Lena Fritzén

Pedagogical approaches in quality improvement coaching in healthcare : a Swedish case study of how improvement coaches approach learning in a contemporary healthcare system

In this study we adopt a critical perspective and explore different coaching styles in quality improvement (QI) work in the provision of healthcare. Coaching has gained attention as an effective way to enhance QI in healthcare. This study investigates how coaching is realised in terms of learning: What kinds of learning ideals pervade QI coaching, and how is support for learning realised, given the prevailing conditions in a contemporary healthcare system? For the purpose of this case study, a group of coaches exchanged experiences about their pedagogic roles and the strategies that they employed, on four occasions, over a period of 4 months. The conversations were filmed and then analysed, using critical discourse analysis as an analytic framework. Three parallel styles of coaching were identified, which were symbolised by (1) a pointing, (2) a bypassing and (3) a guiding discourse. No persistent dominance of any one of the discourses was found, which suggests that there exists an ever-present tension between the pointing and guiding pedagogies of coaching activities. The findings indicate that QI coaching in healthcare is more complex than previous conceptualisations of coaching. Additionally, the findings present a new, ‘bypassing’ coaching style which the coaches themselves were not fully aware of.

One lens missing? Clarifying the clinical microsystem framework with learning theories.

Introduction: The clinical microsystem (CMS) approach is widely used and is perceived as helpful in practice but, we ask the question: “Is its learning potential sufficiently utilized?” Objectives: To scrutinize aspects of learning within the CMS framework and to clarify the learning aspects the framework includes and thereby support the framework with the enhanced learning perspective that becomes visible. Methods: Literature on the CMS framework was systematically searched and selected using inclusion criteria. An analytical tool was constructed in the form of a theoretical lens that was used to clarify learning aspects that are associated with the framework. Findings: The analysis revealed 3 learning aspects: (1) The CMS framework describes individual and social learning but not how to adapt learning strategies for purposes of change. (2) The metaphorical language of how to reach a holistic health care system for each patient has developed over time but can still be improved by naming social interactions to transcend organizational boundaries. (3) Power structures are recognized but not as a characteristic that restricts learning due to asymmetric communication. Conclusion: The “lens” perspective reveals new meanings to learning that enhance our understanding of health care as a social system and provides new practical learning strategies.

Leading and learning through myth and metaphor.

A group of about 20 city council directors takes a study trip to Toronto as part of a leadership-training course, in order to compare the Swedish and Canadian health care systems. The purpose of the course is to discover new organizational improvements that can contribute to improving the Swedish health care system. Even if everyone in the group has much experience with leadership, so far it has proven difficult to put into words the characteristics that leadership for change should embody in a complex organization. Theoretical models from various subject perspectives have been presented and discussed; yet the participants have still not been able to fully reflect on or question their own leadership. The group’s discussions have taken place at the abstract level, which means that the group members’ established ideas of the health care system and their own leadership have not changed at all. After a long trip over the Atlantic, the study trip to Toronto begins with a sightseeing trip to Niagara Falls. During the visit something happens that opens the group up for a different type of discussion. The power of the falls, their sheer height, human beings’ insignificance in contrast to the enormous forces of nature, and a sense of wonder at the beauty of nature all meld together to form a new picture that summarizes the complexity of organizational change and what it means to find oneself on the brink of chaos.