Methodology

The social constructivist worldview allows me to focus “on the participants’ views of the situation being studied” Creswell (2009). It suggests open-ended questioning to find what people think or do in their daily lives. A phenomenographic approach is a good tool for that task – providing insight into the more subjective side of the world.

On the other hand, although IPL and QIE have become quite well-known concepts, most interviewees haven’t had a chance to practice it. They haven’t experienced it as something real and objective. To better understand objective aspects of the phenomenon, case study focused on how their professions and their professional associations are tackling that issue may be needed.

Methodology is the systematic, theoretical analysis of the methods applied to a field of study.

Case study

Therefore, the methodology of choice will be a qualitative, interpretive multiple-case case study (Yin, 2003) that encompasses phenomenographic analysis. Activity theory will be used as a lens to analyze interrelations among multiple elements in this system.

QIE/IPL-related practices and learning technology that can support QIE/IPL used by each profession will be analyzed as an independent case. The four cases are:

• ASA,
• American Association of Nurse Anesthetists (AANA),
• American College of Surgeons (ACS), and
• American Academy of Physician Assistants (AAPA).

An alternative solution was to use single-case with embedded multiple units of analysis. That approach would be appropriate if we had collaboration and shared programs among two or more of the specialties in place. In that situation the case would be shared QIE/IPL-related practices and learning technology that can support QIE/IPL of all professions together. Activities specific to each profession would be embedded units of analysis.

Since at this time I’m not aware of any collaboration on QIE/IPL, QIE/IPL activities in each specialty should be analyzed as separate entities.

Case study data sources will be interviews with staff and physician members, the website of a professional association, and literature published by a professional association. Two interviews (non-phenomenographic) and one site visit/meeting will be scheduled with representatives of each profession. Phenomenographic interviews will also serve as a source of data over and above standard phenomenographic research.

Phenomenographic analysis

Phenomenographic analysis focused on how CPD professionals, clinicians (anesthesiologists, nurse anesthetists, surgeons and anesthesiologist assistants) and their respective leaders perceive QIE/IPL and technology that supports those practices will be the central part of the case study. Phenomenography appears to be the optimal method for this approach, because at this point QIE/IPL is in its early stage and human perceptions are the dominant factor. Additional reasons are:

1. Attempts to implement QIE/IPL in the U.S. healthcare system have a long but troubling history, and drivers influencing implementation of QIE/IPL create a very complex picture. The phenomenographic approach is recognized as a good tool to analyze changes in such a complex system (Bunniss & Kelly, 2010; Stenfors‐Hayes, Hult, & Dahlgren, 2013).
2. Understanding the perceptions of groups involved in the learning and teaching process can enable us to address current and emerging challenges in that dynamic environment (Richardson, 2005).
3. QIE/IPL is ultimately a social endeavor.

During the past two decades, phenomenography proved to be very useful in medical education (Stenfors‐Hayes et al., 2013). It provides insight into the different ways that people perceive phenomena in the world around them and how those perceptions relate one to another (Marton, 1981; Marton & Booth, 1997). Therefore, it can serve as a lens to analyze a specific research question and direct how research is carried out. In a medical setting, phenomenographic research is valuable for topics like clinical practice, communication and healthcare learning, and, especially, the processes and outcomes of learning (Larsson & Holmström, 2007; Richardson, 1999). According to Stenfors‐Hayes et al. (2013), phenomenography can serve as a link between three important elements this research is tackling: research, organizational change and educational development. That feature can be especially valuable in the context where, as the Macy (2013) expert team concluded, huge changes affecting the U.S. medical system are not linked effectively with changes affecting CPD of healthcare professionals in the U.S.

Phenomenography was chosen over phenomenology because QIE/IPL is in this context an emerging concept. Therefore, we can expect numerous ways in which QIE/IPL is perceived (Larsson & Holmström, 2007).

Activity theory

The third element of the research framework is activity theory: a descriptive framework taking into account all elements of a complex activity/work system. Examples of such an activity system may be teams like a perioperative surgical home team or organizations such as the ASA. Therefore, activity theory can serve as a lens to analyze human activities in such a complex and dynamic system. The third generation of activity theory is specifically interesting for this research because it is focused on how different activity systems interact (Engeström, 2001). Each profession (anesthesiologists, nurse anesthetists, surgeons, etc.) and patients or the public can be analyzed as a separate activity system. The third generation of activity theory can help us understand how those systems interact during preparation for implementation of QIE/IPL activities. A small detail that confirms the suitability of activity theory is that in the paper introducing the third generation of activity theory, (Engeström, 2001) uses interaction among healthcare activity systems (hospital, patient’s family) as the main example.

Figure 4. Two interacting activity systems are the minimal model for the third generation of activity theory (Source: Engeström, 2001). Each profession can be analyzed as a separate activity system. Outcomes (Object₂) of each profession interact creating outcome of collaboration – Object₃.

Resources

• Bunniss, S., & Kelly, D. R. (2010). Research paradigms in medical education research. Medical Education, 44(4), 358-366.
• Creswell, J. W. (2009). Research design: Qualitative, Quantitative, and mixed methods approaches. London: SAGE.
• Engeström, Y. (2001). Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of education and work, 14(1), 133-156.
• Larsson, J., & Holmström, I. (2007). Phenomenographic or phenomenological analysis: Does it matter? Examples from a study on anaesthesiologists’ work. International Journal On Qualitative Studies On Health And Well-being, 2(1), 55-64. doi:10.1080/17482620601068105
• Macy, Josiah Macy Jr. Foundation. (2013). Transforming Patient Care:  Aligning Interprofessional Education with Clinical Practice Redesign. Paper presented at the Macy Conference on Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign, January 2013.
• Marton, F. (1981). Phenomenography — describing conceptions of the world around us. Instructional science, 10(2), 177-200.
• Marton, F., & Booth, S. (1997). Learning and awareness. Mahwah, NJ, US: Lawrence Erlbaum Associates, Publishers.
• Richardson, J. T. E. (1999). The concepts and methods of phenomenographic research. Review of Educational Research, 69(1), 53-82.
• Richardson, J. T. E. (2005). Students’ approaches to learning and teachers’ approaches to teaching in higher education. Educational Psychology, 25(6), 673-680.
• Stenfors‐Hayes, T., Hult, H., & Dahlgren, M. A. (2013). A phenomenographic approach to research in medical education. Medical Education, 47(3), 261-270.
• Yin, R. K. (2003). Designing case studies. In R. K. Yin (Ed.), Case study research: design and method (pp. 19-56). London: Sage.