Work-based learning is at the heart of continuing professional development (CPD). Yet to be truly successful a learning culture needs to include all members of staff, and enable them to become educational leaders. The question is, how can this be achieved in practice?
In answering this Purcell and Lloyd-Jones (2003) suggest that we first need to ask, ‘what is good clinical teaching’? As they say, without clear guidelines and standards it becomes difficult to create a culture of continuous learning that includes and enables all staff.
It’s a view supported by Mohanna (2007) who makes the point that the role of the healthcare professional as teacher should be recognised as a core professional activity, one that simply cannot be left to chance, aptitude or inclination.
Most health care providers now recognise the importance of continuous learning as a way of improving patient care services. In short, top to bottom and end to end learning is essential as a way of sharing good practice and increasing the ability to learn from errors.
So, what qualities are needed to create a culture of continuous learning and educational leaders in healthcare?
It’s an important question that a recent international study explored (The Kings Fund 2016). They found that in compassionate and inclusive leadership cultures, all staff focused on continuous learning and through this, on the improvement of patient care.
Creating a Culture of Continuous Learning
Important leadership behaviours that are known to encourage learning and innovation include:
Focusing on both the emotional as well as the cognitive elements of practice; and
Ensuring that team members regularly take time out to review objectives, strategies and processes.
The aim is to collectively learn and improve as well as supporting personal wellbeing. Practically, this can be done in numerous ways. For example:
Sharing learning about errors, near misses, and improved practices;
Improving the quality of work practices, including regular reviews of working methods;
Developing and implementing ideas to improve quality;
Supporting others in implementing ideas for new and improved ways of working;
Avoiding blaming unnecessarily by creating a psychologically safe environment
The Kings Fund (2016)
Listen, Learn and Act
Continuous learning is just that – it never stops. Even practitioners who have a well-developed knowledge base with years of experience still need opportunities to refine or challenge their current practice before integrating new learning.
Sign Up To Safety (2015) offer some excellent practical suggestions for facilitating, creating and capturing these learning moments within the healthcare team. They include:
Regularly review incident reporting and investigation processes to make sure that all staff members are truly learning from them;
Listen, learn and act on feedback from patients and colleagues; and
Continually measure how safe your services are.
Capturing Teachable Moments
Key to optimising continual learning is making use of teachable moments, occasions that spontaneously arise out of an ongoing clinical situation in which a practice question, concern, doubt, or uncertainty suddenly surfaces (Thomas 2004).
Teachable moments usually occur as short conversations, often in response to uncertainty about how best to proceed, or how to make the right, or best decision for a patient. The term naturalistic decision making has also been used to describe this type of real-life decision making, where there is both significant uncertainty alongside opportunities for learning.
Structured learning will never lose its value, but could more be made of teachable moments at the bedside?
Thomas (2004) suggests that much more could be made of these learning opportunities. For example, when a practitioner’s clinical expertise or judgement is challenged. Or when new practical skills need to be learnt or consolidated.
Teachable moments are not just for junior members of staff, however. They can also offer precious learning opportunities for more experienced practitioners on their journey from novice to expert. Everyone can benefit, and everyone has the opportunity to be both a learner and a teacher.
Thinking Out Loud
As Thomas (2004) suggests teachable moments present precious opportunities to make critical thinking conscious and visible by reflectively thinking out loud. Done well, this has the potential to move theoretical knowing into a conscious, reflected upon, and articulated knowing-in-action. Thinking out loud is also a strategy that has been identified to promote evidence-based practice.
Useful questions to encourage learning could include:
What surprised you about this patient, or this situation?
What did you do differently in this situation?
What do you expect from your patient over this shift and in the coming days?
Would you do anything differently next time?
It’s open ended questions like these that are known to maximise learning through reflection and inquiry, allowing the learner to grow in understanding, and by reflecting on their practice, self-identify future learning needs.
Coming back to the question of how an all-inclusive culture of learning can be established within the healthcare team, Sign Up To Safety (2015) offer the following thoughts for consideration:
Real, sustainable, active improvement depends far more on learning and growth than on rules and regulations.
It’s important to find a balance between the hard guardrails that keep things in proper order and the culture of continual learning that helps everyone to grow.
To become a learning organisation, leaders should create and support the capability for learning, and therefore change, at scale.
Rules, standards, regulations and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.
A commitment should be made to lifelong learning about patient safety and quality of care through customised training for the entire workforce. Topics should include safety science, quality improvement methods, approaches to compassionate care and teamwork.
Collaborative learning through safety and quality improvement networks can be extremely effective and should be encouraged.
Patient safety cannot be improved without active interrogation of information that is generated primarily for learning, not punishment, and is for use primarily at the front line.
Investing in learning, growth, development, ambition, and pride can unleash momentum for improvement that no simple, top-down, control-oriented, requirement-driven culture ever can.
Perhaps it could be argued that some of these suggestions are idealistic, or simply unattainable with limited resources, but that doesn’t stop them from being goals to reach for in the pursuit of greater learning.
Mohanna, K. (2007) ‘Teaching in the healthcare setting’, Postgraduate Medical Journal, 83(997), pp. 143-144 [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599984/(Accessed: 10.05.19).
National Advisory Group on the Safety of Patients in England (2013) A promise to learn – a commitment to act. Improving the Safety of Patients in England, Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf(Accessed: 10.05.19).
Purcell, N. and Lloyd-Jones, G. (2003) ‘Standards for medical educators.’, Med Educ., 37(2), pp. 149-54 [Online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12558886/(Accessed: 10.05.19).
Sign Up To Safety (2015) Continually learn , Available at: https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/11/su2s-continually-learn-overview.pdf(Accessed: 10.05.19).
The Kings Fund (2016) Culture and leadership programme: Concepts and evidence, Available at: https://improvement.nhs.uk/documents/1546/01-NHS101-Evidence_030417.pdf(Accessed: 10.05.19).
Thomas, M. (2004) Teachable Moments in Clinical Practice: Promoting Clinical Judgment Skills, Available at: https://www.insightassessment.com/content/download/4096/42083/file/Teachable+Moments+in+Clinical+Practice+-+Promoting+Clincial+Judgment.pdf(Accessed: 10.05.19).