Alison Ledger

Can the tools of activity theory help us in advancing understanding and organisational change in undergraduate medical education

Continued changes to healthcare delivery in the UK, and an increasing focus on patient safety and quality improvement, require a radical rethink on how we enable graduates to begin work in challenging, complex environments. Professional regulatory bodies now require undergraduate medical schools to implement an ‘assistantship’ period in the final year of study, where senior medical students ‘shadow’ the work of junior doctors, with an expectation that they will be better ‘prepared’ for work. However, there is little guidance about what an ‘assistantship’ entails and the current emphasis on preparedness of students arguably underplays the importance of contextualised learning within the workplace environment. This paper will describe a modified Development Work Research (DWR) (Engeström in Developmental work research: activity theory in practice. Lehmanns Media, Berlin, 2005) approach to organisational change, enabling academic, clinical and administrative partners to develop assistantship placements in different hospitals. Our findings indicate that a modified DWR approach can reveal factors indicating organisational readiness to support change within a locally contextualised framework. The process has significant practical applications across a range of healthcare disciplines, as all professions seek to engage with the challenge of enabling successful transitions of graduates to the workplace.

Exploring Multiple Identities as a Health Care Ethnographer

Previous discussions about the role of the ethnographer have weighed the advantages and disadvantages of occupying insider or outsider positions, or dual practitioner-researcher identities. In the authors experience, additional identities can come to the fore when a seasoned health professional returns to the field as a novice ethnographer. In this article she reflects on ways in which she shifted between the identities of researcher, therapist, friend, and student in her ethnography about music therapy service development. These experiences are presented to reveal the inherent complexity of the researcher role and to encourage health care ethnographers to consider ways in which they can hold multiple identities in their own research.

Developing understandings of clinical placement learning in three professions: Work that is critical to care

Abstract Background: This study contributes further evidence that healthcare students’ learning is affected by underlying assumptions about knowledge, learning and work. Aims: To explore educators and students’ understandings of early clinical placement learning in three professions (medicine, nursing and audiology) and examine the profound impacts of these understandings on students’ learning and healthcare work. Methods: Narrative interviews were undertaken with 40 medicine, nursing, and audiology students and 19 educators involved in teaching these student cohorts. Interview transcripts were read repeatedly and interpreted using current practice-based understandings of learning. Results: Across interviews and professions, students and educators made distinctions between aspects of clinical placements which they understood as “learning” and those which they tended to disregard as “work”. In their descriptions of learning in clinical workplaces, medicine and nursing students and educators privileged activities considered to be technical or specialised, over activities that were understood to be more “basic” to care. Furthermore, interviews with medical students and educators indicated that rich and unique possibilities for learning from other members of the healthcare team were missed. Conclusions: Distinctions between “learning” and “work” are unhelpful and all participation in clinical workplaces should be understood as valuable practice. Action is needed from all parties involved in clinical placement learning to develop understandings about learning in practice.

Performative, Arts-Based, or Arts-Informed? Reflections on the Development of Arts-Based Research in Music Therapy

Arts-based research (ABR) has emerged in music therapy in diverse ways, employing a range of interpretive paradigms and artistic media. It is notable that no consensus exists as to when and where the arts are included in the research process, or which music therapy topics are most suited to arts-based study. This diversity may pose challenges for music therapists who are developing, reading, and evaluating arts-based research. This paper provides an updated review of arts-based research literature in music therapy, along with four questions for researchers who are developing arts-based research. These questions are 1) When should the arts be introduced? 2) Which artistic medium is appropriate? 3) How should the art be understood? and 4) What is the role of the audience? We argue that these questions are key to understanding arts-based research, justifying methods, and evaluating claims arising from arts-based research. Rather than defining arts-based research in music therapy, we suggest that arts-based research should be understood as a flexible research strategy appropriate for exploring the complexities of music therapy practice.

Coproduction without experts: a study of people involved in community health and well-being service delivery

Coproduction (equal professional-public involvement in service delivery) has been widely promoted as a means of revolutionising health and social care. Service providers/professionals are tasked with working more in partnership with service users/clients, recognising their experiences and knowledge as critical to the success of the interaction. Fundamental to the coproduction model is the notion that service providers and service users are separate groups, with different interests, identities, training and work protocols. This paper reports findings from a pilot research project which examined coproductive practices in two different health and social care organisations in the UK in 2012. In both settings we observed a range of initiatives in which most of the facilitators were people who had initially been service recipients, but become service deliverers in the spirit of coproduction. Analysis of fieldwork notes and interview transcripts indicated that though facilitators developed expertise, they were reluctant to call themselves ‘experts’ and their learning was rarely recognised by them as expertise. To progress coproduction practice and research, we suggest that more attention needs to be paid to the ways that knowledge, experience and expertise are distributed across organisations, as well as the significance of context in service change.

Critical Junctures in Narrative Research: Collaborative Reflections on Methodological Issues

The co-creation of narratives can be a complex and intricate process where findings are shaped and molded by the interactions between researcher and study participants. From the moment the researcher enters the field of inquiry through to the writings of each story, and often beyond the final storytelling, there are poignant moments or junctures that the researcher may face in relation to methodology and ethical practice. The authors present three narratives about their experience of conducting narrative research within the field of music therapy. Each author tells her story in relation to the methodological and ethical challenges and considerations encountered. Looking both within and across these three stories, the authors highlight five critical junctures that may arise during the research process. Common strategies for negotiating these challenges are identified to assist narrative researchers in any discipline who may be experiencing their own pivotal junctures.

Entering a new profession: Patient educator interns' struggles for recognition

Objective: To ascertain patient educator interns′ (PEIs) views on the internship experience and to explore how the transition to the workplace is experienced by new graduates from emergent professions. Methods: In this case study from Saudi Arabia, semi-structured interviews were conducted with 10 PEIs. Following a narrative type of analysis, case summaries were created, compared and interpreted. Results: Interns held preconceptions regarding the patient educator′s role, and these preconceptions were frequently not mirrored by actual practice. The clash of preconceptions and actual experiences led participants to encounter shock. Conclusion: Transition shock for PEIs seemed to be exacerbated due to their position within a new profession. This study adds to a growing literature about the challenges experienced by workers in new and emerging healthcare roles.