. F. Coffield, 1999 chap1 pg12) discusses the issues of implicit

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learning and tacit knowledge. He describes the use of tacit knowledge by individuals as a

process which is a combination of externalisation and internalisation.

Eraut takes a similar stance to Wenger in relation to the issue of whether knowledge is

held by the individual or whether it exists in a social context. He acknowledges that no one

theory can account for the ‘full complexity of knowledge and learning in action’. However

Eraut’s view point in contrast to Wenger takes little note of the social setting, group

interaction, or the individual’s own background and family setting. Variations in these will

modify the implicit learning and thus the tacit knowledge.

Learning and the environment

This relationship between individuals’ learning and their surroundings is taken up by

Bourdieu (1977) who developed the concepts of Disposition and Habitus. This concept of

a relationship between the individual and their surroundings and their learning has

similarities to those in activity theory. Building on the cognitive psychological concept of

‘schema’ Bourdieu’s Disposition is similar but builds upon the action of the individual.

Schema is defined as those mental structures which integrate and attach meaning to events.

The latter may also include attitudes, events, concrete or abstract objects. Sinclair cites

Bourdieu’s dense description of Disposition (Sinclair 1997 pg. 20 from Bourdieu 1977):

‘structures structures predisposed to function as structuring structures, that is, as principles of the generation and structuring of practices and representations which can be objectively regulated and regular without in any way being the product of obedience to rules, objectively adapted to their goals without presupposing a conscious aiming at ends or an express mastery of the options necessary to attain them and, being all of this ,collective orchestrated without being the product of the orchestrating action a conductor’.(Bourdieu 1977 pg.72)

Habitus is the collective summation of the mental and physical manifestations of

dispositions embedded in the individual and this relationship is complex in its own right.

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So far, the discussion has considered the relationship between the individual and their

surroundings using a wide definition of artefact. In the next section I consider the concept

of social capital and in particular trust.

Social capital

Introduction

So far, I have discussed aspects of learning theories with an emphasis on social learning

theory since these would appear to lend themselves most to the research questions. Both

activity and communities of practice lack a sense of dynamism and time line. If the

complexity of these theories is confronted and then examined using the concept of a

complex adaptive system (as a social metaphor), additional understanding is brought to the

dynamism of the learning process within an organisation.

Earlier the issues of power and hierarchy in a system and their role in enhancing or

otherwise learning in an activity system or community of practice was discussed. Within

activity theory there is a possibility that the system with its goal directed endeavours could

be constructed with a controlling process (Illeris 2002 pg.51). That is rules and division of

labour could be set to enhance control. The components of learning in an organisation are

therefore understood through activity theory (and given additional depth through

Bourdieu), communities of practice, complex adaptive system theory utilised as a social

metaphor. The earlier discussion hints at the potential for the politicisation of an

individual’s learning. What is lacking at this point in this review is an understanding of the

notion of what ‘holds the organisation together in terms of its learning’. This leads to a

discussion of social capital and its place in social learning theory.

For the purposes of this chapter I use Putnam’s definition of social capital.

‘By social capital I mean features of social life-networks, norms, and trust-that enables participants to act together more effectively to pursue shared objectives’ (cited in Baron, Field and Schuller 2000 pg9).

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There is a synergy in this definition with that of activity and community of practice

theories with their emphasis on rules and community. Putnam’s definition to a certain

extent gives a sense of direction to an organisation’s activity and places trust as central to

the triad of networks, norms and trust. The latter he would argue can exist in an

organisation even when their activity is antisocial.

Schuller’s review debates the place of trust within society as a whole and acknowledges

within it a dynamic of high and low trust and that the interplay between the two ends of

this spectrum can be complex. Schuller cites the contrasting work of Fukuyama and Fox

(Schuller et al. pgs 15-19) to underline the importance of trust within the workplace and

see it as a characteristic of the system. Fukuyama places trust as that which unites an

organisation with its power and status. Fox takes the view that the inequalities caused by

power and status inhibit the development of trust in an organisation. Overall as a concept

social capital would appear to be relatively immature and I sense that it runs the risk of

over applicability and therefore nullifies its usefulness.

Sztompka gives a more pragmatic perspective on trust (Innes 2003). Innes in ‘Rebuilding

Trust in Healthcare’ (Innes 2003 pg 21) gives an overview of Sztompka’s classification.

There are four levels or sorts of trust in Sztompka’s model. These are primary trust,

secondary trust, trusting impulse, trust culture.

Primary trust is the ‘inner’ or individual sense of trust and in this research would relate to

professional reputation, performance and appearance. The latter is described as dress,

readiness to smile and body language. Sztompka includes the appearance of buildings in

primary trust.

Secondary trust relates to the sense of trustworthiness in institutions and the context in

which their actions take place. Accountability and awareness of bodies that monitor

performance are placed within secondary trust.

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The ‘trusting impulse’ is to be thought of as inculcating or fostering trust in the individual

through “fostering family life, encouraging trusting relationships in schools and

encouraging public discourse about moral choice” (Sztompka in Innes et al 2003 pg 22)

and this then becomes elaborated through a trust culture.

A trust culture develops through the myriad of interactions between individuals and from

this develops norms and values that ‘regulate, grant, meet, return and reciprocate trust’

(Innes 2003).

Working with the concept of trust, I would like to conclude with the relationship between

philosophy of trust and social learning. The new NHS relies heavily on performance

management in both primary and secondary care. Accountability has become the

watchword of NHS management. If this is then considered in relation to activity theory

then a disproportionate reliance is placed upon rules and division of labour. This point is

made most eloquently by the philosopher Onora O’Neill in her series of Reith lectures

(2002). Her discussion has a Kantian background with its emphasis on trustworthiness and

honesty.

‘Bit by bit I concluded that the ‘crisis of trust’ that supposedly grips us is better described as an attitude, indeed a culture, of suspicion. I then began to question the common assumption that the crisis of trust arises because others are untrustworthy. …..Our revolution in accountability has not reduced attitudes of mistrust, but rather reinforced a culture of suspicion Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it.’

She argues that trust should be used more carefully

‘Far from suggesting that we should trust blindly, I argue that we should place trust with care and discrimination’

So for an activity system, trust becomes a complex variable within the system and

similarly its counterpart mistrust and the problem that then poses for learning in a social

system.

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Summary

In this chapter I have given an overview of the learning theories that relate to the research.

Through its writing I had hoped that one theory more than another would predominate. In

fact this is an unrealistic expectation given the inherent complexity within an organisation

and its learning and therefore I have sought to consider in what way the theories might be

unified and in what way they can help inform work based learning.

In this chapter I have used the mathematically derived theory of complexity as a social

metaphor in an attempt to draw together the dialectic that exists in learning theory between

individual and group. As a metaphor, complexity theory appears to explain the

interrelationship between the potential mediating factors present in Engeström’s Activity

system theory. Changes in one or more parts of the system have the potential to produce

transformation in learning in the system and in the individual. At the micro level of the

individual this transformation is driven by the complex interactions of internalisation and

externalisation. In terms of Stacey’s diagram and the development of the individual the

process is from competence to capability and that within the ‘zone of complexity’ it could

be postulated that the artefacts and other mediating factors proposed within activity system

theory produce change or transformation for the individual and the organisation.

The authors of the learning theories described would all appear to subscribe to the view

that the process of learning is complex. This is either expressed explicitly or is implicit in

their description and specifically in this case the learning that takes place in a general

practice

Activity theory is persuasive but has a lack of cohesion with individual cognition in terms

of internalisation and externalisation and therefore in this sense fails as a unifying theory.

This problem with activity theory is acknowledged by Minnis and John-Steiner (2001) in

their review of Engeström’s ‘Perspectives on Activity Theory’ (1999). They cite

Toulman’s view (pg 53) on the construction and reconstruction of knowledge at the social

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–individual interface and in this there may be synergies with complexity theory with its

dynamic and changing perspective. Ultimately activity theory in itself does not provide an

overall explanation to work based learning and in itself only reflects a system at any given

moment. In terms of its historical development and Marxist traditions, activity theory

reflects its economic perspective. An organisation is perceived as having a purpose in

terms of output. Knowledge and its production are entrained into the overall purpose of the

organisation. In this sense it then blends with Wenger’s Communities of Practice (COP).

A similar difficulty exists for COP as for Activity theory in that both struggle to fully

integrate individual cognition.

Each theory when taken at a moment in time is equally persuasive. However if the

dimension of time and therefore change or potential for change is added to the social

learning theories either activity or community of practice then complex adaptive system

theory in terms of organisation provides an additional dimension and depth of

understanding to the process of learning. To add a further layer, social capital provides

insight in terms of a group’s norms and in particular the need for a trust culture to catalyse

learning.

I would suggest that when these theories are brought together they describe a ‘learning

consciousness’ which like the tides of the sea ebbs and flow relative according to the

multiple influences upon the individual and community of practice. Like Engeström’s

view, the ‘learning consciousness’ almost feels palpable, its palpability or density of feel

and for individual and community of practice dependent on the organisation as a complex

adaptive system.

The theoretical place of the practice professional development plan (PPDP) as described in

the Chief Medical Officer’s Report (1998) would appear to be potentially influential. It

would appear to sit neatly within activity theory as a significant mediating artefact since it

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potentially could reflect the knowledge transformed within an organisation and the

relationship between knowledge and the organisation’s economic purpose. As a potential

artefact there is a tension between the PPDP and its holistic approach and other

government policies identified within ‘Working Together, Learning Together’ where there

is an emphasis on the individual’s cognitive development.

At the start of this chapter I set out to consider whether any one theory gives a satisfactory

epistemological explanation for the research setting. Sociocultural theories are centre stage

and to develop the theatrical metaphor further then it is reasonable to suggest that

complexity theory and social capital give a significant supporting role and extra texture to

the main ‘players’ of Activity Theory and Communities of Practice. Complexity theory

gives a perspective on the dynamic interrelatedness between mediating factors in a system

which is in itself is self evolving. Social capital fills the void between mediating factors

and acts as a catalyst in which the complex relationships can evolve.

The answer then has to be no one theory gives an overall epistemological explanation. As

a general practitioner who lives with degrees of theoretical uncertainty everyday this is

familiar cognitive territory. I am left with a pragmatic view that a lack of a single theory is

perhaps not surprising given the potentially multifaceted and multilayered nature of any

organisation. Looking for an understanding through unifying the theoretical stances

appears to be the way forward.

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Chapter Three - Methodology

Introduction- In Search of a Voice In this chapter I set out the methodology for this research and explore the basis for the

methods employed. The chapter gives the background to ethnomethodology, the

methodological structure and a discussion of its validity, reliability and reflexivity within the

research.

The methodology employed reflects the reality of daily life within a general practice and to

capture its ontology. In this research there are multiple voices. Voice is used here in its

expression of feeling and judgement by the informants. The practice culture is reflected in the

voices of the informants and the researcher. Individually and collectively their voice reflects

the culture of working in the practice. The research centres on gaining an understanding of

how a group of health professionals learn in the setting of delivering primary care in the late

20th century. The group is composed of professionals from a variety of disciplines and who

are employed within the National Health Service

Intuitively, the research takes account of the history of the practice as it existed within my

time within the practice and also the history of legislation change within the NHS. This

history and derivation of the research questions have been outlined in the introduction. As a

focus of research activity, the practice (the practice nucleus team and the extended team) lent

itself to a social model of enquiry. On a personal level this was a novel concept given my

personal development as a doctor was located in science and biomedical traditions As a

general practitioner my practice was influenced by the rise of ‘evidence based medicine.’ and

yet in daily practice my professional knowledge was frequently faced with problems for

which there was uncertainty as to the correct solution. The problem was often solved through

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experience and what might be termed the ‘art of medicine’. Schön in ‘Educating the

Reflective Practitioner’ (1987, pg.13) recognises this artistry as being

‘inherent in the practice of the professionals… Artistry is an exercise of intelligence, a kind of knowing, though different in crucial respects from our standard model of professional knowledge. It is not inherently mysterious; it is rigorous in its own terms; and we can learn a great deal about it- within what limits, we should treat as an open question-by carefully studying the performance of unusually competent performers’

This artistry or “kind of knowing” and its discovery in the practice culture were therefore

explored through a social model of enquiry. The research was designed to understand the

cultural components that comprised Schön’s ‘artistry’ of professional life within the practice.

Choice of Method

Methods which might have been based on questionnaire or focus group enquiry were clearly

unable to give the depth and breadth of understanding which I sought in order to examine the

research question. With this in mind I chose an ethnographic approach and I explore this in

more detail in this chapter. Ethnography as a research method has been undertaken in other

fields of medicine. Atkinson and Pugsley (2005) have reviewed the use of the ethnographic

method in medical education. They comment that its use has a long tradition in medical

education. In addition to several American studies, they cite Sinclair’s study (1997) of

ethnography of undergraduate medical students and again in a hospital setting Atkinson did

an ethnographic study of bedside teaching of medical students. However there has been little

use of ethnography in a primary care setting.

An ethnographic approach permitted study of naturally occurring data. The methodology has

been adopted from the discipline of social anthropology. Silverman (1993 pg24) quotes Agar

when defining ethnography as

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‘The social research style that emphasises encountering alien worlds and making sense of them is called ethnography, or ‘folk description’. Ethnographers set out to show how social action in one world makes sense from the point of view of another’.

Silverman (1993) homes in on the relationship between qualitative research and ethnography

and concludes via Hammersley’s definition of ethnography that ethnography sits within the

social science research methodologies. That is, ethnographic methods show similarities with

other forms of social science research in that ‘all social researchers are participant observers’

(Hammersley and Atkinson 1995).However what appears more problematic is that within the

social science world there is no one clear framework that describes ‘how to do ethnography’.

In their review Maynard and Clayman (1991pg.387) describe the different approaches that

have evolved within the field of ethnography. Through their rehearsal of the critiques of

ethnomethodology, they conclude that

‘in a nutshell…..the substantive concern of ethnomethodology is the achieved intelligibility and organization of everyday activities…. That social order does not come about because individual actors bring their own cognitive definitions of the situation into some kind of convergence or common agreement. The focus in ethnomethodology on what are called, interchangeably, “procedures”, “methods”, and “practices” runs contrary to a cognitive-interpretive solution to the problem of order, wherein actors produce patterned courses of action……’

Maynard and Clayman emphasise the role that ethnography plays in elucidating the social

structures within an organisation.

‘Thus ethnomethodology avoids inferences about how other otherwise separate actors abstractly think and negotiate definitions for joint projects and instead investigate how members are from the outset embedded in contingently accomplished structures of social action consonant with their acting and reacting to one another in real time.’(1991)

Maynard and Clayman continue in their review with a commentary on the ‘subgroups’ of

ethnomethodological enquiry that have emerged within this field of qualitative enquiry. The

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‘subgroups’ described are phenomenology, ethnomethodology and cognition, conversation

analysis, ethnomethodological studies of institutional settings, and studies of work-the

discovering sciences.

Although I sense overlap between these subgroups, within the field, it is difficult to

distinguish between function and an informant’s cognitive influence on a specific function.

Thus within any study it would seem there is interplay between the inner perspective of the

use of an artefact by an informant and observations recorded of use by the participant

observer. Function as observed by the participant observer is more likely to be an agreed use

within a group but have embedded within it varying individual cognitions. The subgroups

reflect the diversity of empirical approach to ethnography. Within the realms of exploration of

institutional settings, Maynard and Clayman differentiate between the studies that have

focused on an analysis of ‘the order’ within an institutional setting and how informants make

sense of their roles within an organisation from those studies that rely on spoken interaction

as providing insight into the wider setting.

A Pragmatic Approach

For the purpose of this study I needed to make a decision where this study was to be situated

in terms of the methodological spectrum. At the start of the study I was aware there was need

to begin to gather the data at an early date and therefore needed a readily accessible

ethnographic framework. In addition I sought to gather the data at an early date so as not to be

influenced by any one theoretical perspective.

The initial research questions arose from a change in government policy with regard to

postgraduate education for general practitioners. In part this change centred around the

introduction of the practice and professional development plan (PPDP) as a means of

claiming the postgraduate educational allowance instead of through attending lectures and

courses . The change had been presaged by the Royal College of General Practitioners

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‘championing’ of self directed learning. In an operational sense I anticipated the PPDP

becoming integrated within the practice organisation in a positive manner especially as it

followed on from the work in relation to Fellowship by Assessment (FBA).

I took a pragmatic approach in terms of ethnographic method and to this end I used

Spradley’s ‘The Ethnographic Interview’ (Spradley 1979) whose approach and choice of

method takes account of the need to approach the research setting not only from making sense

of the order of the institution but also how the participants in that organisation make sense of

their roles. It is attractive in that it utilises a structured approach to the gathering and analysis

of the data which is lacking in other ethnographic methodologies. Spradley’s approach

ensures a systematic approach to the research setting which if other ethnographic methods had

been used, might have led to a biased focus on one area of the practice culture.

Spradley in ‘The Ethnographic Interview’ presents what he names the ‘Developmental

Research Sequence (DRS)’. This leads the researcher through a twelve stage process.

Spradley’s view is that this focuses the researcher on parts of an ethnographic study that

should be done before others. These phases are listed as follows

1. Locating an informant

2. Interviewing an informant

3. Making an ethnographic record

4. Asking descriptive questions

5. Analysing ethnographic interviews

6. Making a domain analysis

7. Asking structural questions

8. Making a taxonomic analysis

9. Asking contrast questions

10. Making a componential analysis

11. Discovering cultural themes

12. Writing an ethnography

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The phases give an emphasis to the interviewing of informants and the subsequent analysis of

transcripts of field diary notes. Within the framework, the process is through gaining an

understanding of function and then deriving meaning through attribution towards the end of

the research sequence. In terms of Maynard’s ethnomethodological review, Spradley uses a

synthesis of ethnomethodologies and to paraphrase Silverman avoids the “bedevill-(ment) of

sociology by the adoption of misleading polarities” (Silverman 1993 pg. 26).

This sequence has been broadly applied to this research and although it implies a logical

sequence from ‘locating an informant’ to ‘discovering cultural themes’ I found myself

revisiting in a cyclical fashion some of the phases. For example I revisited on numerous

occasions the phase of interviewing (i.e. phases four to nine).I now describe the methodology

used in relation to the DRS sequence.

Locating and interviewing informants

In considering the practice and the people who worked or visited the building on a regular

basis an early observation was that potential informants worked in certain areas. The group

through its multidisciplinary state had groups within groups. The most significant example of

this was the ‘micro’ group of reception. Therefore in selecting informants it was not possible

to intuitively select informants from within the group. Instead I included all the members of

the primary care team and in an iterative process key informants emerged from this process.

Overall there are sixteen members of the nucleus practice and extended practice teams. In this

study thirteen members were included. The process of inclusion and exclusion was also

checked with the practice nucleus team in a reflexive exercise using the question “who

comprises the primary care team in *** surgery?”(January 1999). Following a description of

the research and my role in it, the discussion concluded that although the three members

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excluded were valued members of the team and who regularly joined the practice team for

social occasions they did not constitute ‘full membership’ on grounds of time spent working

in the practice. The three members excluded were the midwife, dietician and the cleaner. The

midwife one hour once every two weeks, the dietician three hours per month and the cleaner

two hours in the practice building before the practice opened in the morning. Similarly GP

registrars and medical students were not included in the study due to their transitory presence

within the practice and that in general as a group, they took a variable interest and role in the

practice team as an organisation. Their presence as such reflected the practice’s involvement

in teaching but because they were only present at most six months at a time (i.e. GP

registrars), as individuals they were unlikely to have an enduring influence on the practice

culture.

The meeting also afforded an early opportunity to provide clarification of the purpose of the

research and to discuss issues of consent.

The thirteen members of the group included were

General Practitioners 2 (the partner and my reflective self)

Practice Manager

Receptionists 3

Practice Nurse

Physiotherapist

District Nurse

Health Visitor

Practice secretary

Community Psychiatric Nurse

McMillan nurse

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This I described to them would consist of interviews in which I would be asking them about

their biographies and “what is it like to work in **Surgery”. The interviewees were to

imagine that I was a visitor to the practice and knew nothing about the National Health

Service.

Consent

During the interviews I phrased my introduction and subsequent questions to remind

interviewee and myself of this need to stand back from the assumptions that I knew

everything about the practice and the NHS. The informants were also aware that their

involvement was entirely voluntary. Given the size of the practice they were also aware that I

could not guarantee absolute anonymity with any quotations used in the analysis. I also

sought ethics advice from the local research and ethics committee and was informed that the

study did not require ethics approval since patients were not involved. (This was in keeping

with ethics approval at the time).The ethical issues in this study related to the position of

myself both as employer and researcher and hence issues related to an implicit assumption

about hierarchy within the practice. As mentioned consent was freely given and as evidenced

through the achievement of obtaining the FBA the practice had a developed sense of

teamwork and an operational freedom within a ‘flat’ management structure. This does not

entirely eliminate the issues related to consent even within a flat hierarchical structure and if

revisiting this research, consent would have been more ‘transparent’ if obtained by someone

external to the practice. Even then there exists a partial paradox since that person would have

needed to be trusted by the informants within the practice. In giving their consent I strived to

ensure that it was freely given.

The interviewees were also aware that the interviews would be recorded and transcribed. The

practice team were aware that I would also be gathering observations in a field diary and that

informally I would be feeding back my observations to them for comment and inclusion.

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With the permission of a neighbouring practice I piloted my interviewing with a receptionist

and then transcribed the recording for analysis. This allowed me to familiarise myself with

interview technique and the technical aspects of using recording equipment (minidisk

recorder with remote microphone), transcription and to consider Spradley’s method of

analysis

Timeline of data collection

The data collection was conducted over the following timeline.

Jan 1999 May 2003Jan 20032000 2001 2002

Interviews

Initial analysis

Field diary, Reflective diary observations and informal interviews Reflexivesummary

The process of interviews, field diary observations informal interviews and analysis was an

iterative process. Throughout the collection of data there was an informal reflexive process

with the informants. The overall data process was continuous but with a focus on artefacts

and events within the practice which emerged as being important to the informants. There was

no prior theoretical stance in terms of learning theory. The data collection was complete by

May 2003. The decision that the partner and I had made to leave the practice had not been

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communicated to the practice until then and therefore did not knowingly influence the

collection of the research data. (As can be imagined, the decision to leave had been difficult

but as far as I was aware the challenges of the decision making process were not sensed by the

practice team).

Making an Ethnographic record

The interviews

Each interview lasted approximately an hour and the interviews were transcribed in their

entirety. All the interviews were carried out in the seminar room in the practice. Although

pauses, silences and laughter were identified within the transcripts, no special coding for

semiotic analysis was used in the transcription since the purpose of the interviews was to

discover the daily life and the use of artefacts. The transcripted interviews were in a question

and answer format. The tapes were stored securely as were the transcripts in a locked filing

cabinet. For all the informants, two interviews were undertaken.

The first interview was designed to record “what it is like to work in **Surgery”. Each

informant was asked to describe a ‘typical working day’ to permit descriptions of the systems

and organisation used in the practice.

The questions used were as suggested by Spradley to ‘express cultural ignorance’ (Spradley

1979pg.61). The interview used ‘structural’ and ‘contrast’ questions. For example as a

structural question for one of the receptionists “How does a patient make a request for a home

visit?” From this I discovered there were systems in place to record the request and that the

request was recorded in two “diaries” and that the second diary was important because it was

read by the doctors on the little table placed on the landing staircase. In order to explore

reception further supplementary questions would be “what is the routine in reception?” or

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“what was it like to start work as a receptionist here in the surgery?” This style of

interviewing was used for all the informants in the first round of interviews. Following the

first round of interviews the recordings were transcribed.

The transcripts were then subsequently analysed using Spradley’s ‘Domain analysis’. This is

described in detail later in this chapter. A second round of interviews was undertaken

following this analysis in order to explore the emergent themes pertinent to the research. This

round of interviews permitted exploration of themes such as the use of the patients’ notes, the

computer and the organisation of the practice.

Other data sources

In order to permit triangulation, I kept a field and reflective diaries throughout the research.

The field diary was used to record the daily systems employed within the practice and details

of significant events within the life of the practice (e.g. protected learning time events). A

reflexive diary was used for recording my own reflections and those of the informants. These

facilitated understanding and clarification of function. For example, when discussing the use

of notes in the practice further functions were obtained over and above than those revealed

during informant interviews. These I obtained whilst sitting with the reception team in the

notes area and informally ‘chatting’ about the use of notes and the values that had been

attributed to them. Practice meetings were chaired by the practice manager and therefore

allowed me more time to keep notes during the meeting. The chairmanship of the meetings

had been held by the practice manager for some time prior to the start of the research. If I

was facilitating a protected learning time meeting I would write extensive notes immediately

after the meeting. All informants were aware that I was keeping a diary and this became an

accepted part of my behaviour and as far as I was aware, caused minimal distraction to team

members. Apart from recording the interviews, no other recordings were taken as this would

have been over intrusive. Similarly it was impossible to ‘capture’ and record every

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conversation that occurred between myself and others within the practice because of the

volume and practical implications. It was therefore a matter of judgement and availability of

circumstance that allowed events to be recorded.

Data collection focused on noting the presence and siting of the many artefacts that were used

by the practice team. For example these included the various message books, the patients’

notes, the practice computer, the message notice boards and the contents of the filing cabinets.

Large amounts of paperwork arrived by post most days. The content of this varied but was

noted only in terms of the broad categories of information it contained. No detailed analysis

of the content of the information was undertaken. The focus of the research was how the data

was used by the informants and through the research sequence their meaning to the

informants. The sorts of data as artefacts in the practice are summarised in the following

diagram.

Initial interviewsTranscripts

(and then coded)

Field diaryReflective diary

Reflexive diary (and then coded)

Practice diary logbooksMessage books

Patients notes /computer

Uses of rooms/spaces in the practice building

Notice board sites and informationFiling cabinet contents

Clinical and non clinical informationletters, DOH PCG/T information

Further exploration of artefacts, virtual and non virtual e.g.

professionalism, practice minutes; relationship with the building.

Flipchart sheets used in meetings

Recorded in

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Asking descriptive questions /asking structural questions /Making a taxonomic analysis

/asking contrast questions

Given their mutual familiarities with the artefacts and systems within the practice the

challenge within this methodology was the constant need to remind researcher and informant

to ‘stand back’ and permit description as if I was an outsider. The information within the

interviews unfolded from the narrative. Systems and uses of artefacts were explored in depth.

During these interviews and subsequent informal conversations in different parts of the

practice I would take the opportunity to discuss themes that appeared of interest to the

research from within the interviews. Similarly, although I was familiar with the layout of the

practice, I asked to be given ‘mini tours’ of the rooms within the practice. The conversation

during these ‘tours’ gave me further insight into use of the rooms, their layout, contents and

the interactions with the other health professionals. The process of discovering function was

entirely iterative with a cycle of observation and /or conversation with an informant, field

diary recording and reflection. Within these conversations I sought to ask questions which

would give further amplification to the topic through asking how for example other

contrasting uses or non uses.

As part of the taxonomic analysis and as part of a second round of interviews, I used a series

of cards on which I had written the names of artefacts which I had linked to a theme of

‘power and hierarchy’. This was used to discover the relationship between these artefacts and

the building. It formed part of the discovery of the generic cultural themes (see below page 3-

18). The results of these discussions were then tabulated. These tables are discussed in the

chapter that relates to the building.

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Method of analysis and emergence of ‘key informants’

I used Spradley's method of domain analysis. Spradley uses a system of analysis which

centres initially on what he describes as ‘universal semantic relationships’. These he lists as

described in the following table

Semantic Domain Description

Strict inclusion X is a kind of Y

Spatial X is a place in Y, X is part of Y

Cause-Effect X is a result of Y, X is a cause of Y

Rationale X is a reason for doing Y

Location for Action X is a place for doing Y

Function X is used for Y

Means-end X is a way to do Y

Sequence X is a step(stage) in Y

Attribution X is an attribute (characteristic) of Y

(Taken from Spradley ‘The Ethnographic Interview’ 1979 pg. 107)

From time to time during the data collection I encountered phrases which did not easily fit the

above relationships. These phases are termed as ‘informant expressed semantic relationships’

(Spradley 1979 pg.111) which although not initially fitting the classification would then fit

through gathering further examples. For example, the partner describes “fluffing about”. This

subsequently describes a phase of time which had several uses. When she elaborated this,

“fluffing about” was before surgery started in the morning when she would do paperwork and

‘read up’ about a patient’s problem from information that was available on the clinical

computer system or from a textbook or a journal. It was done when she wasn’t consulting or

when she was in a meeting. It was specific to her and was not used by other informants.

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Another example is that of the reception staff who referred to the notes as “thick” and “thin”

to which they had linked certain patient attributions.

The domain analysis was performed using a worksheet which I adopted from Spradley. The

worksheet used was as follows (adopted from Spradley 1979pg.11)

1. Semantic relationship:

2. Form:

Included terms Semantic relationship Cover term

These domains were then compared and contrasted through subsequent short informal

interviews and informal questioning of relevant informants. It was at this point that the

informants began to distil themselves into ‘key informants’. This was usually for reasons of

availability and accessibility. The key informants then became

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It was more likely that I would return to one of these to explore emergent themes than the

other informants. The other informants from the practice nucleus team and extended primary

care team were used to help clarify and supplement field diary observations.

Examples of the use of the domain worksheet

These examples are included to illustrate the use of the worksheet and how the resultant

sheets helped inform the emergent themes.

The example to be used is in the domain of attribution (X is an attribute (characteristic) of Y)

with respect to the use of patients’ (Lloyd George) Notes. In the example I have not listed all

the included terms gathered for the research. The included terms shown illustrate the process

of triangulation within which the data can be viewed for its level of coherence from the

different perspectives recorded. These included terms were derived from the transcripts,

Key Informant

The district nurse

The partner

The practice manager

The practice nurse

The receptionist

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observations from my field diaries (observation and reflective) diaries.

Transcript analysis

Field diaryanalysis

Reflective Practice diaryanalysis

NOTES

1.Semantic relationship: Attribution

2. Form: Characteristics of the use of Notes

Included terms Semantic relationship Cover term

1.Very private, very personal(Transcript) )

2.Bit of a secret document (Transcript) ) characteristic of the nature of Notes

3.Institution’s preoccupation with secrecy(informal interview, reflective notes) )

4.Fat and Thin notes-there is a “Fat shelf”( informal interview, field diary) )

5.Notes go out on (house) calls(observation and transcripts and informal interview) )

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Within the interviews and data collection, questions were used to discover when artefacts

were not used. Within the example of ‘Notes’ I explored who ‘did not have access to the notes

and ‘when notes were not used’. The latter question was used by the informants to discuss the

transition within the practice to ‘Paperlite’ and the increased use of the computer. The field

diaries contained both notes taken at the time of the informal interviews and my reflections.

These diaries were read and reread for themes and these were coded in a card index. In this

example the field diary themes for notes were written on cards and these were linked with

the themes from the domain work sheet and coded within the card index. For the purpose of

clarity I have listed these as items 3, 4, and 5 in the example above.

In another example I illustrate the semantic relationship of ‘means – end’ with respect to the

use of the computer.

The domain worksheet used was as follows

Example:

1.Semantic relationship: Means-end

2.Form: X is a way to do Y

Included terms Semantic relationship Cover term

Correct registration data )

Being comfortable with the software ) way to use computer

Learning about it in doing other jobs )

Generates emotions (field diary observation, “it’s a waste of time”)

Its used as a ‘stopping off place for social discussion and learning’ (field diary

observation)

“It gives me a feel for a patient, gives me an idea” (informal interview)

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To continue with this example the computer had other semantic relationships. These emerged

from interviews, field diary and reflexive observations. I have added some examples of these

in the worksheet shown above. Other included terms included ‘function’, ‘sequence’, and

further ‘means-end’ terms.

As might be expected, there is overlap between the themes. For example, the theme ‘notes

and computer’ overlaps with the theme of organisation and learning in the practice since they

are both artefacts used by the informants on a daily basis.

Overall, I discovered from this approach over one hundred separate semantic relationships

which covered the majority of Spradley’s universal semantic relationship categorisation. The

resultant domain sheets and their triangulation with field diary observations and reflective

diary observations were then arranged into themes which appeared significant to the research

questions. The themes were coded on to a simple card index .Additional data from subsequent

analysis of the field dairies were added to the card index.

In the second round of interviews, I used a separate collection of cards on which the initial

analysis themes were written and conducted interviews with the key informants turning over

the cards to act as a prompt for further discussion. The resultant discussions were recorded in

my field diaries. Part of this discussion was also used to clarify the relationship between the

building and ‘power and hierarchy’ artefacts that appeared frequently in the daily life of the

practice.

I continued collecting data until I was satisfied that from an initial analysis there was no

meaningful additional data to be collected. The main body of the data collection took place

over three years. The analysis of the informants’ transcripts provided the initial themes that

appeared relevant to the research questions. The informants were interviewed at an early stage

of the research so that their interviews could not be influenced by any one particular learning

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theoretical perspective. The field diaries were kept in parallel with the informants’ interviews

and subsequent informal interviews.

Making a componential analysis and discovering cultural themes

This part of the analysis looks at the attributes of the various semantic relationships, cover

terms and their interrelationships. For example some of the ‘computer attributes’ are

represented diagrammatically below. The cover terms generated several key areas which

could be related to the research question.

The computer has different dimensions. In the example above these could be said to be

uses, dependency on use and ‘secrecy’.

Computer

Is used for prescribing most

Have different levels of Access

Is used for statistical searches

Couldn’t exist without it in reception

Used for word processing

is as secret as paper records

Used in consultation mode by GPs

Used for templates and protocols

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Discovering cultural themes

The interrelationships between the emergent themes were then explored in terms of their

cognitive properties through the ‘discovery of cultural themes’ (Spradley 1979 pg.185). This

phase of the methodology was given extra depth with the second series of interviews which

explored themes that had been only partially covered in the informants’ interviews. Through

the taxonomy I had discovered through observation and informant description where artefacts

were placed and used, and in which parts of the building where certain activities were more

likely to happen.

An initial analysis had noted some themes that were generic to the informants but appeared to

be used in different ways and had different cognitions. Examples of these were ‘being

professional’, the practice and professional development plan and ‘doing an audit.’ These

themes were pursued in more depth in the second round of interviews. I have summarized the

process of discovering and understanding the meaning of the cultural themes in the following

diagram.

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Interviewone

Initial analysis

Interview Two

Field diariesReflective

diaries

Field diaries Reflectivediaries

Final analysis

Cultural themes

Initial analysis Initial analysis

ContinuingData collection

ContinuingData collection

ReflexiveInterviews/meeting

On reading this research: Agency, Validity, Reliability and Reflexivity

In this section I explore the issues of agency, validity, reliability and reflexivity. As a

participant observer and a leader within the practice there was a potential for tension between

the two roles. The tension from a positivist point of view might be that my role as a leader

and an employer within the research setting would influence the informants. I recognised that

there were inherent tensions within my role as researcher, informant and employer. In part

these were ethically related. I recognised that as an employer, informants may have felt their

sense of autonomy as participants may have been influenced. Given my comments with

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regard to the ‘flat hierarchy’, the resultant sense of trust and as far as I could sense it all the

informants consented knowing that there was no compulsion and that they could withdraw at

any time. Through the ethnomethodology employed I used various methods to reflect my

esteem and therefore my presence as an informant within the research setting.

In using an ethnographic approach I was aware that in its writing ‘I’ was present with several

‘voices’. These were the ‘I’ voice which reflected me as the participant observer, the voice as

one of the leaders within the practice, personal reflections on the voices of the informants and

during the research a voice within the reflexive voice of the informants. ‘I’ was present as a

‘voice’ within all these discourses. By ‘having a voice’, I mean ‘voice’ in the sense of the

definition of voice as ‘an opinion or attitude, or a means or agency by which it is expressed’

(Oxford English Dictionary). This was present both as me as an individual and as part of the

practice’s corporate voice or agency. The validity of the research can be expressed as

Validating the research

Interviewingthe

interviewerResearcher’s

Esteem

Workshop presentations Reflexivity

Validity- the interview

My agency was implicit within the research. In order to establish validity for this research and

at an early stage of the data collection, I organized an interview in which I was the informant.

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This also ‘closed the interviewing circle’. I recognized that I needed to reflect upon and

record my thoughts in relation to the research questions and my role as a participant observer.

In part this was also to address my concern that my role as a leader and my relationship with

the informants would influence the data. In undertaking this interview it was also to address

the implicit ethical tensions in my multiple roles within this research. From the preparation

for the FBA, I intuitively sensed that the practice and extended teams had a strong sense of

cohesiveness and this had been reflected in the feedback from the visiting team from the

Royal College of General Practitioners at the time of the FBA visit in June 1998(personal

communication FBA visiting team).

For my interview, the interviewer was the project manager of the primary care development

centre. The interviewer was someone who had similar research interests and we had

informally discussed our areas of interest at other times. The interview explored why I was

doing the research, my role as ‘leader’ within the practice organization and my influence to

ensure an efficient and effective service to the practice’s patients. In an informal discussion,

these areas expanded to discuss the tensions between my roles as ‘the boss’ and as a

‘researcher’. The research setting also included the partner as my wife and the interview

considered this area of influence on the data. The issue here relates to a ‘husband and wife’

partnership and whether to the informants this represented an additional influence in terms of

hierarchy and control. This latter issue is considered in chapter five where the role of the

partner within the practice as part of the management is sensed and described as part of the

culture. I did not seek to focus on the issue of husband and wife as partners in a practice since

for the reader this would be reflected in the ethnography of this practice. The emergent data

from the ethnography would inherently reflect the degree of influence of the social

relationship of ‘marriage’ between the partners on the practice culture. As will be seen in the

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subsequent chapters the data does reflect the influence of ‘marriage’. This is evidenced in the

chapters which consider ‘hierarchy and power, organisation and learning’.

I considered my role within the practice team and the relatively flat hierarchy and democratic

management style that prevailed in the practice. My leadership style was democratic in the

sense that all significant decisions were discussed by all members of the practice team and

their views formed part of the decision making. This process and style imbued openness in

the informants’ responses and in terms of the informants’ interviews I felt I was less likely to

be told what ‘I wanted to hear’. Their responses were further validated by the use of field

diaries and my reflections. As an ethnomethodology, the prime purpose was to discover the

properties of the social interactions in the practice and to relate these to the work based

learning processes that all the informants undertook.

Validity- Reflexivity

During the research there were opportunities to feedback my reflections on the research data

to the informants. This was usually done on a one to one basis on an informal basis. Field

diary notes were kept at the time of these notes and fed into data and subsequent analysis.

At the conclusion of the research, I established further validity for the initial analysis of the

data with a reflexive exercise. This exercise was with the main informants from the practice

nucleus team and the extended team. Their observations were fed into the final analysis. The

research and analysis has also been presented as a workshop at the National Conference of

Primary Care Educators with an audience of GP Tutors and subsequently as a workshop for

part of a Strategic Health Authority ‘Learning and sharing’ study day. The audience for the

latter was drawn from across health management and general practitioners. Feedback from

these workshops is discussed in the conclusion.

By default reflexivity highlights issues related to validity and reliability within this research.

Hammersley (1998) and Davies (1999) examine these areas and contextualise them within the

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field of ethnographic research. Using Hammersley’s critique of errors (Davies takes a similar

viewpoint) within the validity of the research, in the area of ‘procedural and personal

reactivity’ as described by Hammersley it is implicit within this research that as the leader

within this group I will have had an influence. However perhaps what is more relevant is to

consider when reading the research is to what extent have my personal characteristics and

behaviour influenced the research outcomes? This is addressed in more detail below. My

comment here might be that in some ways this threatens to become a circular argument since

the research implicitly acknowledges my influence and aims to record that reality.

Silverman (1993) considers that there is greater validity when the ‘interviewee and

interviewer’ become ‘peers and even companions’ (Reason and Rowan 1981 cited in

Silverman 1993 pg95). It is implicit within this research that I am a member of a group with

which I already had a familiarity and because of this was able to explore the research

questions in more depth.

The research will make certain claims about how a practice learns and the relationship

between sorts of learning and the practice culture. Using Hammersley’s approach, the reader

must make a judgement as to whether the claims made have been ‘misperceived’ and

therefore open to error.

Similarly there will be sources of error within the keeping of field notes since they cannot

record everything and a similar argument could be made of the transcripts since they are also

constructed. Finally the quotations I have used are dependent on my judgement and there may

have been relevant quotes which have not been used.

Reliability

From a positivist point of view, reliability is more problematic since taken at face value

another ethnographer might discover different or similar themes or there may be overlap in

certain areas. The reader must make a decision in reading this research as to what extent the

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outcomes have the potential to be reproducible. Within this research reliability was sought by

asking informants similar questions and using a similar format within the interviews.

Observations recorded in my field note dairy helped triangulate the responses obtained.

I would argue that ethnographic research is inherently reflexive. That it is possible to have a

dualism of an ontological understanding of a research setting and an epistemology. This

would be in keeping with Bhaskar’s philosophical theory of critical realism (1989, cited in

Davies 1999 pg 17-19). In support of this, Davies outlines Bhaskar’s perspective of

interaction of human agency with society.

‘Bhaskar proposes a more subtle and complex views of society in which human agents are neither passive products of social structure nor entirely their creators but are placed in an iterative and naturally reflexive feedback relationship to them. Society exists independently of our conceptions of it, in its causal properties, its ability to exert deterministic force on individuals, yet it is dependent on our actions, human activity, for its reproduction. It is both real and transcendent.’ (Davies 1999 pg18.)

In this ethnography I was in a position where my research enhanced my innate trait to be

reflective and reflexive about my observations. Reflection and reflexivity was part of my

democratic leadership style. This is demonstrable through the observations of the informants’

transcripts and the nature of the practice meetings. Thus from Bhaskar’s philosophical

perspective, within the practice, I was part of the complex relationship with the informants

and the society that the practice served and the research explores this. Ultimately it is not

possible to be absolutely detached and objective from the research setting in terms of the

observations. The reflections and reflexivity in the research described is part of the reality of

the practice. In another sense there would have been a greater lack of ‘critical reality’ if I had

been an outside non participant or participant observer’ and therefore deny the research

questions the depth and breadth that they merited. Philosophically, the research complies with

Bhaskar’s viewpoint and acknowledges the inherent tensions between my role as leader and

as participant observer. I would argue that in this instance my leadership style and the

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methodology employed with its care to maintain an objectivity of its validity negated these

tensions. In the next section, I have brought together various sources which have the purpose

of reflecting the sense of self within the practice.

Validity- The researcher’s sense of esteem

The validation and understanding of the data requires a sense of the place of the researcher or

as mentioned above, voice or agency. The data is drawn from part of an interview with the

partner and from verbal and written comments made by colleagues outside the practice. These

comments taken together with my own personal development described in the introduction

give insight into my place in the social geography of the practice. I have expressed these

comments diagrammatically with each comment to be thought of as a coordinate.

Author’s esteem

Difficult to approach,“too posh”

(practice nurse asreported

to partner)

“distant at times”(partner)

“Just /Fair”(partner)

“The Boss”(practice manager

/receptionist)

“Respected”(partner)

Approachable(practice manager

/receptionist)

“Brave,honest,open approach to teaching

and learning,learner centred”

(Associate advisor)

“eminence grise”Parting ‘note’ on my departure

from the practice(Associate

advisor )

“A Polymath”( a professor of

Education)

These coordinates are dynamic variables within the practice and should be viewed as an aid to

understanding the themes and my place within the practice. As my reflective diary shows

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during the data collection, these coordinates in terms of esteem were at times strained and

tested. These episodes of dissonance helped enrich the ethnography.

Summary

In this chapter I have outlined the background to the research method employed and a

pragmatic approach using Spradley’s ‘Developmental Research Sequence’. Finally I consider

aspects of validity, reliability, and reflexivity in this research and my place within the

ethnography. Data and its analysis were iterative throughout with the aim of informing the

research questions. Conscious of the need to give the reader a sense of my voice or agency

within the research I used several strategies to reflect this. The themes that emerged will have

my agency or voice within them. The degree to which this is sensed will be variable between

and within each theme.

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Chapter Four- Organisation, Notes and the Computer and Meetings

Part One Introduction Chapter four has three parts. Each of these exist as separate themes but I have placed them

within a single chapter since they inter relate and as themes, produce the framework for the

remaining themes described in the next two chapters.

Organisation This section explores the emergent theme of organisation. The purpose of this section is to

consider the interaction between the ‘systematic arrangement’ of organisation and what

lies within ‘the state of being organised’. I characterise these as different entities. To

clarify this, I describe the ‘systematic arrangement’ as organisation and the ‘state of being

organised’ as Organisation. These two forms of organisation have a dynamic relationship.

I explore this relationship for the practice nucleus team and the extended primary care

team. Organisation in both forms emerged as a theme which had a history. For the

purposes of this section, the principal historical influences on organisation and

Organisation were the changes wrought by the accreditation and reaccreditation of the

practice as a training practice for general practice trainees (registrars) and subsequently,

the award of Fellowship by Assessment to the author.

Initially I consider organisation and Organisation through the informants’ perspectives. In

its final section I discuss the emergent boundaries internal and external to the practice and

the influence of the key informants as ‘keepers’ within this theme.

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The Practice Manager

The practice manager is a logical place to begin to consider the theme of organisation.

Like the other informants he described his working life and its relationship with

organisation in terms of ‘the way we do things around here’. In turn, these are influenced

by the internal hierarchy within the practice and by the external bodies of authority which

interact with the practice.

The practice manager acts as a conduit for change interacting at the boundary between

practice and external bodies.

He described introducing change by

“Getting a bit of a consensus of all the receptionists”

“That change is effected through lots of forms which have arisen from results of innovations from previous changes”.

“I don’t like change for changing sake”.

There is a sense of reflection on change, that previous paperwork, the forms, has been part

of that history and subsequent change. The experience of those changes and more changes

to come was discussed and negotiated with other staff lower in the hierarchy. His

perspective was that change in the form of new paperwork was discussed with staff lower

in the hierarchy and the information that the new paperwork (the forms) was transformed

through the discussion. Information conveyed through the forms was transformed so that

as in the case of the receptionists “a bit of a consensus” is obtained.

His perspective on change in relation to the NHS Plan gives a view on how he sees the

introduction of the changes by the current government.

“you’ve got the spin doctors ......, giving out all this, you know, leaking information beforehand on what’s going to happen but you’ve(i.e. the

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practice manger) not been given the information to do it until a month before it is has to be done, it seems everything has been rushed”.

The practice manager’s role was the keeper of a virtual boundary. The boundary was

mainly at the interface of rules and regulations. Their meaning was internalised and

interpreted by the practice manager. He had a political perspective “you’ve got the spin

doctors ......, giving out all this, you know, leaking information beforehand” which had the

potential to influence that interpretation and trust in the proposed change. The

transformation of the information was then discussed with the members of the practice

staff with a similar potential for moulding by the internal practice politics and sense of

trust. I have summarized this in the following diagram.

Practice Manager

Keeper of the Boundary (rulesand regulations

External NHS

organisations Transforms information

Practice staff

Transformsinformation

Power/HierarchyTrust

Power / HierarchyTrust

modulates modulates

Within his conversation about external bodies, he describes his feelings about a senior

figure within the primary care authority as

“you look to him and (ask) what’s going on?, now either he won’t tell you or he doesn’t know, which obviously when you see him being an intricate part of the what’s happening within the primary care group .It sort of makes (you) wonder what the hell is going on.”

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The dynamic of trust within the boundary had negative and positive aspects. The threat of

change and the accompanying uncertainty generated mistrust within the practice manager.

However trust was reified through the artefacts of the various forms and requests for data.

For the practice manager organisation both as organisation and Organisation is moulded by

external events or information. The correspondence and literature he receives reifies

control and instruction.

Audit was mentioned within the transcript and when followed up at subsequent interview

the practice manager described audit as

“A tool to improve the service” “Don’t like doing audit for audits sake” “If something is working adequately why waste time on it”

“If it improves outcome for patients, its worth doing”

Little ‘o’rganisation for the practice manger was about

“Making sure everything is done smoothly, if not it would be utter chaos”

“Staff would be short tempered and aggressive”.

Little ‘o’rganisation therefore performs a function of maintaining a homeostasis within the

practice as well as demonstrating when well done something about caring and form part

of Organisation.

Financial organisation for the practice manger was of foremost importance. He listed the

ways that were needed to run the practice finances. It was about

“Doing wages, doing the superannuation scheme”

“Doing the quarterly returns -cervical cytology figures, immunisation figures, booster injections”

“Monitor flow of income/expenditure” “Record items of service” “Capitation payments” “Maternity payments”

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“Monitor invoices for private medicals”

“Fees for signing up passport photos”

There was a teaching element for this as well for the practice manager. These sessions

were constructed in terms of organisation and Organisation. He said

“He undertook to instruct new GP registrars about item of service payments”

He also “monitored the financial pattern” to generate a “healthy finance” for the practice

and giving a “monthly financial report for the doctors”.

The need for a financial framework is a powerful player in the practice’s ‘o’rganisation.

Financial health is required for obvious reasons as much as organisation is need within

reception to prevent “chaos”.

When thinking about change and ‘being organised’ the practice manager described the

example of the practice’s change to a ‘paperlite’ practice. (This meant using the computer

to record all consultations, scanning consultant letters onto the practice computer so that

the result is that there is less need to use the Lloyd George notes.)

“Using the NHS Net, not using the notes. The government wants the NHS Net to be used by all medical professionals”.

He reflected on this fact and made a judgement that there were differences within

reception about their competence to use the NHS net. “Two of the receptionist staff are

more competent than others”

The practice manager developed his description of his daily role as

“Always working to deadlines for returning data to the health authority, Doing audits for the audit health authority manager Arrange meetings Trying to balance time, there is a constant pressure over time”.

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When considering the practice manager’s role as keeper of the boundary, it was ‘Janus-

like’ having the need to look without as well as within the practice. He needs to monitor

and assimilate the financial and organisational information which enters the practice from

the PCG/T and other NHS organisations. This then needs translating and transforming to

be assimilated within the practice organisation. This process was modulated by the

practice’s internal dynamics of power, hierarchy and sense of trust.

The Receptionist

Through the receptionist organisation and Organisation are given a practical description.

Items of knowledge are acquired through the dynamic interplay between organisation and

Organisation. Most of the data for this section is derived from the senior receptionist as the

key informant and supplemented from the transcripts of the part time receptionists.

A receptionist describes how a chronic disease clinic is organised. She describes an event

that is held on a particular day in the week

“Happens every other Monday” and that she has “developed a bit of a system.” For the

vaccination clinic, there is a need “to keep an accurate record of the lot number of a

vaccination”. And who should have the (flu) vaccination. “I know that the elderly people

should have one and the diabetics”

There is knowledge of a system of recall which has been negotiated between doctor,

practice manager and receptionist. The receptionist was aware that diabetic patients are

encouraged to have retinography screening (pictures taken of patients’ retina to ensure

diabetes has not affected the retinal blood vessels). Chronic disease has a sequence of care

in which various measurements of the patients’ physiology are made. These are

measurements of blood pressure, testing urine for protein and sugar, advice is given about

injection sites and about suitable footwear. This sequence is known and shared by the

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doctors and nurses with reception staff and recorded on the computer on parts of the

software called templates. Reception staff were observed conducting searches and organise

data collection guided by doctors, practice nurse and manager.

The need to follow and document a sequence of data collection is organised both in terms

of organisation and Organisation. The members of the team work together with a degree of

mutual understanding of the undertaking. This level of understanding varies has a degree

of heterogeneity between team members. The latter has a subtext of caring (for the

patient).

The receptionist describes a variety of tasks which form part of being organised. The sorts

of tasks being described

“Answer telephone to make an appointment, answer telephone to give advice, arrange a prescription, answer a query.

Filing and drawing notes(medical records).Make sure surgeries run smoothly, dealing with prescriptions, dealing with appointments, taking messages about house calls, filing queries, tying up loose ends, make lists for dieticians clinics, antenatal lists, CPN(Community psychiatric nurse)”

Reception staff act as an internal boundary in organisation between other health

professionals and patients. This was illustrated through ‘the issuing of prescriptions’.

“Doctors put the prescriptions on the computer, reception issues repeat prescriptions on a

monthly basis” and that in issuing a prescription there was a need to use “the chemist’s

book”. This was a system devised with the local chemist so that prescriptions could be

collected direct from the chemist in the village.

Receptionists when issuing a prescription had to make a decision against practice

guidelines, whether they could issue the prescription “being on current medication” or

whether it was on a “repeat list on the computer.”

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They check whether the medication was previously issued if on the “current list” by

looking on the “past medication list”. Occasionally the senior receptionist reported there

was the need to issue a “private prescription”. Again receptionists needed to have the

information and indirectly acquire knowledge about medications and their use. In listening

to this description of the process of issuing a repeat medication, it was apparent that

receptionists have some knowledge of what some medications are for against a

background of no formal training. I return to this theme in a later chapter.

At the receptionist/patient boundary the receptionist describes that when a patient

telephones she “maintains a diary”.

“The time of the telephone call is recorded and it is written in the book, this is like a

Bible” she said.

She said she “found out the purpose of the call. If a home visit is requested by patients she

writes in the visits book”.

When a home visit is requested there is a need to “do a summary”. Doing a summary

comprises running a printout from the computer which summarises the patients most

recent consultations and medication.

Other tasks described are “chopping records”. When observed, this involved trimming the

excess paper from the consultant letters in the Lloyd George notes so that the notes were

tidy and fitted neatly into their envelopes. Overall she summarised these processes as “a

check to ensure we are maintaining certain standards. Standards can be clinical as well as

non clinical.”

These systems had been developed through the need to comply with internal and external

‘rules and regulations’ so as to comply with standards set for a training practice for general

practice registrars. The reference to the recording of telephone calls in a message book

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“like a Bible” was in part a response to rules and regulations or standards set by the

doctors’ medical defence bodies.

The receptionists form an opinion as to what others do. A receptionist described the work

of the practice nurse. She describes her as a

“A little Queen Bee Does injections, dressings, cervical smears Works with the doctor to do minor surgery

Does high vaginal swabs, ECGs, needs to have steriliser on

Has a very hectic role

Amount of paperwork she has to do is ridiculous.”

In contrast the receptionist only briefly referred to the role of the practice manager in the

context of organisation / Organisation. “The practice manager does audits”.

From observation, reception staff were central to the operation of the organisation of the

practice. Through this they acquired and reified Organisation. Through having and

operating “systems” they informally acquired knowledge. Further examples are considered

when I describe the role of notes and the computer. The receptionists were ‘keepers of the

practice rules’ and this is summarised below.

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The receptionist‘Keeper of thepractice rules’

PracticeAppointment

system

Notes and the computer

Message books

Extended Primary care

team

The Doctor

The doctor, a partner in the practice described organisation in terms of a list of tasks. She

talks about

“Writing letters, ‘playing’ on the computer (to construct templates on the computer in order to add data)

Wander off around nursing home to see patients See patients when I come back Have a cup of coffee Read the post Do a surgery

Do Membership by Assessment of Performance (MRCGP - as an aside she expresses dislike of this quality performance system seeing it as being rigid)

Read the journals

Get ready information and timetable for medical student teaching

Do a rheumatology clinic at the hospital”.

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It is told with a sense of much to do and little time to do it in even though time is not

mentioned.

Within the context of little ‘o’rganisation she regarded life as a GP as

“Being organised, being very rigid.

It’s hard work ploughing through people, finding out what they mean, what they are trying to tell you, trying to get things right, do the best for them, its hard work keeping a smile on your face all the time”

There is a sense of tension for the doctor caught between an inner desire ‘to care’ or ‘have

compassion’ and yet sees this in conflict with little ‘o’rganisation. For the partner there is

ambivalence as to where caring lies, does it form part of organisation or Organisation?

Organisation in terms of a ‘framework definition’ and the ‘rules and regulations’ was an

antithesis to creativity. The construction of the templates was a paradox. In one

perspective they could be viewed as something that was creative (‘playing on the

computer’) which insulated the partner from rules and regulations. The creativity through

the construction of the template caused her to read around a clinical topic and assess best

evidence. The activity permitted learning.

However they were also constructed in response to rules and regulations (‘being organised,

being very rigid’). Templates were constructed to shield against “being sued”. As an

artefact making a template on the computer had a dual meaning with an internal paradox

for the partner. The need to construct templates was reified with an affront to justice. It

was ‘unjust’ to have to do this and this transfered into her views about “the rigidity” of

organisation. This paradox to her sense of conscience or as a leader with in the practice,

‘keeper of the practice conscience,’ can be conceptualised as having positive and negative

components. I summarise this as follows.

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The partner(keeper of practice

conscience)

Patients

Practice Nucleus team

Extended team

Clinicalgovernance

PCG /TThe government

positive

positive

posit

ive

negative

negative

Makingtemplates

Makingtemplates

The expression of conscience was not only for the patients for which she was responsible

but also for the practice nucleus and extended members of the primary care team. I have

summarised this ‘keeper role’ in terms of conscience. The partner expressed ‘conscience’

as a set of values that revolved around caring, socialisation through friendship and a strong

sense of justice. The latter is sensed in her thoughts about the issue of accountability

within the NHS and its “rigidity”. The expression of this value was therefore at times

perceived as being frustrated by organisation (rules and regulations from the PCG /T, ‘the

government). This is explored in more depth later in the chapter and is also reflected in the

analysis of the other informants’ transcripts in relation to organisation and ‘being

organised’.

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The practice secretary

The practice secretary was the ‘keeper of information’. The boundary was maintained

through the written word. A large part of this was the maintenance of the primary

secondary care interface. At this boundary the practice secretary describes “doing hospital

referral letters- letters from GP to hospital consultants” Her role covered other areas where

information was requested and transferred.

She describes doing “Medical reports to solicitors, occupational health reports, employee

references”

Her post appeared in some ways similar to reception staff in that she was also involved in

filing and pulling of notes and when the reception practice team were ‘short handed’ she

would book patients appointments and’ do repeat prescriptions. Her role differed in that

she held “information about specialists” and listed other roles as:

“Doing copies of medical examinations/insurance claims

Finding out waiting times for consultants

Maintaining doctors personal files/GP registrar files

Maintaining diabetic files, retinography files, doctors’ personal files, GP registrar files. Files for medical examination fees. Doing hospital referral letters- letters from GPs to hospital consultants Medical reports to solicitors, occupational health medical reports, keeping copies of medical examinations and insurance claims, and a file for medical examination reports for collection”

The practice secretary also had the role of taking the practice minutes which were then

typed up and circulated to all members of the team that were employed within the practice.

The use of the practice minutes will be discussed elsewhere in this research.

Her office, which was physically remote to the rest of reception, not only fulfilled the

function of providing a boundary between hospital consultants and the practice but also

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several other functions which revolved around maintaining the professionals’ diaries and

activities beyond those directly associated with patient care.

I frequently observed her engaged in telephone conversations with patients who were

enquiring about the dates of their appointments and waiting times.

She filed a range of information relating to secondary care organisation “information about

specialists, waiting times for consultants, booklets about private health care”

She also kept files about the annual diabetic retinography day. (On this day the practice

was visited by a mobile van which was equipped to take pictures of the retinas of the

practice’s diabetic patients. The appointments and organisation of this day was a

considerable undertaking and this was led by the practice secretary. It was also a time

which required significant liaison between herself and reception staff).

Her office and role was predominantly about ensuring the flow of information across the

primary secondary interface. Like the reception staff she needed to use patient notes for the

letters that had been dictated and re-file them in reception. Her responsibility and

Organisation was about ensuring the efficiency of the transfer of information. As keeper of

the minutes of the practice meetings (word processed and circulated to members of the

practice nucleus team), she was ‘the keeper of the written information’ of the practice

organisation and ‘being organised’. The flow of information is summarised below.

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Practice secretary(Keeper of the written

information)

Doctors’letters Hospital

Medical insurance

Insurance Co.solicitorsDoctors’

personal files

Practice minutes

Patients’enquiries

Summary

Through the informants from the practice nucleus team it is apparent that within the

practice there are multiple boundaries. These are internal and external and their

interrelationships inevitably complex. For the individual (e.g. the receptionist) there is an

inner boundary that interacts with others within their particular area of the practice. For

others such as the practice manager there is a need to be looking within and without the

practice.

These boundaries form an important part of the role for the practice manager, the doctor

and the practice secretary. In the next section I describe this relationship for the nucleus

and attached team members.

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The practice and its relationship with external bodies

The external bodies or organisations that interact with the practice are usually other NHS

bodies. Principally these are the Primary Care Group (subsequently the Primary Care

Trust) and on a broader front the Health Authority.

The perspective of this relationship is described through the data arising from the key

informants transcripts and field diary observations.

The Practice Manager

The practice manager is the main contact between the internal milieu of the practice and

the NHS bodies. These contacts appear to be at two levels. In an example of a telephone

call, at one level there is an exchange of information and secondly, if the person is known

to the practice manager there is an exchange of social ‘chit chat’. He reflects on the effect

of change. There is a sense of him trying to maintain the balance or making a judgement

on behalf of the practice.

“Everything (i.e. change) has been rushed. We seem to be in a slipstream of change, you don’t feel as if you are in control of the situation, we’re rushing head first into this vortex, there aren’t enough hours in a day”.

He describes this overall as the external bodies “making life difficult” for the practice. He

amplified this by saying that

“It’s about them (i.e. government) making rash promises about the NHS net. They get involved where they shouldn’t be.

I had to do a search; it was a waste of time as to whether the practice has any policy as to whether it is ageist. I hope they are not going to bury us under paper”

For the practice manager, organisation, checking about ageist policy does not equate with

‘O’-rganisation.

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When asked about the sorts of paper information he receives he described

“Doing audits, receiving information from the Primary Care Development Centre, minutes of the Primary Care Group meetings, letters from the chief executive of the Primary Care Group”.

The practice manager is also expected to generate information form within the practice to

be sent to the NHS bodies. He described as

“An Annual report for the Family Health Service Authority”. (This body is now represented by the PCG/T.)A statutory document, it’s about crunching numbers, recording referral patterns, consultation rates, nursing home consultation rates, information about which staff are attached. It’s a paper exercise”

There is here a sense of dismissive- ness towards this task. The report appeared to be ‘a

nuisance’.

Exploring the phrases “crunching numbers and it’s a paper exercise” he explained that the

information supplied is not discussed with the practice and he didn’t know what happened

to the information. Information is generated for others outside the practice but is not

transformed by the nucleus team which contrasts with the flow of information from

without. The manager acts as a controlling filter or valve at the boundary.

For the practice manager he listed his main contacts with the PCG/T as being about

“IT purchase Extra contractual referral Training for staff Doing Audit Maintaining contact with the practice managers’ link group”

“You have a relationship, there is an informality”, meaning that information and opinions

about the information were exchanged such that his internal understanding about an item

of information was transformed. The information to be received by the practice and its

internal milieu appeared to be buffered by these cross boundary transactions.

A second kind of report that the practice manager had to provide was the (annual) health

promotion report. This contained data about “Diabetes, asthma, eye screening”.

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Since he had to do the report he said he became aware that for diabetics

“There is a retinography day, that diabetic patients received chiropody care, that side effects of a chronic disease can be devastating, that it takes time to explain a chronic disease for a newly diagnosed patient”

(For asthma patients) an awareness “of the standard treatments for asthma, of the prescribing exercise (programme)”

For the practice manager there appeared to be relevance to documenting this information

and as a two way process stimulated informal learning. Information was transformed to

personal knowledge.

Within the boundary, the topic of clinical governance surfaced. Clinical governance was

perceived as an external activity that was internalised within the practice. The practice

manager perceived clinical governance as describing quality. In addition within the

manager’s comments there is an implication of dissociation between the external body, the

PCG and the internal milieu of the practice. This might be paraphrased as ‘quality is out

there, we do our own quality.’

“Clinical governance helps set minimum standards, what constitutes good practice.”

“It will get practices up to a minimum level. It’s led by the PCG. It gives the primary care sector time to sort itself out. It affects everyone from the cleaner to clinical people. It allows people to share experience. Clinical governance goes hand in hand with quality.”

The practice manager linked clinical governance with the practice professional

development plan (PPDP). He defined it as follows

“Having individual development plans, all members to have a PDP.The PPDP focuses on strengths and weaknesses and helps structure training. Inhibited by informal appraisal training. Being pushed by the government”

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He reflected further suggesting that there were wider themes to the introduction of the

PPDP. These he suggested were

“GP concerns about revalidation. The government sees primary care drifting away.

“It’s something to help us prove that we are achieving certain standards. It gives us a vehicle to prove where you’ve got to”

The practice manager reflects the inherent tension between an imposed tool by government

and that it was also a vehicle through which quality could be demonstrated. For the

practice manager the PPDP is logical and useful. However intuitively he reflects the

concern that it has to be demonstrated for someone else. There is a conflict, the PPDP

reifies education on a personal level and also has something of ‘self’ as well which is

private and difficult to share with others or is not seen as being relevant. External bodies

or organisation causes it to be regarded as a management tool.

The Partner

The expression of self and its learning is expressed graphically when listening to the

partner in the practice. Again it is logical to consider that she is someone who has the

opportunity to cross boundaries literally and metaphorically.

She regarded life as a GP as

“Being organised, being very rigid. It’s hard work ploughing through people finding out what they mean, what they are trying to tell you, trying to get things right , do the best for them. It’s hard work keeping a smile on our face all the time”.

When describing the relationship between the practice and the government (this term

government recurs through the transcripts and in field observations) she graphically

describes it as being

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“The choking black fog which is in every room. General practice is a government run institution. We run about doing what they say. The government hasn’t taught us how to be doctors”.

There is a sense of not being in control of her development but being controlled by an

external body, in this case the government. Her views are more polarised than the practice

manager. When considering the more local version of ‘government,’ the partner observes

that a Primary Care Group is a body which

“decides how to spend money. It sends out its chairperson to bother people about quality. It decides what we are allowed to prescribe. It has a lot of meetings and does a lot of talking. They dictate (to us) at meetings.”

The PCG is reified as representing government even though many of its members are

known personally to her and with whom she has a good collegiate relationship (field diary

observation).As a subset of the PCG, Clinical Governance represents for her an external

body which

“Says thou shalt. It’s about making things better. It’s something that came out of the USA, it’s just like a mission statement. It’s out of touch with reality. I’m the practice Clinical Governance lead.”

Clinical Governance is reified as Government and as such struggles to cross the boundary

into the practice. Its role about quality is lost even for the partner for whom it is embedded

as part of responsibility.

Quality is recognised as part of responsibility. “It’s about making things (i.e. within the

practice) better” However this is separate to or is inherent to a sense of ‘well, we do this

anyway, why we need somebody from outside?’

There is a tension for the partner across the boundary between the internal reification of

Clinical Governance on behalf of the practice by the partner and her perception of Clinical

Governance as expressed by the PCG on behalf of the government. Here we begin to sense

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a tension between responsibility as a reification of professionalism and accountability

identified through the vehicle of an external body such as clinical governance.

Thus, it is not surprising that when describing the PPDP it emerges as

“Deciding what we all we want to do. The PPDP is hidden in a mist of benefiting patients. It has come from the government to make it appear as though we are diligent about our work and where we are going. It’s an achievement of a mission statement. It’s something trendy from USA.”

However she did enjoy the creativity associated with the development of the PPDP. “I like

the little meetings about it because you’re thinking about something different”

The opportunity to reflect is welcomed as part of responsibility but responsibility is to self

and other professionals within the practice and not linked with the reification of

government.

For the partner and the practice manager clinical governance and the PPDP are located at

or beyond the boundary. The perception of these two government strategies has been

mediated overall more by the practice manager than the partner.

The Receptionist

When government and its representation in the form of the PCG are discussed by the

receptionist, there is an awareness of function and a sense of dissociation from their direct

influence on the practice.

“(It) decides how the health service is run. It sets guidelines”-she gave the example of coronary heart disease. “It says how the GPs should run the practice and has written the Health of the Nation”

The PCG’s function is known to her in general terms

“(The PCG) is the collective headquarters for GP practices. (She) knows the people who are in the PCG and they do the finance” and “hold all the cards” “The PCG is the connection with new government guidelines and the PCG hands down the new government guidelines” (my underlining)

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She was also aware that the PCG had become a trust. “Don’t really know the difference,

has something to do with the finance”

She said that she got the information “by reading the materials from the PCG/T in the

administration (notes) area of the practice and in the practice manager’s office”.

From this example learning is in two parts. The first is the informal acquisition of

information from outside and the reflection on that information. The resultant knowledge

is used to set the internal boundary with regard to the external body and its relationship to

the practice.

Her discussion of clinical governance was similar to those of the partner and the practice

manager in that there was the perception of control but also she felt the practice needed a

steer from the PCG which contrasts with the partner’s viewpoint. She discussed clinical

governance as “means guidelines which we must follow from government or the PCG.

These guidelines influence how we run the practice. Someone has to guide us”

For the receptionist there was a positive feel about clinical governance

“I felt positive about it, other people didn’t like it because may be they didn’t want to

change”

Clinical governance was “channelled towards clinical members”. She said that clinical

governance was discussed in the practice and that it was most likely to be discussed in the

“little back room” and that it was discussed by “the doctors, the practice nurse, the practice

manager and the community nursing team”.

Clinical governance was therefore about giving direction and that the strategy for clinical

governance lay with the clinical team and the practice manager. She was able to relate

clinical governance to a place such as the “little back room”.

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Discussion: Boundaries and the internal practice team

External bodies produce information about itself and information which may have a

message of ‘must follow’ and also about ‘guiding’. For health professionals there is a

different feel about guidance or information from outside. Rules and regulations from

outside had different meanings for the individuals within the practice nucleus group.

For example, having read information derived from external NHS bodies relating to

clinical governance, the receptionist had formulated the view that she felt “positive about

it”. This contrast with the partner’s view that “it’s a lot of meetings and it’s about making

things better; it’s out of touch with reality.” but the boundary for her was ‘we do this

anyway’.

Knowledge or information is reified with respect to the PCG/T and the government and

therefore the boundary has a different permeability to different members of the team. In

turn this would suggest that with this spectrum of permeability to the information from

external bodies and subsequent transformation to knowledge by the individual, the

intended change by an external body will have a different individual interpretation and in

itself will be modified by the varying individual knowledge transformations. The

individual knowledge transformations of an intended change are internalised and meaning

is negotiated within the small professional groups that exist within the practice and its

extended team. These professional groups reflect the intended meaning of the individuals’

professional bodies. It is difficult to conceptualise the practice nucleus team as a

community of practice in relation to their cognitions of external bodies but more as several

micro communities of practice within the sense of organisation and ‘being organised’.

Ultimately the practice nucleus team’s negotiated meaning is a compromise between these

different perspectives of organisation and being organised. These heterogeneous

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perspectives are held together and driven by the practice nucleus’ sense of self. The

moulding of self in terms of this disposition of organisation /Organisation takes place at

the internal and external boundaries of the micro communities of practice (e.g. reception,

the doctors and practice manager). The permeability to change in organisation /

Organisation is controlled by its hierarchy and financial need.

Organisation and the extended team. View from the other side of the Boundary

This section describes and discusses the extended team informants’ organisation and

‘being organised’ (Organisation)

The extended team and their managers

Interviews with the extended team often spontaneously polarised to describing tensions in

their relationship with their managers. The health visitor reflecting on her professional life

observed that the opportunity to discuss change with management became “less and less,

obtained no response from management.”

Organisation appeared split with ‘o’ for lots of data collection but ‘O’ has a negative

perception with lack of trust in management. There is a sense that ‘o’rganisation has a

sense of purpose that is controlled but which is not shared with the professionals in the

extended team The district nurse in describing her relationship with her employer

(manager NHS) said that management

“demanded completion of certain documentation, use of a hand held computer to record how long spent with the patient, what task done, how long it took to get to patients, records how many flu injections given, record forms which patients have had an assessment, which patients have medication, which patients are at risk from pressure sores”.

Her manager “audits documentation of paperwork” and “do not give any information

back”.

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For the district nurse having a colleague on the PCG board “was a good thing, (I) will have

a nurse voice on the board, the PCG will be a powerful group, but will not make a lot of

difference to day to day work”. She perceived that although she would have a “voice” and

the PCG will have a distant relationship with her daily life.

Interview data was also obtained from a physiotherapist who was self employed but her

business had negotiated with the PCG to provide physiotherapy services for several of the

small practices in the PCG area. Her observations were of interest as someone who had

worked within the NHS and had now opted out. As a private practitioner in terms of her

business she had some anxieties about her future.

“PCGs don’t agree with private practitioners, it’s the powers that wield the money, this is where we feel the threat. I feel very threatened, who knows this time next year what’s going to happen. Pressures come from government-private practitioners we don’t want you”

Her observations about NHS managers were that “they need to have ultimate control over

everything”. Control in organisation appears to have a both positive and negative flavour.

It is understood by informants as needed for the ‘o’ of Organisation but it conflicts with

‘O’rganisation within which the individual is prima facie sensed as caring in terms of

professional responsibility.

Comment

The boundary between the external team and the practice nucleus team was formulated

around the area of control. For example, the practice manager was shielded from the direct

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management of external NHS bodies through his employment in the practice. His narrative

reflects a greater degree of professional autonomy. The contrast between the professional

narratives within and without the practice structures the boundary as it is based around the

tension between the different ‘states of being organised’ (‘O’rganisation). ‘O’rganisation,

the collective sense within the practice team forming part of the culture of the practice was

used as a shield to control from government NHS bodies such as the PCG.

Sorts of Meetings

Although I intend giving a more detailed description of the types of practice meetings as a

separate section in this research it is relevant here within the description of organisation to

describe the sorts of meetings that the informants attended and which form part of

organisation.

The practice manager described the meetings he attended within and without the practice.

He described the organisation that related to the practice meetings. The agenda was

produced by him and that these meetings were minuted. He said that in the meetings

“everybody’s opinions are valued” and he also sensed that there was an indirect

acquisition of knowledge with a sense of bartering within the overt and covert hierarchy of

the practice. We are just learning as we’re going along, we trade ideas” (my underlining)

He said that other meetings that he went to were “practice managers’ meetings, internet

users group meeting for the NHS and the PCG meetings”. He said that “all staff was

invited to attend meetings arranged by the PCG”

The practice nurse said that she attended the monthly practice meeting but also attended

the primary care team meeting to which all members of the extended team were invited in

addition to the practice nucleus team.

The practice nurse said that the meetings were about

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“Dr Milne talking, anyone can say anything” and that in the primary care team meetings

“PUNS and DENS (patient unmet needs and doctors’ educational needs) were used to set

the topics for the meetings”. The McMillan nurse said that she would like to be more

involved in “knowing the political background of the practice”

Members of the extended team describe meetings with other colleagues beyond the

primary care practice nucleus team.

For the McMillan nurse, she attended meetings with other McMillan nurses, the chest

consultant physician, meetings with an oncologist, and meetings to organise educational

packages for other health professionals.

Health professionals were involved in a variety of meetings .These were ranged across a

spectrum of business (practice nucleus team) meetings, educational meetings, and informal

(‘over coffee’) meetings. Field diary observation was that the primary care team meetings

which included the extended primary care team members were infrequently attended by

reception staff. These meetings tended to have clinical topics.

The community psychiatric nurse (CPN) described “going to meetings with other CPNs,

meetings with colleagues over coffee”, and “going to locality meetings.”

Both the practice monthly meetings and the primary care team meetings were held in the

practice seminar room. Meetings were therefore an important part of organisation and

were sensed by individuals as serving multiple roles of ‘O’-rganisation and socialization.

As mentioned the role of meetings within the culture of the practice and socialisation will

be explored in later sections of this analysis.

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The place of leadership within Organisation

The analysis so far has described the relationship within the practice between organisation,

the state of systematic arrangement and Organisation, the state of being organised. Both

are influenced by information that comes into the practice and the process of

transformation that takes place at the boundaries described. For example, the inherent

hierarchy within the practice requires the information and the practice manager’s

transformation of that information into knowledge to be transferred to his employers the

partners. Within the practice the author was perceived as the leader and within the

informality of the practice was referred to as “The Boss” by the practice nucleus team. The

purpose of this section is to give some reflective insight into that role.

Over the period of the research I recorded in a reflective diary my observations on my role.

These observations were recorded at times which I regarded as important moments in the

practice’s development and within the remit of this research. The purpose is to discuss in

general these reflections and their influence on the disposition of organisation and

Organisation.

Over the preceding fifteen years there had been an incremental improvement in the quality

of patient care within the practice. This culminated as one end point in the process of

fellowship by assessment. My leadership style was mediated through trust, the inherent

hierarchy and power (as an employer) and through the confidence attained through

vehicles such as the fellowship by assessment framework (from reflective diary). The

development of organisation and the sharing of my internal value of ‘being organised’ was

dependant on my enthusiasm and my place as leader within the practice.

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This enthusiasm or ‘keeper of the flame’ led to tensions for organisation /Organisation in

this overall value of quality of care within the practice. Examples of this tension or

discomfort from my diary were a salaried doctor left as she did not hold or could not

engage with this value and the partner was not always comfortable with the role of leader.

She saw her role as she put it as acting as a “safety valve” or as I have conceptualised it as

‘the keeper of conscience’ for the practice team. I comment in my diary that ‘this was an

unrecognised role within the practice team’. Other negative influences were the ‘blame

culture’ prevalent within society and the need operationally to consider risk.

Leadership promoted the awareness of these positive and negative cognitions within the

practice team and, I would suggest, influenced the informal learning within the practice. In

turn, the author’s leadership implicitly as ‘keeper of the flame’ created or influenced the

boundaries or boundary objects within the practice. Although the extended team worked

within the boundary of the practice nucleus team and was influenced by the author’s

leadership they were never truly part of the Organisation of the practice.

Organisation (being organised) is a significant part of the practice’s culture. It constructs

organisation and is moulded by the influence of the author’s leadership who in turn has

imbued the sense of his leadership into Organisation. Information from external bodies

principally NHS organisations and the cognitions of those bodies is transformed by the

practice manager. The cognitions are shaped by informal conversations between members

of both the practice and extended team.

Leadership and ‘keeper of the flame’

The interaction between organisation and Organisation is complex and is mediated by

individual cognitions and the negotiated meaning within the smaller groups. As leader my

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boundaries were multiple. These boundaries interacted with the partner, the practice

manager and with all the members of the practice and extended members of the team on a

daily and for some others monthly basis. I have labelled myself ‘keeper of the flame’.

The flame represents the embodiment of the enthusiasm and commitment to general

practice and the delivery of a high standard of care. The ‘flame’ was sustained through my

role and network as a member of the panel of examiners for the MRCGP exam, as a GP

trainer and the trainers group, and as a GP tutor and the GP tutor deanery network.

The author(keeper of the flame)

Quality framework(FBA)

MRCGPExaminernetwork

GP trainer

GP tutor

Summary: Keepers of the Boundaries

The two forms of organisation as a framework and dynamic of ‘being organised’ interact

within and between individuals At the point of interaction boundaries emerge. The

boundary is a consequence of the complex and dynamic interactions between individuals

and in this context their interpretation of rules and regulations from inside and outside the

practice. These boundaries within organisation are both internal and external. The key

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informants within the practice nucleus team for organisation /Organisation were the

practice manager, the partners, the receptionist and the practice secretary.

Their keeper roles overlapped as I summarise below.

Keeper of practice conscience(partner) Keeper of written information

(Practice secretary)

Keeper of the flame(Author)

Keeper of the practice internal rules(Receptionist) Keeper of Rules and

Regulations(practice manager)

Each informant through their professional roles brought a different influence to

organisation /Organisation. These influences I have labelled as ‘keepers’ in recognition of

their ‘championing’ of these aspects of the overall disposition of organisation

/Organisation. The term ‘keeper’ is intended to serve as an indication of the social role that

the informants were more likely to perform within the practice culture. It is not intended to

indicate that this was an absolute label of function. All these informants as ‘keepers’ acted

as a focus or agency in the generation of organisation and Organisation. The practice nurse

and the extended primary care team were more peripheral within this theme. The latter

were employed by the PCT. The practice nurse throughout the research showed little

inclination to become more involved within the wider organisation of the practice.

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However she followed the organisation for chronic diseases via the templates and within

her treatment room and professional role needed to demonstrate ‘being organised’. As her

transcript demonstrates, the practice nurse was content and happy within this role.

The keepers’ roles are envisaged as dynamic in terms of their interactions. These

interactions and their outcomes crystallised through the socialisation of the formal and

informal meetings that took place between the informants. Organisation in both senses

acted as drivers or stimulants for learning. This is exemplified through the practice

manager and the knowledge he acquired about diabetes and asthma and the partner with

her development of templates. Information or information that has been transformed to

knowledge by the informants was modulated by the priorities set by the leadership. The

resultant information from organisation and Organisation are then renegotiated within the

localised areas of the practice as exemplified by the reception/ administration area.

The production of knowledge through organisation and Organisation was explored further

through two artefacts which were widely used within the practice. These artefacts are the

‘Lloyd George’ notes and the practice computer clinical system. The next section explores

their use and meaning.

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Chapter Four-Part Two-Notes and the Computer

Introduction

During the data collection for this research the frequent use and interaction with the Lloyd

George notes and the computer became self evident. As a clinician I relied on the clinical

notes in order to retrieve and add to the information of a patient’s medical history. The

Lloyd George notes recorded events in a patient’s history from ‘birth to grave’. For some

of the older patients in the practice the Lloyd George Note envelopes contained the hand

written cards which were used by my predecessors before the introduction of the National

Health Service. The historical narrative of the patient’s illnesses used the note form of the

medical profession. Indirectly, the notes also reflected the changes in medical management

over the decades. The computer performed a similar function although its physical

appearance was more homogeneous.

Through observation, it became apparent that the notes and the computer had multiple

uses and that as artefacts were reified with different meanings by the practice informants.

This chapter explores these meanings through the informants. The first section relates to

the Lloyd George notes (for brevity I refer to these as notes) and the second the EMIS

computer system (the computer) Notes and the computer are discussed in terms of their

importance to organisation and Organisation.

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Notes and the receptionist

I start this section with an initial set of field observations which give a sense of the role

and purpose of the notes. The reception staff was tasked with the role of managing the

notes and shepherding their presence around various areas in the practice. Before the start

of each surgery the notes were retrieved from the shelves in the administration area of the

practice (“the notes area”) and placed in boxes. These boxes were then taken through and

placed on the desk of each consulting room. On completion of the surgery the notes were

retrieved in their boxes and the notes returned in alphabetical order to the shelves. Notes

that were needed for referral letters to secondary care were set aside by the doctors and

placed in similar boxes in their consulting rooms. In other areas of the practice notes, were

seen in boxes on the small table on the staircase landing. These were patients’ notes that

were needed for the home visits for the day. The set of shelves on the staircase landing

served as a storage area for the boxes of notes for each doctor. These notes had been set

aside for doctors to answer queries from patients and for the completion of life assurance

forms which were attached to the notes by the reception staff. Notes were set aside by

reception staff in the administration area for “pruning” and “tidying up”. The order of

information within each set of notes had a set pattern. This ordering of information is

described later in the chapter.

Notes and the receptionist

The receptionist was well aware of the importance of the Lloyd George notes saying that

“(Notes hold)…all the information on a patient, it describes who they are. All the patient’s

history is in the notes”.

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Notes to the receptionist embodied different sorts of patients from the size of their Lloyd

George envelopes. The receptionist described them as “thick and thin” notes and showed

me the “thick notes shelf” in the administration area. The receptionist saw them as

symbolic; “they are a medical life, if they are thick they say a lot about patients, they come

a lot”. There was a “Fat shelf, large records that are always coming off the shelf, the

regular attenders.”

For thin notes “this has been a well person all their life. If notes are lost, GPs will have

little knowledge of the patient, the GP will not have knowledge of treatment. Lost notes

are the bane of our lives”

Uses of notes in reception

In describing the process of the use of any sort of notes she used the phrase that when

removing the notes from the shelf this was “pulling the notes” and these were then given

to the doctor or practice nurse.

A set of notes was organised. This was determined by the requirements of being a training

practice and reflected the influence of an external body, the local vocational training

scheme. As a requirement of being a training practice, notes had to have a systematic

arrangement. The notes were organised with summary cards. These were cards on which

the clinicians recorded contacts with patients, copies of referral letters to consultants,

consultant letters, and details of vaccinations. The surgery used summary cards that had

been produced to improve the transfer of data to the computer. These cards had a green

colour and as such were referred to as “the green cards”. Reception staff were also

expected to reduce the volume of paper by trimming excess paper from consultant letters.

This was referred to as note “chopping.”

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The summary cards had data which consisted of important health problems and details of

vaccination dates, blood pressures, allergies and family history. This data had been entered

on the cards by the GPs and a medical student who had been employed to ‘summarise’ the

notes several years ago. These ‘green cards’ were then used to transfer data to the

computer by one of the reception staff. At this point of transfer, the receptionist said that

“If I don’t understand a term or word on the green card, I would ask the practice nurse what it meant or would look it up in the practice nurse’s reference book or in the medical dictionary”.

When asked why the practice nurse was asked, the receptionist said that “she was in and

out of reception most often.”

Transformation of knowledge and reception

The notes and the computer acted as artefacts in the production of knowledge for the

receptionist. An example of how knowledge was constructed within the administration

area of the practice building was described by a receptionist whose role was partly as a

data entry clerk. The description is taken from my field diary notes. She described that if

she wanted to know more about a drug to satisfy her own curiosity she would ask a

colleague who had previously worked for the national prescribing authority as a data entry

clerk. The specific example was given of how she worked out how the drug Warfarin was

used by realising it was linked with a blood test which was important for the doctor to

know in terms of its anticoagulant action. The discourse between receptionist and practice

nurse was not simply a transfer of information from receptionist to nurse and vice versa.

Within the discourse, the nurse had to sense the receptionist’s level of biomedical

knowledge in order to provide a satisfactory explanation. In addition the ‘flat hierarchy’

and the trust between nurse and receptionist created a culture within which curiosity

thrived.

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Through this example notes in reception were therefore not only being used as “being

pulled, filed, or chopped” but also as sources of information which were transformed into

knowledge in conversation with other members of the team as they moved in and out of

the reception area of the practice. Notes were actively used as a resource by reception staff

to create new knowledge without any formal training or teaching on their use. The

knowledge was acquired in an informal setting. In this example knowledge known to the

nurse was transformed through the artefacts of the notes and the computer. However the

transformation was dependent on other factors. These were the organisation of the practice

and the implicit sense of ‘being organised and the level of trust between the informants.

Notes and other perspectives

Throughout their ‘lives’ in the practice notes were shepherded and nurtured. “Tatty

envelopes” were repaired and their every move was important. Notes came from another

practice and these were then reorganised to comply with practice’s own sense of order.

The receptionist was anxious to describe and emphasise that the Lloyd George notes were

“Central to that person, very individual and very personal. (Notes are….) a bit of a secret document, but you get used to it. I was surprised at how secret the information is and regarded as such”.

This feel of needing to tend the notes was reiterated by the practice manager.

The Practice Manager and Notes

His description repeated the receptionist’s view that notes “had to be kept in good repair,

that the contents (i.e. the green card etc.)had to be kept in a specific order, in chronological

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order, that the patients’ investigations had to be at the back and that the clinical records

had to be near the front with the summary card nearest the front”

If the doctor did not have the correct notes it would “result in the doctor not being able to

consult properly, that it’s very unprofessional”, and “reception hadn’t done their job”.

Overall the practice manager felt “I have little contact with notes”. His role was to follow

up “the leavers” (i.e. the patients who have changed address out of the practice’s area) or

had “demised”. Before returning patients notes to the health authority he described how

“he checked their contents” and then the notes were placed in a “courier bag to go back to

the health authority”. The sustenance of the notes was therefore maintained right up to

their departure from the practice.

The impression in following the progress of notes around the practice building that most

people had access to their contents for the individual professional’s purpose. However the

impression does not reflect the reality. When the practice manager was asked “who doesn’t

use the notes?”, he said that the extended team (District Nurse, Health Visitor, Community

Psychiatric Nurse) “only have limited access to notes”, “only certain information released

to the District Nurse. The information released to these professionals has to relate to the

problem the health professional is trying to resolve, reception staff find the information for

them. This was to protect patient confidentiality. The notes area (i.e. the administration

area) because of confidentiality associated with notes means that people who don’t have

access to notes go into the coffee room” However, “notes are occasionally left in the

coffee room by the doctors”

With regard to patient access to notes he said that

“Patients have to write a letter to request access; the doctor can remove parts which could be detrimental to the patient. The access system (to the notes) had evolved in the medical profession, something that has just built up within the profession. Lots of

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information is privileged information based on trust between the doctor and patient, derived from the Hippocratic Oath”

The practice manager reflected on the relationship between notes and the practice finances.

“Notes do not hold financial information, but information from them is used to help with achieving targets and therefore indirectly had a financial value”

Overall the practice manager’s involvement with the notes was relatively peripheral. It was

primarily concerned with their movement across the practice boundary. This was either to

receive them or to send them back to the health authority.

The partner and notes

The partner’s transcript had relatively little to say in direct comment about the notes. She

was comfortable with their use. She focused on notes as “the bits you write during a

consultation”

Overall she summarised the structure of the notes.

“Little Lloyd George envelopes, they contain letters from consultants, investigations we have done , a green summary card, asthma cards, diabetic cards, copies of letters to consultants. You can do little pictures; notes are solid, more comprehensive than the computer”

Notes were also used by the doctors to “complete insurance reports”. The partner contrasts

the use of notes with the computer and this is described later in the chapter.

Comments

An outsider visiting the practice could expect the notes to represent a document which

records the distillation of thoughts between the doctor, the patient and other health

professionals. This process could be considered a simple transfer of information between

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the different parties. However this does not appear to be so. The Lloyd George notes were

found to have been reified by the informants.

Notes are reified in several ways. I have summarised these in the following concept map.

NOTES

Informal Learning

As an artefactfacilitate

Trust

Enshrined with“Secrecy”

Ethical rules

Vocational Training practice

rules

Being a trainingpractice

OrganisationAnd

‘being organised’

Influenced byLeadership,NHSrules

Medico legal

Professional bodiesRules and regulations

First and foremost notes were the artefact that transformed information. This can be

developed in several ways. Within the consultation between the doctor and the patient, the

doctor edited and recorded the conversation. The written narrative was in the codified

language of the medical profession and was the doctor’s interpretation of the problem.

Trust was implicit in the recording of that information. Trust was enhanced by the ethical

principles codified in the rules of confidentiality and sensed by the informants as “secret”.

Knowledge of this code was part of “being professional” which is discussed in the chapter

related to hierarchy and power.

The Lloyd George notes had meaning in four main areas. The first was simply the

recording of information from ‘birth to grave.’ The second was as a medico legal

document the nature of which guided by the rules constructed by the various national

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bodies. Thirdly, their link with other bodies in terms of their structure for teaching

purposes embodied them with further importance in terms of the practice culture and

quality of care. The latter linked with the practice leadership which placed an emphasis on

the quality of the notes. This was to comply with the rules of the vocational training

scheme. If the sense of trust is linked with the notes as an artefact then in turn this enables

informal learning. Finally, notes reify Organisation and ‘being organised’. Considerable

effort was expended by the receptionists to maintain the quality standard for notes required

by the vocational training scheme. The notes and their organisation acted as a focus for

‘being organised’ and the value of quality of organisation. The combination of attributes

gave the notes a symbolic meaning. They were linked with power and control both from

within the practice from the consultation through to their wider uses in the practice and

externally their links with the influence of external bodies.

In the next section of the chapter I consider the place of the computer in the practice.

Through this discussion there is an opportunity to compare and contrast the computer with

the Lloyd George notes. This is a theme that is taken up by the informants.

The Computer and the Practice

The informants’ narratives are given in the same order as for notes. As might be expected

the computer shares similar attributes to notes. The computer in general practice can be

considered to be a ‘late arrival ‘within the context of communication and data collection.

As a result the computer is compared by informants to the Lloyd George notes. The

practice used the form of general practice software called EMIS. This system is set up so

that different parts of the system performed different functions. The EMIS software could

be thought of as chapters of a book. Each chapter is linked to others but can be entered

independently to record data.

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Some History

The practice purchased its first computer in 1987. It was a single VDU unit and was used

solely for generating repeat prescriptions .The software in this system (Leeds Genisyst)

was entirely different to the software used during the period of this research and essentially

it was only able to generate repeat prescriptions and do simple searches. Subsequently and

quite rapidly, the software became more sophisticated such that over the following fifteen

years the practice computer system evolved into networked stand alone computers in all

the clinical and non clinical areas of the practice.

Over the fifteen years various types of data were entered. Initially this was largely

prescribing data. Over the following years this evolved into entering more health

prevention data (e.g. smoking, alcohol, blood pressures) such that by 2002, the practice

felt able to largely ‘abandon’ the Lloyd George notes and rely on the computer. This

significant change was lead by both doctors.

For the doctors there was a transition in confidence in moving from recording

consultations in the notes to recording similar information on the computer. As will be

seen even after fifteen years of close association with the computer, the doctors and the

health professionals within the practice had mixed feelings about the computer and its

place in the practice. However it was abundantly apparent to the observer that like notes,

the computer played an important part in the day to day life of the practice.

The Receptionist’s View

In the early days of its introduction the computer for the receptionist was a tool which

eased the burden of generating patients’ repeat prescriptions. Until then the repeat

prescriptions were written by reception staff and then checked and signed by the doctor.

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The collection and analysis of data by the computer was familiar to the receptionist. From

her narrative, when compared to notes, the computer provided a greater transparency and

immediacy for the collection of data and its analysis. These were linked with the practice’s

contract as a provider of primary care services and as a training practice which required the

practice to undertake audits. The data collection was linked to financial rewards as

exemplified with the flu vaccination campaign.

She described the computer as being used as being used as

“Prescribing mode more than any other, reception issues prescriptions on a monthly basis. It’s used for health checks, searches to do the flu vaccination list, search for blood pressure patients”

“Use the communications menu to send a message to the doctors in their rooms”

“Use the word processor mode when the practice secretary not in”

Computer data has similar professional values as notes which she describes as

“computer data is as secret as proper records.”

The receptionist’s interaction with the computer may be represented diagrammatically as

The computer

Collection of data

prescriptions ‘secrecy’

organisation

FinancialReward for thePractice e.g.Flu vaccn.

Performance targets

Produces and monitors

For internal& externalaudits

Professional rules

Targets set by the Practice contract with the PCG/T

Data collection produces

ReifiedQuality ofcare

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I have added organisation as part of the diagram above since the computer formed part of

the practice’s organisation and is implied in her comments overall.

The Practice Manager and the Computer

The practice manager confirmed the sensitivity of the data when he explained that the

primary health care team had

“Limited access to the computer, that there were different levels of access to different professionals using different levels of security codes”

In addition, I note he buys special screens to go onto the front of the computer so that the

patient cannot see what is being written when they consult. These screens provide a literal

and metaphorical example of the “secrecy” described by the receptionist in reference to the

Lloyd George notes.

He described his role with the computer in more bureaucratic terms. He needed to ensure

that the computer had a

“Current registration to comply with the data protection act, ensure we have adequate maintenance (support), and ensure we have adequate insurance if we are broken into. We have data discs to do regular back up”.

In terms of his interaction with the computer he described how he learnt how to use it

“(I).. fiddle around in the play version of EMIS, what I picked up myself, and other people taught me. I learnt a little bit off different people in the practice. You’ve got to do it two to three times, you do it basically that often its just second nature”

There were frustrations for him with the EMIS computer system

“EMIS is a pain some of the time or quite a lot of the time. EMIS send people out to you, three months of work builds up”.

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The computer is maintained by the practice manager. He ensures it works correctly and

that it complies with the various legal requirements. He is the ‘tender’ of the computer but

his day to day interaction with software is limited compared to that of the receptionist.

The Partner and the Computer

The partner described the computer as “having more or less everything in it that the notes

have.”

However, she felt limited as to what she could record and sensed there was less flexibility

compared to using notes.

“You can’t write as much on the computer or at the same time. You can’t put all the patients presenting complaints on the computer because of lack of time”

She described “templates” which were part of the computer programme for recording data

about “blood pressure, urine analysis”, and “family history.” There was a frustration for

the partner that not all the data could be recorded. There was a sense of incompleteness.

“You couldn’t put all the patients presenting complaints on the computer because of lack of time, not patient letters, not all investigations”

She described using the information software on the computer to help her learning. She

described two programmes “Mentor and Prodigy.” Mentor provided background

information on a range of clinical topics based on the Oxford Textbook of Medicine.

Prodigy was an information system which advised on the use of medications. She added

“It’s possible to modify the information on Prodigy to tailor to the needs of the practice”

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This modifying she described as “playing with the computer, putting templates on, doing

protocols”

Templates and the partner’s learning

The computer for the partner was a giver of information; the information was transformed

or modified. Knowledge was formed through the interaction as an inner reflection for the

partner. The interaction between the medical topic and the construction of the templates on

the computer was an informal method of problem based learning. The template was a

record as well as an aide memoir of learning for the partner. “Playing about” as noted by

myself was an important educational process for her. The templates were a tool through

which information was transformed. The partner spent a considerable amount of time

writing the templates. The writing was almost entirely done by her. The content was a

blend of information derived from evidence based literature and discussion with members

of the clinical team. Their development was a demonstration of an output from informal

learning and professional discourse. Prodigy is an electronic evidence based resource for

common conditions developed by the Sowerby Centre for Health Informatics Newcastle

(www.prodigy.nhs.uk). At the time of the research the practice had access to an early pilot

version and the partner had invested a great deal of time in tailoring the information to the

needs of the practice. She was proud of this development. This modification together with

the writing of over twenty six templates was for her a time in which she dissociated from

the rest of the practice. She became engrossed in their development. During the time of the

research, her modifications to the Prodigy information (not the templates) were lost when

the software supplier upgraded the system and deleted her work. This did little to endear

her feelings towards computers.

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An example of a template is shown below to illustrate the interface that they provided

between clinical guidelines and the user.

The template shown is for the problem of ‘headache’. This can be a difficult problem to

diagnose accurately and with confidence. The template guides the doctor through the

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different possible underlying causes for the headache symptoms. These usually required a

‘yes /no’ answer. From the partner’s point of view (and her clinical colleagues) the

educational value was the application of knowledge acquired through training, from other

headache ‘guidelines’ and from experiential knowledge. These were condensed into the

clinical template. The partner produced approximately twenty six templates which covered

a spectrum of common general practice acute illnesses and chronic diseases. The number

produced was limited to using the alphabet coding by the computer software.

As a tool, the computer for the partner appeared to be less integrated within the practice’s

day to day life when compared to the Lloyd George notes. The partner said

“I miss the feel and smell of notes……an inability to write a spontaneous comment….I would like to draw little pictures…….I have no trust in the computer”

Expanding on the comparison between notes and computer she described the notes as

“Notes are solid…….Consultations feel different; notes are something to cling on to.”

The partner liked to be able to see the colours of the investigation forms as used in the

notes compared to the black and white monochrome of the results on the computer screen.

Notes appeared to have visual and kinaesthetic properties for the partner. The computer

although sitting on the desk was also sensed as an intruder something which represented

some of the desires of the external bodies for information and therefore was not trusted.

Trust or lack of trust was about “not trusting its ability to give information back”. There

was a dissonance within the realm of the acquisition of knowledge. The computer was able

to satisfy that desire to satisfy a curiosity or creativity with an immediacy that was

impossible through the medium of the notes. By contrast there was a tension created

through its other functions of the ‘mechanistic assimilation’ of data entered and the

perceived ability of its accessibility by an external body.

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Comment

The computer had similar functions to the notes in terms of the collection of information.

The information was collected and recorded in consultations between patient and doctor

and other data was added by the other members of the practice nucleus team. Notes and

the computer were similarly reified and both acted as conduits for informal learning by

members of the practice nucleus team. However notes within the practice appeared to be

embedded within the practice culture and were imbued with greater trust.

Although it was valued as a gatherer of information and a ‘saver of time’, the computer

was sensed as “rigid” and that it had to be given information. This necessity grew out of its

perceived connections with the external NHS bodies and that as an artefact it sat on the

boundary between the external and internal practice milieu.

The computer in its various forms over the fifteen years of existence within the practice

had yet to be integrated entirely in to the practice. Information recorded on paper was

harder to extract and indirectly notes acted as a barrier to external interference from other

NHS bodies and maintained the privacy of the practice culture.

I have summarised the relationships between notes and the computer in the following

diagram. Trust appears as the bond which links their use for the informants. The diagram

is complex. Organisation is applicable to both notes and the computer. The double arrows

reflect the dynamic relationship that existed between the rules and regulations, values and

themes that related to notes and the computer.

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Computer

Notes

TrustInformal learning

organisation

Rulese.g. vocational

training

‘secrecy’

Rulesfinancial

CollectionOf

data

PerformanceTargets

(PMS contract)

Embedded High trust

Uncertain trust

As artefacts it was apparent that both played a central role in the culture of the practice.

Their use was essential in the daily life of the practice and as a result acquired meanings to

the informants. At the time of the research the Lloyd George notes were regarded as the

senior information tool.

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Chapter Five: Hierarchy and Power.

Introduction

For a neutral observer, a starting point might be that within the practice there is a linearity of

flow and action through the organisation and that this is a focused and harmonious activity. It

follows that this assumption of practice organisation will be marshalled through a hierarchy

which has a sense of power. In this chapter these themes are explored in terms of their

interrelationships and place as part of the practice culture. Power is to be understood in its

use in terms of its dictionary definition as ‘influence, authority and control and hierarchy in

terms of the ranking of people in an organisation’ (Oxford English Dictionary 2005).

The chapter considers my place within the hierarchy and then explores the issues of power

and hierarchy within the practice as perceived by the informants. The informants reflect on

my role within these issues. In its third section I consider the comparisons and contrasts

provided by the extended primary care team and the notion of trust as seen through the data

from the informants and my reflective diaries. I consider professional responsibility and

accountability which within hierarchy and power and finally, the relationship between these

values and the building.

Leadership, power and hierarchy- reflections through dissonance

Within this research setting my role was as one of the leaders within the practice. The practice

manager and reception staff referred to me in informal conversation as “the boss”.

My leadership style and its outcome are reflected in the organisation of the practice. As is

discussed in a separate chapter, my leadership influenced the organisational structure and the

sense of being organised shared within the practice nucleus team. It is in this area of the

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practice that my presence is sensed both directly and indirectly within the practice. The

informants’ term “the boss” reflected the tacit understanding through the practice team that

responsibility and accountability for the caring and the quality of care of the patients

registered with the practice was reified through me. This term was also used for the partner

but less often and implied that within the practice she fulfilled a different role and this is

explored through her narrative. The practice as an organisation had a flat hierarchy within

which the partner and I encouraged staff development. This style of leadership intuitively

reduced the possible effect that ‘marriage’ and both being their employers could have had on

the data collection from the informants. With respect to the latter, I would contend that the

data collection was enhanced through having the close cooperation and trust of the partner.

Thus the partner was included as a focus (key informant) but due to the overall style of

leadership, the fact of marriage between the partners did not emerge from the data as a

significant influence and therefore was not included as a focus within the research .

Author’s ‘esteem’

In the methodology chapter I felt the need to expand on how I was perceived by the

informants and others in terms of ‘esteem’. Its purpose was to give the reader a sense of my

role or agency within the practice. As a value or agency it will have formed part of how my

leadership style was regarded. I repeat the use of the diagram that describes the researcher’s

‘esteem’. This diagram represents the comments from the informants within the practice and

other contacts outside the practice.

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Author’s esteem

Difficult to approach,“too posh”

(practice nurse asreported

to partner)

“distant at times”(partner)

“Just /Fair”(partner)

“The Boss”(practice manager

/receptionist)

“Respected”(partner)

Approachable(practice manager

/receptionist)

“Brave,honest,open approach to teaching

and learning,learner centred”

(Associate advisor)

“eminence grise”Parting ‘note’ on my departure

from the practice(Associate

advisor )

“A Polymath”( a professor of

Education)

The above diagram does not reflect how the leadership and strategy were sustained during

times of dissonance.

Leadership style

My reflections on my leadership style were to encourage a flat hierarchical structure within

which team members were encouraged to express their thoughts and ideas. This was

independently confirmed by a member of the primary care development centre team who was

tasked by the Primary Care Trust in 2000 to visit all the practices in its area and prepare a

report from individual and focus group sessions on the developmental needs of the practice.

This report was separate to this research but is in itself an artefact and forms part of the data

in the research (Howe M. Personal Communication and report, 2000 pg.5). My leadership

style (pg5) within the report was noted by the reception staff informants as ‘Dr Milne

encourages personal development and (the practice) was a learning organisation and that

overall staff are prepared to learn’

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Inevitably, this style will have been influenced by my awareness of the complex of

developments within primary care, government regulation, practice financial need, the

development of the practice nucleus team, and the partners’ personal development.

My leadership was at times tested by discordant events which were inevitably produced by

the complexity of the social interactions. These events served to situate the responsibility and

accountability for the practice and its collective collaborative activities.

For the purpose of this chapter, it is intuitive that these events took place as a result of the

complex interactions and that any perturbation in terms of change in the interactions had the

potential to cause discord or accord. Examples of these discordant events or disjunctions and

their analysis are now described, and through these, my intention is to enable the reader to

consider where leadership was sited within the social map of the practice, and to give depth to

the concept map of my ‘esteem’ described. The data is derived from my reflective diary and is

given in double quotation marks.

The partner and leadership-disjunction with external bodies

During the course of the data collection the partner’s thoughts on her role and place within the

practice were a source of anxiety to her and the practice team. At times during the research

she expressed the desire to leave the practice. Reasons for this were professional difficulties

related “to feeling worn out seeing the same patients all the time”. In general this was an

unhappy time for her. She resented “doing audits” for the PCT and regarded these collections

of data for external organisations in Orwellian terms. My diary reflects these worries

“The partner is an excellent clinician; she does not get regular feedback as to how well she performs. She has no interest in playing a lead role within the practice-prefers a role where she stands one step behind-she is an imaginative thinker and crucial to the group in this role.” (20.11.99)

At another moment I reflect that “she is afraid of failing patients and lives in fear of being sued”

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The partner did not like large meetings and the use of terms and abbreviations like PDP and

PPDP which were an agenda item in one of the practice meetings. These were terms which

were brought in “from outside”. She also felt I “did all the talking” (the practice nurse made

this comment as well). By contrast, I note that she was happiest when we met with the

practice manager and we were engaged in considering the future development of the practice

as a PMS practice. In this meeting her creativity was given full reign.

The author as ‘keeper of the strategy’-personal disjunctions

My role within this was to pull the strands of thought together. As leader I reflect in my diary

as “feeling as if I am on a rack pulled in different directions by the partner, patients, practice

organisation, teaching and (this) research.” At a later date in my diary I note the tension

between my desire to encourage reflective practice and the seemingly inevitability of this

ambition being denied

“This creates a dissonance within me since as the leader within the practice I am keen to foster reflective learning as an important part of the practice. Paradoxically because of the service needs, the financial needs of the practice I have created ‘a monster’ that drives us all without pause for reflection….. I have no qualms in nailing my colours to delivering quality care ….. However there is no time and I am concerned that it may be unrealistic to produce change in a team who have been swimming in the torrent (of change) for so long they no longer feel able to make it to the ‘eddies of the riverbank’ and use time to restore their professionalism”(19.7.00)

In an early section of the diary I reflect on the level of trust between the partner and myself in

terms of professional practice. We both willingly engage in discussing patients’ problems and

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their management. There is in this a sense of separation or different layer of trust. As doctors

of similar standing the relationship is open and transparent. For the partner my role as leader

is problematic. I am linked with external institutions and “bring words from outside” that are

perceived as threatening. I hold information that is ‘powerful’ or ‘controlling’ as exemplified

in the use of ‘PDP and PPDP’.

Leadership, power, micro politics and the practice nucleus team

During the research there were episodes when there were disagreements between members of

the practice team. These disagreements focused on areas of hierarchy within the practice

nucleus team. My diary records one of the administration staff’s concerns over the allocation

of the title “senior receptionist” to one of the receptionists. Subsequent informal conversations

reveal worries about “cliques” within the practice team. A member of the team feels that the

word “Senior” implies that she is “better than others” and that “this should not exist within

the practice”. My diary considers this in terms of Goffman’s interpretation of ‘mini teams or

cliques’ (Goffman 1969 pg.73).

“He (Goffman) views cliques as a form of team who join together for informal amusements, that they tactfully conceal their exclusiveness from some non members while advertising it snobbishly to others. This within the practice seems to overstate the case of snobbish. It appears to be more about perceptions of age i.e. older members seem to share the same values rather than as is implied in the use of snobbish a social class hierarchy or a hierarchy that someone is better than others. In terms of Goffmann it might be better understood that there is a shared value that some team members think they are better in terms of skill, knowledge than others”.(28.3.00)

To continue with my reflections from my diary, I consider that it is likely that the cliques are

in Goffmann-esque terms “like two mute individuals with remainder of the cast (team)

performances affected by their distant or silent behaviour. This has lead to misfiling of letters

(in patients’ notes).” (26.3.00)

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In turn in my role as leader, I interviewed both parties in the seminar room to resolve the

problems. This was partly successful but the process left me “with a set of negative emotions

which hinders the day’s work and creative thought”(26.3.00) As “the boss” I did not find

these episodes easy to manage. It contrasted with my desire for the practice which, in the

practice manager’s words, was for “the team to act of its own accord and that individuals are

lightly managed because they are able to manage themselves”. In using the word ‘senior’ I

had created a paradox since this did not fit with a flat hierarchy. Its intention was to respond

to the request from the team that roles were better defined.

The difficulty with role and expectations of role was apparent in the employment of a salaried

doctor. My expectations in terms of quality and ‘being part of the team’ led to discord

between the doctors and the difficulties that the salaried doctor created were brought to my

attention by the reception staff. In reflecting on this episode I consider the relationship

between myself as a leader and the practice culture.

“(the partner) said she could rely on me picking up work to be done in other areas of the practice such as extra home visits, repeat prescribing checks when she was in the middle of a surgery…….” This causes me to consider in rhetorical fashion “So what is it about me that is important to the well being or culture of the practice? Do I breathe enthusiasm and motivation into the practice team?” (19.3.99)

I muse on Schein’s model in which he considers leaders as culture managers

“Have we acquired (within the practice) a model of management based on self actualization and one that inherently finds it difficult to challenge assumptions of group members? As per Schein” (19.3.99)

My leadership style brought enthusiasm to the practice and no doubt had a sense of ‘being

driven’. I had an expectation that others within the team would share and develop within this

ethos which I regarded as positive, but equally, it did not allow for a diversity of opinion in

terms of quality. In turn, I was also reflecting the boundary with the quality agenda of the

external bodies such as the vocational training scheme and the Royal College of General

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Practitioners. From these reflections, I would add to my ‘esteem’ the dimension as an idealist.

Through my leadership I attempted to convey the vision of the ‘perfect’ practice.

Author’s esteem

Difficult to approach,“too posh”

(practice nurse asreported

to partner)

“distant at times”(partner)

“Just /Fair”(partner)

“The Boss”(practice manager

/receptionist)

“Respected”(partner)

Approachable(practice manager

/receptionist)

“Brave,honest,open approach to teaching

and learning,learner centred”

(Associate advisor)

“eminence grise”Parting ‘note’ on my departure

from the practice(Associate

advisor )

“A Polymath”( a professor of

Education)

Idealist(self reflection)

From within the practice, the picture of power and hierarchy comes mainly from the partner,

the practice manager and the receptionist. Transcript analysis produced little detail on these

areas from the other practice informants. The partner gives some insight into why this might

be so.

The partner’s perspective on power

When considering the issue of power within the practice, the partner described power resided

within several members of the practice nucleus group. She also highlighted power that that

patients have. “Patient power, its what they want that matters, that(s) who I listen to most”.

She identified individuals within the practice as having power because they had a particular

knowledge. This she listed as

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“The senior receptionist’s knowledge about the computer, the practice nurse’s knowledge about the treatment room and the practice manager’s knowledge about practice finances.”

She said that the “practice manager has knowledge across many areas within the practice”,

but recognised that

“Everyone is powerful in their own domain but the practice manager is knowledgeable (about these domains) but not powerful.”

When she thought about power, she sensed it as “there are fluctuations of power within a

meeting in the seminar room”.

In discussing power she had particular concerns about the influence or power of government

and other professionals. Power was sensed in terms of an unspoken accountability.

“The government tries to suppress everyone, tries to push equality. There is pressure from other doctors, there is an unspoken ‘he’s not doing it properly. They (the doctors) go behind people’s backs”.

She used the activity of clinical audit as an example of this. “It’s a childish activity and

paternalistic. It’s done for the PCG and is crunching numbers for the government.”

She gave examples of doing clinical audits on “patient appointment availability, patient

satisfaction, diabetic audits and doing audits towards a professional qualification.”

The partner described a hierarchy of leadership within the practice. She described the author

as “the leader” followed by the senior receptionist and the practice secretary. She saw others

as people who did not want to lead. “The practice nurse won’t lead, she stands her own

ground and so do I”. The practice manager was not mentioned with her conversation

concerning leadership. As previously mentioned he was described as “knowledgeable but not

powerful”.

From the partner’s perspective there was a dissonance for her since in terms of accountability

there was a need to lead and yet she was aware that she was not a ‘natural leader’. However

her tone was to suggest her and the practice nurse saw their role as ‘people who would not be

lead as much as people who would not lead’.

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The Practice Manager’s perspective on power

For the practice manager there was a definite hierarchy. The partners had the responsibility

and are seen as the leaders.

“The team (the nucleus team) looks to the doctors for guidance. Ultimately yea or nay is with the GP”.

The process of decision making was described as

“The GPs are the steering group behind a decision, people put ideas forward and GPs give it their blessing. Anybody could make a decision and if it is viable and they perfect it, it will get their blessing”.

The GPs in the practice manager’s view were the leaders but when the GPs were away from

the practice he took over that role although this did not seem to be explicit.

He described his style as

“Leadership by example. There are times when the girls obviously need somebody to relate to if they have got concerns downstairs. I’m the father confessor for want of a better word. If I have concerns then I in turn come and bend your (i.e. the author’s) ear”.

He acknowledges that there were leaders in different parts of the practice.

“Everybody to a degree is going to lead if they have the expertise” and gave the examples of “The senior receptionist is a dominant person downstairs, the practice nurse if she is looking for leadership within administration she will come to me, if it’s a clinical problem she will go to the doctors”

His comments reflect a tacit discourse between the members of the nucleus team which has

internal boundaries between administration, practice management and clinical practice created

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by an implicit or tacit understanding of role within their workplace. At these boundary edges,

the interactions were mediated by internal individual cognitions of role and power of those

within and without the practice.

In his role as practice manager he was a gateway for ideas and liaison for the communication

of decisions. These were shaped by other sources of power.

“I am aware of the power exerted by the PCG/T, the government, and patients have a strong voice.”

He perceived his own power in terms of “to do our best when we come to work everyday”

The practice manager reflects a personal role that is a gateway, a junction at which there is a

meeting of sources of power or influence. His power is as mediator and the holder of

information derived from across the external and internal boundaries. He interacted with the

professional values and views of the doctors and the practice nucleus team and with the

various managers of the PCG/T.

Although leadership was sensed as being primarily through the doctors it was not necessarily

so. In his view if a project was being undertaken within reception then it would be lead by the

senior receptionist and that others with whom she worked in her area of the practice would

expect leadership from her.

Hierarchy and its influence was therefore a complex phenomenon within the practice and not

necessarily a linear relationship predicted by the hierarchical relationships.

The Senior Receptionist and power

The receptionist like the practice manager was at a boundary between their world within the

practice and the administration area and the outside world represented by their daily contacts

with members of the extended primary care team. Here as a third party, she was aware of the

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indirect manifestations of power through their informal conversations she had with these

professionals. She described the relationship between the district nurse and her manager as

“She works under a manager. They (i.e. district nurses) are timetabled and use (district nurse) protocols. The district nurses get really upset about everything”

Similarly with the health visitor, she commented her view as to what she thought the health

visitor should be doing.

“Being mainly involved with children, that (the children) have all necessary immunisations and she provides support for all the family. She is supposed to visit the elderly”

Through her acquisition of this information, she gained an understanding of the role of the

extended team and through this knowledge power to influence these professionals, and the

inner world of the practice.

In summary, the practice nucleus team reflect a range of views within this theme. These were

disparate with the partner taking a more global viewpoint whereas the practice manager an

receptionist considered power from the point of view of role.

The Extended Team, Power and Hierarchy

This account begins with the views held by the district nurse.

The District Nurse

The influence of managers was sensed directly and indirectly within their day to day work. In

her working world, a gap was felt between herself and her manager. This gap was expressed

in terms of feeling valued and is also expressed through the skills she held.

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“Groups within a PCG have a power. They don’t necessarily influence my day to day work. I would like to feel valued enough to make a change. Nurse prescribing has helped by giving (nurses) some power”

The Physiotherapist

For other health professionals the gap in terms of power and leadership between themselves

and their managers was more pronounced. This gap had caused her to leave the NHS.

“There was a clash of ideas not personalities with my immediate boss. I was being prevented from what I wanted to do by my immediate superior. She wasn’t a physiotherapist, she was a remedial gymnast. She was out of touch. She was out to protect herself. My junior colleagues came to me to discuss problems and not my boss. I couldn’t rely on my superintendent to defend me and I was getting no back up whatsoever. Experienced people were not allowed to develop their own job; you weren’t allowed to use your brain”.

The McMillan Nurse

The McMillan nurse reflected on the relationship between her manager’s role and the

manager’s career ambitions.

“Managers were interested in their careers and she went to lots of meeting to advance this. She kept herself away from patients. She didn’t understand the role of a McMillan nurse or what a palliative care nurse does. They take big chunks of time, weeks, months out of the budget developing themselves”.

In contrast when considering the manager’s decisions on the McMillan’s nurse’s

development she observed that “they perceive a need not necessarily when I have a need”

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The Health Visitor

The Health Visitor provided a historical narrative. She compared and contrasted the

relationship between managers and herself over her working career.

“Initially you felt valued by superiors but now no support from superiors. They have a fear of litigation The medical officer of health and the superintendent had our interests at heart and they had a lot more trust in us. Now they (the managers) use too many memos. You know you are in a hierarchy with varying degrees of authority.”

For the extended team there is a spectrum of observations. The district nurse’s observations

unconsciously allude to the change in professional hierarchy between the nursing and medical

professions with the acquisition of prescribing skills. The physiotherapist and the McMillan

nurse reflect the dissociation between themselves and their managers. In part this was sensed

as a desire for greater professional autonomy, and partly their managers reflecting changes

within society; “they have a fear of litigation” .Accountability inhibited their professional

development. The McMillan nurse’s development felt stultified by the manager’s lack of

support. Power and hierarchy played a negative role on this informant’s learning.

Power, Hierarchy and Learning-Considering other influences

In these accounts it is apparent the different styles of leadership or management are reflected

in the experiences of the practice nucleus and extended teams. For many of the professionals,

there is a strong sense of professional autonomy and, in her narrative, the health visitor

reflects the societal changes in the power of the professions. In general, this was sensed as a

‘flattening’ of the professional hierarchy and in their relationship with society. Their

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discourse within this theme reflect the tension between responsibility and accountability with

the latter capable of generating some polarised comment.

This was especially evident with the partner. Her sense of accountability jarred with her sense

of responsibility.

“Big brother telling us what to do think and learn. We are being assessed all the time. They just want me out.”

This strength of feeling was important when considering the influences on learning for the

individual.

Power and hierarchy and the leadership which arises from this can be viewed as part of the

mechanism which influences decisions within the practice and in turn this is influenced by

decisions and policy taken outside the practice. An example of this was noted with the

influence of the PCT on data collection within the practice.

Prior to the organisational change within the NHS, practices had a choice largely arising out

of individual or group interest whether to gather data for audit to inform their professional

practice. With the organisational development of the PCG/T and contractual changes, data

collection assumed a more important part of practice life.

During this phase of change, a manager from the PCT responsible for data collection attended

a practice meeting. She was anxious to ensure that the practice had accurate data collection

saying that “if the practice had accurate data collection then it would be able to develop a

solid business case”. She wanted to encourage “the practice to develop data entry policies”.

Data would be extracted from the computer system by the PCG and could be used by the

practice to justify a financial bid to the PCG in order to provide an additional patient service.

Data collection requires the practitioner to make the practitioner to make a judgement about

the most appropriate code from the Read Codes (Dr James Read developed these clinical

codes and these have been subsequently developed and used as the national NHS clinical code

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system). In collecting and entering the data on the computer, the partner reflected during the

meeting that “codes push you to make a decision”.

She observed that the codes influenced the information entered, and in turn, the code did not

accurately reflect the patient’s problems. This will influence learning since in extracting the

data the codes have the potential to only partially reflect the problem presented to

practitioners by patients. The sort of data collected and the control of the sort of data collected

passed from the practice to the PCG and in doing so produced a change of emphasis in the

practice’s informal learning. Thus in the act of recording the data the professional’s focus is

on recording the sort of data the PCG wants since there is a financial return. To a certain

extent innovation and creativity are lost and with it learning opportunities.

At that meeting I reflected in my diary that the practice “exists in its own little world and goes

at its own pace. There is a tension between what the PCG wants and its pace of change and

the innate pace or activity of the surgery”.

This innate activity is an outcome of the complex daily interactions between staff, staff and

patients, staff and patients and the practice building. This innate pace entrains the informal

learning. The collection of data is regarded as ‘collecting to meet a target’ rather than using

the data for learning. Collecting data therefore moves from being an activity from which the

practice learns, to something that is done because of the financial power of an outside body, in

this case the PCG.

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Summary: Power and Hierarchy

This chapter’s theme arose from field diary observations which were followed up through

interviews with the key informants. Power and hierarchy inevitably intertwine with and form

part of the organisational culture of the practice. They have the potential to influence the

learning for the individual and the practice nucleus team. Certain themes emerge from the

informants discourse on power and hierarchy. Some of these are common to the practice

nucleus team and the extended practice team. Others are more diffuse and complex.

Hierarchy differs for the practice nucleus and the extended practice teams. Within the practice

the hierarchy is sensed as ‘flatter’ with the informants more enabled to influence the ‘leaders’.

However this is not a homogeneous perception amongst the informants. The partner describes

the practice manager as “knowledgeable” but “not powerful”. The receptionist through her

understanding from the acquisition of information expresses her thoughts freely about what

she feels the health visitor should do. Within the practice nucleus team there were micro

politics which reflected tensions between members of the reception and administration team.

Their perceptions of hierarchy were reflected in the example of the dissonance caused by the

ranking of a receptionist as senior.

The practice manager describes his influence at the boundary between the practice and

outside agencies. For the partner, there were other hierarchical relationships which she sensed

as being that with the medical profession and government agencies. These relationships with

external bodies were expressed in terms of fear and lack of trust. I now examine trust and its

relationship with power and hierarchy.

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Power, hierarchy and trust.

The extended team

The informants from the extended practice team describe a ‘taller’ and more remote

hierarchical relationship with their managers. The informants feel keenly the ‘gap’ between

themselves and their managers. There are expressions of not feeling valued and, as for the

partner, a lack of trust in themselves by their managers.

Trust surfaces here as a theme and although not uniformly so across the practice nucleus team

is felt more positively than for the members of the extended team. It emerges as a mediator in

the power and hierarchy relationship, and in turn plays its part in the learning and culture of

the practice. A lack of trust negates the relationship with management and deflects learning

into more sterile areas of learning. By this, I mean the professional’s innate curiosity or

creativity is blocked by the need to satisfy targets or the collection of data which in itself may

be of no interest to the professional. This tension between accountability and responsibility is

influenced by the hierarchy and control within the NHS. In her narrative the district nurse

explicitly draws a distinction between accountability and responsibility and this is implied by

the health visitor and McMillan nurse. The power of accountability was exerted through the

use of rules and regulations. Accountability produced a set of negative cognitions which were

part of the social discourse and negated the individual professional’s sense of responsibility.

Accountability was reified through the requirements to collect data which the informants

reported was never discussed which in itself created a lack of trust.

An area within this discussion that did not link entirely with the above groupings was the use

of individual power or influences to further a career. For the McMillan nurse there was the

implication that her manager used her position to go on courses and training in order to “be

away from patients” and an implication of a lack of trust in her leadership.

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External control was mediated through the rule and regulations which formed part of the

contract between the practice and the NHS. The contract exerted financial control. In turn,

this influences the learning opportunities for the informants. These opportunities were more

readily available to the doctors rather than the receptionist staff. The opportunities for

attending courses for the informants from the extended team were limited by the control

exerted by their managers.

Within the Practice nucleus team

The cognitive interplay between accountability and responsibility for the individual and its

collective reification within the practice team created an implicit discourse around the issue of

trust. The level of trust was variable both within and between the hierarchal layers of the

practice nucleus team. This has been exemplified by the dissonance between the author and

the salaried doctor, the relationship between the practice manager and the receptionists and

within the administration team. This was not a persistent theme during the course of the data

collection, but through these episodes, insight is gained into how power and hierarchy were

tacit within the practice culture even though leadership encouraged a flat hierarchy. Trust was

buffeted by these episodes within the practice. Power used inappropriately by a member of

the practice nucleus team as exemplified by my use of the label ‘Senior’ created dissonance at

the deeper levels of the practice culture.

For the informants, the discourse related to trust, power and hierarchy crystallised into a

theme about the nature of being a professional and professionalism.

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Professionalism

Within the transcripts the term “being professional” emerged as a recurring theme. This term

was used by all the key informants. In particular this term was noted in the discourses of the

receptionist and practice manager whom an outside observer would not intuitively regard as

belonging to a member of a profession.

The Oxford English Dictionary defines the noun professional as

‘A vocation (my italics) in which a professed knowledge of some department of learning is used in its application to the affairs of others, or in the practice of an art founded upon it’ and in a wider sense as this 16th century usage would suggest ‘any calling or occupation by which a person habitually earns his living.’

There is an element of performance within the term ‘professionalism’ which the OED

supplements its definition as ‘a professional quality, character, method or conduct’

In the previous section I described the issue of power and hierarchy as perceived by the

informants. The question arose from my diary notes and discourse with the informants as to

what was ‘being professional’?

The partner’s view

As a member of the medical profession, the partner’s comments centred on her profession’s

values. In addition she discusses this in terms of “doing your job properly”. Within this she

said that “doing your job properly” included “Being satisfied with what I am doing, feeling

happy. Putting templates on computer so that they come out right”

Her observations covered the spectrum of definitions. She started by alluding to the

Hippocratic Oath. “Practicing your profession, codes, the Hippocratic code”, but did not

elaborate on “code” as this term did not satisfy her.

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She elaborated “being professional” with a strong sense of cognitions and listed these as

“Being polite in your daily life Not gossiping discussion about patients Having time Being relaxed in your role Dress nicely By thinking of others rather than yourself Like to be learning more, going to courses, lectures and being excited about research”

There were areas of frustration within “being professional” related to stultification of

creativity and innovation.

“Living in a box, you’re not a human being Lots of pressure in the medical profession to be in a box There is pressure from other doctors You would think having been trained you could be let loose”

‘Being professional’ for the partner had another perspective. When asked what was ‘not being

professional’ then a sense of ‘a stage’ is obtained. “Talking about the patients behind the

scenes-but it is necessary otherwise you become cranky. Looking scruffy”

The partner when expressing herself as ‘being professional’ is someone who gives a

performance on a stage. This had an internal tension for her, “being relaxed, by thinking of

others than myself. Like to learn more, going to courses, lectures and being excited about

research”. This was countered by “living in a box, you’re not a human being. Lots of pressure

in the medical profession to be in a box and pressure from other doctors, living to and

acceptance of a code”. At the boundary with the world of the practice it was about “dressing

nicely, being pleasant and happy, having time.”

Performance was constructed for the daily interaction with patients. The partner performed or

sensed the various facets of being professional as part of her consulting process. ‘Being

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professional’ was also present in her interactions with the practice nucleus team. ‘Doing

audits’ was ‘part of the job’ and sensed as ‘being professional’.

Her performance of ‘being professional’ was part of the daily discourse which was distinct

from socialization. Conversations with members of the practice team could be entirely ‘being

professional’ or have a social nature or a complex mixture of both.

The perceptions and values described by the partner are those that might be expected to be

present in someone who has entered a profession and institutionalised by that body. Two

strands of ‘being professional’ emerge. The first is characterised by the internalisation of

growing up in her undergraduate and postgraduate education and the development of the

resultant performance. This coexists with the second strand of ‘being professional’ which has

themes within it which are more generic to a coexistence within the workplace. The latter

themes are now explored through the remaining key informants.

The Practice Manager

The practice manager differentiated between “doing a job” and “being professional”. His

understanding of “being professional” related to the sense of vocation. Although he was “paid

to do a job”, “being professional” was doing something not on the job description, it’s not a 9-

5 job”. Like the partner, the practice manager had a sense of performance’ in relation to the

service delivered to the practice’s patients. His ‘performance’ related to time and efficiency.

“To have a courteous manner, have time for a patient. It’s the total service that you deliver to patients and is adjusting to what is needed at the time. (Its)... Doing a task within a reasonable time, being efficient, being organised”

“Being professional” for the practice manager was about a quality of service.

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“Give the best service we can, doing something that’s not on the job description” “If we fall short of giving the best care we can, we try to find out what went wrong, why we didn’t do it”

The practice manager related “being professional “to some wider themes. These were about

leadership and keeping up to date. “Motivating people, encouraging people and

reading the Institute of Managers journal at home.” He recognised there were negative

cognitions to “being professional”. These related to confidence, frustration and anxiety. These

he listed as

“Going paperlite, a patient complaint, a receptionist worries about the computer link (between the practice and the hospital laboratory), about delays of getting decisions from outside bodies, about managing personnel, frustration with the computer supplier”

Comment

For the partner and the practice manager there are similarities. They describe positive and

negative perspectives on ‘being professional’. Both describe a desire to go beyond the “9-5

job”. Their performance with the public is about striving to achieve an ideal. This is sensed

rather than overtly stated. The achievement of this ideal is the outcome of a dynamic tension

between a professional value of autonomy and fear of coercion from external professional and

government bodies. The partner and practice manager have a professional value of autonomy

which is contextualised in quality. The latter is an internalised perception which resents the

barriers to achieving this. The source of these barriers was perceived as coming from outside

the practice. I summarise the practice manager’s and partner’s sense of ‘being professional’ in

the following diagram.

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Being professional

Internal“By thinking of othersrather than yourself

Like to learning more”

External“Courteous, being pleasant

Dress nicelyBeing efficient

Doing something noton the job description

InternalLiving in a box

You’re not a human beingFrustration with a computer supplier

ExternalDealing with

a patient complaint

What purpose can be derived from the “being professional” values? I would suggest that

‘being professional’ has a purpose in developing and maintaining trust between two

individuals. There has been an internalisation of a professional code. This internalisation has

positive and negative attributes.

In turn there was a distillation from within the informants with a common positive theme of

delivering a quality of care.

“By thinking of others than yourself, having time … (for the patient) It’s the total service you deliver to the patient, giving the best service you can” (practice manager)

The partner and practice manager had negotiated their own meaning of ‘being professional’

from the interplay between the internal tacit understanding within the practice nucleus team

and the external bodies. For both this understanding of ‘being professional’ had the potential

to modulate their perception of information and transformation of this into knowledge.

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‘Off stage’ and away from the interface with patients, ‘being professional’ was still present

with partner continuing to be aware of the professional code and sensing that she may be

breaking her perception of that code with its strong emphasis on confidentiality. To continue

the theatrical metaphor, the practice manager’s primary role was in the wings and behind

stage. There his ‘neo-medical professional code’, a distillation of personal, practice and

professional medical values shaped the interpretation of the information from across the

boundary and had the potential to influence the ‘script’ between the actors within the

consulting room.

The Receptionist

For the receptionist ‘being professional’ was described more in terms of ‘a job’ rather than

‘vocation’. The receptionist described ‘being professional’ was about “coming in to work and

do work. No biased attitude to anyone or anybody. Not to discuss patients’ problems, treat

every one the same”

The receptionist distinguished her role as being different within the sense of ‘being

professional’ and implied a hierarchy was present between those who were professional and

not professional. “I think it’s very good that professional staff involve non professional staff.”

‘Being professional’-accountability and responsibility

This spectrum of ‘being professional’ encompasses the definitions both of vocation and as an

occupation. Within the practice hierarchy, this is vocational for the doctor and here there is

dynamic tension for her with vocation meaning a desire for greater autonomy which is

negated when she considers the wider medical professional institution across the external

boundary. She senses the tension between responsibility and the accountability inherent

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within a professional code. For her the element of accountability implied that the outer world

mistrusted her with its demands for audits and other data. Accountability was the ‘job’ rather

than the ‘vocation’ of being professional.

To a lesser extent this was mirrored by the practice manager. For him accountability was part

of his contract and a different personal development of having been an employee rather than

employer. There might be an expectation he would have felt more comfortable with or was

more likely to default to a position that relied on accountability. From the data, the opposite

prevailed with an adoption of some of the professional medical code pertaining to care or

quality of care. His values of responsibility and vocation were a synthesis of personal values

nurtured from within the practice culture and lead by the partners.

The practice nurse views contrasted with those above. It was clear she enjoyed her working

life.

“It’s a lovely job, its varied, you’re your own person really, you can organise your day yourself. Just to look after people really, that’s all I wanted to do”

This tension between accountability and responsibility within “being professional” is

highlighted further when described by the district nurse a member of the extended primary

care team.

The District Nurse

The district nurse described “being professional” in terms of the values of her profession

being “honoured”.

“It’s about showing your profession in a good light, being an advocate for your profession. Being professional is being accountable and is about competencies”

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For the district nurse responsibility was an innate moral or human value. “Feeling responsible

for something is innately human.” Accountability for the district nurse was connected with

the documentation that she was required to complete. This was resented.

“District nurse work documentation is heavily based on accountability. District nurse work is bogged down by documentation”

In turn the documentation and its reification in terms of accountability as

“Accountability depresses or distracts from motivation. Accountability is a lot of repetition, risk management, fear of doing harm”

She described the documentation that was required as

“Keeping copious documentation, caseload information, entering details into a big diary. The trust requires information as well. How many complex assessments, average age of caseload, how many flu injections, fill assessment forms for medication, fill forms who are at risk from pressure (sore) damage, mileage, time spent seeing patients, enter all of this into a hand held computer”. (My diary notes record her tone of exasperation and frustration)

In terms of “being professional” accountability was “the job” rather than the vocation which

was enshrined within responsibility. Similar accounts were obtained from the health visitor

and the community psychiatric nurse with accountability described in terms of gathering data

about a wide range of activities.

Responsibility, accountability and being professional.-summary

Power and hierarchy are implicit within an organisation. It was therefore inevitable that these

themes would surface directly and indirectly within the research. Power is understood ‘as an

influence upon’ and hierarchy is explored with the informants to compare and contrast its

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place within and without the practice. From these twin themes certain values emerge for the

informants.

Responsibility

These might be characterised by the individual’s sense of purpose in terms of responsibility.

This is linked with ‘being professional’ and although not explicitly voiced in the informants’

transcripts a value of caring. The latter was sensed through responsibility and ‘being

professional’. “Being professional” was described by the informants in terms of going beyond

the job description, “by thinking of others other than yourself”. Caring was implicit in these

thoughts. Caring also had a performance and this was mirrored in the comments of the partner

and the practice manager (e.g. “being courteous and dress nicely”). The performance was

intended to reflect the individual’s purpose was to care and respect the people for whom they

had a responsibility.

Accountability

Accountability is sensed as external to the informant and is shaped by the rules and

regulations of their professions and in broad terms the NHS management. There is a tension

between responsibility and accountability and I would suggest this shapes the informants’

sense of social reality. In turn, the tension that exists between accountability and

responsibility has an implicit influence on learning or knowledge and its transformation. (see

diagram).

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Informant’sProfessionalresponsibility

Informant’sAccountability

Power andhierarchy

Modulated by trust

influ

ence

s

influences

Informant’sLearning confidence

Influencedby

Power and the practice building

Meetings and informal learning are discussed elsewhere, but within this discussion, I wish to

address the issue of the relationship between power and the practice building. Trust was

implicit within the informal and formal meetings which were held in the practice building.

The discourse within some of the meetings was about making sense of the rules and

regulations.

To return to the relationship between the building and trust I examine the relationship

between the spaces as defined by the geography of the building and the artefacts which

reflected the themes of hierarchy and power. These artefacts appeared to be used more in

certain areas of the building. The identification of the artefacts had been derived from the

informants’ transcripts and field diary observations. I then used these as foci for further

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discussion with the key informants. The latter were the partner, practice manager, practice

nurse, senior receptionist and the district nurse.

The names of the artefacts were written on separate cards and then the informants were asked

to discuss whether they thought there was a relationship between the artefacts and the areas of

the building (e.g. a relationship between the minutes of the practice meetings and the seminar

room). These replies have been distilled as simple Yes/No answers. The results have been

tabulated and are appended (Appendix2). This method was similar to Spradley’s in which he

uses cards with informants to ‘discover cultural themes’. It is not intended as a quantitative

piece of work but to help inform an overview of their perceptions. The cards acted as prompts

for the informants for further discussion in addition to the Yes/ No responses.

The artefacts were a mixture of physical objects, organisations and values. The latter were

either derived from the informant’s transcripts or had been noted from field diary

observations as being important to the practice culture. The layout of the practice building is

appended which show the plans of the ground and first floor (appendix 1). The following

table lists the artefacts.

Objects

Letters Primary Care Development Centre Practice and Professional Development Plan Practice minutes

Organisations

The Government Primary Care Group / Trust Clinical governance /Audit

Values

Authority Being professional Leadership Responsibility Time

The salient features from the informants’ tables appear to be that the seminar room was linked

with ‘being professional’ and ‘responsibility’. Other areas such as the corridors and doorways

were less likely to have a similar association with these themes. Artefacts such as the PPDP

and practice minutes had no linkage for the majority of the informants. As artefacts, these

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documents had little meaning for the informants and were viewed as objects that complied

with rules and regulations. Apart from their own working area the seminar room was linked

with the artefacts discussed. This is not surprising given that the informants were more likely

to formally discuss the physical artefacts listed.

Only limited conclusions can be drawn from this piece of analysis. For the informants the

seminar room acted as a focus for the artefacts discussed. Their presence was sensed

elsewhere but overall more diffusely. Consulting, seminar and treatment rooms were more

likely to be linked with these higher order values such as being professional. Corridors,

doorways and the secretary’s room were linked with artefacts such as practice minutes and

information from the primary care development centre and the PPDP. By way of contrast my

field diary records that for me the seminar room was a quiet place and was where I held

tutorials with the general practice registrar or the medical students.

For the other informants it could be postulated that the seminar room with its function for

them as a formal meeting place took on other meanings. Being professional and responsibility

were linked with the purpose of the room for the informants. I would suggest that the seminar

room and its purpose for the informants was an opportunity for them to reaffirm their

professionalism and sense of responsibility.

Summary

Through the exploration of the emergent themes of power and hierarchy within the practice

and the extended teams, the value of responsibility emerged. Within this context, it is useful

to label this further as professional responsibility to include the informants’ notions of ‘being

professional’. In turn, there is a tension for the informants with the rules and regulations

characterised as accountability. This is not an absolute polarisation but it was apparent there

was interplay between responsibility and accountability. The resultant modulation was

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influenced by the hierarchical structure of the organisation and, as a generalisation, the

presence or absence of trust. From an ontological point of view, power and hierarchy with the

values of responsibility and accountability form part of the informants’ social reality. That

reality also expressed itself in terms of the geography of the building. From the card exercise

which explored possible relationships between the geography of the building and the artefacts

related to power and hierarchy, the informants attributed a link between the seminar room and

those themes.

For the outside observer the reality might only be viewed through the data available through

the rules and regulations and reports written for the informants’ managers. In fact, there is a

dualism at play. The informants’ construction of this part of their social reality was through

the value of professional responsibility and where possible a transformation of the

accountability environment. The latter process was to comply with rules and regulations but

not to actively engage with accountability. This transformation is exemplified by the data

collection and the rules of the professional organisations.

This picture is incomplete since within the body of this chapter trust is part of the modulation

between responsibility and accountability. Finally, I would suggest that the resultant level of

confidence for the practice and extended team in tolerating the tension between professional

responsibility and accountability influenced the ability to learn.

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Chapter Six: Learning in the Practice-informal and formal

Introduction

In this chapter I describe the learning both formal and informal that took place within the

practice and during the course of their working day. I use formal learning in terms of the

learning that took place through the planned acquisition of knowledge. Examples of this

might be attending a course, study days, and formal meetings. Informal learning is considered

as learning that takes place experientially as part of an informant’s working day, and through

problem based reflection. The distinction is to a certain extent arbitrary with potential for

overlap. The results of the transcript analysis and field diaries gave multiple themes that

related to ‘how learning happened’ and the mediation of learning through the use of artefacts.

The themes are derived from the analysis of the transcripts and field diaries. First, I describe

the informal learning from the practice nucleus informants.

The Partner’s learning

The partner’s initial thoughts about how she learnt were about “reading, meetings, writing to

and receiving letters from consultant colleagues and using the computer in my consulting

room”

Her description was fragmented with different tools being used in different areas of the

practice or at home. As will be seen, there was a perceived influence from external

professional bodies that she felt influenced or drove her learning. She described reading

professional journals e.g. British Medical Journal, British Journal of General Practice,

clinical guidelines and a magazine called Bandolier (evidence based medicine). These were

read partly in the practice and at home. She said

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“I would read more journals if they were placed in the coffee room in the practice. I’m reading more because I’m doing an exam”.

She described reading other sources of information. This was material from the Primary Care

Group and associated NHS bodies, “Primary Care Group meeting minutes, guidelines”

Attendance at outside meetings was perceived as conduits of information. She perceived

attendance as a means of gathering information. The meeting was a source of information. “I

attend clinical governance meetings and quality ‘lead’ meetings” (The partner held the lead

for clinical governance within the practice)

She described how she learnt through

“writing a referral letter, by writing about a condition which ‘isn’t cop able’ with in a practice”

She found that she learnt through describing the patient’s problem to a consultant. The writing

of the letter and thinking about its content and context appeared to be a reflective process and

allowed her to learn through the written articulation of the problem.

“You read the patient’s notes, the bits you write during the consultation and this reminds you of what the patient has said and what you have done. You tell him about the patient and what you’ve done so far. I use information (about the patient) that is in my head, psychosocial aspects are in your head”

The letter was handwritten and then typed up by the practice secretary, read by the doctor and

signed. A copy of the letter was placed in the notes and a copy scanned into the computer.

The format of the letter was written in a style learnt from her days as a junior hospital doctor.

She used the start of her letters as “presenting complaint”. The ‘case’ would then be

encultured using the language of the accepted biomedical model to facilitate communication

with hospital colleagues. The written narrative used had the accepted terminology and

abbreviations. This narrative would then change as she introduced her experiential knowledge

about the patient’s psychosocial setting.

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Comment

At this interface there is transformation of knowledge, from the knowledge learnt at medical

school or in postgraduate training to ‘knowledge’ peculiar to that patient and the doctor and

the practice. There was a synthesis of knowledge obtained from medical school and her

postgraduate training and experience which in turn was entwined within the accepted

professional cultural mores of letter writing. In the consultant’s reply there was further

opportunity of knowledge transformation. The process of articulation through the

correspondence was both reflective and lowered the threshold to curiosity and enquiry.

Letters from consultants were discussed between the partners when the daily post was read

during coffee breaks or over lunch at home.

These discussions were not only clinical knowledge but also about feelings such as

“confidence in making the correct diagnosis, did the consultant think I was wrong to refer?”

Medical tradition with its implicit hierarchy between general practitioner and consultant

persisted and in doing so acted as an additional external agency for the partner and her

learning.

Templates and learning

Problem based learning was also captured within the computer with the use of ‘templates’. A

template was a grid on a screen on the computer. Its purpose was to act as prompts for

specific clinical disorders. Their construction was done in a period of time before the working

day starts. The partner gave the example of

“HRT (Hormone Replacement Therapy), Ischaemic Heart Disease, Osteoporosis and Cerebrovascular Disease”.

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6-4

The prompts would be to help remind to enter data related to the clinical aspects of the

disease (e.g. blood pressure, urine dipstick test results). The templates were reconstructions of

knowledge from a wide range of sources. The reconstruction was therefore a summary of the

disease process. Each summary was a distillation of knowledge acquired from books,

journals, local clinical guidelines (e.g. from local working groups for diabetes, consultant

guidelines) and the partner’s personal experience and judgement. A constraint was that the

individual templates could not contain all the information needed because of the limitations of

the computer software. The templates were a powerful tool in terms of their ability to remind

and prompt improved quality of patient care.

The partner produced twenty six templates for a wide range of conditions that the partner

thought were common and important problems. These were a mixture of templates that were

personal knowledge needs and templates that were derived from discussion with myself, GP

registrars and the practice nurse. The latter were usually templates that related to chronic

disease management (e.g. asthma, diabetes). The production of these had also been prompted

and refined by the practice engaging with the RCGP Fellowship by Assessment process in the

preceding two years. (An example of a ‘headache’ template is described in the chapter four).

The partner said “the templates were good for auditing. The process of constructing the

templates on the computer acts as a reminder for the clinical aspects of the disease”. On

another occasion she reflected further on experiential knowledge “the bits I carry in my head”

This she amplified as

“There are some things in medicine that you know, that you can’t write down, there are some things that you know you carry in your head that you cannot explain to someone else”.

This was sensed as experiential knowledge from which is derived an intuitive wisdom or

‘sixth sense’ that guides or acts to alert an experienced professional when symptoms and

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signs presented by a patient are either not typical or minimal. Intuition was informed from the

experiential knowledge of her medical practice.

The partner’s learning relied on interaction with a variety of artefacts as the following concept

map describes.

Partner’s learning

Constructs

Reorganises

knowledge

Discussion of ‘cases’ with

other members of

the team

socia

lisat

ion

Written synthesis

of knowledge

Prom

pted

by

doin

g an

exa

m Selectively

reads

Partner’s learning

Information from PCG/T

MeetingsTemplates

Experiential reflection

ReferralLetters/letters from

consultants

Reading journals

The partner and the politicisation of her learning

For the partner there were political attributes or perceptions to her learning and issues of

confidence affected her choice of topic and learning method. She perceived her learning as

being influenced by the government using the metaphor of Orwell’s ‘1984’ (1984, Orwell G.

1949)

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6-6

“Big Brother telling us what to do and think, doing what I’m supposed to do, at work your mind is grabbed, squeezed and so are your emotions, I feel just a number.”

There was a sense of isolation and entrapment within her professional role and in turn this

affected her professional autonomy and therefore her learning. She described this as

“Sieg Heil-ing- there are lots of ‘have to s’; have to be available at certain hours, have to see patients at certain times, have to write to letters at certain times, got to get things right, got to do what the government tells you to do, got to do what the PCG tells you to do.”

Her professional learning autonomy was demonstrated through the work she was doing for

the professional qualification of membership of Royal College of General Practitioners by

assessment of performance (MRCGP MAP). The following example illustrates the desire to

satisfy her curiosity and creativity, but also there was awareness that there were significant

political influences on her learning. There is a tacit but resented acceptance that outside

bodies played a part in her learning.

“It was interesting learning about screening for diseases like carcinoma of ovary, and diabetes. It was interesting because there is not much written about it. Also it’s not being rammed down your throat every ten minutes like hypertension. I resent the degree to which other topics are imposed.”

Her interest outside medicine was in Art and from this world she used a quote to illustrate her

resentment of the external pressures to learn about particular topics.

“To describe is to destroy, to imply is to create” (Bill Varley lecturer Fine Art Newcastle personal communication)

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6-7

Partner and learning styles

When she was considering her learning, there was a tension between the learning styles

inculcated through her undergraduate and postgraduate training and the learning that she was

engaged with on a daily basis. There was a lack of confidence in her experiential knowledge

and a need to defer to a perceived ‘greater’ knowledge held by hospital consultants.

My field diary observations record that the partner was concerned about her learning, and

yet, there were examples on most days when it was apparent she was reflecting and gathering

more detailed information about patient’s problems. At times, there was mismatch between

her perception of learning and obvious learning activity. The mismatch was driven by her

medical training in which consultants were the holders of the knowledge and expertise.

“I don’t learn about anything these days. I must have a certain degree of focusing (about) what I want to learn and my focusing is about what consultants are doing”

This quotation was noted whilst she was sitting at her desk in her consulting room at the end

of a surgery when I noted she was reading a book about interpretation of pathology

investigations and a letter from a consultant giving advice about a new form of diabetic

treatment. In this scenario a patient problem (an abnormal laboratory result and its

interpretation) had been shared with a consultant colleague who in a written reply had given

some advice. The letter and the book acted as prompts in two ways. The first and most

obvious was that there was a sharing of knowledge and experience and secondly since the

letter was from a consultant it had authority. Her prior medical education experience

conditioned her acceptance of the consultant’s interpretation.

There were frequent informal professional conversations about clinical problems. These

covered a wide spectrum of areas of knowledge and often about problem solving. The setting

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of these conversations was often over a cup of coffee or during the evening meal at home.

Two examples of this were

(Both in the partner’s consulting room) ‘About paediatric problems, a child with a foot deformity- we look it up in a text book. We learnt about the condition and its association with other conditions’

‘The management of depressed patient, discussion of the options, discussion about social services and psychiatric care’

These examples did not have the authority of a consultant’s opinion but were similarly

‘knowledgeable’.

Reflections on the doctors’ informal learning

In this section my purpose is twofold. First, I consider some further examples of informal

learning which provide a comparison and some contrast between the partner’s learning and

my own learning and secondly, to begin to consider some of the influences on informal

learning.

External agencies and learning

It was apparent that informal learning was a complex phenomenon. It was not done as an

individual activity shielded from other influences. Within this practice these influences were

the doctor’s cognitions which in turn had been influenced by individual learning history and

the influence of external academic and professional regulatory bodies. To describe this, my

field diary notes record how the partner “wanted to go part time in order to pursue other

interests and to feel human.”

When reflecting on a patient’s complaint and the inevitable consequential loss of confidence

and low morale this caused in myself the partner comments on how historically

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“Through their work professional artists such as the ‘Dada’ movement, e.g. Kadinsky and Pollock had expressed their disgust through their work at the way government controlled the population. I can’t understand why the profession doesn’t rise up in arms or protest at the way we are treated”

Although I could identify with the sources of informal learning identified by the partner I

would add some additional and potentially contrasting influences. These were my

involvement as a GP trainer for the local vocational training scheme and as an examiner for

the Royal College of General Practitioners. The latter role required preparation in terms of

detailed reading around clinical topics in order to write suitable questions. As an example in

preparation for one exam paper I record reading about

‘Causes of chest pain, hepatobiliary disorders, lumps in the neck, causes of visual disturbances, allergic disorders’.

The inherent values of these professional bodies personified within the network of ‘like

minded’ professional colleagues will have influenced me and the mutual experience of

working in the practice. These influences will have been through the explicit standards set by

the vocational training scheme (e.g. the summarising of notes) and through my perceptions

and cognitions of the expectations of these external bodies (e.g. keeping up to date through

setting and writing questions). These standards are transformed through my leadership within

the practice which in turn interacts with other external or internal influences (e.g. financial

support from the PCG/PCT).

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Author’s learning

Financial PCG/T

RCGPExaminer

GP TutorPostgrad.Deanery

GP Trainer

Nee

d to

mai

ntai

n po

litic

al

and

finan

cial

wel

l bei

ng

Maintainknowledge

Politica

l influ

ence

Network with Other GP tutors

Strategic influence

Pre

para

tion

for

tuto

rials

Network with

other GP

Trainers. Peer re

view

National network

Peer review

External bodies: crossing boundaries

Additional themes to those of the partner

These influences on my learning are in addition to and interact with the sources of informal

learning described by the partner. The relationship between the sources of learning is dynamic

and complex. Over a period of a month (December 1999) in the research I noted 19 items of

clinical and non clinical topics of informal learning. These were

Clinical Non Clinical

The consultation x2 Internet training Diabetes PMS Audit heart failure ‘Paperlite’ PSA Flu vaccination campaign Evidence based medicine Pneumovax campaign Critical appraisal skills Patient access Nurse prescribing Continuity of care Breast cancer screening Risk Varicose eczema Hypertension, Dyspepsia

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These topics were explored in varying amounts of length and depth. Some formed part of

tutorials, others were informal discussions in different parts of the building or formed part of

a meeting. The influence of the external agencies was internalised within me and their values

in turn informed my leadership. Involvement with institutions like the Royal College of

General Practitioners and its progressive thinking (e.g. FBA) permitted anticipation of future

PCG rules and regulations with regard to quality markers.

External agencies were therefore given permission implicitly to cross the boundary into the

practice culture. This permission was mediated by myself and as such became artefacts in

their own right within the practice culture. From another point of view I was aware that I was

also using their presence politically to give the practice a more influential standing within the

PCG locality, and at the time of the research, the partners had made a considerable financial

commitment to the new premises.

The partners’ learning shared a common background in terms of their medical education.

Their subsequent development was shaped by their professional roles in the practice and the

development of the practice as a business. The external agencies that had the potential to

influence learning were perceived and adopted in different ways by each doctor. For the

author and in a leadership role the external agencies were adopted and adapted to sustain the

wellbeing of the practice. For the partner the relationship with external bodies was more

internalised and perceived as threatening and invasive.

Recording informal learning

During the course of this research, I purchased and installed software on the computer which

would allow nucleus members of the team to record their professional development plans and

any record of learning or training. This was an attempt to reduce the work involved in

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bringing together the material needed for the practice annual report which was a contractual

requirement by the PCT. Its introduction was discussed and demonstrated at a practice

meeting. Subsequently, I noted in my field notes that the software was not used in any way

and only infrequently by myself. Reasons for this related to the relative complexity of the

software and its use and informants reported difficulty in finding time to use it. From

observation, time constraints predominated and in terms of learning, these influenced the

predominant mode of learning which was through an oral culture.

As described elsewhere, the informants had little option but to respond to requests for reports

with written material. Although the written material was produced it was not discussed within

the practice and as exemplified by the extended members of the primary care team, data and

reports produced no feedback from NHS management. Informants within the practice either

between themselves or in conversations with extended primary care teams engaged in

frequent informal learning. This was invariably through informal discourse. The lack of

engagement with the computer in its role as recording of information was therefore doomed to

fail since the recording of data was resented due to lack of feedback and the inherent informal

learning culture was through conversation. The computer was preferred as a giver of

information to enhance those conversations.

Discourse and solving problems- the doctors

Although it was not the purpose of the research to look at the language of the informal

learning I noted that many of these conversations were about ‘problem solving’ patients’

illnesses. During these conversations, it was rare to see anything written down that recorded

the conversation. Professional colleagues used a compressed memory of events and a

narrative history, knowledge about local resources to help solve events and experiential

knowledge to help solve events. Examples which I noted during the research were coloured

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with ‘black humour’ and reflections on personal professional attitudes and personal

philosophy. It was unusual to observe an in depth discussion using an evidence based

approach to a clinical problem. A conversation witnessed between two doctors working in the

practice about patients they had seen with mental illness covered areas about the overall

family context, previous experience with similar problems, and psychosocial issues relating to

stress and distress. Narrative was used as a means to be creative. Social discourse stimulated

creativity. Informants felt able to explore problems freely and were able to take ‘acceptable

risks’ with their ideas.

On occasions there were three way conversations between the partners and the GP registrar. I

noted informal conversations in the coffee room and on the landing on the staircase. The

topics were clinical and non clinical and about

‘Cerebrovascular disease, birth and marriage certificates, exasperation at the number of home visits’

I explore the theme of the site of these conversations and the influence of the building will be

considered as a separate section.

The Practice Manager and his learning

In his description of learning, the practice manager recounted the different opportunities for

learning within and without the practice. These covered meetings, national conferences,

reading, teaching and seeing pharmaceutical company representatives (‘drug reps’). Learning

was not approached in a structured fashion and at a superficial level there was no apparent

relationship between the different methods of acquiring information. His learning is now

discussed in more detail.

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As an example of the ‘oral learning culture,’ he described going to a national meeting about

sharing good practice.

“It’s an opportunity to see what other people are doing, to use their ideas, share information by talking to others” “It’s easier to get information that way”

“It’s about trading, gathering and giving information”.

He elaborated on his informal conversations that he had

“Short conversations with partners, GP registrars and medical students, I listen to the drug reps, drug reps use me as a filter. Day to day banter”.

The drug representatives would tell the practice manager about new drugs. The practice

manager would relay some of his information to the partners. In return the drug

representatives provided sponsorship for food for lunchtime meetings.

He felt that information sharing was distracted or stopped if there other projects taking place

within the practice e.g. going paperlite in the practice. When compared to the partners there

was a shared purpose about providing a service for patients. For the practice manager he

shared a tension with the partners between personal curiosity and the perceived imposition of

change from external agencies.

His reading was informal and covered areas of clinical interest and where they could be easily

found. Learning had a browsing nature. He gave examples of how he had read about asthma

and the practice policy for hormone replacement therapy. His reading followed the national

medico politics and the medical financial magazines. He gave examples of “Pulse, GP

newspaper and Medeconomics”. During his lunchtime he enjoyed reading “Readers Digest

and completing puzzle books”

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“Scanning the journals, read leaflets in reception, repeat patient prescriptions and pick up names of drugs, hazards of a disease or treatment”

Teaching the general practice registrar was seen as a source of learning for the practice

manager. His teaching helped the registrar to understand the organisation of the practice. He

had acquired some background knowledge to the requirements for the general practice

registrar’s vocational training programme. This had been gained from informal discussions

with the author and from the registrars.

“What goes on in the background of general practice, what the practice team is, what the PCT is, how people sort of interlock together”

He was aware the registrars learnt about a wide variety of clinical areas which he referred to

as

“The bread and butter side of things, basically about patients, they learn about heart disease, measles, chickenpox, the cough and the sore throat” “They do a further two years experience in the hospital, go on to study for the RCGP exam, get their training certificate”

There was an ‘osmotic’ feel to his learning. He had acquired an understanding of the roles of

the various members of the extended team largely through informal conversations with the

different team members. He had internalised an understanding of the contextual information

within the practice. He gave examples that

“District nurses do blood tests for the housebound, give flu vaccinations to the nursing home population” “Health visitors dealt with children providing an educational support role” “The community psychiatric nurse has a major role within the practice providing help with stress in patients and helping patients with phobias”.

As might be expected he had a greater knowledge about staff working within he building. He

described the practice nurse as

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“Needing as much skill as a doctor, that she helped support the practice with health promotion, she went on courses with family planning and assisted general practitioners with minor surgery. She has her own clinic looking after asthmatics, diabetic patients, does all the immunisation programmes”

He felt his learning arose from being a “Jack of all trades” and learnt about people and what

they did “through day to day banter”. When asked about other professionals’ learning within

the practice he thought that the practice nurse did not learn. When discussed further, the

practice manager thought it was more important that the nurse engage more with the

o/Organisation than with clinical topics. This gives a sense that the practice manager had an

internalised concept that learning should be codified through the PPDP.

In summary, the practice manager’ learning was largely informal. Knowledge was acquired

through informal reading of a variety of sources of information that were readily available

within the practice. Practice policy with regard to ‘drug reps’ caused their information to

come to him initially rather than the partners. His informal role in this setting as a filter lead

to him gather information which he could choose to pass on to the partners. Networking with

colleagues was an important source of information both inside and outside the practice.

The concept diagram summarises the drivers for the practice manager’s learning which were

derived from interviews and field diary observations.

Page 203: Paul Milne Thesis

6-17

Practice manager’slearning

Drug representatives

ReadingLeaflets

magazines

TeachingGP Registrar

Meetings

netw

orks

Personalinterest

Mee

ts w

ithLe

arns

abo

utN

ew d

rugs

Motivationenthusiasm

The Practice Nurse and her learning

The practice nurse’s learning had informal and formal perspectives. In informal mode, the

practice nurse’s learning was through “chats” with the district nurses and the reception staff.

There were similarities to the partners’ referrals in that she was able to informally refer

certain types of patient problem to her district nurse colleagues. This was mainly in the area

of the management of the assessment and dressing of varicose ulcers. The district nurse had

trained and had an interest in the management of this problem. The practice nurse would meet

informally with the district nurse to discuss this sort of case. Learning took place through the

discussion of the case. Other sorts of learning that she described were about disease processes

through the blood tests that she was responsible for obtaining from the patients. She gave the

example of her improved understanding of the monitoring of under or over active thyroid

disease.

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Practice Nurse Learning

Patient problems‘Cases’

Attendance Courses

Blood test investigation

resultsDiscusses with

partnersDisc

usses w

ith

Distric

t nurse

partners

Net

wor

ksC

alib

rate

sA

cqui

res

new

K

now

ledg

e

My notes record that the practice paid for the practice nurse to attend courses on coronary

heart disease and updates on gynaecology problems.

This section of the analysis has been framed within the general term of learning. Interestingly

informants referred infrequently to their attendance on courses. Training or informal learning

remained internalised within the informant and the opportunities for crystallisation and

reification of knowledge within the practice were lost. Informal conversations with the

practice nurse about a recent coronary heart disease certificate course which she had attended

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“Whether the course was good?” were met with comments from the nurse “The course was

good; it’s a lot of work”

Feedback was given in outline and informally. Similarly I recorded an informal feedback

when she had attended a course on ‘Best practice and shared care in respiratory disease’. She

relates her comments standing in my consulting room where I was sitting writing up some

case notes during lunchtime. I listed her learning as

‘Learning about new medication, about a shared care book, how the accident and emergency and minor injury unit run, about (the role of) nurse practitioners’

In attending the course there was a sense of a need to gain reassurance and an internal

calibration of her professional knowledge. Equally, she expressed a need for socialisation and

networking in terms of “I need to know what is going on.” Her description of the course was

sprinkled with phrases such as

“It was something different, it was really good, when you’re single handed you can end up not keeping up to date”

She did not enlarge on any detail and subsequently it required persuasion on my part for her

to give a short presentation at a practice meeting. This reluctance was also mirrored by the

partner and although not fully explored, the reason for this was sensed as the internalisation of

information and its transformation to knowledge was a private experience. There was a lack

of confidence in sharing that new knowledge with others of the practice nucleus team even

though in terms of social discourse there was a perceived trust between informants. A tension

was sensed within the social discourse in which trust was inherent and the sharing of

knowledge.

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The Practice secretary and her learning

Informal learning for the secretary was obtained through speaking to consultants’ secretaries

on the telephone to arrange an appointment, to expedite an appointment, through speaking to

patients, taking the minutes at practice meetings or at primary care team meetings.

Knowledge gained was primarily about organisation rather than clinical knowledge although

the two were linked when ‘cases’ were discussed with health professionals.

However she did have informal “chats” with the community psychiatric nurse, the

physiotherapist and with the doctors. In these, the context of a patient’s illness was discussed

in order to inform the need to expedite an appointment or if a patient had requested a private

appointment.

Practice secretary’slearning

PatientsMinutes practice Meetings/

Primary care team

Health professionals

Consultantsecretaries

Discus

ses

refe

rrals

Writes

Talks

abo

ut

Hospit

al ap

poin

tmen

t

date

s

Discusses referral letters

Appointment dates

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Like the practice manager the practice secretary’s role was of a ‘boundary keeper’. Her

external boundary was principally with secondary care with the writing of referral letters, and

liaison with consultant secretaries.

The Receptionist and her learning

The receptionist worked primarily within the administration and reception areas of the

practice. She expressed an overall enthusiasm for her job; “I enjoy the job, and to try to

learn.”

She was able to describe examples of the informal learning she had done during her working

day. This learning was often about acquiring information through her involvement writing

and reading the entries in the various books (i.e. day book, visits book, open access book, and

book for the chemist). Through this she said she learnt “Medical terms, names of drugs,

names of diseases”.

The receptionist would make frequent use of the information software on the computer. This

was called the Patient Information Leaflet system (PILS). She listed the information she

would come across as

“INR (anticoagulation) results, Flu injections, Allergy tests, Hearing tests, Urgent laboratory results (these were telephoned through to the practice and the message taken by the receptionist), messages from hospital doctors, child development data.”

From these sources of information she would take the opportunity to ask other health

professionals their use and meaning. My field diary notes conversations about

(with myself),

‘a patient with a cough, about the relationship between calcium metabolism and the generation of pins and needles, about diabetes and its control’

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At other times the receptionist demonstrated clinical knowledge acquired informally and then

applied to her role within reception. An example was of her acquisition of knowledge relating

to thyroid disease and its investigation. This was noted when she was teaching the partners

about the new computer electronic pathology links between the practice and the local hospital.

‘She had made links between the disease processes of over and under activity of thyroid disease and the thyroid blood test results. She had thought about how investigations could be used during the consultation’

She reported reading Family Health Service Authority magazines which were “lying around”.

She said she did not read clinical magazines. She gave an example of reading a dermatology

book which she would pick up and read when chaperoning a male doctor.

She described how she would learn about drugs or medications. She would combine

knowledge acquired from her previous post with the Prescribing Pricing Authority (PPA)

with information from health professionals who stopped “for a chat” in reception. She also

listened to the informal conversations between doctors and the nurses.

“Everybody converges at some point in reception; it’s probably the only place in the building that we all get together other than our practice meetings. I sometimes think you pick up more just in general day to day chatter.”

I noted examples of this sort of conversation between the community psychiatric nurse (CPN)

and a receptionist. The latter outside her role within the practice had a role in setting up a

bereavement group. There is a glimpse of learning from members of the extended team and

the sharing of information from other practices. I note she asked the CPN ‘about helping the

varying needs of the bereaved’. The CPN related her experience of how to approach

bereavement and enlarged her discussion about a primary care team meeting in a

neighbouring practice where the topic had been about bereavement.

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This knowledge was held within the confines of the setting and social context and relationship

of the informal conversation.

“I don’t do anything with the knowledge as such, it’s always there the knowledge and once you know it’s never forgotten”.

When discussing whether she had an opportunity to read she explained “I would feel guilty if

I slipped off to read something in the seminar room.” A tension surfaces for her with curiosity

muted by the role of her post. This surfaced again when she asked me

“Is it OK to go to a training session at the primary care development centre instead of coming to the protected learning time session with the rest of the practice?”

This was said with a sense of guilt and that she was being disloyal in addressing her learning

need which did not match that of the practice. In this example, the acquisition of knowledge

was potentially being influenced by the power and hierarchy within the practice. By way of

contrast, another receptionist informant when asked about how she acquired her information

confined her information seeking to the “demised and respite care notice board; I don’t look

at other notice boards”.

Within reception there would appear to be a spectrum of curiosity. When observed the notice

boards contained information across a range of topics. These notice boards had the function of

aide memoirs, social and celebratory, and ritualistic. Much of the information was out of date

which reflected little engagement with the sources of information placed on the notice boards.

The act of placing the information on the notice boards had a ritual function which

acknowledged the presence of external bodies. I noted

‘Information about the birth of a colleague’s baby Messages between receptionists

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Confidential letters from the Family Health Service Authority- these letters were labelled confidential and were about “Suspicious patients” (usually about patients who may be abusing medications Lists of patients who had been admitted, patients who had died, patients in respite care, patients needing follow up appointment (all of these I noted were out of date) Holiday rota for reception staff, practice secretary and practice manager Practice meeting dates, practice audit meetings Dr Milne’s action plan’

When considering ‘places to learn’ the receptionist commented that

“The table on the stairs (halfway landing) is a learning area. It’s a prime meeting point, four to five people can meet at this spot. It’s a central spot; it’s just outside reception, its easy access from everywhere. It’s because the books (visits book, message book, and district nurses book) on the table (on the staircase landing) are checked so often. The seminar room is a big learning area; it’s also a quiet and peaceful room”.

She thought that the kitchen area was “a chatty area. The kitchen area is where lots of things

can get discussed”

Informal learning was spontaneously undertaken. A receptionist commented that she would

ask the practice nurse “what a medicine is for?” Learning appeared to be about ‘grazing’

through the information which was available in the various rooms in the practice.

She said “she would read the posters, notice boards and leaflets in the nurse’s room”. When

thinking about information from the PCT she said she read

“The literature in the practice manager’s room, flicked through the newsletter from the PCT. She enjoyed reading articles on the personalities in the PCT e.g. the coronary heart disease nurse.”

The receptionist blended this innate curiosity with awareness that experiential learning was

important.

“Learning through experience is most important, everybody helps each other”

There was an oral culture of learning. She listed several examples of the sorts of information

that was discussed and exchanged in reception.

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“Information about people who have died, changes in people who are chronically ill” There was a lot of information about organisational changes or problems “About clinics for the day, do we have a dietician today, changes in the doctor’s routines, about a diabetic clinic, about an antenatal clinic, sudden requirements for a holiday”

She reported informal conversations with various members of the extended primary care team

“the health visitor, physiotherapist, McMillan (palliative care) nurse”. These were about

patients.

Receptionist’slearning

Health professionals

noticeboards

Computernotes

Leaflets,magazines

books

InformalconverationsIn notes area

Rea

ding

Placing of InformationRitual

Stim

ulat

e cu

riosi

ty

When considering how not to learn she said that

“It was going to Protected Learning Time sessions when all the practices get together, when the topic goes over my head and when the room is cold”.

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Attending courses for training was linked with socialisation. This was observed in the

administration area when two reception staff discussed attending a course on coping with

aggression. Attendance for one was dependant on “Who is going?” and “Can I get a lift?”

For the other who had already attended a similar course persuasion was made through

reflection on this previous course; “It was really good; I might come to this course”

I noted that attendance for both receptionists was dependant on the opportunity to socialise,

enthusiasm, and friendship. The content of the course was not explored and appeared not to

matter.

Multidisciplinary informal learning and the buildin g

For the practice nucleus team the acquisition of information and its transformation into

knowledge was through a variety of methods. It was achieved through the individual reading

leaflets, the computer and through the informal conversations that took place in several key

areas within the practice building.

The reading was unstructured and relied on the availability of the information within the

physical area where the individual worked. Reading was done in the form of ‘grazing’ on the

material where it lay and then moved on leaving the information where it had been found.

Within the reading of prescriptions or patients letters there was an inherent curiosity about the

use of a drug or the medical term or diagnosis. Reception staff in particular ‘grazed’ on the

professionals information or knowledge who were either passing through the reception area or

who ‘stopped by’ for a chat.

These informal conversations were brief but had an implicit purpose of the sharing of

knowledge. There was a merging of experiential knowledge between professional and non

professional. In doing so, this unconsciously flattened the inherent hierarchy within the

practice.

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The influence of the building and its design was important in these discourses. It provided a

literal and metaphorical framework for the informal learning and the

Organisation/organisation. The following example helps explain this.

The Staircase

The staircase in the building had a small ‘landing’, an intermediate platform area in which

there was a wooden table. The table acted as a resting place for two books. The first was used

by reception staff to record requests for home visits by patients and nursing homes and the

second by doctors and reception staff to record messages for the district nursing team who

visited on an almost daily basis to read and collect their messages. The home visits book was

read several times per day as doctors finished surgeries or were passing by the table on the

stairs. The message books stimulated conversation and the staircase and its little landing was

where people frequently passed each other. The little table and its chair invited the passer by

to stop and read.

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The practice building staircase

Building, organisation and being organised fused at this location. Informants with their own

cognitions shaped and influenced by present and past experiential knowledge, professional

institutions and health service management were led to stop in order to gather information

from the books.

Here on this small landing, there were frequent multi professional conversations which I

observed as ‘going beyond the practical solution’ that a particular patient problem required.

As an observer, the conversations on the landing were wider ranging and had a greater depth

and intensity than those observed elsewhere. The conversations crossed the boundaries

between the practice, the community and wider NHS organisations. Individuals from these

bodies through their daily activity of checking the message books engaged in informal

discourses. The following are examples of the many conversations that took place as a daily

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event. They are presented to demonstrate the variety of topics and the opportunity nucleus and

extended members took to cross professional boundaries and to give a texture to the

physicality of the staircase landing and its role as a ‘mini theatre’. The conversations

frequently covered a wide variety of topics but were predominantly of a clinical problem

solving nature.

(On the staircase)

Between three doctors

‘About a patient who has had a stroke’, which then flowed into a conversation about ‘birth, marriage and death certificates, numbers of visits and about a mental illness called manic depression’.

The latter was interspersed with black humour, sharing of experience about this problem,

professional attitudes and personal philosophy.

A conversation was noted about the Shipman court case and the role of the regulatory bodies

in the trial.

Between two doctors, a colleague who had retired some years before and was one of our

predecessors and a receptionist.

‘About the current flu outbreak, the retired colleague reports he borrowed the suture kit, there is much banter’

Between the doctors and the practice manager

‘Initially about a patient problem and then about the practice managers problem with solving an electrical problem’

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Between the author and the General practice registrar

‘About a career in general practice, solving a chronic care problem in an elderly patient, about a skin condition, handing over the care of certain patients whilst the GPR is on holiday.’

Other topics included discussions of our patients care by other NHS departments. These were

not always complimentary and centred usually on lack of communication. The starting point

for these sorts of conversation was stimulated by a patient’s request for visits.

On some occasions, the partner was to be found sitting at the table reading a patients set of

notes prior to going out on the home visit and in doing the act of reading produced enquiry by

a passing colleague. Requests for home visits as recorded in the visits book and the reason for

the home visit as recorded by the reception staff could at one level appear trivial. Having read

the message, the doctor responsible for the patient’s care in the company of another team

member would ‘unpack’ the patients and family’s history. Experiential medical knowledge

became interwoven with social and village history.

Between the receptionist and the doctors

‘The latter compared and contrasted her experience of working in another practice several miles away. This was laced with well meaning humour.’ ‘A conversation about weekend duty rotas and holiday arrangements, the use of EMIS codes and going paperlite’.

Between the district nurse and the general practice registrar, two medical students stand one

or two steps of the staircase away partly listening in.

‘A conversation about the management of a terminally ill patient.’ The students standing listening in discussed between themselves their next attachment and what time it started’.

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Between three doctors

‘A conversation about a child psychiatry problem. ‘The conversation is free and easy and began to explore other concepts linking neurology and psychiatry’

All the conversations had a tone of informality and within that a topic that was clinical in its

outset would rapidly diverge into other related areas. The informality allowed informants to

explore topics in breadth but only partly in depth hinting at greater potential at both depth and

breadth. The informants were observed to step out of professional role or shed the

performance veneer used when in consultation with patients.

Good conversations

The staircase landing, the administration area and the doorways of consulting rooms and the

practice manager’s office were the principal sites of this type of conversation and within this

there was a spectrum with the staircase conversations predominant. I observed the

professionals dissociate from the boundaries produced by professional power and hierarchy

and engage in what I term ‘Good Conversations’. The tone and tenor of the conversation had

mutual respect, was relaxed and captured shared inter professional understanding and

experience. This was more apparent than at other zones where there was more formality. In

administration, there was the ever present distraction of answering the telephone, “pulling

notes” and for reception staff the need to be getting on with the job.

Why was it that these areas of the practice acted as nodal points of learning? In a reflexive

exercise with my informants at the end of the data gathering exercise, one informant

commented that “the staircase is a central spot, it’s just outside reception.”

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At the same reflexive exercise, when asked to contrast it with the seminar room which had

been designed as a learning area the informants were of the view that

“(The seminar room) was a big room, quiet and peaceful and was where formal meetings and training were held”.

.

As previously described the Practice Nurse commented that this where “Dr Milne did the

talking.” For the informants the seminar room was where the practice meetings were held and

in doing so the seminar room was reified with ritual, and where power and hierarchy were

ritualised.

Other influences on informal learning

Informal learning within the practice was therefore an activity which was influenced by

several factors. These were the artefacts held on the staircase or in the administration area,

their content e.g. the messages, and the building. For the individual it was cognitions,

experience, and curiosity. These interacted or had the potential to interact in a complex

manner. That interaction was enabled by the informants sensing that theses were areas where

they could put aside their professional roles and spontaneously cross internal and external

practice boundaries.

As individuals, their status facilitated their learning within the practice. For the doctor who

had access to a higher password code to the practice computer she was able to modify and

develop templates which in turn acted as learning opportunities and aide memoirs. The

practice manager capitalised on learning opportunities with conversations with

pharmaceutical representatives in his room. The partner’s and practice manager’s learning

was sensed as being ‘held’ within their work areas and contrasted with that of the receptionist

who felt unable to go the seminar room to read. The ‘zones of freedom’ such as the staircase

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and the notes area of the practice provide a further contrast in learning with their neutrality in

terms of power and hierarchy. In turn they engendered trust within the team.

Learning and the extended primary care team

In the next section I explore the methods of learning and the reflections on their learning by

members of the attached primary care team. Its purpose is to complete the narrative so that the

full spectrum of learning activity can be understood across several health professional

disciplines. The interviews were semi- structured but the main focus was on learning since

this was the area of research and my field diary noted many informal conversations between

health professionals.

Through the transcripts there emerged small differences of emphasis around the area of their

learning. The informants are the health visitor, physiotherapist, community psychiatric nurse,

district nurse and McMillan nurse (palliative care). For clarity I have constructed tables to

differentiate between the formal and informal areas of learning described by the informants.

This contrasts with the nucleus practice team where overall there were fewer opportunities for

structured learning.

The Health Visitor and her learning

At the time of this research the health visitor was coming towards the end of her working

career. She took the opportunity to compare and contrast the learning opportunities she had

during her working life.

She gave examples of formal and informal learning during this time and highlighted her

frustrations with the current system of allocation of training courses. This appeared to be done

for financial reasons.

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Attendance at courses “in the 60s” was encouraged. It was apparent she enjoyed attending

these and that there was a sense of greater educational freedom.

“It was motivating. There was a very friendly atmosphere. You talked ‘shop’ in the evening. You found out what others were doing and what other people’s workload was”.

When describing the current course system she said “You apply to see if you can go on a

course.” If she felt she wanted to attend a course it was limited by funding from the health

authority.

“Other courses you have to pay for yourself and it is questionable whether they would allow you to go other than in holiday time”

She described that the Health Visitors as a group got round this difficulty by having meetings

in which feedback was given by colleagues who had attended a course.

She said that as a health professional she had to undertake five days training over three years.

She thought it was going to be an opportunity to attend courses but “it was diluted down to

whatever you’ve read. We do get a lot of updates to read”

When discussing informal learning, she described having many informal conversations with

many colleagues about patients. These included colleagues within the community paediatric

clinic (i.e. speech therapists, consultant community paediatricians, child psychologists, other

health visitors). She discussed patients with the GPs and reception staff whose practices she

visited as part of her role. The entrée to these informal discussions with the reception started

with the need to record data on

“How many visits, how many elderly visits, numbers attending her clinics, sleep clinics, home visits for sleep problems” ( children under age of five years with sleep problems).

There would then be informal discussions between health visitor and receptionist about ‘what

was happening elsewhere’ in the area that the health visitor served.

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In terms of informal learning the health visitor crosses the boundary between the nucleus team

and the outside bodies. In addition her professional work is done in clinics in a variety of

settings. Within this surgery there is a sense of transience. She “does the clinic” and “does her

statistics chatting to the receptionist” in the administration area. She was a frequent attendant

at the primary care team meetings held in the seminar room in the practice and was an active

participant both in giving presentations and engaging with the team discussion. Information

obtained from elsewhere has been transformed by her into knowledge. That transformation

will have been influenced by the hierarchy, power and politics between her own colleagues

and her managers. In that transformation she will have crossed multiple boundaries (other

practices and other health professionals working within secondary care) before crossing the

boundary into the practice.

To summarise her sources of learning can be represented as

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Health Visitor’slearning

Peer supportmeetings

Reports of

educational courses

from other H.V.s

(H.V.)

Other health visitors

Informal c

hats

SecondaryCare team

Informal chats

Other general practices and their

teams

Informal c

hats

The researchPractice team

Informal chats

The research practice

Primary care teammeeting

Attends / leads discusssion

.

Health Visitor’s learning Formal Informal

Course attendance local * * Course attendance national * * Consultant clinic team * HV colleagues (their course reports

* *

Informal HV discussion * Informal discussions other practice teams

*

Attendance Primary care team meetings (other practices)

*

Informal discussions research practice

*

Reading at home * Attendance research practice primary care team meeting

*

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The majority of health visitor’s learning was informal and experiential. Formal training was

controlled using financial constraints by NHS management.

The Physiotherapist and her learning

The physiotherapist service was provided through a contract with a private physiotherapy

business run by two physiotherapists who had previously worked within the NHS. The

contract was financed through the PCG/T. The contract was for two half day sessions within

the practice using the practice nurse’s treatment room. She had similar contracts with other

practices.

Learning and the influence of financial factors was more evident. She itemised the issues as

“Time, whether there was a long journey to the course, Cost of the course and the cost of staying over Need to self fund Whether there were other bills to pay”

There were personal factors such as finding child care; “I always look after the little ones

first.”

Learning was interwoven into the informal consultations that she had with members of the

practice nucleus staff who approached her in the administration area for help with various

musculo- skeletal problems (e.g. back and neck pains). She found herself “reassuring,

encouraging them to try (therapeutic) exercises at home”. She received feedback from the

staff on this advice which was described as “being helpful, very positive” and found herself

saying that they could “always come back for more advice”

She described social conversations about “what sort of weekend you’ve had” with reception

staff, discuss appointment problems with reception, patients who have not turned up for

appointments”

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She mentioned informal conversations with her business colleague (also a physiotherapist)

who called in at the surgery to discuss

“Developing the business, making it more efficient, discuss the PCG/T., information about patients who need injections”

She said she had little or no contact with the community nursing team or with the practice

nurse.

Returning to the courses she attended she described the process prefacing her comments with

“working on your own is that you lose touch”. She said that as a professional she had to “do

twenty hours postgraduate training per year and fill in a professional development sheet”. She

had attended courses on

“Ski and snowboarding injuries, Achilles tendon problems, conference on osteoporosis, back pain, pain management, shoulder and knee problems”.

The courses provided an opportunity for her to network with other colleagues. She did “audit

on the business and physiotherapy work”

The contrast with the health visitor is self evident in terms of control over when and what

types of course they could do. For the health visitor financial control was exerted by NHS

management and for the physiotherapist control was exerted by personal domestic and

financial cares. The health visitor was able to discuss learning with other colleagues but this

was limited for the physiotherapist.

In comparison to the health visitor, the physiotherapist had a closer informal working

relationship with the practice reception staff. This may have been due to staff seeing the

physiotherapist more frequently and the sorts of problems that they had whereas the health

visitor’s knowledge was more remote in terms of immunisation and child development. The

physiotherapist reported that in comparison to other practices she had little contact with other

practice members or health professionals. The physiotherapist’s learning is summarised as:

Page 225: Paul Milne Thesis

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The Physiotherapist’sLearning

Courses AttendsNetworks

Complies with professional

body requirements

Practice nucleus team

Discuss

es

Patients

Provides a

dvice

Quality assurance

Auditsdiscusses with her business partner

Physiotherapist’s learning Formal Informal

Courses * *

Practice nucleus team *

Physio business colleague *

Audits of work *

Other practices limited

The Community District Nurse and her learning

This member of the professional extended team was employed by the health authority. She

visited the practice on a daily basis in order to collect messages from the book kept on the

table on the staircase landing. She attended the primary care team meetings.

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Her office was in another practice building several miles away. This was shared with her

health visitor colleague.

When discussing professional learning she described informal meetings with the health

visitor, the practice nurse and reception staff. She said she learnt about “peoples’ roles and

practice organisation” within the practice at the primary care team meetings. My field notes

record her having frequent conversations with the doctors and the reception staff in the

practice and that these were often on the staircase. These conversations were about organising

resources for patients, solving a clinical problem, getting information from the computer and

social discussions about family and holidays.

She said her “formal learning” was to do “a post registration education profile (PREP). This

required her to do “five days of training in three years and was needed to maintain her

registration”. PREP documented courses, meetings and writing up ‘cases’”.

She summarised her daily working life as “meeting with other members of the nursing team

to discuss caseload, write in the big diary and divide up the workload.” When the workload

was divided up it was an opportunity to

“Discuss patients, discuss clinical issues, talk about wounds, aggressive patients, difficult patients”

This learning was sensed as intense and experiential grounded in her daily experience with

patients. The learning was in a narrative form. She made “copious patient clinical notes” but

these were not shared with other professionals. Her informal and formal learning can be

summarised as follows:

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District nurse’slearning

PREP

Attends courses/meetingsWrites up ‘cases’

Health ProfessionalsInside /outside

the practice NetworksInformal conversations

Primary health careTeam meetings

Attend

sGive

s pre

senta

tions

The McMillan Nurse’ learning

The McMillan’s nurse’s role within the extended primary care team was to provide liaison

and advice between patients with advanced cancer, their general practitioners and hospital

doctors. She was employed by the health authority but the funding for her post came from the

District Nurse’s learning Formal learning Informal learning

Attending courses training *

Attending primary care

team meetings

* *

Informal case discussions *

PREP preparation *

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McMillan nurse charitable trust. Like the community district nurse her learning was both

formal and informal with a need to maintain her registration with the preparation of her

PREP. Her informal learning opportunities were similar to the district nurse but also included

contact with colleagues in secondary care.

The McMillan nurse’s informal learning with other professionals offers the

opportunity to see more clearly those underlying professionals’ values which

experientially drive their learning. I take the opportunity to explore this in more

detail. She described much of her working day is spent talking with patients.

“Give relatives an opportunity to offload, talk with other health professionals, doctors and managers in the health services”.

Like the other members of the extended team her working day had an administrative and data

gathering role in addition to conversations with various members of the nucleus practice team.

Her role is clearly seen as existing at the boundary between the practice and external bodies

and within this a need for sensitivity with regard to colleagues’ practices and values. It is

apparent within this practice she felt able to discuss ‘cases’ in a supportive environment.

“(I) gather data which is channelled into a computer which managers use to pull out statistics that have very little meaning. I use ‘comcare’ which is a hand held computer system for data entry, (used) to record daily activities and details of contracts with patients. I use patients’ notes, it can feel awkward when discussing patients with doctors and the notes are not available, (if this happens) the doctor can feel threatened. I organise a prescription for a patient, talk to the receptionist about the prescription either in person or by telephone. (In the practice) people are very approachable and helpful; there is a really good atmosphere in the practice. I feel part of the team but I never feel an integral part of the team. As a McMillan nurse you don’t really belong any where. I don’t use the message books as information is confidential and intimate, (you) can get the wrong vibes from a message, for example a short message to the district nurse could be misinterpreted.”

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Conversations with the McMillan nurse had a framework of a discussion between a

generalist, the GP and a specialist the McMillan nurse. The conversations were embedded

within the shared experience of their knowledge of the patient and the patient’s family. The

McMillan’s expertise was within the area of the use of medications to alleviate pain and

distress. Learning took place informally about a disease process for both parties and about

knowledge of medications used in palliative care.

Within that process in my own conversations with her and in those that I observed, there was

interplay between the knowledge, the pathological process of the disease, the pharmacology

and therapeutics of the medications to be used and the experiential knowledge held by the

participants. This experiential knowledge was a combination of the GP’s experience of caring

for the patient and the family over a number of years within the community and that of the

McMillan nurse whose experience of dealing with similar problems but whose knowledge of

the family may be less detailed.

Within that conversation are other values which although present in other inter professional

conversations were more explicit in the discourse with the McMillan nurse. These values

were of caring and trust which empowered the inter professional learning in these informal

conversations. Caring and trust were present in other informal conversations but with the

McMillan nurse these values allowed the participants to acknowledge those personal

vocational values.

The McMillan nurse had a need to complete a portfolio for her ‘PREP’ and continued

registration as a nurse. Her links with secondary care colleagues and the knowledge that she

brought to the practice following these conversations were valued by the doctors in the

practice. This contact improved confidence in the terminal care management of patients in the

community for all members of the practice nucleus team. Her learning is summarised as

follows

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McMillan nurse’slearning

PREP

Attends courses/meetingsWrites up ‘cases’

Health ProfessionalsInside /outside

thepractice in primary

care

NetworksInformal conversations

Primary health careTeam meetings

Attend

sGive

s pre

sent

atio

ns

Secondary careconsultants

Discussescases

Patients andtheir relatives

Reflection onpersonal values

The opportunity that the McMillan nurse had for discussion with consultant colleagues was

unique within the context of this primary health care team. In the next section of this chapter

the Community Psychiatric Nurse (CPN) reflects on her learning.

The Community Psychiatric Nurse’s learning

The CPN attended the surgery to see patients referred to her by the doctors in the practice.

She used one of the consulting rooms in the surgery to see the patients. The referral letters

were kept in a folder which she would collect from the administration area of reception. The

letters were typed and placed in the folder by the practice secretary. As with the other visiting

health professionals, she would spend time in the administration area ‘chatting’ to reception

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staff whilst waiting for patients to arrive or as frequently happened, did not attend. These

conversations often had an informal learning element which interspersed the socialisation.

“(Describing) a weekend away with the girls Types of clients (patients) Children and grandchildren Dieting, smoking (stopping) Depression and counselling skills Post traumatic stress disorder St John’s Wort”

She described that she learnt about “the practice computer, the practice, the internet.” In her

interview she reflected spontaneously on the practice and its learning

“People (in the practice) do different courses People do tutorials People always available if you need to talk to them People have protected time People are permitted to learn”

This ‘permission’ to learn within the practice exemplified by the opportunities repeatedly

described by the informants from outside the practice facilitated informal learning. The

informants felt able to discuss topics both within and without their professional boundaries.

Through this discourse, reception staff were the principal beneficiaries, and in turn, their

informal knowledge of how the practice worked and their ability to give descriptions of

patients allowed the extended team members to use a blend of formal and informal knowledge

to bring care to the practice’s patients. The CPN described her formal learning as

“Supervision sessions Writing up cases for her portfolio (PREP) By going to lectures that are interesting”

There was also a sense of coercion in the area of her formal learning when she said that “(I)

was pushed towards different certificates, different nursing grades do different learning.”

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Although invited to the primary health care team meetings the constraints of her timetable in

which she was contracted to attend other practices prevented her from attending these

meetings.

Community psychiatricnurse’s learning

Supervision sessions

Practice Nucleus

team

Portfolio(PREP)

Training for Certificates lectures

“pushed” to do

attends

Writ

es u

p ‘ca

ses’

Discuss

es

Cases,

mental

Health pr

oblem

s

socia

lisatio

n

Discusses cases

CPN’s learning Formal Informal

Doing certificates *

Going to lectures *

Supervision sessions *

Writing portfolio *

Informal conversations with

practice team

*

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Summary: Learning and the extended primary care team

The informants from the extended team reported a spectrum of learning. Learning was

predominantly informal which took place between themselves and members of the practice

nucleus team. The transcripts reflect that this process was dynamic and experiential. Through

the McMillan nurse’s account other values of caring and trust are more clearly seen.

For all the informants from the extended team there was a tension between “having to learn”

(CPN), the rationing of the opportunity to attend courses (HV)” by management which

contrasted with the “permission to learn” described within the practice. The extended team’s

managers were sensed as inhibitors of learning and that hierarchy and power influenced these

informants’ learning.

Discussion

In this chapter I have described and discussed the intuitive and informal methods of learning

that the informants used within the practice building.

Having explored the themes which emerged from the transcripts and filed diaries, I now draw

together the learning methods which are embedded within the overarching theme of informal

learning. These learning methods for all the informants centred on the focus of patient care.

The informants described their discussion of patients in terms of ‘cases’. The methods of

learning included a variety of processes. These can be summarised as follows.

The learning methods are intuitive and make use of artefacts such as the Lloyd George notes,

the practice computer system, patient information leaflets, and academic journals. The

processes employed require permission and enhance the articulation of learning of cases. It

was apparent that the practice team had a large body of codified knowledge which informed

the practice organisation. Codified knowledge was informed by the professionals’ attendance

at courses. This knowledge was ‘imported’ from attendance at courses and can be considered

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as an example of boundary crossing. The practice manager epitomised this concept of

mediation of information in his role at the boundary interface between the practice and the

external institutions and their rules and regulations. The role required him to read and

interpret a wide range of information that related to rules and regulations. This required

discussion with the doctors as employers to help align new rules and regulations to the norms

and values within the practice.

Central to the process of learning were the social processes referred to by the informants as

‘chats’. These informal discourses were dominated by discussion of ‘cases’ (patients’

problems). Within these ‘chats,’ knowledge was transformed and crystallised. This process of

transformation and crystallisation occupied a metaphysical space in that discourse. Thus for

the individuals there was transformation and crystallisation and this process was mediated by

artefact. This could be metaphysical or physical in its nature.

For example, a metaphysical artefact might be the understanding of a professional rule or the

experiential memory of the management of a patient with a similar problem. A physical

artefact might be the patients’ notes or record on a computer. Other examples of mediating

physical artefacts were the patient information leaflets that were read by the informants, the

books that receptionists picked up in a consulting room to read when asked to chaperone a

patient’s examination. Further examples were the notice boards, and the influence of the

physical spaces of the building. The interrelationship was both complex and dynamic. This

interrelationship will be explored in a later chapter.

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Chapter Seven: Discussion - The empirical findings and synthesis of social

learning theories.

Introduction

This chapter summarises and reviews the findings from the analysis and discusses them in

relation to social learning theory. This has been an empirical study which grew out of various

questions which related to the practice’s professional development. The context of the

research has been described in the introduction. The research sought to explore learning

processes in the practice through the perspective of understanding its culture and was done as

an empirical study. In this chapter I draw together the strands of the analysis and consider in

what way the emergent picture can be explained in terms of the sociocultural models

discussed in the literature review.

Examples from the research findings are used to amplify and illustrate the discussion. In its

final section the discussion postulates a synthesis of these theories which arises from the

research findings.

The themes, their relationships and practice culture

From the research there are generic themes that unite the whole. The analysis considers the

relationships of these generic themes and how they relate to learning for the individual and for

the practice as a social body. The principal themes that emerged from the analysis were

1. O /organisation (being organised and systematic arrangement)

2. Learning in the practice: informal and formal

3. Hierarchy and power (control)

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I have summarised the themes and sub themes below. Their summation and interrelationships

constitute the practice culture. These are the ‘cultural themes’ of Spradley’s framework

described in the methodology chapter.

PRACTICECULTURE

ORGANISATIONHIERARCHY &

POWERLEARNING

MeetingsFormal/informal

Notes /computer

LeadershipProfessionalismExternal bodies

The BuildingSpace

Informallearning

Formallearning

Intuitively learning is sensed within the practice as complex. The relationships between team

members both external and internal to the practice were multiple and in turn were mediated

by other agencies and artefacts. The latter were internalised and externalised as ‘mental

models’.

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Concept maps

In the following series of concept maps, I illustrate these relationships for five of the key

informants. I propose that the relationships shown are generic to all the informants described

in this research. The degree of homogeneity is variable within the broad themes. The themes

are generic but the informants’ perspectives vary and the concept maps help to illustrate this.

Within each concept map I have synthesised the emergent themes and given illustrations of

their interrelationships. These illustrations exemplify some of the relationships described in

the research. These are a highly fluid and dynamic concept and each theme or groups of

themes and their interrelationships will vary in their dominance within the practice culture

along any given timeline. The concept maps are for the partner, the practice manager, the

practice nurse, the full time receptionist and the district nurse and are supplemented in the

subsequent discussion.

The Partner

The partner’s relationship map has multiple boundaries in terms of learning. At a personal

level there was a boundary with external professional bodies. With the practice team the

boundary was mediated through power and hierarchy in her role as employer and reified in

the various artefacts of the practice’s internal organisation. Her relationship with the computer

as an artefact illustrates this. In terms of informal learning, the computer was a powerful

learning tool used by the partner to develop templates for a wide range of clinical conditions

which she thought were important for the care of the practice’s patients. Equally the presence

of the computer was resented since it represented an intrusion by the rules and regulations of

the external NHS bodies.

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7-4

The Partner’s Learning

PCG/TGovernment

Professional bodies

Accountable toThreatened byBeing organised by

PPDP/PDP

List

s tra

inin

g ne

eds

Thre

aten

ed b

y

NotesComputer

Accountable forLearns from

Zones of freedom

Social/’Good’ ConversationsStaircase etc.

Clinical governance

AttendsFinanciallyrewarded

networks with other health

professionals

Accountable forFinanciallyrewarded

‘cases' usedto comply with

Clinical meetings

Presents ‘cases’

Shares experiential

knowledge Used to describe‘cases’

Being professional

Mediates‘Looking nice’

Additional qualifications

‘Needs to do’

Reads

jour

nals,

boo

ks, d

oes c

onsu

ltatio

n

video

s

Practice meetings

Partners’meetings

Internalorganisation

Suggests /discussesAgenda items

Provid

es

leade

rship

Provides

leadership

leadership

organises

Working within a

professional code

Powerhierarchy

mediatesmediates

the building

Her consulting

Room, pays the

mortgage

The Practice Manager

The practice manager has been previously referred to in this research as a ‘boundary object’.

The concept diagram reflects this but does not reflect the extent. He was the first point of

contact when an external body such as the PCG/T contacted the practice. The practice

manager’s role required him to gather and interpret a diverse range of administrative and

financial information from both external and internal sources. His learning both informal and

formal revolved around these areas. His curiosity enabled him to further develop his personal

or non practice role learning through conversations with other professionals, health

information leaflets and pharmaceutical representatives.

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7-5

Practice Manager’sLearning

PCG/TGovernment

Internal organisation

Crystallisation

Transformation rules

Practice organisn.

Partners' meetingHelps with strategyPractice

meetings

AttendsChairsorganises

NotesComputerLeaflets

Drug reps

Being organised

PowerHierarchy

employed bypractice

Mediated by

Thebuilding

Uses the seminar ro

om

Monitors upkeep and finances

Different size rooms

Zones of freedom Social/

’Good’ ConversationsStaircase etc.

Facilitativeartefacts

Beingprofessional Working within a professional code

Transfer and interpretation of externalInformation rules/regs/financial

Lists training

needs

Sets standardsFinancial support

Professional rules

NHS rules

mediates

Practice rules fromFBA, Voc.training

PPDP /PDP

Page 240: Paul Milne Thesis

7-6

The Practice Nurse

The practice nurse’s relationship diagram has fewer boundaries although like the partner there

was an internal boundary which related to professional governance. Geographically, her foci

were her treatment room and the notes area of the practice. Her learning was informally

mediated through the themes identified in this research.

Practice Nurse’slearning

Professional bodies

PDP

PPDP

PCG/T

Being professional

Attendscourses

Notescomputer

Practice meetingsPower

hierarchy

Internal organisation

Zones of freedomLists training

needsDescribes cases

Required forregistration

Lists training needs

Social/’Good’ ConversationsStaircase etc.Notes area

To increase knowledgefor chronic disease

Med

iate

s

Mediates

Employed

by practice

Uses to inform

Case studies

Working within aprofessional code

Attends /networksMeetings with othernurses

Working within aprofessional code

Workingwithin aprofessionalcode

Clinicalmeetings

Reluctant to feedback

The building

Has her own room

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7-7

The Receptionist

Receptionist’sLearning

ProtectedLearning time

Training courses

NotesComputerLeaflets

Practice meetings

PPDP

Power hierarchy

Zones of freedom

The building

Internal organisation

Being professional O

rganised by

primary care

development centre

/PCG

Org

anis

ed b

y PC

G/H

ealth

auth

ority

Doing a good jobSocial/’Good’ Conversations

Staircase, reception / notes

area, discuss ‘cases’Fac

ilita

tive

arte

fact

s

mediates

Read while filing

Entering data

Participates i

ncr

ysta

llisa

tion

Tra

nsfo

rmat

ion

rule

sP

ract

ice

orga

nisn

.

Lists training needs

Employed bypractice

Em

ployed bypractice

Works in

Reception

/notes area

ritualisation

Seminar roo

m

Learning

The receptionist’s learning took place largely through her work area. This was an interesting

area in terms of informal learning since it was visited albeit briefly by all the professionals

involved in providing care. Although these visits were task based (e.g. to collect a set of

notes) they were also used to discuss ‘cases’ and problem solve using the receptionist’s

experiential knowledge of the practice patients.

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The District Nurse

DistrictNurse’s learning

ProfessionalBodies

PCG nursemanager PDP

Being professional

Zones of freedom

Primary health care team

meetings

Message books

Informalmeetings

Internal organisation

Social/

’Good’Conve

rsations

Staircase etc.

Notes area

responsibility

Med

iate

d by

Accountable to

Accountable to List tr

aining needs

Needed byRequired for

Facilitativeartefacts Practice rules

FBA / VTS

Presentscases

Informal case

discussion

Discusses casesWith other nursesOutside the practice

The building

The seminar

room

Through the nature of her role the district nurse’s learning was divided between her

relationships with colleagues outside the practice and who had no contact with the practice

(e.g. other district nurses) and the mixture of informal and formal experiential learning that

took place on the staircase and notes area and seminar room.

Boundaries and Organisation

The concept of boundaries emerges further when the theme of organisation is considered.

From O/organisation, boundaries both as internal and external concepts begin to appear. I

differentiate between the state of being organised as Organisation and organisation as

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‘systematic arrangement’. This was done as there was a strong sense of individual

internalisation of ‘being organised’ as a value. ‘Being organised’ arose internally within the

practice both through individual cognitions and which in turn were influenced by the practice

leadership. The strategic lead was given by myself and was envisioned in terms of a need to

improve the quality of care within the practice. Quality of care was not only about the

individual health professionals’ humanistic and professional qualities but also a need for the

practice to consider its future in terms of a wider political and social sense of purpose.

Political is used in the sense of the practice’s place in the wider scheme of the development of

primary care in the locality.

In terms of practical development, FBA was the principal artefact that reified quality within

the practice and heightened awareness for the need for organisation. Organisation , systematic

arrangement straddled internal and external boundaries and was concerned with the rules and

regulations of professional life and those that were implicit through working within the

National Health Service.

On a day to day basis the relationship between organisation and Organisation for the nucleus

team was managed, shepherded and buffered by the practice manager. I label him the ‘keeper

of the boundary’ between the internal practice milieu and external agencies exemplified by

the PCG/T, the Health Authority and government regulation. The practice manager translated

regulation both written and oral narrative in the non clinical areas. Similarly but with a

different set of professional rules, the practice secretary had a similar function of linking at a

boundary between the practice and the external clinical agencies such as the local and private

hospitals and the offices of the extended primary care team.

Within the practice Organisation, systematic arrangement is exemplified by the various

systems for the various clinics and surgeries and message books. These in turn had been

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modified and improved by the external agency of working through and thinking about the

FBA criteria.

The partner’s sense of ‘being organised’ was described through facets of performance in the

consulting room. Organisation with its rules and regulations were perceived as a threat to her

individual sense of ‘being organised’ and clearly gave rise to an internal dynamic of tension

between a personal value of caring and matching this with Organisation. The state of being

organised was important for the internal practice team. Although the internal practice rules or

systems were described through the agency of having engaged with the quality framework of

the FBA these systems were dependant on the memory of the history of their development

and the social capital that was implicit and required for organisation to function and to

manage external Organisation. Being organised had its own rules and regulations but these

were imbued with trust and history.

External agencies with their rules and regulations were often perceived as a threat. The

practice manager as the keeper of the boundary buffered these either through his own role or

through the partners. Through the partner’s observations the practice manager’s role as a

buffering system developed to shield the partners’ values of caring from rules and regulations.

Organisation and organisation were significant modulators in terms of influence on the

practice culture and its learning. The ‘systematic arrangement’ and ‘the state of being’

organised were in a dynamic interplay within the practice. Although never explicit, the

underlying value that pervaded this internal relationship was dependant on the nature of trust.

This becomes more explicit when the practice manager’s role as keeper of the boundary is

considered and the partner’s cognitions when the opposite dynamic emerges of mistrust with

respect to the external agencies.

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Notes and the computer

Throughout the research two artefacts within the practice culture predominate as foci for

informal learning. These were the patients ‘Lloyd George’ notes and their successor the

clinical computer system (EMIS).

Notes have been recognised and described elsewhere as the record of a person’s health from

‘birth to grave’. These records had a medico -legal and a teaching role. The latter was specific

to this practice. The information that was held was a mixture of clinical notes about illness

events and also held records of organisation (systematic arrangement, e.g. immunisation

records) and in turn was also subject to systematic arrangement as required by the external

agency of the vocational training scheme. Notes were imbued with meaning by the practice

nucleus team. Receptionists described patients as having “thick or thin” notes reflecting on

patients that were frequent attenders to the practice.

For all the health professionals notes were not only reified as a symbol of professional

confidentiality but for receptionists this value was extended such that notes were viewed as

secret. Through the practice manager this viewpoint can be understood when he explained

that the extended members of the practice team only had limited access to the patients’ notes.

Within the practice building notes were stored in the administration area of the practice,

frequently referred to as the ‘notes area’. Much time and effort was invested in their upkeep

and availability. A lost set of notes caused significant anxiety within the practice nucleus team

and especially for the reception team. Notes were transported in boxes customised to the size

of Lloyd George notes. Notes were “pulled” for surgeries, placed in boxes and taken to the

consulting rooms. Similarly, boxes of notes for the home visits appeared on the small table on

the little landing on the staircase. Notes were set aside and placed in similar boxes for referral

letters and the various medical reports.

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There appeared to be a spectrum of reification. In contrast to the receptionists with their

concept of secrecy with regard to notes, the partner regarded notes as a tool that provided

information. Notes and their reification reflected the hierarchy and power within the practice.

Notes were a tool that was ‘owned’ by the leaders or perhaps more accurately, the

responsibility for the keeping of the notes ultimately resided with the leaders of the practice

the partners. The accountability for the notes resided in the contract of provision of general

medical services between the practice and the government.

There were some similarities with the computer in that secrecy re- emerged. However the

information held by the computer was regarded as incomplete. In addition the computer was

trusted less in terms of the information that it held and because its function needed frequent

maintenance because of its propensity to ‘crash’ its role as an artefact within the practice

culture which facilitated the transfer of knowledge was fitful. As described in the analysis

with the example of the receptionist through her use of the computer and enquiry from

members of other health professionals’ knowledge was created and transformed. Learning

was actively prompted through the agency of the computer.

Notes and the computer played a significant if informal role in the practice nucleus team’s

learning and were the tools that stimulated tacit leaning. They acted as stimuli to discourse

since both were important in providing information. Notes had a greater familiarity and longer

history for all users and at that time were imbued with greater trust. Notes and the computer

were symbols of organisation and Organisation and were links with external bodies of

authority.

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Informal learning

As artefacts that encouraged learning, the Lloyd George notes and the computer played an

important role. Informants described a variety of methods and interactions which amplified

this important area of the practice culture.

The Partners

External agency exerted an influence on the partner’s learning when she described reading

journals which in part was driven by “doing an exam”. In writing referral letters it was

apparent that she reflected on the patient’s problem. For the partner there was an internal

dialogue which was about reflection on patients’ problems or “cases”. Notes were read to help

inform these reflections. These reflections were influenced by attendance at meetings with the

PCG/T as the practice clinical governance lead and her perceptions of government and

professional institutions. These perceptions of external agency conflicted with her personal

professional values and generated anxiety and mistrust. The computer and in particular the

writing of and use of clinical templates were powerful learning tools for the partner with

transformation of explicit knowledge from journal and text books.

External agency formed part of my own learning in my role as a member of the panel of

examiners for the MRCGP exam. Within that role I was tasked to research and write

questions for the multiple choice paper and to assess the video consultations that candidates

submitted. In writing these questions knowledge was explored and re interpreted. In turn it

ensured I was ‘up to date’ and acted as an internal marker in terms of confidence. For both

doctors within the practice external bodies were important influences on informal learning

and generated an internal dialogue. Within this dialogue learning had an internal dynamic

influenced by trust and mistrust.

Page 248: Paul Milne Thesis

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The Practice nucleus team

Within the internal practice team there was a spectrum of activity with regard to informal

learning. The practice manager used opportunities to learn by meeting with drug

representatives instead of them seeing the partners and by browsing through patient

information leaflets, magazines and other forms of literature which were readily available

within the building. The practice nurse described ‘chats’ in the notes area with the reception

staff. She attended courses but did not feed back the acquired knowledge to the rest of the

team. Knowledge was acquired, internalised and there was a process of crystallisation which

was a private experience. The dynamics of communication between the internal practice team

influenced by O/organisation in turn moulded the dynamics of informal learning.

Space and learning

A significant observation within the practice building was the use of space by informants for

informal learning. Areas of the building were reified with meaning and in terms of Activity

Theory acted as artefacts in their own right.

In particular was the use of the staircase landing where informants attracted by the need to

read the visits book, patients notes and to leave messages in the district nurses book about

patients. Doctors and other members of the practice team would gather in twos and threes for

conversations. These ranged across clinical and non clinical areas and varied in depth and

breadth. These conversations I have labelled as ‘good conversations’ where informants were

observed to spontaneously explore a wide range of topics in a context of freedom from

constraints imposed by o/Organisation. The staircase landing experience was also witnessed

in the notes area and to a lesser extent in the doorways, corridors and kitchen area of the

practice. These areas and in particular the staircase I have labelled as zones of freedom. The

staircase landing was a cross roads within the practice building and was a virtual interface or

Page 249: Paul Milne Thesis

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boundary crossing with the extended team mediated through the artefacts of the message

books. As a point in practice space it sat at a boundary and this boundary with its artefacts

promoted learning. The informants felt free to discuss topics and issues without the

constraints of rules and regulations and ‘division of labour’.

Extended team and informal learning

Beyond this boundary the extended team members described their informal conversations

with the internal practice team and with other health professionals that were rarely seen in the

practice giving a glimpse of the informal learning in their own offices. Informal learning had

a complex interplay as witnessed in the conversations with the McMillan nurse and the care

of patients receiving palliative and terminal care.

There was a sense of ease with permission to learn within the practice and this was noted by

the community psychiatric nurse and was self evident within the transcripts of the informants.

This comfort level with informal learning was dependant on trust and this in turn was

modulated by mistrust. The latter was evident and more transparent through the partner’s

views on regulation. The ability or desire to stop and discuss problems within the practice was

repeatedly observed and for the individual and the team as a whole, trust played an important

part in their interactions

The other influences on informal learning are now discussed together with the relationship

with the methods of formal learning undertaken by the informants. From the analysis themes

of power and hierarchy emerged.

Page 250: Paul Milne Thesis

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Leadership and informal learning

Leadership was embodied within the practice by the doctors. The self evident lead came from

me but decisions were mediated through meetings with my partner and the practice manager.

The management style was democratic with responsibility devolved to members of internal

practice team. Learning therefore was encouraged through the devolvement of responsibility

and individuals had a sense of agency. Trust empowered creativity and curiosity and as

already described encouraged learning. Learning as a dimension had physicality in terms of

artefact as exemplified by the staircase landing, the seminar room, the doorways and these

areas were reified as learning areas within the practice culture.

Professionalism

Through observation the informants commonly couched the descriptions of their decisions or

daily role as “being professional or not being professional”. There was a spectrum of narrative

related to this term. The partner’s related to the medical institution with its values not only in

terms of the professions’ rules as professed by the General Medical Council but also those of

self image. External organisations and their rituals created a tension between the partner as a

doctor and as a person. For the practice manager and other members of the practice team there

was a gradient of explanation of “being professional”. Confidentiality was common to them

all as was “doing a good job” with reception staff perhaps not unexpectedly having the least

sense of responsibility and accountability.

This latter tension of accountability and responsibility was a significant consideration for the

informants and was repeated in the extended team narratives. Accountability detracted and

distracted from responsibility with consequences for the self motivation and confidence of the

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individual informants. Thus learning was torn between that empowered by the high level of

trust within the practice and threatened by perceptions of ever increasing accountability from

external bodies. Power therefore sat buffered at a virtual boundary between the internal

practice team’s internalised cognition of learning through a disposition of mutual trust on one

side and external organisations on the other. External agencies rules and regulations were

accommodated within the practice culture since the financial well being of the practice was

dependant on this but in other regards the practice’s sense of self in terms of responsibility

and caring predominated.

This leads on to a discussion of the rituals that reflected this buffering process namely the

meetings that were held in the practice and pertinently the place of the practice and

professional development plan (PPDP).

Meetings

Meetings within the practice were of several sorts. The monthly practice meetings were held

in the seminar room. The meetings had a standardised format with minutes and an agenda.

The meetings dealt with the organisation of the practice and how changes within the NHS

would or could affect the practice. These meetings were otherwise informal and were attended

by all members of the internal practice team. Other meetings were held with the extended

primary care team and less frequently there were clinical meetings for the doctors and the

practice nurse. Strategic meetings were held with the practice manager and the partners.

Informants at the practice meetings described that these meetings were lead by Dr Milne

“doing the talking”. From observation and the transcripts the informants made little use of the

practice minutes. As artefacts the practice minutes played little part in the Organisation of the

practice but were recorded and formed part of the ‘systematic arrangement ‘of the practice.

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The meetings were sensed as a ritual of reaffirmation within the internal practice team and a

statement of embodiment.

The practice team needed the meeting framework as a form of ritualisation and created a

ritual sense within the individual as to their purpose and place in the practice. In turn this

created a ritualised body that met and sat at preordained times in the seminar room. The latter

then acquired another dimension for the informants as other than a place where anyone could

go and read a journal. In doing so the ritualisation became a structuring body and was

structured by the ritual of systematic arrangement.

The Practice and Professional Development Plan

The place of the PPDP was at first tenuous within the learning ethos. It was not until there

was a financial threat from the PCG that there was any significant engagement with the PPDP

tool. The away day records reflect the tension between the practice culture and the concept of

the PPDP tool. The team members listed training needs but there was little in terms of

utilising the inherent informal learning within the practice. The PPDP as a piece of paperwork

was completed as a contractual requirement and played a minor role in the practice culture

and therefore never entered the ritual of the practice meetings.

The building and its geography had an influence on the themes and although not conclusive

informants reported links between higher order themes such as responsibility, ‘being

professional’ with recurring areas of the practice. Thus consulting, seminar and treatment

rooms were more likely to be linked with these higher order values. Corridors, doorways and

the secretary’s room were linked with artefacts such as practice minutes and information from

the primary care development centre and the PPDP. Although not too much should be read

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into this small area of the study it is possible to hypothesise that certain rooms or areas within

the practice were more likely to be reified with professional values than others. To a certain

extent this also underlines the comparison with areas such as the staircase and notes area

where learning was catalysed through socialisation.

Initial considerations: Inter thematic relationships

I therefore come to a point where the question arises as to the inter relationships between the

key themes and how do they relate to sociocultural learning theories? I would restate that all

the themes can be thought to be in a dynamic interplay which has implications when

theoretical models are considered. I will return to this when relating this empirical study to

theoretical models described in the literature review.

From the analysis, learning in the practice was structured by and structured the organisation

both through systematic arrangement and as a social cognitive state of ‘being organised’. Sub

themes that had the potential to influence these two areas were hierarchy and power both

inside and outside the practice. Transformation of knowledge occurred at boundaries and was

enacted through various artefacts. Examples of this were the message books, the computer,

notes and the various journals that were scattered throughout the practice. External

organisations were viewed with suspicion and the internal practice team acted as a virtual

body and had a mutual understanding of ‘how PCG/Ts, government were to be considered’.

The themes of organisation /Organisation and its informal learning created a performance that

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was used on a daily basis that allowed it to maintain its confidence, creativity and caring for

its patients.

An interlocking and important theme that emerged through the analysis was that of social

capital. Within social capital it was the value of trust which was pre-eminent. This was not a

homogenous entity since there were times when there loss of trust between team members but

it was self evident that the devolvement of responsibility was only possible through the

element of trust and vice versa. I return to a more detailed discussion of trust later in the

chapter

An initial tentative summary of the themes and sub themes in a linear interpretation has been

suggested earlier. This is duplicated below.

PRACTICECULTURE

ORGANISATIONHIERARCHY &

POWERLEARNING

MeetingsFormal/informal

Notes /computer

LeadershipProfessionalismExternal bodies

The BuildingSpace

Informallearning

Formallearning

Page 255: Paul Milne Thesis

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The direction of flow of the arrows is incomplete. From the narrative there is a potential for

interaction between all the themes and sub themes and that this relationship is complex. Any

one of these can subsume the other at any point in time and produce an overall change in the

trajectory of the practice culture. The diagram in this single dimension cannot reflect the

practice trajectory. If practice culture is placed at the centre of a hub and spoke diagram then

the complex dynamics are represented in terms of the two way arrows. I have used the sub

themes since these relatively smaller units of the practice culture give a better over view of

the practice culture.

professionalism

The building

.Formallearning

Hierarchy /power

O/organisation

Informal learning

Practice culture

External bodies

Leadership

Page 256: Paul Milne Thesis

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Any one of these themes can predominate at any given point in the history of the practice

either on a day to day basis or over an extended period of time. The predominant theme can

be an individual ‘mental model’ or shared by the practice and extended practice teams.

Again although the dynamism is sensed through the use of the two way arrows the

relationships between the themes feels one-dimensional. As will be discussed later, although

complexity is sensed it does not explain in itself how learning takes place.

The relationship between the research findings and social learning theories

In the next section I explore the link between this empirical study and social learning theories.

The study does not align itself entirely with any one theory. However the emergent themes do

lend themselves to further exploration using one or more of the following

1. Activity theory /socio cultural theory

2. Communities of practice

3. Social capital

4. Complex adaptive system theory

The relationship between the four theories is discussed using examples from the analysis.

Although not a learning theory in its own right, complex adaptive system theory is useful in

elucidating the inter relationships and sense of dynamism and trajectory within the practice.

Activity theory and the empirical findings

Activity theory would appear to lend itself most closely to the empirical findings. In the

research there were multiple artefacts. Individual informants had internalised and externalised

mental models of their working world in the practice. In this section I focus on the example of

the notes and the computer in their role as artefacts and which in turn influenced informal

learning in the practice. The purpose is to illustrate the relationship between the research

findings and activity theory. Later in this section I broaden the discussion to consider the

Page 257: Paul Milne Thesis

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relationship between activity theory and the areas of the building used for social discourse.

Finally I consider the individual key informants’ concepts maps and their relationship within

activity theory. This leads to the development of a discussion of boundaries and a natural

progression to consider the findings in terms of a complex adaptive system.

Notes, the computer and activity theory

The Lloyd George patients’ notes and the computer were used extensively on a daily basis.

For the informants these artefacts are reified with various properties which include a narrative

of a person’s health, a medico legal record and they are both considered to be secret. The

degree of engagement with the elements of the artefacts (mental models) varied between the

informants. As an illustration of this was the expression of ‘secrecy’ by the informants. The

element of ‘secrecy’ was an observation made by the receptionist. The receptionist from a non

medical background was “surprised” by the degree of “secrecy” of the notes. By way of

contrast, for the partner the ‘secrecy’ of the notes was implicit since this was part of the

professionalism inculcated through the institutions of the medical profession and the National

Health Service.

Notes were constrained by the rules and regulations of the external bodies. These were the

rules of the GP vocational training scheme and the National Health Service. Their completion

and use were influenced by the rules. For the partner there was partly a dissonance in their

use. They also represented ‘big brother’ and through the rules engendered mistrust of external

bodies. Notes were cared for and the reception team had a system which maintained the order

and appearance of the notes which in turn was regulated by the rules of the vocational training

scheme.

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The computer-templates as an electronic zone of freedom

The appearance of the computer and the data that was collected was also shaped by the

software, the rules and regulations of the NHS and the rules of use from within the practice.

The development of the templates by the partner could be considered an ‘electronic zone of

freedom’. For the partner part of the reason for their development was a fear related to “being

sued”. However there was a strong sense that the templates within the framework of activity

theory had a sense of neutrality and homogeneity as an artefact when used as a starting point

for professional discourse. This neutral state was achieved through trust and this interaction

between the physical artefact of the electronic template and trust. This interaction shifts the

learning experience or process into a harmonious balance with a resultant positive outcome.

Within activity theory this might be considered to be the midpoint in Engeström’s triangular

framework.

They were used by the clinical team and their content discussed. The clinical topics used were

those that the partner and the clinical team thought were important. The content of the

templates were relatively unaffected by rules and regulations but were influenced by

‘community’ (the clinical team). The content was a distillation of national and local

guidelines current at that time. Rules and regulations of the PMS contract had no influence.

The templates were an externalisation of learning by the partner and the clinical team which

were readily accessible. The workload (division of labour) was mainly undertaken by the

partner but had input from other members of the clinical team. However they both have a

function of conveying knowledge from one professional to another and to act as a mediator in

interprofessional learning. The mediation is amplified if there is trust between the interacting

activity systems.

Using Engeström’s model this emerges as

Page 259: Paul Milne Thesis

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Subject (e.g. Health professional)

Management of a health problem

Learning

Computer template

Rules Community Division of labour

However in the findings from this research the informants (partner and the clinical team)

dissociated from rules and division of labour. This is not an absolute statement but it would be

true to say that other components of the activity system predominated.

In the context of this practice, the activity system then becomes

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Subject (e.g. Health professional)

Management of a health problem

Learning

Computer template

Rules Community Division of labour

Activity theory – geography and spatial relationship

The practice activity system had a variety of mediating artefacts that were derived from the

history of the practice (e.g. the FBA and the practice team that worked within this and

implicitly from the previous practice teams and their doctors) and that of the National Health

Service. Mediating artefacts therefore took many forms. Artefacts could combine to stimulate

professional discourse. I would suggest there was a combination between the physicality of an

artefact and its spatial relationship which stimulated learning in the practice. An example of

this was the relationship between the message books for home visits and the members of the

extended team and the staircase landing.

The message books were situated on the small staircase landing which in itself was an internal

crossroads within the building which in turn acted indirectly as a mediating artefact. The

message book for the district nurses mediated information and care for housebound patients.

The information recorded in the book and discussed between professionals produced a

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transformation of understanding for the professionals. In addition because of the network of

trust between the health professionals there was the potential for further discourse around

topics which were indirectly related to the patient as the object of care. The informants were

observed to discuss a range of topics beyond those immediately related to clinical care. This is

clearly seen when the informants’ views are considered in relation to the rules and regulations

of general practice and professional performance. These conversations were intertwined with

topics of social conversation which served to enhance the trust between these informal

meetings of the various members of the practice and extended teams. The activity frame

work could be formulated in this setting as nearing its ‘purest’ state.

This could be represented diagrammatically as follows

Subject (Health professionals)

Management of a health problem Learning

Staircase

Viewed in isolation then it is difficult to understand the interaction between the three

components. They appear isolated and unrelated in diagrammatic form. This changes when

the factor of trust is introduced which reflects the energy or dynamism to the system. Changes

in the level of trust in a setting where the relationships between the artefacts are complex lead

to unexpected outcomes. This then returns the discussion to the example of the staircase

Page 262: Paul Milne Thesis

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where the outcome was at its most unpredictable with the freedom away from the rules and

regulations, constraints of hierarchy and power within the ‘community’ and ‘division of

labour’.

Subject (Health professionals)

Management of a health problem Learning

Staircase

The rooms and areas of the building which were used on a regular basis by the informants

were reified with different meanings. There was not always a commonality in the informants’

perspectives. For example the seminar room had a spectrum of meaning for the informants.

These varied from my own perspective of the seminar room which was where I sat with the

general practice registrar for a tutorial and a place for reflection to that of the practice nurse

who thought it was the place “where Dr Milne tells us what to do”. The seminar room was

where the team met for practice meetings with the attendant ritual artefacts of practice

minutes and agenda. Rules and regulations were predominant in these meetings. Trust was

deflected and the activity framework biased and distorted such it could be postulated that trust

was tested within the setting of the activity area of rule and regulations. The outcome in terms

of a learning process was a loss of balance in the system. Another example of this loss of

Page 263: Paul Milne Thesis

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equanimity in the activity system would be dissonance between members of the internal

practice team and for the extended team their relationship with their managers.

The staircase area contrasts with the seminar room for the informants. It was a potent area

for social discourse. The informants became unaware of the practice hierarchy, rules and

division of labour. The spatial relationship was the staircase acting as a crossroads both in

terms of the buildings geography but also as a crossroads for social discourse. The latter

imbued trust and empowered the solving of patients problems.

There were other areas that performed a similar function but these were incomplete. Examples

of these areas were the reception- administration areas of the practice and the kitchen.

Potentially the latter should have been nearer the staircase setting of social discourse but its

relatively remote setting in the building militated against this. In the reception-administration

area the effects of community (receptionist’s community) and rules (confidentiality,

hierarchy) inhibited the more spontaneous discourse of the staircase area.

In the away day to discuss the PPDP, the informants externalised their values about working

in the practice and in doing so created a pan-activity system of ‘what it is like to work in ****

surgery’ and a reaffirmation of purpose. In doing so they also reflect the socio cultural

history of the practice and their communal sense of vocation and ‘being professional’. To

paraphrase Daniels, the informants’ discourse and internalisation “communicates the

institutions (the practice’s) principles of social order, moral practice, …..conduct, character

and manner. It also transmits features of the school’s (practice’s) local history, local tradition

and community relations” (Daniels 2004, pg.128).

Activity theory and boundaries

The spatial relationship can also be considered in terms of boundaries. These could be

spatially related or for the individual informant the extent of internalisation and

externalisation of the artefact as a mental model. As has been demonstrated the informants

Page 264: Paul Milne Thesis

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engaged in a wide spectrum of informal learning. The spatial relationship described could be

considered in terms of boundaries. Areas of the building such as the staircase and the notes

area are boundary sites where informal learning took place between members of the attached

primary care team and the practice nucleus team. The computer acted as an electronic

boundary in terms of learning. The boundary in this case was between the formalised and

codified knowledge and the experiential world of the health professional. Boundaries were

also evident in the informants’ mental models of their internalisation of external codes. For

example ‘being professional’ is a transformation of an adopted external professional code

which in the case of the practice manager has been internalised and crystallised as a code

which he uses when he is in his role.

Synthesis of Concept maps

If I now return to the concept maps there is a multiplicity of artefacts, their relationships and

their boundaries. Each informant’s activity system has the potential for overlap and

interaction with another. I have brought the concept maps together to primarily illustrate the

complexity and potential complexity of interaction. I do not intend to derive these

relationships but as a diagram it illustrates the potential for complex interactions.

The components that generated the boundaries were the individual informants. For this

research I have focused on the key informants. These represent only part of the practice and

extended team members.

Page 265: Paul Milne Thesis

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The Partner’s Learning

PCG/TGovernment

Professional bodies

Acc

ount

able

toT

hrea

tene

d by

Bei

ng o

rgan

ised

by

PPDP/PDP

List

s tra

inin

g ne

eds

Thre

aten

ed b

y

NotesComputer

Accountable forLearns from

Zones of freedom

Social/’Good’ ConversationsStaircase etc.

Clinical governance

AttendsFinanciallyrewarded

networks with other health

professionals

Accountable forFinanciallyrewarded

‘cases' usedto com

ply with

Clinical meetings

Presents ‘cases’

Shares experiential

knowledge

Used to describe‘cases’

Being professional

Med

iate

s‘L

ooki

ng n

ice’

Additional qualifications

‘Needs to do’

Reads

jour

nals,

boo

ks, d

oes

cons

ultat

ion

video

s

Practice meetings

Partners’meetings

Internalorganisation

Suggests /discussesAgenda items

Provid

es

leade

rship

Provides

leadership

lead

ersh

ip

organises

Working within a

professional co

de

Powerhierarchy

mediatesmediates

the building

Her consulting

Room, pays the

mortgage

DistrictNurse’s learning

ProfessionalBodies

PCG nursemanager PDP

Being professional

Zones of freedom

Primary health care team

meetings

Message books

Informalmeetings

Internal organisation

Social/

’Good’Conversations

Staircase etc. Notes area

responsibility

Med

iate

d by

Accountable to

Accountable to List tra

ining needs

Needed byRequired for

Facilitativeartefacts

Practice rulesFBA / VTS

Presentscases

Informal case

discussion

Discusses casesWith other nursesOutside the practice

The building

The seminar

room

Practice Nurse’slearning

Professional bodies

PDP

PPDP

PCG/T

Being professional

Attendscourses

Notescomputer

Practice meetingsPower

hierarchy

Internal organisation

Zones of freedom

List

s tr

aini

ing

need

sD

esc

ribes

cas

es

Required forregistration

Lists training needs

Social/

’Good’

Conversa

tions

Staircase

etc.

Notes area

To increase knowledgefor chronic disease

Me

diat

es

Mediates

Employed

by practice

Uses to inform

Case studies

Working within aprofessional code

Attends /networks

Meetings with other

nurses

Wor

king

w

ithin

apr

ofe

ssio

nal

code

Wor

kin

gw

ithin

ap

rofe

ssio

nal

code

Clinicalmeetings

Reluctant to feedback

The building

Has her own room

Practice Manager’sLearning

PCG/TGovernment

Internal organisation

crys

talli

satio

nT

rans

form

atio

n ru

les

Pra

ctic

e or

gani

sn.

Partners' meetingHelps with strategyPractice

meetings

AttendsChairsorganises

NotesComputerLeaflets

Drug reps

Being organised

PowerHierarchy

employed bypractice

Med

iate

d by

Thebuilding

Uses the seminar room

Monitors upkeep and fin

ances

Diff

eren

t siz

e ro

oms

Zones of freedom Social/

’Good’ ConversationsStaircase etc.

Fac

ilita

tive

arte

fact

s

Beingprofessional Working within a professional code

Tra

nsfe

r an

d in

terp

reta

tion

of e

xter

nal

Info

rmat

ion

rule

s/re

gs/fi

nanc

ial

L ists t ra in ing

needs

Sets standardsFinancial support

Professional rules

NHS rules

med

iate

s

Practice rules fromFBA, Voc.training

PPDP /PDP

Receptionist’sLearning

ProtectedLearning time

Training courses

NotesComputerLeaflets

Practice meetings

PPDP

Power hierarchy

Zones of freedom

The building

Internal organisation

Being professional O

rgan ised by

primary care

development cen tre

/PCG

Org

anise

d by

PCG

/Hea

lth

auth

ority

Doing a good jobSocial/’Good’ Conversations

Staircase, reception / notes

area, discuss ‘cases’F

acili

tativ

ear

tefa

cts

mediates

Read while filing

Entering data

Participates in

crys

talli

satio

nT

rans

form

atio

n ru

les

Pra

ctic

e or

gani

sn.

Lists training needs

Employed bypractice

Em

ployed bypractice

Works in

Reception

/notes area

ritualisation

Seminar room

Learning

Informants’ concept maps and their synthesis

Page 266: Paul Milne Thesis

7-32

I have placed the partner’s activity system at the top since although the team operated in a non

hierarchical system ultimately she had a hierarchical position as an employer within the

practice nucleus team. This did not apply to the district nurse and therefore diagrammatically

could be shown as more peripheral in a community of practice model. Daniels (2004)

describes Engeström’s model of interacting activity systems as the third generation of activity

theory. As Daniels suggests, this interaction is complex and cites the Russian philosopher

Lektorsky’s concept of creativity through internalisation and externalisation of the meaning

and mediation of the artefacts. There is an interaction between the internalisation of the

meaning of the artefacts, rules and regulations and these undergo an externalisation in terms

of meaning and use

The above diagram can be expressed more simply as a Venn diagram as follows with the

resultant overlaps expressed as the practice activity system.

Partner’s Activity system

Practice nurse’s Activity system

District nurse’s Activity system

Receptionist’sActivity system

PracticeManager’s

Activity system

PracticeActivity System

Page 267: Paul Milne Thesis

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Comment-Activity theory

Through its reductionist approach, activity theory as applied to this study gives insight and

understanding to the inter relations between the key themes that lead to learning. However it

does not give a full understanding of the complexity of the interaction and the dynamic

relationship between the parts of the activity system model. The concept maps illustrate this

difficulty. Activity theory gives its insight at a point in time but there is no sense of its

direction. The spatial relationship is important in the empirical findings of this research. As an

artefact the areas of the building had a particular importance in this research and this was

illustrated through the example of the staircase. Activity theory is useful in explaining the

empirical findings if a change is considered in the system. For example, the change that

would be created in an activity system when the rules are changed in their relationship with an

artefact such as the computer. This needs little explanation when the current new General

Medical Services contract is considered and the imposition of new templates and the removal

of the templates generated by the partner. Therefore as a tool it offers some potential in

prediction of the effect of change in a component in the activity framework. It is limited

because of the complexity of interaction between individual informants’ activity systems and

the resultant practice activity system.

In the next section I address the organisational dynamics of the interactive activity systems

through the use of complexity theory and in particular complex adaptive systems. This is

employed in this research through its theoretical stance to offer an explanation between the

practice’s organisation and its learning. The empirical research findings are discussed in

relation to this organisational theory.

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Complex adaptive system theory, practice organisation and its learning

As discussed in the literature review my purpose in using complexity theory is to address the

acknowledgement by observers and commentators that there is an inherent social complexity

in an organisation like the practice. Complexity is acknowledged by these authors as being

present but is not necessarily explored. Complexity in the context of this research is to be

considered as a social metaphor. The overall place of complexity and complex adaptive

systems has been discussed in the literature review. This section explores the theory of

complex adaptive systems in more detail and its applicability to the research findings.

In terms of complexity theory the practice can be viewed as a complex adaptive system.

Complexity in this research is to be used as a qualitative metaphor as opposed to chaos theory

with its quantitative study of non linear systems. Complex adaptive systems are characterised

by numerous elements that interact and have ‘reiterative feedback loops’. In organisational

terms, these feedback loops can be positive or negative, and since the polarity can be

unpredictable, outcomes from the system are uncertain.

Complex adaptive systems have indeterminate boundaries and they always have a history. For

example, in general practice the boundary between primary care and social services can be

blurred but in terms of organisational rules there are clear demarcations. Finally, a complex

adaptive system is different to the ‘sum of its parts’(Kernick D 2004). No one agent within

the system can know the whole and the resultant behaviour of the parts at a local level (in this

case the practice) ‘evolves from the interaction from the parts without direction from external

organisations or the presence of internal control’ (Kernick D 2004 pg.28).

Complex adaptive systems have certain additional features. Principally these are emergence

and self organisation. These will be briefly described and from these derive an understanding

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of simple rules, attractors and special attractors. The themes from the research will be

examined and discussed in relation to these features of complexity theory.

Emergence relates to the development of unpredictable patterns that cannot be predicted from

knowledge of the individual parts of the system at a lower level. Thus within the practice

although the individual has a well defined role as per their job description, their resultant

behaviour as an outcome from their interactions with each other and the artefacts is different

from that anticipated.

Complex adaptive systems have a property of self organisation. This term has been borrowed

from the biological sciences and refers to the adaptive behaviour of an organisation or living

system to its environment. If the practice is viewed as a ‘living system’ then the buffering role

of the practice manager is understood and subsequently the diffusion of this effect within the

organisation of the practice. The interaction between the practice manager the practice and

external organisations leads to an adaptation to the ‘NHS environment’ and this is reiterated

by the other members of the practice nucleus team.

Complex adaptive system, organisation and ‘simple rules’

As described in the literature review (pg.17) the complex behaviour that is witnessed within

these systems in a mathematical analogy follows simple non linear equations or rules. The

everyday examples used were flocks of birds or shoals of fish. In these systems there are three

simple rules. These are ‘move to the centre of the crowd, maintain a minimum distance from

your neighbour and move at the speed of the element in front of you’ (Kernick D 2004 pg.31,

Sweeney and Griffiths 2002). Organisational change is better understood if the rules that

guide a system can be understood. The simple rules that I list in the table below are derived

from the emergent themes. The interactions between an informant’s curiosity and a meeting

Page 270: Paul Milne Thesis

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or a leaflet read in the notes area or information discovered on the computer lead to problem

solving or ‘creativity’. Through this, a problem for the individual or the practice is solved. In

an earlier chapter I gave the example of the transformation of the knowledge for the data

collecting receptionist about anticoagulation.

At face value this was about curiosity, but it lead to greater understanding of its importance to

that receptionist and in turn to the receptionist group as the information was informally

shared. In a more formal setting, the partner gave a presentation to all the members of the

practice nucleus team in the seminar room. The presentation was about an audit of ischaemic

heart disease (angina). During the presentation she noticed that the reception staff appeared to

have little interest. At this point she stopped and asked “Who would like to know more about

angina?” The team were all keen to know more and what followed was an informal tutorial on

heart disease supplemented with the use of a heart. The partner then returned to the audit

presentation with renewed interest from the team. Of interest in the context of this research

was that the team members wanted to know more not only for their own roles but also for

their family members. This was in keeping with the observation from the physiotherapist that

team members asked for advice not only for themselves but also for family members who had

back pain or other musculoskeletal problems. Knowledge was therefore used by informants to

empower or to further inform their practice role. ‘Being organised’ by the individual health

professional was an internalised value which externalised through informal discourse to

improve the practice’s internal organisation and given formality through the ritual of the

practice meetings. Responsibility for the health professionals was contrasted with

accountability. Accountability was sensed as being imposed. Responsibility was a core value

for the health professionals and fits within the concept of simple rules within a complex

adaptive system. The simple rules suggested by the research were both on an individual and

collective basis.

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Attractors in complex adaptive systems relate to a point to where a system always moves

towards or where it stays. Examples are a marble released into a bowl or a swinging

pendulum which after a time settles into repetitive pattern of movement in a given space.

However if the pendulum is placed between two or three magnets and the magnets are now

the attractors the pendulum’s swings neither through a predictable point nor through a

repeated loop. The pendulum describes a complex but clearly ordered shape. The pendulum

follows a similar course but does not exactly follow the same pattern. This system in

complexity terminology is referred to as a ‘strange attractor’. I have listed informal learning

(the pendulum) and parts of the building (the magnets) as strange attractors. Informal learning

was more likely to take place in certain areas. The message book and the staircase or notes

and the computer in the notes/reception area provoked a recursive pattern of behaviour where

informants gathered informally and had informal discussions. The notes area and the staircase

were notable for this activity and from observation were often used to explore topics beyond

those directly relevant to the initial issue that had been raised. I have named these special

spaces within the building ‘zones of freedom’.

The following table summarises the relationship between complex adaptive system theory and

the relevant research themes. These relationships do have the potential for overlap and in

terms of this research do not account for all the potential relationships between the research

themes.

Page 272: Paul Milne Thesis

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THE SURGERY

SIMPLE

RULES

Curiosity and creativity (problem solving)

Being organised

Responsibility (caring)

ATTRACTORS

Being professional

STRANGE

ATTRACTORS

Within the building-the staircase and the notes area (‘zone of

freedom’)

As a result of the interactions between the themes and at these points and within limits (or in

complexity terminology, phase space), there was a likelihood that new knowledge would

emerge. The quantity or quality of that knowledge was unpredictable as was its level of

transformation within the individual. Similarly, it was not possible to predict the extent of the

application of the transformed knowledge within the practice as an organisation. These are

significant limitations and limit their theoretical use.

The use of templates was an interesting area in which there was a more tangible

transformation of knowledge. Within the context of their spontaneous and unpredictable use

by the informants, it was not possible to predict the degree of transformation of knowledge.

As previously described, there was the potential for its use within the informant’s family. I

discuss Social Capital later in this chapter but in terms of complexity theory it could be

regarded as an emergent property of a complex adaptive system.

Complexity theory relies heavily on metaphor. It attempts to synthesise multiple disciplines

drawing together elements of the social and physical sciences. It has been critiqued as being

over reliant on metaphor in that it does not necessarily follow that those mathematical

Page 273: Paul Milne Thesis

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principles from the natural sciences and which work well within the natural sciences can be

applied to social complexity (Gatrell 2001, Stewart 2001). However, it does permit an

overview of a network or system and an understanding of the dynamics within the system.

It would seem that there are similarities between activity theory and complex adaptive system

theory. By this I mean that activity system theory permits identification of the elements with

in a system and their potential relationships. Complex adaptive systems as a metaphor afford

an explanation of the direction of the system and permits examination of the core elements

that drive the system through the organisational explanation of simple rules. Although ‘simple

rules have theoretical limitations, the simple rules of curiosity, creativity, being organised and

responsibility give insight into the trajectory of the practice. These simple rules stimulate

‘recursive patterns’ exemplified by the informal and social discourses on the staircase and the

reception-administration areas. Complexity emphasises the unpredictability of outcome and

gives more insight into the influences on the organization’s learning rather than the

individual’s. Activity theory gives a reductionist viewpoint at a given point in the life of the

practice and for that reason appears limited in terms of giving an overview of the practice

learning culture.

I now turn to consider the theoretical stance of Wenger’s communities of practice and its

application to the empirical study.

Communities of practice and the research findings

As noted in the literature review Wenger and Lave’s perspective on work based learning has

been highly influential and is also cited by complexity theorists. As a social learning theory it

sought to explore work based learning in a variety of settings. Fuller et al (2005) summarise

Wenger’s theory as a move away from ‘the standard paradigm of the learner as a receptacle of

taught knowledge’ and is recognition of learning in the ‘lived in world.’ In addition through

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the concept of ‘legitimate peripheral participation,’ understanding is gained of the learning

through participating in a community. Wenger and Lave’s work initially described how

‘newcomers’ to a social system learnt their role and job. This concept had been elicited

through ethnographic studies of apprentice tailors in Liberia. There is recognition that

communities of practice have structures that have power and hierarchy and as described in the

literature review describes the processes of mutual understanding and learning through

artefacts.

Lave and Wenger’s work relates well to this study but as Fuller et al (2005) observe there are

limitations. Established workers also learn from newcomers and in this study the ‘old timers’

were constantly learning from each other and this is also in keeping with Fuller’s empirical

study (apprenticeships in engineering, and steel production). Lave and Wenger pay little

attention to individual cognition and their interactions, and learning on courses which have

the potential to be brought back to be shared in the community of practice. This was described

as a method of learning by the Health Visitor.

Although Lave and Wenger’s concept of communities of practice is persuasive and has

applicability in certain general areas it lacks the ability to explain a learning setting in detail.

Thus although I set out in this study with a view that communities of practice as a theoretical

stance would predominate in the study of this practice, its findings are more likely to be

explained in terms of activity theory. I would contend that in order to understand the overall

practice as a learning organization then complex adaptive system theory is also needed. This

enmeshes neatly with activity theory since complexity is also present as an inherent internal

concept on an individual basis.

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The role of Social Capital and the research findings

Although I hypothesize that there is coherence between the empirical study and the socio-

cultural model of learning in the form of activity theory and its enhancement through complex

adaptive system theory, there remains the issue of what holds the overall activity system

together?

Within activity theory, community is used in the sense of Wenger’s community of practice

and specifically in the area of mutual understanding of rules and regulations, “how we do

things around here?” Implicit within this for the individual and for the organisation is the

concept of social capital. This concept is to be understood as described by Robert Putnam in

Schuller, Baron and Field in their review and critique of social capital (2000). Putnam’s

definition is used

‘By social capital I mean features of social life-networks, norms and trust- that enable participants to act together more effectively to pursue shared objectives’ (Putnam 1996 in Schuller , Baron and Field( 2000 pg. 9)

Norms and networks would have synergies with Wenger’s communities of practice, but it is

trust that that plays a central role in the culture of the practice and, metaphorically, holds the

organisation and its activity systems together. Trust and mistrust persistently intrude when

synergies are sought between the theoretical models and the empirical findings of the

research. In other words and to return to complexity theory, it is the equivalent of a

mathematical constant. In Putnam’s description this is discussed as a ‘reinforcement of

homogeneity’. Trust was present within the practice because of devolvement of responsibility

and the resultant flat or flatter hierarchy. The extended team’s notion of trust contrasted with

the practice nucleus team. The rule book was no longer needed between the members of the

practice and when it was, I felt unfamiliar with its content

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However when viewed at a micro level, it was apparent that at times there were disturbances

within this homogeneity. These disturbances within trust were present at times between

reception staff and the practice manager and between members of reception staff and the

practice secretary. It is tempting to invoke complex adaptive system theory here to account

for these disturbances. One explanation might be that individuals or micro communities of

practice held values or ‘strange attractors’ that disturbed trust in the multiple trajectories

within the imagined phase space represented by trust. Schuller et al. recognise this complexity

and its dynamic through social capital when they write

‘Social capital offers a purchase on such interactions but not an unrealistic promise on holding it still’ (Schuller et al., 2000 pg.14).

Trust is described in a wider political sense by Schuller and they cite Gambetta where they

reflect that although trust ‘pervades the most diverse situations…. scholars tend to mention it

(only) in passing’ (Schuller et al. 2000pg.15) and yet it appears central within this study as it

has potential to influence the themes that emerged.

A recurrent theme within the practice was the boundary both literally and metaphorically with

external bodies and the greater likelihood or propensity for ‘mis-trust’ by practice team and

extended team members. I would suggest this arose through a lack of ‘shared mutual

understanding’ or that in terms of complexity theory there were different attractors. By way of

example, it could be speculated that external organisations had a different value or attractor

on funding and effective use of resources to that held by the practice. Fukuyama’s (in Schuller

et al 2000pg. 16) view is that societies can be classified as high trust (e.g. USA, Japan) or low

trust (France, Italy) and that ‘communities do not require extensive contractual and legal

regulation of their members’. It follows within the micro world of the surgery with a high

Page 277: Paul Milne Thesis

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level of trust with some perturbations, that regulation (and therefore external power and

hierarchy) was viewed with mistrust and yet it needed to assimilate, adopt and adapt

regulation to remain organised and financially viable.

Pursuing this further, then the question arises as to what sorts of trust were present within the

practice? I use Sztompka’s model of trust as a framework to help explore this. Innes in

Rebuilding Trust in Healthcare (Innes 2003pg.19) gives an overview of Sztompka’s

classification. There are four levels or sorts of trust in Sztompka’s model. These are primary

trust, secondary trust, trusting impulse, trust culture.

Primary trust is the ‘inner’ or individual sense of trust and in this research would relate to

professional reputation, performance and appearance. The latter is described as dress,

readiness to smile and body language. Sztompka includes the appearance of buildings in

primary trust.

Secondary trust relates to the sense of trustworthiness in institutions and the context in which

their actions take place. Accountability and awareness of bodies that monitor performance are

placed within secondary trust.

The trusting impulse is to be thought of as inculcating or fostering trust in the individual

through ‘fostering family life, encouraging trusting relationships in schools and encouraging

public discourse about moral choice’ (Sztompka in Innes et al, 2003 pg.22).

Trust culture develops through the myriad of interactions between individuals, and from this

develops norms and values that ‘regulate, grant, meet, return and reciprocate trust’ (Sztompka

in Innes et al, 2003 pg. 23).

In the surgery, the forms of trust emerge as shown in the following table.

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Primary trust Reputation / Performance

/Appearance

Partner’s account of ‘being

professional’

Practice manager- doing

that bit extra

Reception: “the girls in

blue”

The new purpose built

building

Secondary trust Accountability Rules and regulations (PMS

GP contract, External

bodies /Govt / governance)

Trusting impulse Individual members of the

practice upbringing to trust

Trust culture The norms and values that

exist within the practice

reified through informal

meetings, socialisation,

‘zones of freedom’, being

organised.

There is an overlap between primary and secondary trust since ‘being professional’ in itself

has rules and regulations.

The practice had a culture which relied on trust for its functioning with its flat hierarchy

which in itself permitted learning. The lack of use or need for a hierarchy as identified by the

informants could be interpreted as emphasising the trust culture within the practice. The

introduction of the PPDP was an artefact that did not fit within the trust culture and was

linked with accountability rather than responsibility. It was an artefact that existed at the

periphery of the practice culture. It was needed as it provided financial sustenance to maintain

that practice culture.

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Summary of empirical findings and their analysis

In this chapter I have reviewed the principal findings arising from the analysis. Its purpose

was to consider the interrelationships of the themes and in what way they promoted or

inhibited learning in the practice. Most of the learning that took place was informal and that

learning formed part of the practice culture. The processes that the informants used to enable

learning have been described. I propose that the central values that reflected the practice

culture and which allowed learning to take place were caring (professional responsibility),

curiosity, creativity, and being organised. These were reified through various processes and

artefacts (e.g. the partner’s use of templates).

I have summarised the themes in the following diagram. Each theme is a ‘building block’ in

the overall emergent picture that is the practice culture. The arrows represent the values of

caring, creativity, curiosity, responsibility and being organised.

PRACTICECULTURE

ORGANISATIONHIERARCHY &

POWER LEARNING

MeetingsFormal/informal

Notes /computer

LeadershipProfessionalismExternal bodies

The BuildingSpace

Informallearning

Formallearning

Practice culture- arrows represent the practice’s cultural values: caring (professional responsibility), curiosity, creativity, and being organised.

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Formal learning was sensed as peripheral and only identified through the informants’

professional development plans and the practice professional development plan. The latter

had little legitimacy within the practice culture as a tool which in terms of face validity had

the potential to promote reflective practice.

The place of the emergent themes in the culture of the practice and its learning has been

reviewed through the theoretical perspectives of activity system theory, as a complex adaptive

system, communities of practice and social capital. These social learning theories lend

themselves to the emergent themes and I have drawn together the areas where there are

commonalities between the theories and speculate that trust emerges as the overarching theme

within this practice culture. In terms of origin trust is problematic. It could be argued that trust

is implicit within the individual and that its summation produces trust within the organisation.

Similarly, I would also suggest that trust emerged from the complex interrelationships

between the informants and the multiple artefacts present in the organisation.

No one theory aligns itself completely with the analysis. Activity theory provides an

explanation for individual learning and although limited by its lack of dynamism there is an

understanding of how the individual and the practice as an organisation learns. Complexity

theory as a complex adaptive system gives some further insight to the relationships between

the themes but it is at the level of the organisation and does not take cognizance as a theory of

the human element and implicit individual complexity. Through the concept of ‘simple rules,’

it gives a perspective on the trajectory that the practice follows. It only provides limited

additional insight in terms of prediction.

Complex adaptive system theory does provide a useful framework if the question ‘what are

the key themes or elements that drive the practice culture?’ is addressed. Complexity is

persuasive through its ability to account for the trajectory that the practice as an organisation

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follows. What is less certain is its reliability as a metaphor since it does not take account of all

the elements present in social complexity.

Communities of practice like complexity theory give insight into the dynamics that allow and

inhibit learning in the practice as an organisation. Like complex adaptive systems it does not

take account of individual cognition and in its original form related to new members and their

learning in an organisation.

Synthesising the social learning models

In this section I suggest a synthesis of the sociocultural learning theories that accounts for the

research findings. As previously observed, no one theory entirely explains the empirical

findings in this research. The theories that best lend themselves to the research findings are

activity theory, social capital in terms of trust and complex adaptive system theory.

Communities of practice form part of Activity Theory

Activity theory in the synthesis

Activity theory is persuasive and has practical applicability and gives insight into areas of an

organisation and its learning. The components of Engeström’s framework have been

reconstructed as a questionnaire (Mwanza 2002). However, the questionnaire makes certain

assumptions about the degree of trust in the organisation and represents an organisation’s

activity at a moment in time. I have discussed activity theory in relation to the empirical

findings earlier in this chapter.

In this section I consider the interrelationships between the additional components of trust and

complex adaptive system theories which I think enhance activity theory as a social learning

theory. Finally I consider the role of social spaces as identified in the empirical findings.

Examples of this in this research were the relationships between the spatial relationship of

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building and learning, the crystallisation of learning at the boundaries between the practice

team and the extended primary care team.

Trust in the synthesis

The empirical findings highlight the place of trust within the research. This was especially

apparent through its negative connotations. Mistrust was expressed by the informants. Lack of

trust was apparent in the informants’ views of their managers (extended practice team), the

practice manager’s views of the PCG and the partner’s thoughts about the external world of

the NHS and professional bodies. The practice manager’s role was of interest in the context of

maintenance of trust and avoidance of mistrust. In this research the practice manager filtered

information from the external NHS. Much of that information was about changes in NHS

regulations and their effect on the practice finances. These changes were assimilated and

transformed for understanding by members of the practice team. In order to maintain the inner

practice milieu the practice manager would attempt to manipulate the changes so that it

maintained the status quo and therefore trust. An example in this research was the practice’s

engagement with the Primary Medical Services (PMS) contract. The latter allowed the

practice to provide the services which it thought its patients needed and also introduced some

finance. This allowed the partner to focus on practice development (e.g. the writing of the

templates).

Through these moments of dissonance, the informants were characterising their sense of self

as practitioners in their micro world of the practice. There was a desire to cocoon ‘self’ in

their practice culture. This is not intended as a negative commentary. Through their

descriptions of their busy daily working lives, a gap is sensed between the health professional

and their managers. This is then reified as a boundary whose presence is dependant on

mistrust. Within the practice there were episodes of dissonance that punctuated the sense of

trust in the practice nucleus team.

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These moments both in the practice nucleus team and in the extended team caused the

informants to focus on the rules and regulations of their organisations. In turn this causes the

individual informant’s activity system and the organisations activity system to focus on rules

and regulations. These then lead to perturbations in the sense of community. Overall the

balance between the facets of the activity framework is disturbed and the focus of the activity

system and its learning is lost. Trust is required to maintain this homeostasis in which

learning can take place. Embedded within trust for the individual were the values of

compassion and patient centred care. Mistrust arose when there was a tension between these

values and the influence of economic and political capital of the external organisations.

Fugelli (2001) places trust at the centre of general practice in the context of this tension.

‘This is the drama of general practice in 2000: trust is the fuel, the essence, the foundation of general practice. Trust in general practice is, at this very moment, in danger’ (Fugelli 2001)

In the absence of trust there is no cohesion between the components of Engeström’s activity

theory framework. As exemplified in this research a change or threat to an individual’s or

practice’s contract can potentially lead to mistrust and therefore a breakdown in the activity

system. Changes in these components lead to a need for adjustments in the individual’s and

practice’s sense of trust and in turn distracted from the maintenance of equilibrium within the

activity framework.

Complexity in the synthesis

The components of the activity framework can be thought of as being in a dynamic

equilibrium. Whilst in equilibrium there is positive trajectory to the learning process in the

practice. This process is characterised by spontaneous episodes of informal learning which are

stimulated by interaction with a diverse range of artefacts. The degree of positivity can be

considered as being dependant on the level of trust in the system. For the individual informant

this interaction with the artefacts is a two way process of internalisation and externalisation.

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The outcome from that process is the informal learning for the individual and the practice as a

social group. To return to the activity framework and its components as described in

Engeström’s second generation model, there is a need to understand their interrelationships.

As postulated the framework is a dynamic system with a trajectory. This can be further

understood if the system is understood in terms of a complex adaptive system. Biological

systems such as a flight of birds or a shoal of fish function as the result of ‘simple rules’.

They give a trajectory to the system which is imparted by the compliance of the individual

bird or fish to the ‘simple rules’. In the research I suggest that the individual’s activity system

or framework is guided by ‘simple rules’ or norms as derived from complex adaptive system

theory. The rules or norms in this research were caring (responsibility), curiosity, creativity,

and being organised. In complexity language there were attractors (being professional)

towards which a system always gravitates and special attractors (staircase) where informal

learning was more likely to take place. These places need energy for the interactions to take

place and this ‘social energy’ is provided through trust.

The synthesis takes account of the dynamism needed to explain the learning that took place in

the practice and the complex interrelationships. The diagram below recognises the emergent

‘simple rules’ of the practice culture and how they were mediated by the activity system. It is

trust that provides the interconnection, understanding and emergence of the practice as a

culture and its learning. The diagram is represented as a pyramid as an extension from the

triangular relationship of activity theory. The components of the diagram are in a dynamic

and complex relationship. Trust provides the continuum between the components. It could

also be considered as the fourth corner of the pyramid. The shape of the resultant model is

many ways arbitrary given the dynamic and complex relationships.

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TRUST +interaction=knowledge

transformation

Rules and Regulations

Divisionof labour

Comm

unity

Artefact

Health Professional(being organised, responsibility,caring, curiosity)

LEARNING

Spatial(The building)

Wor

king

spac

e

Lear

ning

spa

ce

patients

Diagram of social theory learning models using empirical findings

The complexity of an activity system has been recognised by Engeström (1999 pg.31). The

synthesis with social capital and complex adaptive system theories enhances the activity

theory model. However there is a significant caveat to this proposition.

As stated earlier in this research I wish to use complex adaptive theory as a powerful

metaphor to help explain the processes observed in the practice’s organisation. The debate

and danger lies in over extrapolating from the natural sciences perspective of complexity

theory. It is tempting to suggest that the simple rules derived from the natural sciences can be

applied literally to the practice organisation. I would suggest that this is not entirely plausible.

The simple rules described above are themselves subject to multiple influences and on an

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individual basis the emergent behaviour cannot be predicted. The discovery of simple rules or

values is attractive in that it would suggest to those that wish to improve an organisation,

producing change in the simple rules or values will produce improvement in the organisation.

Complexity as a social metaphor does give insight into the processes that are important in an

organisation. It is the processes of interaction between people that are important that produce

knowledge. The process of knowledge production is a ‘narrative like sequence of gesture and

response between human bodies’ (Stacey 2002 pgs 146-148). This process is an interaction

between the ‘individual’s reinterpretation of their world and some anticipated future state’

(Stacey 2002).

In turn, this interpretation will be mediated by the artefacts or mental models of the

individual’s environment. To emphasise the social nature of learning and its complexity,

Stacey (2002) would suggest that knowledge production is a social phenomenon that is

dependent on ‘processes of relating’ rather than systems.

Spatial influence and complexity

The empirical findings suggest there is a spatial influence in the practices’ learning. From a

complex adaptive system theory perspective, the spatial influence is conceptualised as a

‘strange attractor.’ In this example, the equilibrium required for meaningful learning was

likely to be in the areas that I have termed ‘zones of freedom’. These social areas were where

it was more likely that the influences of power and hierarchy were suspended and, as a result,

trust was more likely to be evident. In activity theory, power and hierarchy were represented

in terms of rules and division of labour.

These zones of freedom were less influenced by the facets of the second generation

framework. The trajectories of the health professionals learning were more likely to enmesh

and lead to learning. However if there were distractions to that trajectory due to the influence

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of rules and regulations or through dissonance within the community, then there was less

likelihood that the activity system would remain in equilibrium and an increased certainty that

the system will lose its trajectory. The Practice and professional development plan was part of

the rules and regulations in the Primary Medical Services (PMS) contract. This was an

imposed ‘rule’. The completion of the PPDP paperwork was only accomplished once there

was a threat of a financial penalty. The PPDP failed because its meaning was linked with

rules and not with learning. The trajectory was deflected to rules and away from the

equilibrium equated with optimal informal learning.

At the conclusion of this study, the details of the new GMS (General Medical Services

Contract Department of Health 2003) contract were emerging. This provides an example of

potential for deflection or distraction from the intuitive trajectory of the practice. The new

contract places considerable emphasis on quality of care. The contract rewards improved

quality of care across a range of clinical and non clinical areas. The contract has produced a

significant change in the rules and regulations for general practitioners and places an

emphasis on the collection of data via the templates. In this research, the content of the

templates and their meaning was controlled by the partner and the other clinicians in the

practice. The new contract introduced templates for a range of chronic diseases. Their

structure and content could not be altered since the data was collated electronically and sent to

the PCT. The practice receives considerable financial rewards for achieving performance

targets reflected in the template data. The templates as an artefact which were a promoter of

learning are now reified with a meaning related to rules and regulations and mistrust. The

latter arises from the need to rely on reliable data collection, transfer and interpretation by the

PCT. In addition the practice is visited by a team from the PCT on an annual basis to verify

the data and check there is no fraudulent practice. I suggest that the original use of the

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templates for the partner and the clinical team as artefacts were an electronic ‘zone of

freedom’.

This is perhaps ‘pushing at the boundaries’ for the concept. However their development and

subsequent use links with the parameters for equilibrium and learning noted for the staircase

and the administration areas. The partner used clinical guidelines which she had summarised

and then converted into the computer templates. She was not influenced by the rule of the

wider NHS but was supported by the practice team. The templates as artefacts shared the

sense of dissociation that was present with the other zones of freedom. In relation to the

building and spatial terms, the templates represented a ‘virtual’ space or zone of freedom. The

new contract will be a threat to this ‘virtual’ space and this learning used by the partner.

The spatial dimension of the activity system is represented by the arrow which differentiates

between working and learning space. For example, the notes area and the staircase coexisted

as a place of work for the receptionists and as an area of social discourse or, as I term it, a

‘zone of freedom’ and in which there was a high level of trust. In these areas the informants

engaged in ‘good conversations’. These conversations could find health professionals

involved in discourse which related to current evidence for an illness, a discussion about a

medical ethical problem, or about where to find more information about a problem. These

conversations were necessarily relatively brief due to the busy nature of the working day.

However they held the kernels for further enquiry or helped to signpost the enquirer and

above all facilitated the solving of patients’ problems.

Other areas of the practice could intuitively be seen as more clearly representing work or

learning but this perception would vary between informants. The consulting rooms were more

likely to be viewed as a working space by most of the informants but for the doctors there was

considerable potential for learning from the notes and the computer.

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To summarise, the spatial arrow recognises the relationship between trust, the building, and

learning. Although not an absolute finding, the areas of the building were reified with

different meanings. The example of the seminar room has already been discussed. The areas

such as the staircase and the notes administration area were reified with trust and were spaces

where informants dissociated from activity theory’s rule and regulations and division of

labour. Other areas were less clearly defined and held no particular relationship with learning.

The synthesis of the learning theories and its validation is given further currency if

consideration is given to circumstances when trust was potentially diminished. For example,

when there were difficulties within the practice team, time was spent with the ‘rules’ (of

employment) or the ‘division of labour’ and a potential negation of community. These

situations created disjunctions with the practice culture’s ‘simple rules’ of complex adaptive

system theory and therefore prevented learning.

This argument can also be applied to the recent change in the General Practitioners’ contract

which is largely based on performance targets. The need to constantly address these targets

within a practice is not contiguous with the core values that emerged in this study. Through

this theoretical synthesis, the imposition of targets can be seen as potentially distracting from

learning and cause significant perturbations within the overall practice culture. The practice

manager as a boundary object in the face of this contract change is no longer able to buffer the

internal milieu with consequences for trust and the health professionals’ core values as

described in the diagram.

Interaction between activity systems and learning

So far I have considered the separate elements of the synthesis and exemplified them from the

research findings. In this section I consider the synthesis in terms of the interactions between

the informants as individual activity systems and speculate how this produces the learning in

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the practice. In the discussion I have considered activity theory, trust, complex adaptive

systems and the spatial relationship.

This summary is intended to give an overview as to how this enhancement of activity theory

enmeshes and gives rise to learning. Each informant has his or her own activity system. There

is an implicit assumption that the purpose of the health professional is to improve the health

of a patient (object). The activity is mediated through an artefact. These may be considered to

be a mental model which is both internalised and externalised and in turn acted upon by the

rules and regulations of the practice and the NHS, the sense of community and the practice’s

timetables and rotas. The individual health professional works with others. For this to be

successful activity the system conforms to ‘simple rules’. Since these are shared this gives a

trajectory to the practice’s development. The energy for that trajectory arises from trust

between the informants. The resultant interactions between the informants give rise to

informal learning. It cannot be predicted what will be learnt. Information will be transformed,

internalised and crystallised. Artefacts such as the practice and professional development plan

are mistrusted and do not form part of the practices learning. Formal learning undertaken by

individual informants is not integrated because of difficulty of integrating it within the

organisation of the practice and its link with formality.

Potential criticisms and generalisability

The empirical findings have face validity but may be biased through my influence as

participant observer and the informant’s employer. Methodologically alternative qualitative

methods might have been employed. Action research with its emphasis on reflexivity would

have been an alternative research paradigm. Questionnaires and more structured interviews

would have brought a negative controlling influence to the study. The data might have been

interpreted differently by another researcher but this bias was addressed through the

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triangulation of the data. It would be difficult to replicate this study because of the nature of

my role as participant observer. In turn this brings the discussion to the generalisability of the

research.

The data and its analysis are unique to the practice studied. I would suggest that the emergent

themes are to a certain extent generalizable. All NHS general practices will have similar

teams and to a varying extent will share the values of the practice and extended team studied.

Issues of leadership will vary considerably between practices.

Overall the themes are sensed as being generalizable to other practices irrespective of size but

the degree to which the themes exist between practices will vary and therefore dictate to what

extent informal learning is enabled. Further work is needed to take this study further and to

examine the issue of its generalisability.

The research has described the culture of a general practice. The findings from the research

explain how learning takes place in the practice. The empirical findings have helped to

synthesize an enhanced version of activity theory through the use of social capital and

complex adaptive system theory. The resultant synthesis brings an understanding to the

dynamic inter relationships and the emergence of learning for the informants in this research.

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Chapter Eight. Conclusions and future work Introduction

In this concluding chapter I return to the research area and questions described in chapter

one and summarise the work presented in this research so as to consider the contributions

made. Finally I consider the research’s generalisability, applicability and future

development within the field of primary care.

The research questions

The research considered the nature of practice culture, the place of the practice and

professional development plan and finally the relationship between the empirical data and

social learning theories. The final research question was posed in terms of validation of a

social learning theory. In the context of this research it was unlikely that the empirical data

would validate one particular theory since the analysis is derived from only one practice. It

is more accurate to conclude that the analysis as described in the discussion supports the

range of social learning theories presented in this thesis and their proposed synthesis.

Chapters four, five and six present the salient themes relevant to the research questions.

The findings from these chapters are important in that they bring an understanding of a

NHS organisational setting which has been little researched in terms of its culture. There

has been little use and discussion of social learning theories in postgraduate general

practice medical education.

Thesis summary

The research described arose from the introduction of the PPDP in 1998 following the

publication of the Chief Medical Officer’s report (A Review of Continuing Professional

Development in Primary Care) and, through this, a shift in direction was signalled for how

general practitioners would be encouraged to undertake their future professional

development. Although there had been the initiative of self directed learning by the RCGP

in the early 1990s (Al-Sheri 1993), little emphasis had been placed in terms of

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postgraduate medical educational policy on learning in the practice. The concept of the

PPDP was to provide a framework for this and subsequently in this research, the PPDP

became part of the PMS contract for the practice.

Thesis contributions

The principle focus of the research was to describe the culture of the practice and within

this the place of Practice and Professional Development Plan (PPDP). The research

explores an area which has received little attention but has importance in terms of the

concept of learning organisations as described in the NHS document ‘Working together,

learning together, a framework for lifelong learning’ and subsequent NHS educational

developments. I return to this area later in the chapter when I consider the wider

implications of the research in primary care learning.

Initially in terms of research enquiry, I wished to discover how the PPDP might be used

within the practice culture. Subsequently and iteratively, the wider issue of the practice’s

culture and its learning assumed pre-eminence. The PPDP became an artefact within the

ethnography and its place with the practice culture is described.

The research questions of practice culture, its learning and the PPDP then raise issues

related to theory. The ethnography describes the practice culture and the use of the PPDP.

These empirical findings are then used to consider to what extent they support social

learning theories. The research findings lead to a synthesis of these learning theories. The

theories are activity theory, social capital and complex adaptive systems. The latter is used

as a social metaphor to explain and gain an understanding of the complex dynamic

relationships between the informants and the artefacts in the research. A synthesis is

required since no one of the three theories discussed is entirely validated by the empirical

findings.

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Methodology

The research describes the culture of a general practice in the North East of England. This

type of research which uses an ethnographic approach is a relatively novel application in a

general practice setting. Ethnography is little used as a methodology within medical

educational research. For the purpose of this research the ethnomethodological approach

gives breadth and depth to the social setting of the practice and its learning. The

ethnographic methodology permitted description of my role as a participant observer and

the sense of my ‘voice’ within the practice culture. The method employed permitted

discovery of the practice’s ontology, its epistemology and their interrelationships.

The practice culture

At the time of the formulation of the research questions the use of the word culture (and

the need to change it) was widespread within NHS policy. The cultural description of a

British general practice organisation has not been previously described. I now summarise

the important areas of the practice culture as it relates to the learning in the practice. When

explored, the practice culture is multi faceted and complex.

Organisation

The chapters that describe the facets of practice organisation and meetings highlight the

complex interactions between the informants and the various artefacts that reify ‘being

organised’ and organisation in terms of structure. In turn structure in terms of rules and

regulation is also structured by the configuration of the building. The practice meetings

had their rituals and were situated in the seminar room which in itself had a spectrum of

meaning for the informants.’ The rituals of meetings were part of ‘being organised’.

Rules of organisation existed within the practice. In turn these were influenced or were

bounded by rules and regulations of the external bodies and institutions of the National

Health Service. The informants assumed through their assigned roles, the informal roles of

‘keepers’. For myself I was the ‘keeper of the flame’ of the overall practice vision, the

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practice manager the ‘keeper of the rules and regulations boundary’, the partner the

‘keeper of the practice conscience’ and the practice secretary the ‘keeper of the written

information’ which abounded in the practice. These roles were implicit within the practice

organisation. I reflect via the informants and those outside the practice with whom I

worked in my other roles on my leadership.

The reception staff who had little prior experience or training in health acted as conduits

between the keepers. They created a micro community of practice that was used to help

make sense of their working world. This micro community of practice was of particular

interest as it spontaneously used a variety of artefacts in their informal learning.

The notes and computer as artefacts are described and analysed to reveal their meaning for

the informants. They had a particular prominence in the organisation of the practice. The

Lloyd George notes are shown to have a wide spectrum of meaning and it was evident

they were used as tools for informal learning in the practice by the informants. The

computer had similar functions but at the time of the research was less trusted. The latter

related as much to its unreliability as well as its use for the collection of data which was

shared with external NHS organisations. Within the computer’s development, the

computer templates were revealed to be a powerful learning tool for the partner and her

clinical colleagues. The templates were used by all the clinical staff in the practice. The

templates and their data brought together data, knowledge and satisfied the needs of NHS

management at the time of the research. The latter’s needs have now changed with the

introduction of the new contract and the ‘zone of freedom’ which the templates

represented has had its autonomy eroded.

Meetings

Meetings were used to make sense of the social reality of working in the practice. Through

the away day described which purported to consider the development of the PPDP, there

was a strong sense of reaffirmation. This is seen through the flip chart pictures. The

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meetings were part of socialisation in the practice.

The place of the PPDP was considered and its relationship to the concept of a learning

organisation. The informants highlighted trust, good communications and enthusiasm and

a set of values which acted as a subtext for the notion of social capital. These were

honesty, (mutual) respect, loyalty and confidence. The PPDP reified with mistrust of

external bodies and in particular was situated within management.

Hierarchy and power

Throughout this chapter there is a contrast between the practice nucleus team and the

extended team’s perceptions of hierarchy and power. The contrast relates to their sense of

trust in their managers and their respective sense of leadership.

Through this emergent dissonance the term professionalism surfaces and is explored by

the informants. Some of the informants were not members of a professional institution.

These informants reified ‘being professional’ in terms of their lived reality of working in

the practice. There were tensions within being professional for the district nurse and the

partner. The tension was between the ‘excess’ of accountability and professional

responsibility. The latter can also be paraphrased as ‘caring’.

The building had a role within the practice culture. The seminar room had a different

meaning for the informants compared to my perception. The seminar room’s ‘power’ was

derived from the fact that the practice meetings were held there and “Dr Milne did all the

talking”. This contrasts to the other areas in the building which were used for informal

learning.

Learning in the practice

The research demonstrates that informal learning predominated in the practice. Formal

training was undertaken by the practice but any knowledge obtained by the individual was

unlikely to be shared. A wide variety of methods of learning were used by the informants.

The methods adopted were influenced by the artefacts available to the informants. The

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artefacts most readily available to the informants were the Lloyd George notes and the

computer. These artefacts acted as foci for informal conversation. Their presence in

different parts of the building facilitated curiosity and creative thought. The research

highlights the role of the spaces in the building and their influence. In particular the

staircase and the notes / administration area of the building were sites of informal

discourse and learning.

The staircase with its small landing was at a physical and metaphorical crossroads for the

informants in terms of their learning. Small groups of the team discussed issues related to

patients. In addition at this physical focus, the informants were at their most divergent in

terms of their thinking. This created a powerful socialisation process such that the

informants shed their professional roles and hierarchy. I chose to call this area a ‘zone of

freedom’. The informants freed themselves from the rules and regulations of the NHS and

entered a highly varied discourse.

Across the spectrum of the informants there was a variety of informal learning methods

reported. These varied from the informal browsing of the reception staff and practice

manager through to the partner’s use of the construction of the templates on the computer.

Their reading was informal but used to make links with their roles. Rules and regulations

in terms of accountability were commented upon by the informants. These were sensed as

a negative influence on the informants’ learning.

Trust

Trust emerges as a promoter and inhibitor of learning in this research. It is foremost in the

discourse of hierarchy, power and organisation for all the informants. It is implicit within

the professional rules for the use of the notes and the computer. The building and its

geography creates or dissolves boundaries for learning within which trust plays a dynamic

role. Trust forms part of the boundaries as exemplified through the rules, regulations and

accountability issues for the informants.

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Trust or mistrust is implicit within the daily discourse of the practice and forms part of the

practice culture. Here I would digress to use a metaphor in order to situate trust and

conclude its place in the practice culture. Astrophysicists use the concept of dark matter

and dark energy. This term is used by astrophysicists to account for the fact that galaxies

are moving apart at a faster velocity than can be accounted for by the observable matter.

There appears to be a strong theoretical stance that dark matter and dark energy exist.

Dark matter and similarly dark energy have yet to be detected but their presence is

essential to account for the dynamic changes observed in the cosmos.

With this in mind, trust fills a similar place in the theoretical base for this research. Its

presence is sensed within the emergent themes from the research but it is also intangible.

It is readily sensed when there is mistrust within the practice culture and is implicit within

the informants’ daily discourse. To pursue this further, trust could be regarded as the

factor that gives the dynamism, complexity and ‘energy’ to the interrelationships between

the artefacts, the informants and their learning. Within the final synthesis, trust is required

to maintain the overall dynamic of informal learning. In a wider sense of trust, the

research reflects the issue of the underling philosophical debate for the future of general

practice in the NHS. This lies between the emerging biomedical corporatism and the

individual psychosocial holism as described in the Future General Practitioner (RCGP

1972). This was tacitly played out within the discourse of the practice informants.

In the next section I consider the place of the research findings in terms of its

generalisability and validity in the wider context of postgraduate medical education.

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Generalizability and validity of the synthesized learning model

The research findings were derived from a general practice culture. The findings that

appear to be generalisable to general practice situated within the National Health Service

are now described in relation to the resultant theoretical synthesis derived from the

empirical research. As an overall generalisation, the final synthesis derived from the

empirical findings would appear to be applicable to most general practices in the NHS.

However within the features of the model there is potential for variability.

Within the organisation that constitutes a general practice there are artefacts that promote

or inhibit learning. The reification of these artefacts will be variable. Rules and regulations

exist within and outside the practice that perform a similar function with regard to

learning. Their meaning to the participants within the organisation will be different and in

common with all the aspects of this model can change. Community when considered in a

spectrum of generalizability has perhaps the greatest variability. It will be dependant on

the size of the general practice (e.g. single handed, small, group practice) and the skill mix

of the health professionals. Within the practice described there were several communities

or micro communities. The division of labour within the organisation of the practice will

vary from one practice to another. All the components that form the synthesised model

will be present but in a dynamic system. The energy and direction given to the system will

be derived from trust.

Trust will be present in all practices. The level of trust and its degree of homogeneity will

fluctuate. Similarly, the complex interaction between the components of the synthesised

model is a generalizable prediction but it is self evident that the outcome in terms of

learning is unpredictable. The ideal of a ‘high trust’ system in the model proposed will

have an increased capacity for curiosity and creativity for the individual and practice team.

The model’s validity and generalizability has been presented and discussed at several

venues. The findings from the research have been presented to a GP Tutor audience at

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their national conference in the form of a workshop. The group discussed the model in

some detail. Their comments revolved around the novelty of the learning theories

presented and their synthesis. The feedback mentioned that in the proposed model that ‘a

corner was missing from the model, that this ‘missing corner’ might be the theme of

‘communication’. This might be possible but I would suggest that this is included in the

socialization of the practice achieved through the daily informal discourses and the

various meetings. The group, who were all GP Tutors, described anecdotal narratives

which were similar to the research findings with regard to the PPDP and individual GPs’

PDPs. These artefacts were peripheral to the practice’s learning culture and were regarded

as objects used by NHS management. There was also agreement that there was a tension

for these objects. This tension was between accountability and responsibility. The PPDP

and PDP were embedded within accountability and therefore, as in this research, were

linked with a loss of educational autonomy.

The research and the synthesised model have been presented at a Strategic Health

Authority workshop in the North West. The workshop was part of a Knowledge

Management study day. The workshop was attended by health managers from across

primary and secondary care. Their backgrounds were as providers of training,

development of clinical guidelines and others were there as practice managers. For those

members of the group who were ‘outside’ the practice culture insights were gained as how

to better understand practice culture. New guidelines could be regarded as artefacts. Their

introduction, place and integration in the practice culture could be better understood

through the use of the synthesised model. The model encourages a raised awareness of the

boundaries and barriers for external changes.

Work based learning is of developmental interest with the modernisation of the NHS. As

noted in the introduction learning has traditionally been a uni- professional activity. In the

context of this research I use the term work based learning in the sense of an ‘individual or

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collective responsibility within a work setting’ (Mckee and Burton 2005pg.130). The

research has demonstrated that informal learning is a common experience in the practice.

This observation is not new but the research has demonstrated the components and the

mechanism through which learning takes place. In the development of work based

learning in East Lancashire, I have proposed a pilot study which will use the components

of the synthesised model. The study will explore the development of one or more

individuals within three practices who will record and reflect the informal learning to

colleagues in their practice and importantly between the three practices. The proposal has

been accepted and awaits funding. This PhD has attracted interest especially with the

renovation and conversion of several large cotton mills as new primary care centres (Local

Improvement Finance Trust Department of Health 2001) and the expressed desire by

Primary Care Trusts to develop learning environments and avoid the errors of the former

health centres.

The synthesised model will provide a structure to this study with its emphasis through

activity theory and recognition of trust and the complex dynamics. The model as a

paradigm shifts the emphasis away from the individual and accepts the importance of

social learning in organisations.

Implications for the Professional Development of the Primary Care Team

As I have previously noted, the development of health professionals in health care has

traditionally and historically relied on formal training. Little value has been given to the

experiential knowledge acquired through informal learning. This research reflects a rich

mixture of learning undertaken by the informants. In the introduction I noted the

dysjunction between the government policy in 1998 of the ‘learning organisation’ and the

subsequent policies which increased bureaucracy and accountability for the health

professions.

The research has clearly demonstrated the presence of informal learning within the

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practice. However it is threatened by increasing accountability which will serve to distract

individuals from their innate curiosity and creativity and undermine confidence.

The research gives some insight into some of the dissonance with the new General

Medical Services contract. This contract places an emphasis on performance targets across

a range of areas in primary care. These targets are linked to financial incentives and

require a greatly improved level of organisation and data collection. For the practice that

encourages curiosity and creativity and a positive learning culture there is an inherent

tension. The practice that encourages an enquiring and learning culture in many respects

will be able to readily achieve the performance targets and their financial reward.

However, the contract imposes externally created and imposed clinical performance

targets. Although many of these are evidence based they are not owned by the practice

culture. The rule and regulations that accompany the contract create mechanistic thinking

since targets have to be achieved and leave little time or desire for informal enquiry. The

over emphasis on rules and regulations which forms part of this contract threatens to cause

a dissonance in trust and a loss of educational autonomy.

As part of the modernisation of the NHS (Agenda for Change), employees are required to

have a review of their job specification. The process uses the guidance of a knowledge and

skills framework (KSF). Two of the dimensions in the framework (Learning and

development and information and knowledge) relate to this research. Both dimensions and

their descriptors place a range of requirement on the employee to be involved in learning.

Although not mandatory at present for general practices it is likely that this framework

will become applicable in the future. If so, then a practice manager will require some

informed understanding of the culture and community of practice in which their employee

is working.

In the research practice the informants intuitively operationalised their learning so that

there was a compromise which was implicitly accepted. For individuals their learning was

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influenced by the practice culture and this has been explored in some depth in this

research. Their learning was a transformative process between the artefacts of the practice

culture, their practice colleagues and the demands of individual roles. Learning was

influenced by the geography of the practice building with some areas of the building such

as the staircase area being culturally imbued with a social freedom from the perceived

constraints of the NHS organisation. As a team their learning was modulated by the

demands of the wider organisation of the National Health Service. The synthesis of

individual, team and organisational learning was complex and interwoven through the

sense of trust. These complex interwoven relationships define and describe the resultant

learning culture and from which arises the practice’s sense of being, purpose and future

development. This study turns then full circle to its original purpose of the discovery and

description of a practice culture in terms of its ontology and epistemology.

Summary

The culture of a general practice is a poorly researched area. Through an ethnographic

method, the research describes a general practice culture in the North East of England. The

researcher was a participant observer in the practice. The role and esteem of the researcher

is described as part of the research. The research analyses the components of the practice

culture and considers their influence on learning in the practice. The practice culture

described had a sense of self and although imperfect felt enabled to learn. This was

predominantly through the use of informal learning. The practice culture generated

spontaneity for learning and informants used a variety of artefacts. These had meanings

which enable or inhibited learning. The research adds weight to the need in NHS

organisational terms to acknowledge and promote a ‘bottom up’ development for learning

in primary care. For the individual, this would necessitate a shift away from the current

emphasis on the mechanistic development of the individual and recognise and reward the

innate ability of the individual in their social setting to learn through curiosity and

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creativity

The place of the Practice and Professional Plan is described within the practice culture. It

emerges as a management tool and was not used as a formative educational tool. The

PPDP was regarded as an artefact that was peripheral to the overall purpose of the

practice.

The empirical research findings are used to consider the validity of the social learning

theories. The study was not designed so that it could validate any one theory but it does

strongly support a range of social learning theories. These were activity system, social

capital and communities of practice. A synthesised model is proposed since no one theory

explains the empirical findings. This is based on activity system theory and given

additional dimensions through social capital and its dynamism through complex adaptive

system theory.

The resultant synthesised model has been presented at academic meetings and workshops.

It requires further evaluation to establish its validity. This might be achieved through

repeating the research in other practices and also consider the use of other qualitative

methodologies. These might include action research methods.

The dissemination of the research findings will inform the modernisation of the National

Health Service. The modernisation process in primary care places an emphasis on

effective teamwork. The research reflects the need to place an increased value on the

informal learning process in primary care.

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References

Arrow H., McGrath J. E., Berdahl J.L. (2000). Small groups as Complex Systems., Sage

Publications.

Atkinson, M. H. P. (1993). Ethnography, Routledge.

Atkinson, P. and L. Pugsley (2005). "Making sense of ethnography and medical

education." Medical Education 39(2): 228-234.

Barnett, R. (2000). Realizing the University, Open University Press.

Beecham, L. (2001). "Most GPs would consider resigning from NHS." British Medical

Journal 322(7299): 1381.

Bourdieu, P. (1977). Outline of a Theory of Practice., Cambridge University Press.

Caley, L.R.S. (2002). Work related learning-key influencing factors. Cambridge, NHS

Leadership centre: 1-41.

Caley, L. R. S. (2004). Key influencing factors of work-related learning, A summary of

the findings of a research project conducted by Lynne Caley and Stuart Reid at the

University of Cambridge Programme for Industry, on behalf of the NHS Leadership

Centre: 12.

Calman, K. (1998). A Review of Continuing Professional Development in General

Practice, Department of Health.

Clayman, Steven.E, Maynard Douglas W. (1991). "The Diversity of Ethnomethodology."

Annual Review Social Sciences 17: 385 - 418.

Coffield, F. (1997). Nine Learning Fallacies and their replacement by a National Strategy

for Lifelong Learning. University of Newcastle UK.

Coffield, F. (1999). The necessity of informal learning, Bristol: Policy press.

Page 306: Paul Milne Thesis

Cornford, C. S. (2001). "The development of practice professional development plans

from the postgraduate education allowance: a discussion of the causes and implications."

Medical Education 35(1): 43-48.

Daniels, H. (2004). "Activity Theory, Discourse and Bernstein." Educational Review

56(2): 121-132.

Davies, C. A. (2002). Reflexive Ethnography : A Guide to Researching Selves and

Others, London ; New York Routledge.

Department of Health, (1998). A First -class service: quality in the NHS. Her Majesty's

Government

Department of Health, (2001). NHS local improvement finance trust (NHS LIFT)

prospectus. Her Majesty's Government

Department of Health, (1997). The new NHS Modern Dependable, Her Majesty's

Government.

Department of Health, (2001). Working Together - Learning Together, Department of

Health. Her Majesty's Government.

Eagleton, T. (2000). The idea of culture, Blackwell.

Editor (2001). The Doctors' Doctor Proposals to reform the GMC merit a cautious

welcome. The Times. London.

Edwards, N., Kornacki, Mary Jane, Silversin, Jack (2002). "Unhappy doctors: what are

the causes and what can be done?" British Medical Journal 324(6th April 2002): 835-838.

Engeström, Y. (2001). "Expansive learning at work: toward an activity theoretical re

conceptualization." Journal of Education and Work 14(1): 133-156.

Page 307: Paul Milne Thesis

Engeström, Y., Engeström, R and Karkkainen, M. (1995). "Polycontextuality and

Boundary Crossing in Expert Cognition: Learning and Problem Solving in Complex

Work Activities." Learning and Instruction Vol.5: 319-336.

Engeström Y., M. R., Punamaki R-L. (1999). Perspectives on Activity Theory,

Cambridge.

Eraut, M. (1994). Developing professional knowledge and competence, London Falmer.

Eraut, M. (2000). Non formal learning, implicit learning and tacit knowledge in

professional work pgs. 12-30., Bristol: Policy Press.

Fenwick, F. (2001). Questioning the Concept of the Learning Organization in

Knowledge, Power and Learning pgs. 74-88.

Fox, S. (2000). "Communities of Practice, Foucault and Actor-Network Theory." Journal

of Management Studies 37: 853-867.

Fugelli, P. (2001). "Trust -in General Practice." British Journal of General Practice(July

2001): 575-579.

Fuller Alison, Hodkinson Heather, Phil Hodkinson and Lorna Unwin (2005). "Learning

as peripheral participation in communities of practice: a reassessment of key concepts in

workplace learning." British Educational Research Journal 31(1): 49-68.

Gatrell, A. C. (2003). Complexity theory and geographies of health: a modern and global

synthesis? Lancaster Complexity Network.

Goffman, E. (1969). The presentation of self in everyday life. London: Allen Lane,

Grant Janet, Stanton Frances.(1997). The effectiveness of continuing professional

development. A literature review for the chief medical officer's review of continuing

professional development in practice, The Joint Centre for Education in Medicine.

Page 308: Paul Milne Thesis

Gray, P. (2002). "Deprofessionalising doctors?" British Medical Journal 324: 627-628.

Ham Chris, Alberti, K G M M (2002). "The medical profession, the public, and the

government." British Medical Journal 324(6th April 2002): 838-842.

Hammersley, M. (1998). Reading Ethnographic Research, Longman.

Horder J, Byrne P, Freeling P, Freeling P, Harris C, Irvine D, Marinker M (1972). The

Future General Practitioner Learning and Teaching, British Medical Journal.

Howe M. (2000). Diagnostic Findings for ****** Surgery, *****Primary Care Trust.

Illeris, K. (2002). The Three Dimensions of Learning, Roskilde University Press.

Innes, R. (2003). Rebuilding Trust in Healthcare, Radcliffe Medical Press.

Irvine, D. (2001). "The changing relationship between the public and the medical

profession." Journal of the Royal Society of Medicine 94: 162-169.

Kendrick, D., Ed. (2004). Complexity and healthcare organization a view from the street,

Radcliffe medical press.

Knight, P. (2002). "A systemic approach to professional development: learning as

practice." Teaching and Teacher Education 18: 229-241.

Lave J. and Wenger E. (1991). Situated Learning Legitimate peripheral participation.

Leadbetter, J. (2004). "The role of mediating artifacts in the work of educational

psychologists during consultative conversations in schools." Educational review 56(2):

133-145.

Marshall, M. N., R. Mannion, et al. (2003). "Managing change in the culture of general

practice: qualitative case studies in primary care trusts

British Medical Journal 327(7415): 599-602.

Page 309: Paul Milne Thesis

McEwen, Y. (2003). A qualitative study into the drivers and barriers affecting GPs in the

development and implementation of their personal development plans. General Practice.

London, University College: 190pages.MSc. Dissertation

McKee A, W. M. (2003). "Practice and Professional Development Plans in East Anglia: a

case of politics, policy and practice." Work Based Learning in Primary Care 1(1): 33-47.

McKee, A., Burton, J., in Rounce, K., Workman, B.(2005) Work-based learning in

Health Care: applications and innovations, Kingsham Press

Miller W, McDaniel L Jr., Reuben R., Crabtree B.F. (2001). "Practice Jazz:

Understanding Variation in Family Practices Using Complexity Science." Source: Journal

of Family Practice; Oct2001, Vol. 50 Issue 10, p872, 7p.

Michele Minnis Vera P. John Steiner (2001). "Are we ready for a single, integrated

theory?" Human Development 44: 296-310.

Mwanza, D. (2002). Towards an Activity-Oriented Design Method for HCI Research and

Practice, The Open University, United Kingdom.

Newman, P. and E. Peile (2002). "Valuing learners' experience and supporting further

growth: educational models to help experienced adult learners in medicine." British

Medical Journal 325(7357): 200-202.

Nigel Edwards, M. J. K., Jack Silversin (2002). "Unhappy doctors: what are the causes

and what can be done?" British Medical Journal 324: 835-838.

Orwell, G. (1949). 1984.

Oxford English Dictionary, (1973). Clarendon Press.

Oxford English Dictionary http://dictionary.oed.com

Prodigy, Sowerby Centre for Health Informatics. www.prodigy.nhs.uk

Page 310: Paul Milne Thesis

Paechter, P., Scott and Soler eds. (2001). Questioning the Concept of the Learning

Organization in Knowledge, Power and Learning, Sage.

Plamping, D. (1998). "Looking forward: Change and resistance to change in the NHS."

BMJ 317(7150): 69-71.

Plsek, P. E., Greenhalgh, T (2001). “The challenge of complexity in health care." British

Medical Journal 323: 625 - 628.

Rutherford, J. McArthur, M (2004). "A qualitative account of the factors affecting team-

learning in primary care." Education for Primary Care 15: 352-60.

Sandars, J. (2005). "An activity theory perspective." Work Based Learning in Primary

Care 3: 191–201.

Schön, D. A. (1987). Educating the Reflective Practitioner, Jossey-Bass Publishers.

Schuller Tom, Baron Stephen Field John (2000). Social Capital Critical Perspectives,

Oxford University Press.

Senge, P. (1992). The Fifth Discipline: the art and practice of the learning organisation,

Century Business.

Silverman, D. (1993). Interpreting Qualitative Data, Sage.

Sinclair, S. (1997). Making Doctors, Berg, Oxford.

Smith, R. (2001). "Why are doctors so unhappy?" British Medical Journal 322: 1073-4.

Spradley, J. P. (1979). The Ethnographic Interview, Harcourt Brace Jovanovich College

Publishers.

Page 311: Paul Milne Thesis

Stacey, R. D. (2002). Complex Responsive Processes in Organizations, Routledge.

Stange, K. C. (2001). "The best of times and worst of times." British Journal of General

Practice Volume 51(Number 473): 963-966.

Stewart, P. (2001). "Complexity Theories, Social Theory, and the Question of Social

Complexity." Philosophy of the Social Sciences 31(3): 323-360.

Sweeney K., Griffiths, F. (2002). Complexity and Health Care, Radcliffe medical press.

Sylvester, S. (2003). "Measuring the learning practice: diagnosing the culture in general

practice." Quality in Primary Care 11: 29-40.

Tudor Jones Rhiannedd, G. E., Kerenza Hood, Sarah Matthews and Helen Houston

(2003). "Professional and practice development plans: a survey of general practitioners’

views." Education for Primary Care 14: 25-33.

Van Zwanenberg, T. D. (2002). The revalidation of general practitioners: an analysis of

policy development between May 1997 and July 2001, University of Newcastle.(EdD

thesis)

Wenger, E. (1998). Communities of Practice, Cambridge.

Wertsch, J. (1991). Voices of Collective Remembering, Cambridge University Press.

Workman B, Rounce K. (editors), (2005). Work-based Learning in Health Care:

applications and innovations, Kingsham Press.