Collective learning, change and improvement in health care:trialling a facilitated learning initiative with generalpractice teamsjep_1641 630..636

Suzanne Bunniss BA PhD,1 Francesca Gray MB ChB MRCGP DGM1 andDiane Kelly MB ChB MD DRCOG FRCGP2

1Researcher, 2Assistant Director of PG GP Education, Department of Postgraduate General Practice Education, NHS Education for Scotland,Glasgow, UK

Keywords

collective learning, learning organizations,primary care

Correspondence

Dr Suzanne BunnissNHS Education for Scotland2 Central Quay89 Hydepark StreetGlasgow G3 8BWUKE-mail: suzanne.bunniss@nes.scot.nhs.uk

Accepted for publication: 22 December2010

doi:10.1111/j.1365-2753.2011.01641.x

AbstractRationale, aims and objectives Many patients, families, health care professionals andpoliticians desire for quality improvement within the UK National Health Service. One wayto achieve this change is for health care teams to work and learn together more effectively.This research aimed to design and trial a facilitated learning programme with the aim ofsupporting general practice teams in fostering the characteristics of learning organizations.Methods This is an action research study. Qualitative data were captured during and afterthe trial from 40 participants in two multi-professional general practice teams withindifferent Scottish health boards. Data were gathered using observations, semi-structuredinterviews and written learning notes.Results Taking part in the LPP was a positive experience of learning together as a practiceand enhanced communication within the team was a particular outcome. External facilita-tion helped provide focus and reduce inter-professional barriers. Teams found working insmall, mixed role discussion groups particularly valuable in understanding each others’perspectives. The active learning style of the LPP could be daunting at times but teamsvalued the chance to identify their own quality improvement goals. Teams introduced anumber of changes to improve the quality of care within their practice as a result of theirparticipation.Conclusion This trial of the learning practice programme shows that, with facilitation andthe appropriate input of resources, general practice teams can successfully apply learningorganization principles to produce quality improvement outcomes. The study also demon-strates the value of action research in researching iterative change over time.

IntroductionThe UK National Health Service (NHS) is an enviable publichealth system made up of many skilled workers who providehealth care to patients at the point of care. At the same time thedaily provision of care is sometimes hampered by the scarcity ofstaff time and resources, shifting politics and historical tensionsbetween professional groups. Consequently, the time and effortpoured into the NHS does not always produce the positive resultswe might hope for and expect. This has given rise to a desire forchange and quality improvement shared by many patients, fami-lies, health care professionals and politicians: how can the NHSrealize more of its potential?

Collective working and learning withinthe NHSOne suggestion is that we find ways to work and learn togethermore effectively [1]. If health care staff can share their knowl-

edge, skills and professional experience more fully with eachother, we could gain new insights into how this complex systemcan best meet patient needs. This idea of collective learning [2]is gathering momentum in both literature and policy [3,4] as theevidence grows for the power of team-based approaches [5–9].Traditionally, postgraduate education in primary care has centredalmost entirely on separate continuing professional development(CPD) for individuals and individual disciplines; thereforecollective learning is somewhat new territory for professionaleducation, particularly work-based learning. Increasingly, we areasking: how can health care professionals with diverse back-grounds, training and experience navigate the challenges theyface together?

Learning organizations: the theoryThe theory of learning organizations [10] provides one way tothink about these issues. Peter Senge’s concept of organizationscapable of systematically improving their effectiveness has

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attracted much attention within academic business disciplines andworkplaces [11]. The qualities of learning organizations are iden-tified in the literature as openness, trust, outward looking, anabsence of complacency and a belief in human potential (adaptedfrom Mintzberg et al. [12]). The premise is that people at grass-roots levels within organizations can work together effectively, onissues they value, using their professional discretion to design andimplement the changes they believe are needed. The potentialimpact of such a culture shift within the NHS is a powerful idea[13,14].

Learning organizations: applying thetheory in health careIn practice, initiating and sustaining both the energy and exper-tise to cultivate the values of a learning organization is challeng-ing. While much is written on learning organizations, theemphasis thus far has been largely managerialist, often with acommercial orientation and limited empirical research. One sys-tematic assessment of the NHS against the qualities of a learningorganization [15] found the reality to be far removed from theideal outlined by Senge. In part this may be because these ideasare rarely presented in ways that could be practically applied tohealth care teams or other public sector organizations as theynavigate change.

One exception to date is the work of Rushmer et al. [16–18]. In2004 their series of papers outlined a vision of the ‘learning prac-tices’ that could exist if learning organizations theory was appliedby practice teams in primary care settings.

A learning practice is a collection of primary care staff whodeliver services together and who have decided to adopt someof the learning organisations ideas to help them collectivelydevelop their practice and service provision so as to make lifebetter and easier for themselves and their patient alike. [17]In 2007, the Learning Practice Inventory (LPI) [19,20]

offered a further diagnostic instrument to help teams identify theextent to which they reflect the qualities of a learning organiza-tion in their current approach to the health services they provide.This tool gave a way to collect descriptive data about team atti-tudes to working and learning while at the same time raising thequestion of team development. Once a team has diagnosedthe extent to which it reflects the characteristics of a learning

organization, how will it interpret and respond to those results?Can a primary care team usefully use information from the LPIto celebrate its strengths, consider its weaknesses and guidethe kind of authentic change practitioners themselves believe isnecessary?

The Learning Practice Programme (LPP)This study reports the first findings from an initiative seeking toanswer those questions. A facilitated learning programme wasdesigned and trialled with general practice teams with the aim ofsupporting them in fostering the characteristics of learning prac-tices. This Learning Practice Programme (LPP) used the LPIresults of the team as a ‘snapshot’ of their current team attitudesand practice, and a springboard from which they could identifyareas for self-directed improvements. The LPP trial consisted of aseries of four workshops designed and delivered by a trainededucational facilitator during the protected learning time (PLT) oftwo general practitioner (GP) practices over a 6-month period (seeTable 1).

Research methodology and design(Action research is) a collaborative intervention in a real-world healthcare situation to define a problem and explore apossible solution (Morton-Cooper 2000, Action Research inHealthcare) [21]This study was informed by an action research methodology

[22–24] (see Fig. 1). Action research is specifically designedfor projects that aim to introduce a particular change or improve-ment and at the same time understand the nature of thatchange and its transformative potential. In this case, the hoped-for improvement is that participating teams will develop thecharacteristics of learning organizations and deepen theirability to learn and work collectively. The LPP workshop seriescan be understood as the ‘action’ component of this study(Fig. 1, boxes 1 and 2) and is supported by the accompanyingresearch component reported in this paper (Fig. 1, boxes 3 and4). Action research is intended to be a cyclical methodology andthe expectation is that the findings from the trial will informfuture educational interventions and further research, therebycompleting the cycle of learning and change inherent to thisapproach.

Table 1 Learning practice programme trial format

Workshop Title Content and activities

1 The learning practice inventory Team receives feedback from LPI questionnaire they completed prior to workshop 1.Team members discuss results and prioritize areas for improvement.

2 Action planning for qualityimprovement

Team works in small multi-professional groups to identify practical action steps for improvementbased on their priority areas. Groups use ‘force-field analysis’ technique to develop action plansto be implemented between workshops.

3 Team building Team participates in Myers Briggs Type Indicator workshop to explore different working and learningpreferences within the practice team and implications for working together.

4 Review and consolidation Teams review progress they have made in implementing action plans and the changes they haveintroduced. They then refine future action steps and consolidate the processes they will use tocarry these out.

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Data collectionForty participants in two multi-professional general practice teamsfrom different Scottish health boards participated in the LPP trial.Volunteers were invited using an email contact list at NHS Edu-cation for Scotland. Qualitative data were captured during andafter the trial. Each team had two observational visits to work-shops, which were recorded using detailed logs. Participants alsosubmitted anonymous written learning notes (identified below as‘LO note’) to the facilitator at the end of each session. Both teamswere invited to post-trial semi-structured interviews and 12 indi-viduals participated. Interviewees included two GPs, two practicenurses, three staff with practice management responsibilities andfive practice administrators.

Data analysisData analysis was conducted by a team at NHS Education forScotland. Observation logs were analysed line by line and mappedthematically using MindGenius Software. This map was thenrefined to identify key findings from the observations. Interviewswere audio-taped and transcribed verbatim. One transcript wasread and reread, reduced and coded line by line to generate initialthemes. The analysis group then replicated this process withfurther interviews to develop themes and generate key findings.The written learning notes were coded using Nvivo software. Alldata sources were compared and triangulated. Two or more of theanalysis team independently analysed each data source and veri-fied the interpretation.

Results

Participants in the LPP trial reported the following key findings:

1 The LPP was a positive experience of learning together as apractice team

2 External facilitation within the LPP helped to provide focus andreduce inter-professional barriers

3 Working in small, mixed role discussion groups is particularlyvaluable in understanding each others’ perspective in a multi-professional team

4 The active learning style of the LPP could be daunting at times butteams valued the chance to identify their own quality improve-ment goals

5 Enhanced communication between members of the team prac-tice is a particular outcome of taking part in the LPP

6 Teams introduced a number of changes to improve the quality ofcare within their practice as a result of taking part in the LPP

The LPP as a positive experience ofteam learning

Overall, the feedback from the trial phase of the Learning Prac-tice Programme was very positive. Participants believed the LPPhad a positive impact on their practice and they saw value inlearning together through the workshop series. Overwhelminglyinterviewees reported that the programme had been beneficialto the practice and many described the experience as ‘fun’ or‘enjoyable’.

Figure 1 The action research cycle.

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I remember coming away thinking ‘that was quite fun, youlearned something’. (Administrator 1)

A new enthusiasm and excitement for my job (LO note)In particular, participants found it unusual to have the opportu-

nity to learn together as a full team, including colleagues whomthey see infrequently (such as attached staff). Participants reportedthat this, along with protected time away from the demands ofnormal practice, was very valuable and created an environment‘more conducive to learning’.

I think it’s good that they have all the staff there and you areseeing the whole team, so from that point of view it’s quitegood because sometimes we don’t get together as a wholeteam. (Nurse 1)

We have always been quite separated GPs and reception staff(LO note)

Much more inclusive of all members of the team (LO note)It is important to note that, overall the practice nurses reported

a less positive experience of the LPP trial and did not perceive theintervention to be as valuable as their colleagues. Both nurseinterviewees felt the programme did not bring the team together asmuch as they had expected and while they acknowledged thepractice changes that had happened as a result of participating,they felt they did not take much away from the workshops person-ally. This feedback differed from the otherwise consistent reports,which suggests some difference in the way the nurse participantsexperienced the LPP in comparison with the rest of the practiceteam.

The value of external facilitation inovercoming professional barriers

Participants saw external facilitation as a key feature in the successof the educational intervention. They felt the facilitation providedfocus for their activities, which helped them achieve more thanthey would have if the time has been self-directed.

It was different because it just wasn’t like sitting listening tosomebody or something the practice had made up. It wasquite structured and they knew what they were doing andthings like that and kept us on an even track, I think that wasdifferent about it. (Administrator 2)Similarly, interviewees reported that the competence and rela-

tional skill of the facilitator ‘made people open up’, whichimproved the quality of the feedback.

I think it (facilitation) helps to a degree. I think some of thegirls just don’t like speaking up, they feel that, probably feelthey don’t get listened to . . . if we could change that, I thinkthat would be one of the biggest things that we could do inthe surgery. (GP 2)

I think it (facilitation) does generate more discussion, moreopenness about what people are happy with or unhappy without in the practice. (GP 1)Most participants also felt the intervention of the facilitator

helped them overcome normal hierarchical issues within the team,which allowed them to contribute more honestly to the discussion.Interviewees reported that within the workshops they felt they ‘wereall equal’ and that ‘everybody has a valid opinion’; this in turncontributed to their sense of having had a collective experience.

I think the interaction with the different people in the surgeryand having the time to speak to them outwith your work envi-ronment, other people’s views, like the medical staff, theadmin staff and integrating them was good. We were allequal, you know. (Practice management 1)

It was a chance for everybody to talk about some things andeverybody really did have their say, kind of got involved, Ithought that was good. (Administrator 3)Again, there was a difference in this feedback for nursing par-

ticipants who found the facilitation overly directive at times andfelt their practice team did not always work well together duringthe workshops. These participants did not know why this might bethe case but said there are ‘always things that go on under thesurface’ within a team that are not really dealt with. Further dis-cussion indicated that some of these issues related to historicalrelationships within the practice and past experiences of sharedlearning events, which had created preconceived expectationsabout the LPP programme.

Small mixed-role groups as valuable inunderstanding colleagues’ perspectives

The use of small, inter-professional (mixed) role discussion groupsemerged as a particular strength of the LPP initiative. Participantstalked extensively about how valuable it was for them to ‘learnabout everyone else’s role’ and ‘to see things from a differentperspective’. Participants had not had the opportunity to do this inother settings and repeatedly emphasized how important it was forthem to hear about the experiences of their colleagues and shareviews on practice development.

It was interesting to see how people who do different jobs, tosee how, what their angle is on things and you could see itfrom a different perspective rather than just seeing your ownwee square, you could see the bigger picture sort of thing.(Administrator 1)

Usually the doctors, they just speak to us, we don’t alwaysget into groups with them but I found that very good.(Administrator 4)

And seeing everyone’s side, even like workflow, like thereception staff don’t know what it’s like in the consultationroom and trying to deal with all the mail but we could discussit in groups and say ‘What’s it like for you?’ I just felt it wasvery good. (Practice management 2)

There is massive untapped talent in this practice (LO note)In particular, participants focussed on the improved quality of

their communication. A number of the team members commentedon the perceived divisions within their group and the opportunitythey had to overcome these.

Working together in groups and coming together to discusschanges is better than all sitting round a table shouting sug-gestions and nothing being achieved. (LO note)

The active style of the LPP and theopportunity to identify qualityimprovement goals

Participants valued the active nature of the learning processes andcompared it positively with didactic educational approaches.

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I think it was a good atmosphere, it was, you know, it wasn’ta lecturing situation, it was participation, which at first wasprobably quite daunting for some of us but then as yourconfidence grows I think it was good for certain people whodon’t like to maybe speak up in front of a large audience andit was becoming apparent during those days that people weregaining more confidence and being more able to do that.(Administrator 1)

Much more proactive, interactive (LO note)At the same time, some participants found the active engage-

ment daunting and reported that for those who are naturallyquieter, it takes time to get used to speaking out within the biggroup. These individuals found the small group discussions par-ticularly valuable as a way to share their views and make sugges-tions to their colleagues.

Being the youngest and newest member of the team, I feel Ihave come out of my shell more and feel more confidenttalking (LO note)

I learned more about myself: more confident in offering sug-gestions for change, ways of doing things. (LO note)

Enhanced team communication as a resultof the LPP

Both teams identified communication as an area they wanted toimprove upon during the Learning Practice Programme; therefore,perhaps not surprisingly, ‘enhanced communication’ is the mainarea of reported improvement as a result of participating in theprogramme.

I think we are better at communicating, and maybe kind ofunderstanding each other a bit more, and what each of us doas well. There does seem to be more emails, we’ve starteddoing monthly meetings again, which we hadn’t been doingfor a while, so I think the communication side of things hascertainly picked up. (Administrator 5)

I thought it was good for us all to get into groups with thedoctors and nurses and talk about things that some of us feltmaybe weren’t happening, like communication being like themain one . . . now people are making a point of coming to youand saying ‘Do you know about this?’ or ‘Do you not knowabout it?’ so from that point of view, yes, I feel it has, its beengood. (Administrator 4)

Quality Improvements introduced by the teams

The interviewees reported that they introduced a number of qualityimprovements to their practice, which they identified and plannedduring the LPP workshops. These included introducing an elec-tronic workflow system, re-designing staff training and devolvingtraining responsibilities to existing staff in new areas.

We have definitely made changes and that was the good thingabout it because I’m sure you know that yourself when yougo to workshops sometimes, they’re not relevant, you comeback and think ‘Oh that’s good but nothing happens in theday to day working’ but things have changed. (Practice man-agement 2)

It has come on well now . . . that went in about 6 weeks agoand we’ve seen good progress with that so that’s fantastic.

The email is much better now, more people have got it, we’vegot it on different computers, which is one problem solved.(GP 2)Participants liked that the programme design allowed them to

identify and work on issues that they felt were a practice priority.Receiving initial feedback from their LPI responses allowed themto identify areas they wanted to improve upon, which engendereda sense of ownership towards the changes they subsequently intro-duced. It was important for participants that workshop time wasspent resolving issues that were directly relevant to their everydayneeds.

But it was great to have things organized for us, but still bepart of it. It was things for our practice specifically . . . andwe’ve had ownership of that, but it all came from the work-shops basically. (Practice Management 2)

We’ve kind of met and changed things, you know, and kindof everyone, admin, nurses, doctors we’ve all had a say.(GP 1)

I put forward an idea and helped to see it through (LO note)I think it has completely changed the way everybody works.(Administrator 2)Notably, a number of interviewees believed the improvements

they had made within the practice would have a direct impact ontheir patients very shortly after their participation in the initialworkshops.

If you look at workflow, the way we handle results, althoughthe patients don’t know that we handle it differently, we feelthat we now handle it quicker and more efficiently and thereis less chance for the correct action not being done. (GP 2)

I think if we are working better as a team its going to help thepatients and that side of things, yes I do think it has been ben-eficial to the patient’s as well as ourselves. (Administrator 5)

DiscussionOverall, the findings indicate that the trial of the Learning PracticeProgramme was a positive experience of collective learning andimprovement for the participating teams. Both teams took steps toapply the principles of learning organizations and reported changesto their existing practice and more effective team communication asa result. Given that some of the high profile cases of NHS failings inrecent years [25–27] have been directly linked to the inabilities ofhealth care staff to communicate across inter-professional bound-aries these findings are encouraging. The LPP trial indicates that itis possible to support health care staff in learning together evenwhere there is historical professional distance. If these findings areborne out by further research, the LPP may be one way to foster amore joined-up approach within the NHS.

Supporting the relational aspects ofcollective learning

Prior research indicates that informal collective learning in healthcare teams is experiential (teams learn by doing), evolving (the endis unknown) and implicit (over time teams learn to intuitivelyknow and anticipate each other) [2]. These are all relational pro-cesses, which the LPP appears to naturally support. The practicalexercises undertaken in small mixed role groups are experiential

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and the improvement process whereby teams interpret their LPIfeedback, identify shared priorities and plan action steps is anevolving one. Also, as found in this earlier study, shared learningboth relies on and generates a degree of intimacy between people;that is, a sense of knowing and understanding one another whileallowing the vulnerability of learning together. Participant feed-back regarding the small groups suggests a sense of that type ofintimacy within the teams. Finding evidence of the characteristicsof self-motivated informal learning in this more structured trialsetting suggests that the LPP has retained some of the qualities ofinformal collective learning that teams find useful.

The motivation for learning

One of the particular hallmarks of the LPP design is that partici-pants themselves define the nature and focus of the qualityimprovement activities they want to work on. This echoes existingresearch into collective learning, which found that the motivationfor shared learning arises when staff feel they need to work col-lectively to respond effectively to patients [2]. In this trial teamsgenerated the LPI feedback, interpreted this information for them-selves and identified the areas for development they wanted toprioritize. Both teams chose to work on issues they believed wererelevant to their real experience in general practice. This is animportant point of comparison with other learning and improve-ment initiatives, which often ask health care teams to respond topriorities that have been generated externally by other bodies. Theparticipant interviews indicate that teams appreciated the opportu-nity to design their change efforts around information they trustedand knew to be reliable and relevant to their situation.

The role of facilitation

Participants emphasized the value of external facilitation as usedwithin the LPP. Existing literature recognizes that teams often findit difficult to discuss practice issues owing to hierarchical struc-tures [28] and it is notable that the facilitator’s outside perspectivehelped these teams work outwith their traditional team hierarchyand communicate more effectively during workshops. This is par-ticularly important given that the findings of this trial suggest rolegroups engage differently in whole team learning activities andsome may derive less benefit than others (e.g. nursing participantsin this case). It is important that further research explores thesedifferences, and how they influence the success of collective learn-ing projects. This is particularly relevant in GP practices given thatprior research indicates general medical teams have more hierar-chical structures than their dental and pharmacy equivalents,which could inhibit shared learning.

The question of standardization

Finally, the LPP with its emphasis on self-design inevitably raisesthe question of standardization. If teams choose their ownimprovement priorities and how to address them, how will theseactivities sit within the existing top-down clinical governance andpatient safety structures within the NHS? One answer is to quality-assure the process of the LPP rather than the outcomes. In this trialthe LPP was fully supported by an external facilitator and many ofthe team activities are tried and tested in adult learning in other

contexts (e.g. small group discussions, consensus voting, actionplanning); if teams cultivate the ability to use these shared learningprocesses well, constructive outcomes will follow. The LPP is anexample of a standardized process, but with space within it forchoice and self-design. In this sense the LPP reflects the spirit ofthe Scottish Government Quality Strategy [29] which calls forgreater multi-professional working and shared decision making.

Educational trials like the LPP also raise the deeper question ofprofessional accountability. Is there enough political trust toempower inter-disciplinary practice teams to use the knowledge oftheir local context and their particular health care team to meet theneeds of patients? This reflects the current debate about what levelof centralized control will be most effective in producing betterhealth care. The indicators of success found within the LPP trialsuggest that initiatives like this, which are sensitive to localcontext, team diversity and collective responsibility, have a role toplay in improving care. Many political and academic thinkersconsider local ownership and collective leadership to be desirable;however, there is uncertainty about how that can really beachieved. If these findings are confirmed by further research, thisapproach could provide a practical and realistic way to engenderthe grassroots change that centrally controlled improvement strat-egies are struggling to realize [30].

StrengthsThe action research design is a particular strength of this study.Most educational initiatives conduct end-on evaluations whereasthis study gathered data throughout the process. This informed thetrial, resulting in refinements to the workshop series as it pro-gressed. This study also draws clearly on the theoretical frame-work of learning organizations as applied to health care byRushmer et al. Rees and Monrouxe [31] emphasize the importanceof the role of theory in advancing useful knowledge in medicaleducation research.

The study also explored collective learning with full multidis-ciplinary teams. Education initiatives in health care tend to focuson one or two professional groups or to remove some teammembers to train them in isolation from the rest of the team; todate very few studies examine full, mixed teams together. Tradi-tionally certain professional role groups tend not to be involved inshaping quality improvement and change (e.g. administrators andclerical staff), whereas in this case all staff had the opportunity toparticipate.

LimitationsAs yet, the scope of the LPP trial does not provide evidence ofsustainable changes in team behaviours. It is not clear as yetwhether teams were able to maintain the enhanced communicationthey reported or how successful the changes they made to theirpractice were over time. Also, the recruitment of volunteer prac-tices to the initiative could indicate these teams had a greatercommitment to collective learning and improvement at the outset.

Further researchSince the trial, the LPP has been further developed in a year-longpilot study with other teams. Research continues to inform this

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team learning initiative and in time this will explore the sustain-ability of the LPP outcomes and whether the programme is trans-ferable to teams outside general practice.

ConclusionsThis trial of the learning practice programme shows that, withfacilitation and the appropriate input of resources, general practiceteams can successfully apply learning organization principles toproduce quality improvement outcomes in the short term. Partici-pating teams achieved this through collective planning, problemsolving and decision making during the workshop programme.Ultimately, if the principles of learning organizations can beembraced by health care teams in ways that complement existingsafety and governance initiatives, the result could be more relevantand sustainable quality improvements in practice. The study con-cludes that given the right circumstances, learning practice theorycan translate into practice. Further research is essential to explorewhat this will mean if applicable to other teams over a longer timeperiod.

AcknowledgementsMany thanks to both participating teams and the extensive work ofthe trial facilitator. Thank you to Claire Reid, Annabel Shepherd,Barbara Meyer and Jo Dawes who formed the research analysisgroup at NHS Education for Scotland. Also to Janette McCrae,Murray Lough and John McKay for helpful feedback on earlierdrafts of this paper.

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