Literature review: Theories behind IPL and QIE
There are a number of theories that can be used to define and analyze IPL (Hean, Craddock, Hammick, & Hammick, 2012) and QIE. The approach to theory in papers on QIE/IPL has evolved from not using any theory at all, to using multiple theories to explain the concept. However, that progression has been very gradual. Even today, significant numbers of CME/CPD papers do not reference theory (Curtis A. Olson, 2013). QIE/IPL papers, as a subset of that group, follow the same trend.
As described below, in most cases, a specific theory can describe just part of the process. Therefore we have to combine theories. Relevant theories can be categorized primarily as theories that explain QIE/IPL educational process, and theories that describe interprofessional QI practices. A secondary level of classification, mainly based on historical divisions, are theories related to QIE and theories related to IPL.
QI theory. The value and function of theory in healthcare quality improvement has been seriously neglected (Davidoff, Dixon-Woods, Leviton, & Michie, 2015). At the same time, factors influencing sustainability of QI interventions have been poorly understood (Hovlid, Bukve, Haug, Aslaksen, & von Plessen, 2012). That is a huge issue – very often causing QI interventions to fail. Following such QI intervention, returning to old underperforming work practices is a significant waste of resources and, in the long run, can fuel resistance to future/better QI initiatives. Therefore, more vigorous and better-informed use of theory is essential to strengthen QIE/IPL programs, ensure vaid assessment of their impact, and promote their sustainability and generalizability of outcomes (Davies, Walker, & Grimshaw, 2010).
Role of theory. Unfortunately, theory is usually perceived as something mystical and impractical; something even quality professionals do not want deal with. That contradicts practice needs. Theory or “the reasons why things are happening” is intimately integrated into almost all of our activities. Theories may be formal or informal, public and shared, or private. Yet theories drive our decisions and shape our impact (Hean et al., 2012). Whether the theory says: “This is how it has been always done – and therefore we should not change it,” whether it is an informal experience-based theory used by a small team, or it is an official, publicly developed theory, it will have an impact on our activities (Tilly, 2006). The question is not: Are we using theory? We know we are. We should ask: Are we aware of that theory, how good is it, and is it the right theory?
Practice shows that when we lose sight of the importance of theory, bad things happen. A weak hypothesis or even just a hunch, biased and limited in scope (Kahneman, 2011), can be used to drive our actions, often with negative results. Lack of a theoretical background is a common reason why QI and patient-safety interventions in healthcare often result in limited positive changes or no relevant changes at all (Shojania & Grimshaw, 2005). If the intervention proves to be successful, but lacks a sound theoretical basis, it is usually hard to make it permanent and generalize it in other contexts (Dixon-Woods, Leslie, Tarrant, & Bion, 2013).
The literature provides a variety of theories that may foster sustainable QI change. That variety ranges from a big set of learning theories and change agent theories, to organizational change and economic theories. Shojania, McDonald, Wachter, and Owens (2004) argue that it may be challenging to develop interventions based only on one of those theories. Effective QI strategy can be developed more easily when theory and implementation are tested simultaneously. As a manual to help users navigate through that process, Kaplan, Provost, Froehle, and Margolis (2012) developed Model for Understanding Success in Quality (MUSIQ). The model describes 25 contextual factors that may influence success of QI projects. It serves as a checklist of elements that should be included in a QI theoretical plan.
IPL. In the early days of IPL research, a significant number of papers were very pragmatic and didn’t describe a theoretical background. Many later papers grounded IPL research in a single theory – usually related to a specific school of thought and academic discipline (Barr, 2013). Today, a growing number of papers build a sound, flexible and inclusive IPL framework by combining multiple theories and practices. As a result, Hean, Craddock, and O’Halloran (2009) argue that a large number of theories currently used to describe IPL have created a hard-to-navigate quantifier.
Social theories (social constructivism, social capital) (Hean et al., 2012), adult learning (P. G. Clark, 2006), identity theories, situated learning (Ranmuthugala et al., 2011; Wenger, 1998, 1999) and networked learning (Dev & Heinrichs, 2008) are the main theories relevant to QIE/IPL learning processes. On the other hand, the theories most relevant to QIE/IPL context are sociology of professions, organizational theory and activity theory. They present a compelling example of how different theories complement each other. For example, Larson (1979) argues that professional guilds are actively engaged in monopolizing knowledge in specific areas, to ensure cognitive exclusivity. That may explain why, despite learning organization (Roberts & Thomson, 1994; Senge, 2006) being a very popular theory concept (Barr, 2013), it is especially hard to achieve it among different professional organizations and patients. Fortunately, activity theory allows us to analyze organizations as “distributed, decentered and emergent systems of knowledge” (Blackler, Crump, & McDonald, 2000, p. 278); it provides insight into connections between activities and context and reasoning behind complex social activities.
The connected, networked nature of modern life and work is at the heart of learning as a social activity, and knowledge as a social construct. (Hean et al., 2009) Therefore, to fully understand learning, we have to analyze curricula through a social theoretical lens. Only through that lens will we be able to comprehend how organizations, professional societies, professional regulations, education providers and communities of learners shape the knowledge development process.
Social capital theories are focused on the benefits individuals and society can achieve by being part of and nurturing a social network. They suggest the equilibrium concept (Boix & Posner, 1998). Social capital will increase through repeated cooperation and collaboration. In return, strong social capital will boost social collaboration and the happiness of individuals. Research of Leung, Kier, Fung, Fung, and Sproule (2013) showed that social capital is one of the major cornerstones of happiness. In the healthcare field, social capital is popular due to the known relationship between social capital (strong social network) and health benefits. Ultimately, social capital, happiness and collaborative behaviors can significantly improve tacit and explicit knowledge-sharing among employees – creating a basis for a productive learning organization (Hau, Kim, Lee, & Kim, 2013). Therefore social capital theory can be used to describe benefits of interprofessional, networked learning, and guide us to maximize benefits from that learning model.
Adult learning theories are often described as a cornerstone of successful QIE/IPL. They provide a toolset or learning modalities that motivate students as individuals and groups to activate existing knowledge and use it as a platform to develop new knowledge. In that context they can be viewed as an extension of constructivist learning theories.
Networked learning theory uses connections between students, students and teachers, and between student resources and tools to create a framework where students (working professionals) as individuals and groups have access to all elements needed for successful continuous professional development. It created a framework that connects CME/CPD providers and the professional learning community (Jackson & Temperley, 2007). Whether they need access to content, expertise, QI tools or peer moral support, students will be helped by networked learning principles. With that, students can combine real world context and highly integrative learning activites to address complex situated problems (G. Campbell, 2016).
Community of practice, as situated learning theory, can explain many benefits professional societies provide to their members (Webster-Wright, 2009). The society and profession acts as a community of practice; a community of professionals that jointly work together to improve practice in a specific domain (health, nursing, surgery) (Simons & Ruijters, 2004). There is potential to further support that community with social media .
Each mentioned theory deserves detailed description, which is out of scope of this literature review.
What we can notice from the aforementioned brief descriptions is that there is lot of overlapping between theories and that theories often complement each other (Hean et al., 2012). For example, networked learning will benefit if social capital is strong, and social capital can be further enhanced with properly designed networked activities. Adult learning in the QIE/IPL context will also be enhanced if social capital is strong and the proper networked practices are in place. Ultimately, community of practice can benefit from all aforementioned theories – and create a framework where they can be better implemented.
Activity theory, being a macro theory, will be discussed last as a separate example. A macro theory can be used as a descriptive framework taking into account all elements of a complex healthcare activity system. Examples of an activity system include a perioperative surgical home team or an organization 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 examples.
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