The trainee as participant observer

Roy Wallworth

Overview

• Background• Challenging questions• Essential features of a GP• NHS values• Participant observation• Reflective v Reflexive practice• Structured teaching as a ‘reflexive space’

Background

• Thinking like a GP from day one.

• Preventing the trainee from ‘going native’

• Francis report.– ‘ the trainees are invaluable eyes and ears

in a Hospital setting’– ‘the trainees are less likely to be ‘infected’

by poor organisational culture.

Challenging questions

• How do we get the trainee to think like and observe the world around himself as a GP?

• How does a trainee recognise poor organisational culture and what it is that is wrong.

Being a GP

• Essential features

• Attitudinal

• Contextual

• Scientific

Attitudinal features

• Awareness of your own capabilities and values• Delivering care with compassion and kindness• Being able to identify the ethical aspects of your clinical practice• Awareness of self: understanding that your own attitudes and

feelings are important determinants of how you practise.• Valuing and encouraging the contribution of others• Being prepared to participate in service management and

improvement• Justifying and clarifying personal ethics• Being aware of the interaction of your work and your private life

and striving for a good balance between them

Contextual features

• Understanding the impact of the local community (including socio-economic and workplace factors, geography and culture) on your patient care

• Awareness of the impact of your overall workload on the care given to individual patients and the facilities (e.g. Staff, equipment) available to deliver that care

• Understanding the financial, regulatory and legal frameworks in which you provide healthcare both at practice level and in the wider NHS

• Understanding the impact of your personal, home and working environment on the care that you provide

NHS values

• Respect and dignity

• Commitment to quality of care

• Compassion

• Improving lives

• Working together for patients

• Everyone counts

Participant observation

• This is an anthropological or ethnographic approach to learning about cultures– Complete participant– Participant as observer– Observer as participant– Complete observer.

Participant observation

• Skills– Learn the language (jargon)– Be explicit as to what IS seen and heard not what is

expected to be seen and heard– Maintain posture of apprentice (treat the rest of the

group as experts)– Record observations (ideally daily)– Be aware of your own feelings and response to

situations.– Avoid ‘going native’ (this is not observing but living)

Participant observation

• Etic approach– The respondent's behaviour is interpreted

by the observer with reference to known behaviours and beliefs

• Emic approach– The respondent becomes an expert and

gives meaning to behaviour and beliefs.

Reflexive v Reflective practice

• Reflective practice– Reflecting on action

• Consciously review, describe, analyse and evaluate past practice with a view to gaining insight to improve future practice

– Reflecting in action• Examination of experiences and responses as

they occur.

Reflexive v Reflective practice

• Reflexive practice – Involves an internal conversation and is

self referential. – Recognises that observations and

interactions and meaning made of them are influenced by ‘self’

Modes of reflexivity

• Communicative reflexivity– Internal conversations need to be confirmed and completed by others

before they lead to action, thus fostering normative conventionalism• Autonomous Reflexivity

– Internal conversations are self-contained, leading directly to action and characterised by instrumental rationality

• Meta-reflexivity– Internal conversations critically evaluate previous inner dialogues and

are critical about effective action in society, in promoting value rational action.

• Fractured reflexivity– Internal conversations cannot lead to purposeful courses of action and

only intensify personal distress and disorientation, leading (temporarily) to ‘passive agents’

Reflexive space and structured teaching

• Questions to explore– Questions about the world– Questions about my world– Questions about correspondences and

contradictions between those worlds

WHAT I DO…

BehavioursBiological functions

Physical states

BODY and ORGANISM

WHY I DO…

Intentions and beliefsAssumptions

Emotions

SELF and CONSCIOUSNESS

WHY WE DO…

Cultural beliefsNorms, worldviews

Organisational culture

CULTURE and WORLDVIEW

WHAT WE DO…

Social, political, economic… organisational structures, processes and systems.

SOCIAL SYSTEMS and ENVIRONMENT

Individual

Collective

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