Reconceptualising learning in student-led improvement science projects: an actor-network theory ethnography in medical education

Abstract

The National Health Service in Scotland promotes improvement science methodology as an innovation for implementing rapid change in hospital practices. Student-Led Improvement Science Projects (SLISPs) have been developed as a result of this, where students work with clinical teams to identify, implement and monitor quality improvements in the workplace. Working with improvement science in working practices in a hospital environment presents opportunities for different ways to reconceptualise learning. This research critically examines professionals’ learning through practices that are enacted during SLISPs. The focus is on medical and pharmacy students in a hospital setting. The research traces the fine-grained activities, materials, spaces, behaviours and relationships that emerged during a SLISP, with the purpose of gaining a better understanding of what learning means in relation to improvement science. There are recent studies of the educative practices of quality improvement projects in the literature (Armstrong et al. 2015; James et al. 2016) and there are healthcare studies which use sociomaterial approaches (Ahn et al. 2015; Falk et al. 2017; Ibrahim et al. 2015), but this research combines education research, healthcare, improvement science and the sociomaterial approach of actor-network theory. The study described in this thesis draws from ethnographic methods combined with actor-network theory (ANT) to investigate the pedagogies of improvement science. Three ANT dimensions were explored: networks, symmetry and multiple worlds. From the fieldwork data, three ‘anecdotes’ were constructed: (1) antimicrobial prescribing; (2) insulin recording; and (3) pedagogies of improvement science. Each anecdote was analysed using each of the ANT dimensions. Networks were explored by attuning to relations and associations using the method of ‘follow the actor’ (Latour 2005). The notion of symmetry provided an alternative perspective of the data by exploring the treatment of humans and non-humans held together in heterogeneous assemblages. Finally, after-ANT concepts were explored through ‘multiple worlds’ by troubling ambivalences and unfolding practices. Five key insights were presented from this analysis: (1) conceptualising networks presents learning as disruption, as existing networks of practice collide with new networks such as improvement science; (2) materials can invite or exclude practices, leading to learning being shaped materially; (3) invisible or black-boxed activities can become visible through the practices of the SLISP; (4) multiple worlds of practice are manifest in the assemblages of materials which coexist through regulating difference; and (5) professionalism can be conceptualised as an assemblage where learning emerges through practices of ordering. The implications for medical education and education in general are that a broader range of pedagogies exist for improvement science by challenging the conditions of possibility. An ANT methodology contributes to this by noticing details of practice that might otherwise be overlooked and allowing for different enactments of improvement science to co-exist through multiple worlds.