This post was stimulated by an interesting
twitter exchange today, about using activity theory in research and, in
particular, how issues of individual agency are addressed. I am interested in activity theory (and, in particular, Engestrom’s 3rd
generation activity theory ) having drawn upon it in my doctoral studies. In the first study, I analysed medical
student learning on attachments, seeking to make sense of the ways in which
they engaged with the learning cultures of the medical school and the
workplace. In the second study, I set out to make sense of the emergence of
‘faculty development’ as a new set of practices within secondary care medicine.
I was interested in the discourse around the so-called ‘professionalisation of
medical education’ – for me an interesting phrase, given that medicine is one
of the oldest professions with centuries old traditions of apprenticeship.
In
this study, I analysed 20 years of government policy and the grey literatures
of professional bodies (eg GMC, PMETB) in three areas – the NHS, Postgraduate
Medical Education and Undergraduate Medical Education. This led me to conclude
that constant reform of the NHS had systematically dismantled medical
apprenticeship, leaving doctors in a position where they were asked to adopt
training practices that were antithetical to their own learning histories. In
particular, I noted the growing disconnect (conceptually, practically) between
‘work’ and ‘learning’, no longer seen as mutually constitutive. The shift to
formal curriculum in PGME, with ‘competences’ to be gained, tools to evidence their
acquisition etc, signaled a profound culture shift, discussed, in part, in
previous blog postings.
My analysis led me to argue that there had
been a shift from time-served apprenticeship to time-measured training, creating
a series of structurally accumulating tensions. For example, an increasingly
risk averse culture (with consultant led services) sits uncomfortably with
training practices which rely on the delegation of medical work to those in
training grades. My analysis left me concluding that the medical profession
found themselves in a contradictory positioning (an activity theory concept). Training practices of old were
unsustainable in a reformed NHS, yet the solution put forward by the
regulators, to ‘professionalise’ medical education, was unlikely to offer the
creative, expansive solutions necessary to reconcile these tensions. Compulsory, regulated, faculty development
activity was offered up as the means to professionalise medical education, with
the ‘curriculum’ being focused on rather instrumental trainer-trainee
interactions e.g. the use of WPBA tools, how to give feedback, ‘managing the
trainee-in-difficulty’ and so forth. The question for me, was how would
deaneries respond to this positioning? Go with the grain (ensuring all trainers
were ‘trained’) or seek more creative solutions that would genuinely help
trainers find ways of sustaining high quality training practices in a reformed
NHS. This is where, for me at least, the question of agency sets in.
My research led me to an analysis of one
deaneries response and a series of in-depth interviews with a new ‘faculty
development workforce’. I explored their sense making, talked to them about
their faculty development practices, and the types of theoretical and
biographical tools they drew upon in their work. In so doing I was able to
trace a range of responses to the call to professionalise. For some there was a
‘conforming’ response, meeting the regulators requirement to ensure that all
trainers were trained. Typical methods involved short, central workshops,
across all specialties, covering key aspects of educational supervision
practice. Others were a little more creative in their response (which I label
as a ‘reforming’ response). They worked with doctors in a range of ways, always
seeking to offer/elicit a medical context to their work, working with teams on
site, offering up teaching observation type activity, so individual doctors had
a chance to review existing educational practices and adapt them in light of
new requirements. The third ‘transforming’ response involved a radical
re-thinking of training practices. Here colleagues came together to explore
what was working on the ground but also where the difficulties lay. They
adopted and generated new forms of faculty development practices including team
observations, faculty groups and joint development activity between trainers and
trainees to find solutions to the problems being encountered post reform.
So, how does this relate to the initial
query i.e. how the issue of agency is dealt with in activity theory? In
activity theory the world is understood as partially conceptualized, the world acts
on us but we also act upon the world. In finding themselves positioned to act
in a particular way (to professionalise medical education through faculty
development), the doctors and educators I spoke to chose to respond in a range
of ways. They showed agency. This agency was influenced by the biographical and
theoretical tools they had to draw upon, and the extent to which they were
willing to go with, or against, the grain of reform.
