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  • 1.
    Norman, Ann-Charlott
    Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    Har God vård genomslag på ett universitetssjukhus?2011In: Perspektiv på förnyelse och ledarskap inom hälso- och sjukvård / [ed] Gill Croona, Växjö: Linnaeus University Press , 2011, p. 147--155Chapter in book (Other academic)
  • 2.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    “Money only make sense on meaningful goals”: discursive patterns and conditions for learning2012Conference paper (Other academic)
    Abstract [en]

    Background

    Sometimes learning is taken for granted in improvement practices, but what lies behind the taken for granted assumption? What is actually said when professionals discuss improvements and how does that impact on learning?

    Healthcare, at least in Sweden, has been characterized by marketization the last 30 years which ultimately is about giving more power to patients. In practice, that means new payment systems, ever-changing care processes, increased transparency and comparisons to relate to. How does that affect the improvement talk? How do professionals handle the dilemma of giving the best individual care to each patient as they have the responsibility to create equal care for all?

    Objective

    The aim was to identify discursive patterns in an improvement practice and to discuss their conditions for learning.

    Method

    Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic. Both the patient’s micro- and mesosystems were observed. The conversations were analyzed through critical discourse analysis (Fairclough 1992) with connection to a societal theory (Habermas 1987).

    Findings

    Four different discursive patterns were found that deal with (1) marketization, (2) equal care, (3) medical reasoning and (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The findings show that professionals can handle the dilemma of improving the best individual care with equal care as long as quality measurements are not linked to payments. However, when measurements, as for example certain quality registers, are linked to monetary incentives the professionals turn to act for what is the most profitable thing to do.

     

    Discussion

    We discuss that market principles, as for example monetary quality control, impact on learning in terms of displacement effects. Professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients.

    References

    Fairclough, N. (1992): Discourse and Social Change. Cambridge: Polity Press.

    Habermas, J. (1987). The Theory of Communicative Action, Lifeworld and System: A Critique of Functionalist Reason. Vol 2. Boston: Beacon Press.    

  • 3.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik (PED).
    “Money talks”: Conditions for learning in contemporary health care systems2013Conference paper (Other academic)
    Abstract [en]

    Context

    Observations were made at clinical ward meetings and process team meetings at an orthopedic- and rheumatology clinic in Sweden. Mostly nurses and assistant nurses participated along with their manager at the clinical ward meeting. The process team consists of staff from the patient’s process which in this case includes physicians, nurses, physiotherapists and occupational therapists from both primary and specialist care. The improvement work in both meetings is facilitated by a developmental leader.

     

    Problem 

    Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. Given that learning sometimes is taken for granted in quality improvement work, this study set out to address what actually is said when professionals discuss improvements and how discursive patterns influence learning.

     Assessment of problem and analysis of its causes

     The study has an explorative qualitative design to investigate how discursive patterns occur in quality improvement conversations which means that quantified measuring was not appropriate.

     The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings. Assessment of problem and analysis of causes was a mutual effort from both researchers and staff. Ideas for improvements came up during the learning seminars when the researchers highlighted findings.

     Intervention 

    The study had not an interventional purpose.

    Study design 

    A starting point in the methodology is that language is tightly connected to social learning. Five observations of quality improvement conversations were made and transcribed to texts. The conversations were analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). A framework of specific questions was constructed to guide the analytical process in Faircloughs’ three steps of description, interpretation and explanation.

    Strategy for change 

    As the study used a participatory research design, implementation, in its right term, was not needed because the staff saw what they needed to improve along with feedback and analysis from the researchers.

    Measurement of improvement 

    Methods, see questions 3 and 5 above.

    Results

    Four discursive patterns were found in the talk of improvements. We have named them the marketization pattern, the care-for-all pattern, the medical pattern and the value pattern. The marketization pattern dominates the dialogue while money is linked to quality control. The results also showed a balance between discourse patterns when money incentives were absent. In other words, professionals tend to integrate complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when improvement goals are linked to monetary incentives the professionals talk about what is the most profitable thing to do.  

    Effects of changes 

    See questions 3 and 4 above.

    Lessons learnt 

    The discourse order indicates that market principles impact on learning in terms of displacement effects. In a short term perspective, professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside.

    The study implicates the importance of a balancing perspective on quality management if no quality aspect is to be left behind. Replicating studies in other contexts would be interesting to perform.

    Message for others: What is the main message based on the experience that you describe here that you would like to convey to others? Discuss what your findings mean for patients and/or systems of care.

    Money incentives promote learning about economical values and not what creates value for patients.

    Please declare any conflicts of interest below 

    The study is part of the research project Bridging the Gaps which is financed by Vinnvård. Otherwise no other conflict of interest is to be declared.

  • 4.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik (PED).
    “Money talks”: Conditions for learning in contemporary health care systems2013In: Welcome to the 2013 Nordic Conference on Implementation of Evidence-Based Practice, 5-6 februari 2013, Konsert & Kongress, Linköping, Sweden: Abstracts, 2013Conference paper (Other academic)
    Abstract [en]

    Introduction

    Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. In practice, that means new payment systems, increased transparency and comparisons to relate to. Given that learning sometimes is taken for granted in implementation work, what is actually said when professionals discuss improvements? This study identifies discursive patterns when an orthopedic team discusses their improvement data and problemetizes how these patterns create conditions for learning.

    Methods

    Five observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. The conversations were transcribed and then analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). The study used a method of interpretation with Habermas’ societal theory of system and lifeworld as a point of departure.

    Results

    Four different discursive patterns were found that deal with: (1) marketization, (2) equal care, (3) medical reasoning and, (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The results also show a balance between discourse patterns when money incentives were absent. In other words, professionals can handle complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when implementation goals are linked to monetary incentives, the professionals turn to act for what is the most profitable thing to do.

    Discussion

    The discourse order indicates that market principles impact on learning in terms of displacement effects. In a short term perspective, professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside. The study implicates the importance of a balancing perspective on quality management if no quality aspect is to be left behind.

  • 5.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    “Money talks”: Discursive patterns and conditions for learning2012Conference paper (Other academic)
    Abstract [en]

    Background

    Sometimes learning is taken for granted in improvement practices, but what lies behind the taken for granted assumption? What is actually said when professionals discuss improvements and how does that impact on learning?

    Healthcare, at least in Sweden, has been characterized by marketization the last 30 years which ultimately is about giving more power to patients. In practice, that means new payment systems, ever-changing care processes, increased transparency and comparisons to relate to. How does that affect the improvement talk? How do professionals handle the dilemma of giving the best individual care to each patient as they have the responsibility to create equal care for all?

    Objective

    The aim was to identify discursive patterns in a healthcare team working with improvements, and to discuss their conditions for learning.

    Method

    Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic. The conversations were analyzed through critical discourse analysis (Fairclough 1992) with connection to a societal theory (Habermas 1987).

    Findings

    Four different discursive patterns were found that deal with (1) marketization, (2) equal care, (3) medical reasoning and (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The findings show that professionals can handle the dilemma of improving the best individual care with equal care as long as quality measurements are not linked to payments. However, when measurements, as for example certain quality registers, are linked to monetary incentives the professionals turn to act for what is the most profitable thing to do.

     

    Discussion

    We discuss that market principles, as for example monetary quality control, impact on learning in terms of displacement effects. Professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside.

    References

    Fairclough, N. (1992): Discourse and Social Change. Cambridge: Polity Press.

    Habermas, J. (1987). The Theory of Communicative Action, Lifeworld and System: A Critique of Functionalist Reason. Vol 2. Boston: Beacon Press.    

  • 6.
    Norman, Ann-Charlott
    Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    The Clinical Microsystem in a Pedagogical Theory Framework2010Conference paper (Other academic)
    Abstract [en]

    Background

    Pedagogical processes connected to Quality Improvement-discourse in healthcare can be seen as either learning processes or influencing processes. The professionals can be seen as learning subjects or objects for desirable reforms. The pedagogical process takes place in an either bottom-up or top-down perspective. Both approaches exist integrated at the same time in the pedagogical practice of healthcare.

    The evolution of clinical Microsystem entails a change of the hierarchical picture of the healthcare system. Politics and administration become supporters of the clinical Microsystems and not the other way round. What impact has the evolution of the clinical Microsystem meant to the co-existence of the pedagogical processes of learning and influence in a healthcare context?

    Aim

    The aim of the study is to qualify the conceptual framework of the clinical Microsystem from a pedagogical perspective.

    Methods

    Content analysis of the evolution of clinical Microsystem from a theoretical perspective of Dewey’s educational philosophy.

    Anticipated contributions

    Dewey’s intersubjective view of learning with communication as the tool of creating mutual knowledge, innovation and change in a democratic society is a suitable theory of understanding the pedagogical processes in the clinical Microsystem. The interactive pedagogic viewpoint changes focus from the individual to the social and societal perspective where communication between members is the fundament of the knowledge process. In the context of healthcare, and especially the context of the clinical Microsystem, the theory empowers professionals’ ability to create quality improvements.

    References

    Dewey, J. 1916. Demokrati och utbildning. Uddevalla: Daidalos 1997.

  • 7.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik (PED).
    The Implicit or Explicit Character of Negotiation: How Quality Improvements are discussed in Communities of Practice in Health Care2013Conference paper (Other academic)
    Abstract [en]

    Purpose

    This study bases its interest in the discursive importance for change and how negotiation can be supported. The purpose of this study was to analyze what is at stake in the interface between adaptation and change, how improvements are negotiated, and if the negotiation differs between a uniform and a networked community of practice.

    Theoretical framework

    The result is explained in relation to a social learning theory, Communities of Practice and its scientific field. A complementary methodology of critical discourse analysis is used to investigate genre and style of the discourses that are produced in the negotiation of improvements.

    Design

    Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. Ward staff meetings represent a tightly coupled community and a process team represents a network of communities. The process team connects all communities that shape a process of care for a particular subgroup of patients. Two samples of recurrent central themes were chosen from the empirical data for more detailed transcriptions and a critical discourse analysis was made in three steps: descriptive, interpretive, and an explaining analysis.

    The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings.

     

    Results

    Traditional standards were at stake in the interface between adaptation and change and the negotiation needed to be explicit if change was going to happen. In the tightly coupled community standards were taken for granted and not explicitly negotiated. Initiatives of change had no impact because they were not discursively valued compared with old ones. In contrast to the ward meeting, the team had to negotiate and explain old standards as well as new ones because of their unfamiliar relation to each other. As they argued they got hold of new meanings that could be more valuable for patients.

    Limitations

    This study has been limited to analyze how the interactive dialogue is produced and not the participation in a more quantitative sense. The analysis show supportive and equal participation from the samples that were selected. However, if you had looked at the overall texts and made a quantitative analysis of speech space it might have shown inequalities.

    Practical implications

    The study implicates that external coaches of improvement work could be useful in tightly coupled communities of practice. An external coach can help the community create awareness of taken for granted standards and support an explicit negotiation.

    Value

    The contribution of how to support improvement dialogues can be transferable and universal to other organizations that integrate both uniform and networked communities.

  • 8.
    Norman, Ann-Charlott
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik (PED).
    The Implicit or Explicit Character of Negotiation: how Quality Improvements are discussed in Communities of Practicein Health Care2013Conference paper (Other academic)
    Abstract [en]

    Background

    Clinical Microsystem theory underlines the importance of doing improvements both in and between communities. The design and improvements of each clinical microsystem is as important as the pathway between microsystems. But how are uniform or differentiated standards negotiated in a community of practice compared to a network of practices?

    Aim

    The aim was to analyze discursive differences in the negotiation depending on whether practices were shared or differentiated. The study analyzed the interactive negotiation in a tightly coupled Community of practice compared with a loosely coupled Network of practices, with an interest of investigating what kind of pedagogical support different improvement groups need.

    Method

    Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. A clinical ward meeting represents a tightly coupled Community of practice and a process team represents a loosely coupled network of practices. Critical discourse analysis was used and the social learning theory Communities of practice was the theoretical framework that explained the findings.

    Findings

    The analysis showed that the most important difference between a tightly coupled community of practice and loosely coupled network of practices is the explicit character of the negotiation. At the clinical ward meeting standards and traditional hierarchy were taken for granted and not explicitly negotiated. Initiatives of change had no impact because new standards were not discursively valued compared with old ones. In contrast to the ward meeting, the team had to negotiate and explain old standards as well as new ones because of the unfamiliar relation to each other. As they argued they mutually found out new meanings, and new solutions that could be more valuable for patients.

    Discussion

    Given the discursive perspective, the study shows that in the interface between adaptation and change the negotiation needs to be explicit if change is going to happen. This explicit improvement negotiation was more easily done in a differentiated practice which contradicts other research of Communities of practice in health care. Anglo-Saxon research has shown the difficulties of learning and change in networked practices because of rivalry between professionals or specialties. One explanation could be differences in culture between Swedish and Anglo-Saxon hierarchies in health care which has to be considered in future Community of practice analyzes.

    Practical implications

    The study indicates that external coaches of improvement work could be useful in tightly coupled communities of practice. An external coach can help the community create awareness of taken for granted issues and support an explicit negotiation.           

  • 9.
    Norman, Ann-Charlott
    Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    To go beyond knowledge transfer problems – a participatory research effort2010Conference paper (Other academic)
    Abstract [en]

    Background

    In healthcare numerous implementation efforts are made to integrate new knowledge in practice. Some even say that future medical breakthroughs are more dependent on how fortunate these integrating processes are than of the medical research itself (Calltorp et al, 2006). Bridging the Gap is a Vinnvård-financed researchproject which is contributing with deeper understanding about how healthcare systems can acquire new knowledge in practice. The project intends to do the knowledgeproduction and the application at the same time in a participatory research effort to go beyond knowledge transfer problems. Pedagogical and sociological communicative theories support that application interests are constitutive of the knowledge production process and not just related to subsequent forms of the same (Fritzell, 2006).

    Aim

    The purpose of an ongoing subproject of Bridging the Gap is to study learning processes in daily activities that aims for increased value for patients in terms of quality improvement.

    Methods

    The subproject is interdisciplinary conducted with researchers from both a pedagogical and a technical research field. Observations were made to collect data of how the personnel discussed findings and interventions from their registered measurements. The participatory actions with the clinic were planned as three learning seminars building on the model of Ellström (2008) and Fritzell (2003).

    Results

    The first seminar led to fruitful discussion about the problematization of the study and it pointed out the research questions more distinctively. At the second seminar reflections from the data collection were discussed without having it analysed yet just to make sure we were on track together. The researchers benefitted from having the data validated and the practitioners from reflecting about how they can do immediate changes to improve in practice. At the conference in the beginning of may the results from the study and an evaluation of the methodological participatory effort can be presented.

    References

    Calltorp, J., Johansson, A. och Maathz, G. (2006). Kunskapsbaserad ledning, styrning och utveckling inom hälso- och sjukvården. Stockholm: Sveriges kommuner och landsting.

    Ellström, P-E. (2008). Knowledge Creation Through Interactive Research: A Learning Approach. Paper presented at the ECER Conference, September 10-12  2008, Göteborg.

    Fritzell, C. (2003). Towards deliberative relationships between pedagogic theory and practice. Nordisk pedagogik, nr 2 (2003), s. 93-103.

    Fritzell, C. 2006. On the Reconstruction of Educational Science. Educational Philosophy and Theory, vol 28, no 2, 2006.

  • 10.
    Norman, Ann-Charlott
    Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    To go beyond knowledge transfer problems - an evaluation of a participatory research effort2010Conference paper (Other academic)
    Abstract [en]

    Introduction

    In healthcare numerous implementation efforts are made to integrate new knowledge in practice. Some even say that future medical breakthroughs are more dependent on how fortunate these integrating processes are than of the medical research itself. Bridging the Gap is a Vinnvård-financed research project which is contributing with deeper understanding about how healthcare systems can acquire new knowledge in practice. The project intends to do the knowledge production and the application at the same time in a participatory research effort to go beyond knowledge transfer problems. Pedagogical and sociological communicative theories support that application interests are constitutive of the knowledge production process and not just related to subsequent forms of the same. The purpose is to evaluate the participatory research effort of an ongoing subproject of Bridging the Gap which studies learning processes in daily activities that aims for increased value for patients in terms of quality improvement.

    Method

    Observations were made to collect data of how the personnel discussed findings and interventions from their registered measurements. The participatory actions were planned as three learning seminars.

    Results

    The first seminar pointed out the research questions more distinctively. At the second seminar the researchers benefitted from having the data validated and the practitioners from reflecting about how they can do immediate changes to improve practice. At the third seminar a contextual interpretation and conceptualization was made of the analysed data. The research process went beyond validating the data to a collaborative knowledge production of the same.

    Conclusion

    With a participatory research effort the researcher can take advantage of the masseducated professionals in healthcare in the knowledge production. There is a win-win situation by using learning seminars in the research process; the practice make use of the researchers’ observations at the same time as the researchers validate their data. But what is actually happening is not just a mutual consultation but also a constitutive knowledge production process between researchers and practitioners.

  • 11.
    Norman, Ann-Charlott
    Linnéuniversitetet, Institutionen för pedagogik (PED).
    Towards the creation of learning improvement practices: Studies of pedagogical conditions when change is negotiated in contemporary healthcare practices2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s.

    The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies.

    The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change.

  • 12.
    Norman, Ann-Charlott
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    Fritzén, Lena
    Linnéuniversitetet, Institutionen för pedagogik, psykologi och idrottsvetenskap, PPI.
    'Money talks': En kritisk diskursanalys av samtal om förbättringar i hälso- och sjukvård2012In: Utbildning och Demokrati, ISSN 1102-6472, E-ISSN 2001-7316, Vol. 21, no 2, p. 103-124Article in journal (Refereed)
    Abstract [en]

    Based on learning as taken for granted in health care quality improvement, the aim was to identify discursive patterns in practice, and to discuss how these patterns create conditions for learning. Observations of quality improvement conversations were made at a clinic and analyzed through critical discourse analysis. Four different discursive patterns were found; a market pattern, a care-for-all pattern, a medical pattern and a value pattern. The order of discourse shows that the market pattern dominates the others while money is linked to quality control. The findings also showed a balance between discourse patterns when economical incentives were absent. In other words, the professionals can handle all complex, and sometimes contradicting, quality aspects when they don’t compete about money. We discuss that market principles impact on learning in terms of displacement effects which discourages long-term sustainable improvements.

  • 13.
    Norman, Ann-Charlott
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Pedagogy, Linnaeus University, Växjö, Sweden.
    Fritzén, Lena
    Department of Pedagogy, Linnaeus University, Växjö, Sweden.
    Andersson-Gäre, Boel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Pedagogical approaches in quality improvement coaching in healthcare: a Swedish case study of how improvement coaches approach learning in a contemporary healthcare system2015In: Nordic Journal of Studies in Educational Policy, ISSN 2002-0317, Vol. 1, no 3, article id 30178Article in journal (Refereed)
    Abstract [en]

    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.

  • 14.
    Norman, Ann-Charlott
    et al.
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet.
    Fritzén, Lena
    Linnéuniversitetet, Institutionen Pedagogik.
    Lindblad-Fridh, Marianne
    Jönköping University, School of Health and Welfare, HHJ, Quality Improvement and Leadership in Health and Welfare.
    One lens missing? Clarifying the clinical microsystem framework with learning theories2013In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 22, no 2, p. 126-136Article in journal (Refereed)
    Abstract [en]

    Introduction: The clinical microsystem (CMS)approach is widely used and is perceived as helpfulin practice but, we ask the question: “Is its learningpotential sufficiently utilized?”

    Objectives: Toscrutinize aspects of learning within the CMSframework and to clarify the learning aspects theframework includes and thereby support theframework with the enhanced learning perspectivethat becomes visible.

    Methods: Literature on theCMS framework was systematically searched andselected using inclusion criteria. An analytical toolwas constructed in the form of a theoretical lensthat was used to clarify learning aspects that areassociated with the framework.

    Findings: Theanalysis revealed 3 learning aspects: (1) The CMSframework describes individual and social learningbut not how to adapt learning strategies forpurposes of change. (2) The metaphorical languageof how to reach a holistic health care system foreach patient has developed over time but can stillbe improved by naming social interactions totranscend organizational boundaries. (3) Powerstructures are recognized but not as a characteristicthat restricts learning due to asymmetriccommunication.

    Conclusion: The “lens” perspectivereveals new meanings to learning that enhance ourunderstanding of health care as a social system andprovides new practical learning strategies.

  • 15.
    Vackerberg, Nicoline
    et al.
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare.
    Norman, AnnCharlott
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Linnéuniversitetet.
    Jutterdal, Stefan
    Thor, Johan
    Jönköping University, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare. Karolinska Institutet.
    Utveckling och förbättringsarbete är ömsesidigt beroende och berikande2015In: Att lära och utvecklas i sin profession / [ed] Gabriele Biguet, Ingrid Lindquist, Cathrin Martin, Anna Pettersson, Lund: Studentlitteratur AB, 2015, p. 169-185Chapter in book (Other academic)
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