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How Theory Can Inform Our Understanding of Experiential Learning in Quality Improvement Education

Goldman, Joanne PhD; Kuper, Ayelet MD, DPhil; Wong, Brian M. MD

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doi: 10.1097/ACM.0000000000002329
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The importance of an experiential learning approach is widely endorsed in quality improvement (QI) education. “Hands-on” learning, where learners engage in various stages of the development and implementation of a project, has become a key component of QI curricula in many medical education programs.1–4 Despite reports of positive impacts in learner satisfaction, knowledge gains, and project outcomes,5–9 many programs continue to struggle with how to best promote experiential QI learning that occurs in complex health care settings.10 In this Perspective, we explore the opportunities afforded by a theoretically informed approach, to deepen understanding of the diverse factors that affect experiential QI learning processes in the clinical learning environment.

Facilitators and barriers to QI-project-based education exist at the learner, faculty, training program, and organizational levels.3 Although some suggestions exist regarding the importance of topic selection, faculty support and mentorship, ensuring dedicated time to conduct QI project work, and aligning QI projects to institutional priorities, there is limited empirical research about how these factors intersect and influence the experiential learning process and about how to address their complexity to improve educational and project outcomes.4,7,9,11–15

We became particularly interested in further unpacking the concept of experiential learning after we completed analysis of data gathered as part of a four-year longitudinal qualitative study of the Co-Learning QI (Co-QI) Curriculum by the Department of Medicine at the University of Toronto Faculty of Medicine (see Box 1 for curriculum and research details).16,17 Although our research focused primarily on evaluating the impact of the Co-QI Curriculum on faculty development for QI education, the data also provided insights into the complexity of experiential learning through QI project work. For example, faculty had different approaches to project supervision and had various opinions about whether residents should select their own project topics or should align their projects with institutional priorities. Some felt that the primary emphasis of QI project work was on learning, whereas others prioritized project outcomes. Such heterogeneity may contribute to the ongoing challenges faced by learners and the variability seen, both in educational experiences and also in the way learners execute their QI projects. Our QI curriculum experience, it seems, mirrored a key concern in the broader education field: that the notion of “learning from experience” is a “catch-all phrase” that too often escapes critical unpacking despite its variation and complexity.18

Box 1 Co-Learning Quality Improvement Curriculum at the University of Toronto’s Department of Medicine

The University of Toronto’s Department of Medicine has 19 subspecialty divisional programs. The department developed the Co-Learning Quality Improvement (Co-QI) Curriculum for these programs to teach QI to residents and faculty and to train faculty to teach QI. The curriculum spans one academic year and includes two interactive workshops, a resident team-based QI project under faculty supervision, and a final project presentation. The curriculum was piloted in 2011–2012 in 3 subspecialty programs, with additional programs joining in subsequent years, such that 15 subspecialty programs involving 109 residents and 42 faculty participated in 2017–2018.

The department carried out a longitudinal qualitative study of the Co-QI Curriculum from 2012–2015 to examine the effectiveness of this model for building QI faculty capacity. Thirty semistructured interviews with 23 faculty participants from 13 subspecialty residency programs were conducted. The findings demonstrate that the curriculum was effective in improving faculty QI knowledge and skills, and increased faculty capacity to teach and mentor QI. A combination of curriculum and contextual factors was critical to realizing the curriculum’s full potential.

Medical education practitioners are increasingly turning to theory to deepen their understanding and guide their approaches to their educational work. Through the use of theories, medical educators can be more reflective and explicit about the rationale for their planning and assessment of educational practices.19,20 Theories provide “complex and comprehensive understandings of things that cannot be pinned down.…”21 We began to wonder which theories could help us and, by extension, other medical educators, to better understand how project-based learning in QI “works.” We consequently turned to the experiential learning literature for potentially useful theoretical frameworks that could inform our conceptualization and organization of QI project-based learning and its opportunities and outcomes.

Theoretical Underpinnings of Experiential Learning

The Carnegie Foundation study22 of the current status and future direction of medical education identified, as one of its key recommendations, the need for improvements in the integration of formal medical knowledge and experiential learning. The commonly used term, experiential learning, is often employed to refer to the construction of “knowledge and meaning from real-life experience … in a context relevant to learners’ own future careers.”23 Although learning from practice is a long-standing tradition in medical education, it is not a uniform or static phenomenon, with its particular characteristics being informed by technology, contexts, theory, and professional and educational mandates.23–25

Experiential learning is often associated with Kolb’s26 theory of experiential learning, which posits a four-stage learning cycle: concrete experience, reflective observation, abstract conceptualization, and active experimentation. Kolb’s cycle focuses primarily on how individuals interpret and integrate an experience into their existing knowledge structures in order for it to become new or enhanced knowledge.27 Schön’s28 work on reflection-in-action and reflection-on-action is a further example of an individualized approach to systematically thinking about one’s behavior, in the present or past, and making a consequent change in one’s behavior. These theories, although widely referenced, have been critiqued for their narrow focus on the individual learner relative to the social context in which the experience occurs.23,29,30 Theories that focus on learning as an individual activity have been dominant in medical education, possibly reflecting historical perspectives of the autonomous physician. However, medical education researchers are increasingly recognizing learning as being deeply connected to its context and social processes.31 Furthermore, learning theories that focus primarily on the individual do not reflect current emphases on teamwork and systems-based QI.32

The term experiential should therefore be viewed as an overarching concept that could be informed by a wide range of theoretical approaches with diverse philosophical origins. These theoretical approaches vary from those that focus on individual cognitive processes (e.g., Kolb’s, Schön’s) to sociocultural and sociomaterial theories that focus on social relations, objects, and contexts (e.g., community of practice, complexity theory).31,33–35 The use of theories does not require an either/or approach; rather, different theories can be used to illuminate varied aspects of a phenomenon.19,29,36 Indeed, the use of multiple theories throws light on the varied ways in which a concept or practice can be understood, taught, assessed, and researched.19 Being more deliberate and attentive to the use of particular theories to explain experiential learning can enable a deeper understanding of the learning processes involved in project-based QI education and how they could be best supported and optimized.

Using Sociocultural Theories to Inform Experiential Learning in QI Education

QI project-based learning is characterized by project work that individuals and/or teams carry out in their clinical workplaces; it is influenced by existing clinical practices and routines, health care workers, and organizational structures. Our experiences with the Co-QI Curriculum and analysis of our qualitative data16,17 indicate variability in how resident teams executed their QI projects and in how faculty supervised QI projects. The project work is characterized by multiple types of relationships, including those amongst the resident team, between the resident team and their faculty, and between the resident team and the other stakeholders of the QI projects. The projects take place in a variety of clinical departments and in different care settings. Furthermore, the nature of the project work is influenced by the availability of resources and is informed by varied factors such as clinical practice guidelines and organizational QI priorities.

The data we collected began to illuminate the variability, tensions, and opportunities that arise when programs engage learners in project work to learn about QI. Therefore, we became interested in relevant theoretical frameworks that could deepen exploration of the multiple individuals, relationships, objects, concepts, and social contexts that influence the diversity and challenges in the planning and implementation of QI project-based learning. We share these insights in this Perspective to foster discussion about the helpfulness of a theoretical approach in understanding QI project work with the goal of informing future QI education research and practice.

Theoretical Frameworks: Billett’s Workplace Learning Theory and Actor–Network Theory

In the following sections, we provide an overview of two theoretically informed approaches and draw on insights from our data to show how the use of such approaches provides useful frameworks for extending our understanding of QI project learning experiences. We are not arguing for the exclusive use of these two theoretical approaches; rather, we use them as illustrative examples of how a theoretical lens can help to extend our understanding of how experiential learning occurs in the context of QI education.

To this end, we chose a sociocultural theory—Billett’s workplace learning theory—and a sociomaterial theoretically informed approach—actor–network theory (ANT)—as they provide the language and frameworks to understand and position the varied factors we identified in our data as characterizing learners’ QI project work. Billett’s workplace learning theory37 focuses on relational interdependency between individuals and their work environments, whereas ANT gives emphasis to the central role of humans and nonhuman objects in the formation of networks.38

Billett’s theory of workplace learning

Like experiential learning, workplace learning is an umbrella term for multiple approaches with diverse theoretical underpinnings.37 In the workplace literature, there has been a distinction between focusing on learning as “acquisition,” where the goal is accumulation of knowledge and skills, and conceptualizing learning as “participation,” where the aim is for a learner to become a participant of a community of learners or workers.31,39 Workplace learning covers a range of activities, and in graduate medical education, for example, it includes apprenticeship learning and role modeling.40 Workplace learning in health care can be challenging, given the simultaneous and sometimes competing needs for learning/teaching versus high-quality patient care.41,42 QI project work, and by extension QI learning, must be carried out in clinical and organizational contexts, and has similar tensions concerning learning/teaching and organizational outcomes. Billett’s workplace learning theory provides a framework to build on such ideas in workplace learning in relation to QI project-based learning.

Billett’s43 conceptualization of workplace learning strives to attend to both the individual and the social contributions to learning. Billett outlines the following key premises of his approach: (1) Humans have consciousness and subjectivity that shape their thinking; (2) humans act and learn; and (3) social settings have norms, practices, and traditions that shape and transform activities and interactions.43 Billett focuses on learning opportunities that are afforded in a particular workplace setting and how learners’ prior experiences—which shape what they already know, can do, and value—affect how they are able to mediate and negotiate the learning opportunities and choose (or not) to engage with them.24,44 In turn, the workplaces’ social and physical environments, and the more experienced workers within them, provide messages and guidance about performing and learning activities that shape the opportunities for practice and learning. However, workplaces may lack access to the required activities, personnel, and resources to foster learning opportunities and support individuals to achieve their learning goals.24 Billett’s theory, based on workplace education research in non-health-care settings, has recently been applied to medical education in health care settings (see Box 2).

Box 2 Examples of How Billett’s Workplace Learning Theory Is Used in Medical Education Research

Skipper et al40 studied pediatric residents’ and consultants’ attitudes and beliefs regarding workplace learning and contextual and organizational factors influencing the organization and planning of medical specialist training. Drawing upon Billett’s work, they discuss the ways in which workplaces differ in how they structure the learning conditions and settings that are instrumental for establishing participation and engagement between residents and faculty. They also note that residents might not always pick up the affordances of the learning situations, since they may not recognize their role in cocreating and participating in activities, or may lack the tools for doing so in a meaningful way.

Strand et al64 studied physicians’ conceptions of medical student learning in the clinical workplace and how they contribute to student learning.16 The authors drew upon Billett’s conceptual framework of “coparticipation,” in addition to system thinking, to understand the variations in relationships between contextual factors and the individual agency of students and supervisors. More specifically, physicians’ conceptions of learning as “membership” and “partnership” focus on how student learning results from the interrelationships between workplace organizational and cultural structures, continuity of participation and relationships, and how students and supervisors can act on the existing structures and learning systems.

Noble and Billett65 used Billett’s theory of interdependent learning processes to explore how junior doctors learn to prescribe through coworking with pharmacists and consultants. They found that learning to prescribe is an interdependent process, with junior doctors being dependent on coworking with consultants and pharmacists. Three themes were identified: prescribing readiness of junior doctors; need for guidance; and challenges of pharmacists coworking as outsiders. The findings provide insights into how coworking could be better utilized for the development of effective prescribing practices.

Theoretical application of Billett’s theory to QI project learning

Billett’s key messages regarding the importance of attending to both the individual and social contributions to learning, and the need to understand the opportunities and limitations that workplace experiences provide, resonate with our data. Faculty described how residents entered the curriculum with different interests in QI and different expectations from the curriculum. Faculty noted that these attitudes had an impact on QI project selection, project work, work distribution amongst team members, team dynamics, and faculty supervisory approach. They also realized over time that they needed to create learning opportunities to support the QI project work, such as having regularly scheduled meetings, providing extra QI resources to resident teams, and being available for e-mail communication. Faculty also talked about their role in enabling access to data, linking residents to organization stakeholders, and connecting residents to existing QI priorities—all examples of how various aspects of the workplace afforded QI learning opportunities. Faculty reported on changes in their approach to guiding projects as they developed experience over time. Faculty also described variation in the extent to which the residents’ projects were connected to department activities and departments’ engagement with QI activities, and to support for residents’ QI projects. Billett’s theory of workplace learning can provide a valuable lens to research on QI education that more systematically explores questions such as how workplaces differ in how they structure the conditions for participation in QI work, what role faculty can play and how they provide guidance, how residents pick up on the opportunities of the learning situations, and what learners’ readiness is to engage with QI learning experiences.

Actor–network theory

ANT is located amongst the sociomaterial perspectives that view human and nonhuman entities as dynamic and enmeshed in everyday practices.45,46 ANT has its origins in poststructuralism and the sociology of science and technology, and the scholarly activity of Bruno Latour, Michel Callon, and John Law.47,48 It has since been taken up in a range of fields, including health services research,47–49 public health,50 education,51 and more recently, medical education52 (see Box 3 for examples). According to an ANT approach, the world consists of networks, and the aim is to understand how networks come into being, the associations or relationships between network components, and how networks generate effects.47,53,54 ANT practitioners describe ANT as an “analytical technique” for understanding complex situations and the production of change.32,47,50,55

In the term actor–network theory, the word actor refers to any humans (e.g., learners, patients, health care team members), objects (e.g., medical equipment, forms, computers), or ideas (e.g., the Institute of Medicine’s six domains of quality of care; organizational policies; clinical practice guidelines) involved in forming a network. A network reflects the ways in which the above-mentioned types of actors develop connections and meaningfully relate to each other. Actors, in turn, are also themselves outputs produced by networks of other actors.53

To illustrate how actors and networks relate to one another, take, for example, the use of a surgical safety checklist. A network of actors, including humans (e.g., the surgeon, anesthesiologist, nurse, patient), objects (paper checklist, whiteboard with reminders), and ideas (e.g., regulatory requirements to implement the surgical checklist, mandatory reporting of checklist compliance), come together and influence surgical practice. However, the checklist itself is also a product of a separate network of actors (e.g., professional practice leads, patient safety specialists, forms committee, scientific evidence supporting the use of checklists).

In ANT, human and nonhuman actors have the same capability to exert force on each other, which is referred to as the principle of generalized symmetry.32,56 Different actors can play multiple roles in multiple networks at multiple time points.47 Actor–networks are seen to be dynamic, heterogeneous, and inherently unstable, but can be stabilized to a degree when people, technologies, roles, routines, training, and incentives are aligned; stability is required for a network to produce results. ANT draws attention to the quantity and quality of relationships formed in a network and the significance of the interactions that occur at various points of connection. This includes details such as how connections and roles are established, changed, or strengthened, as well as processes of negotiation and resistance.32,46,50

ANT uses several terms to describe the processes entailed in networks; these are useful for understanding variability in how networks form and exert their impact. Translation is the process by which networks are created, expand, and act.50 For translations to develop, the actors must act as mediators (i.e., network elements that transform the meaning or elements that they are expected to carry) rather than as intermediaries (i.e., network elements that carry meaning without transformation).32,55 For example, in the earlier example of the surgical checklist, the surgeon, anesthesiologist, and nurse may act as mediators by engaging in dialogue around the checklist, which then contributes to a revised practice in the planned procedure. In contrast, these same three health care professionals can act as intermediaries if they complete the checklist for the sake of checklist compliance, and the checklist does not contribute to a change in teamwork practice. The relational aspect of ANT is underscored by the concept of affordance, which describes the process where actors shape the possibilities for each other’s existence and capabilities.54,57 Whereas Billett also uses the concept of affordance in his conceptualization of workplace affordances on learning, the dynamic nature of networks in ANT and the multiple directions in which affordances occur provide for workplace institutions, in addition to learners, to be acted on.

ANT has been critiqued for its limitations, such as the assumption that all actors are equal, its lack of acknowledgment of power imbalances, and its being description focused.47 ANT has been used in education research since the earlier part of this century51 and has been discussed in the medical education literature more recently.52,58 Its presence in health care research is currently more apparent in health care services and QI research (see Box 3).

Box 3 Examples of How Actor–Network Theory Is Used in Medical Education Research and Quality Improvement Research

Allen48 studied nursing work practices in relation to a patient-status-at-a-glance whiteboard quality improvement intervention, illuminating the nursing actions that were expected to be “delegated” to the whiteboard, as well as the “prescriptions” the whiteboard expected of the nurses. That study brings attention to how we can think about the mutual effects that exist between humans and objects. The whiteboards were expected to be “intermediaries” and to transport meaning without transformation. However, nurses operate as mediators in their knowledge translation role, adapting meaning for different audiences.

Nestel et al52 conducted a thematic analysis of trainers’ and trainees’ experiences of surgical training in an outer metropolitan hospital. They studied the interactions and alliances amongst the varied actors (e.g., trainers, trainees, patients, surgical program, safer working hours, log books, study groups, operating theater), and how networks are situated within broader networks. The authors identify the importance of designing mediaries to promote network connections and contribute to high-quality training experiences.

Stoopendaal and Bal66 studied a national quality improvement collaborative for the long-term care sector, with the aim to understand what must be accomplished to enable improvements to occur in the everyday life of care organizations and to sustain those improvements. They found that human and nonhuman actors had to undertake different kinds of “translation” work to “displace” improvements into specific organizational situations. These changes were achieved through a process of “inscription,” defined as the translations of values and interests into texts, behavior, or materialities.

Theoretical application of ANT to QI project learning

ANT can be useful to exploring QI project work, given our initial, but still limited, understandings of the structures and processes that characterize these learning experiences, including what makes certain QI group projects more effective in producing change. Our data from the Co-QI Curriculum demonstrate that there were many factors that affected and characterized the nature of a QI project. ANT provides a framework to conceptualize and understand these components by recognizing the significance of both human and nonhuman elements, their interactions, and the effects produced.

In our data, we identified a range of potential actors in a QI project network. These include humans (residents, QI mentors, program directors, health care providers, patients), objects (data, financial resources, organizational space), and ideas (clinical practice guidelines, QI tools and principles, perceived value of QI work). In an ANT approach, we would therefore ask, “How do these actors develop connections and meaningfully relate to each other?”

Faculty in our study reported on numerous points of interactions that would be important to explore. For example, negotiation featured prominently in faculty–resident interactions around topic selection; issues that came into play included residents’ choosing a topic meaningful to them and faculty’s valuing of division and organizational priorities. Program directors reported instances where they met with residents to ensure that project progress was occurring, and also reported their interactions with them to push the project forward. Faculty described residents engaging with other health care professionals in the clinical environments where QI work was occurring.

Each of these points of interaction illuminates work required to sustain a network; attention to the quality and quantity of alliances and the significance of interactions could provide insight into how actor–networks are stabilized in QI project work to produce both learning and improvements in quality. In an ANT approach, we would be cognizant of not just how residents and faculty have an impact on objects such as a checklist, for example, but also on how nonhuman actors, such as wait time measurements and QI guidelines, have an impact on the activities of residents. Attention to the roles of mediators and intermediaries would also provide insights into QI project networks. For example, how do faculty act as mediators or intermediaries? An exploration of this question would enable us to understand whether existing networks are enabling or hampering QI learning.

Future Directions

In this Perspective, we have discussed two social theoretical approaches, Billett’s workplace learning theory and ANT, as illustrative examples of how such approaches provide useful frameworks to inform future research in QI education. These are two amongst numerous theoretically informed approaches that could be used to explore QI experiential education. We have chosen them because of our own interests in the sociocultural and material aspects of learning and because they are gaining traction in the medical education literature more broadly, but we are mindful that numerous other theories may also provide useful approaches. For example, in related areas of QI and patient safety education, Gonzalo et al59 used a communities-of-practice lens to explore how medical students’ experiential learning experiences can add value to the health system in addition to students’ learning. de Feijter et al60 used activity theory to illuminate the contradictions that exist in workplace learning when medical students are learning both to be a doctor and also to deliver safe patient care. The use of different theories allows us to ask and answer different types of questions at different levels of analysis, from microlevel issues, such as learner–faculty interactions in QI learning, to macrolevel issues, such as an exploration of the social and historical forces that have constructed current conceptualizations and practices of QI education.21,61

The use of a range of theories to examine QI education offers numerous potential advantages. It will benefit the field by creating space to ask different types of questions, challenge assumptions, and provide new possibilities for action.61 Such a research approach can also broaden the currently limited range of methodologies commonly used in QI education research because many of these theoretical approaches are normally used in conjunction with methodologies common to social sciences research (such as ethnography) that enable deep explorations and rich descriptions of the perspectives of varied stakeholders, social interactions, and contexts.

We recognize that such use of theory in medical education, despite gaining broad traction, may seem daunting to some who are involved in providing QI education. Fortunately, a number of publications exist that can provide insights into the range of theories that can be used to offer new insights in medical education with practical implications19,20,61,62 and help QI educators become more familiar with theories and their relevance to medical education. Furthermore, QI educators may seek collaborations with education and/or social scientists with expertise in qualitative research and the use of theoretical approaches to elevate the rigor of their QI education practices.63

A theoretical approach to planning, implementing, and evaluating QI education would deepen our understanding of issues such as topic selection, team-based project work, faculty supervision, and the impact of organizational contexts on project work, and would contribute to advancing the field of QI education.20 Such knowledge would allow educators to be more explicit about the reasons for curricular, faculty development, and assessment activities, and would highlight key elements within the clinical learning environment that educators must attend to when organizing project-based learning experiences. Taken together, we believe that a theoretically informed QI education research agenda is crucial to achieving the ultimate goal of optimizing QI educational processes and outcomes.


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