Episode Transcript
[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group, or CUMEG for short. This is a podcast from the University of Cambridge Clinical School, focusing on medical education. We'll be touching on a range of topics medical educators are dealing with. I'm your host, Cheryl France, head of CUMEG.
[00:00:33] Today, I would like to introduce Dr Riikka Hofmann, associate professor in the Faculty of Education, where she leads the research strand 'Dialogue, Professional Change, and Leadership'. Riikka is committed to supporting real world impact on research and will be chatting to us today about some of the projects she has worked on.
[00:00:54] Welcome Riikka, it's wonderful to have you with us today.
[00:00:57] Riikka: Thank you very much for inviting me.
[00:00:59] Cheryl: It's really good to have you with us today because a lot of the individuals that we've interviewed are medical doctors who work in the Clinical School. Your role is slightly different and I think it would be really useful for you to just give us some background into how you've come to work with the medical school.
[00:01:14] Thank you, Cheryl. So, I'm a learning scientist, which means that I'm interested in how people learn and how they're learning can lead them to change their practice. I'm based at the Faculty of Education and my program of research looks particularly at professional learning. And with professional learning, I mean professional development, how people can develop their knowledge and competencies in relation to their workplace practice.
[00:01:39] But I'm also particularly interested in how that learning can lead them to changing their practice in the workplace, so I'm interested in implementation and translational learning. And my work originally very much looks at teachers in school context, which is an area that I still do work in, but I'm very, very interested in learning mechanisms for professional practitioners.
[00:02:00] And one of the key things for that is to think about how does learning happen across different professions. I came several years ago to work with medical professionals because there was a real need at the time to understand how medics learn, particularly trainees and people already working in healthcare settings.
[00:02:18] Riikka: And there weren't a lot of people in clinical settings trained in educational research, educational research methods, and learning theory. And it's something that I've been doing for several years now, collaborating with, local health systems, local hospitals, GP practices, and so forth.
[00:02:34] Cheryl: That's a really interesting and quite a different change, but you're right, it is a specialism that medical individuals may not have. So that is an interesting way to get into it and for us as a Clinical School to learn from you and from what your knowledge and what you can give us in terms of changing practices and thinking about how our behaviours work. Would you be able to [00:03:00] tell us more about the challenges, individuals, and organizations face in creating improvements or change through research and education, even though there is a desire to make that change?
[00:03:13] Riikka: So, one of the things that's not always appreciated by people in leadership positions or policy-making positions, is that making change happen in the professional workplace is actually incredibly difficult and a lot harder than we sometimes think. And when change doesn't happen, even though some kind of organisational restructuring or improvement program has been introduced, there often seems to be this assumption that it's because practitioners are trying hard enough or sometimes even assumption that they really can't be bothered or that they are somehow opposed to those change efforts. And there's a lot of research evidence out there that suggests that this really often is not the case and that in reality, even when people want to make change happen, change often remains quite [00:04:00] elusive, or even when it happens, things revert back to type really quickly.
[00:04:03] So one of the things that my research looks at, as well as some other people in my field, is to try and understand what the nature of some of those barriers is and how can we overcome them to make change happen in the workplace? And I'd particularly like to highlight three key ideas that have come out of this research that are really relevant for professional learning and workplace learning in medical settings.
[00:04:26] One of them is individuals can't just make change happen in the workplace by themselves and not even just with their colleagues or with the support of their seniors, although that support from senior leadership teams is incredibly important. It's because of something that we call norms, so expectations about how things happen in the healthcare setting are really, really informative to people's expectations of what should happen and how things should be run. And those norms don't just arise from individuals, not even from individuals, healthcare departments, so institutions, but really, they exist in the [00:05:00] wider society. And they influence doctors, they influence other healthcare professionals, patients, patients' relatives.
[00:05:08] And people come into those settings with assumptions about how things should work. What should practice look like? What does good look like? And if we don't pay attention to those norms and take them into account, it becomes very, very difficult to make change acceptable to participants.
[00:05:24] So one of the things that we've seen in our research is to make change happen, we often actually need to make those norms explicit, when typically, they remain implicit in practices, as long as we all know them. And work on them really, really purposefully as the first step of our change efforts saying these are the norms that are changing. If, for example, they relate to a new kind of relationship between different professional groups or between professionals and patients, that actually needs to in itself be really actively communicated and worked on.
[00:05:57] Cheryl: That's really interesting because you're right, I think we all think we [00:06:00] see the obvious, but we may not. And by stating this is what the norm is, like you said, a relationship between the colleagues from patient and doctor. What is that relationship? What does it mean? If you're going to make a change to any of those, how would you do that particular change? What would it look like is? have I understood that correctly?
[00:06:19] Riikka: Absolutely, and one of the things is that the nature of norms exists in relation to everything we do, all social activities are guided by norms. And what the really interesting feature of norms is that we don't notice them until somebody breaks them. So, the kinds of experiments that social scientists do is go to different countries and behave in a certain way, in a situation where you should queue, in order to then find out what are the norms in relation to queuing. In some countries you are expected to stay in your place. In other countries, you're expected to kind of shuffle your way forward. In some countries, people go to the front of the queue and the world doesn't fall apart.
[00:07:00] And so in workplace settings where everything is typically works really smoothly because everyone is super good at what they do, we don't notice those norms until somebody tries to do something different. And so, one of the things we've seen in our research, within healthcare settings, for example, is when trainees have been trained to use a new diagnostic tool in healthcare settings, that requires them to work across interprofessional boundaries with seniors, but not just with seniors from their own specialty.
[00:07:29] Is that sometimes the seniors and the trainees hold opposite assumptions from one and other, but in as much as nobody verbalizes those or articulates those, they carry on assuming that that's what the other party thinks is what should happen here. And if it isn't made explicit, everybody thinks that something's going wrong here, we can't do what we want to do and everybody assumes it's the other party's fault.
[00:07:52] Cheryl: Yes, that's really interesting.
[00:07:54] Riikka: And then nothing moves forward. But in as much as we don't realize that we hold those norms and that they are subjective to our professional group and that other people hold other norms, we might never come to talk about them. So, we happily carry on assuming that there is a problem, when that problem is actually something completely different from the one that we are trying to battle.
[00:08:15] Cheryl: That is really interesting, and it's good to pick that apart because I hadn't thought about that in those ways, because as you say, it's a norm. But it's about understanding what your norms are, so that if as an organization, if you want to make a change, you need to understand your norms before you can even start to consider the change.
[00:08:33] Riikka: And I think that's come out very well in the pandemic when, people have had to do things differently doing, for example, online consultations; we have certain assumptions about what do patients assume happens in a consultation and when we can replicate those, if we don't know what those expectations are, we might easily miscommunicate with them. Or in hospital settings, when teams have had to work in a different physical environment to their normal environment, or where teams have been put together where those people didn't typically work with those other professional groups, it can be really, really important to make things work smoothly, but there is actually time and scaffolding to discuss those kinds of aspects.
[00:09:18] Another thing, that we see a lot in research, is that what often happens in change efforts is that there is an assumption that they're going to work for everyone and everyone's behind them. Because nobody tries; as much as we might disagree with certain change efforts from our own professional position, typically no one puts change efforts forward for absolutely no reason. There is some assumed benefit that should come out of those and then there is the puzzle as to why don't people pick those up, or why is there resistance?
[00:09:47] Riikka: And one of the things that research really shows is that a key thing to motivate people, to try and make the effort to make change happen, which we've just described is actually quite hard work, is that we need to be aware what matters to those particular practitioners or those particular professionals in their practice: what drives them to come to work every day? What motivates them to make the effort? And if the change efforts don't in any way link to that, or worse, if they are in contradiction with that, we're going to get resistance, which can be quite effective.
[00:10:20] And I think what we see a lot of trainings that what drives medics, for example, is different from what drives allied healthcare professionals or what drives nursing staff and they see the purpose of their job differently, and so people will advocate for what matters to them. And so, it's really important in our change efforts, we consider all of those different professional groups and we link our change efforts to what matters to them and communicate that well to them. And as a starting point that we know what it is that they actually do hold important so that we find those, you know, nurses’ think that are really important to look after patients in a certain way. Some medical interventions may really clash with that and it's good that we talk about those kinds of things.
[00:11:05] And at an organizational level, what we see is also really important that those change efforts link well and explicitly with locally identified problems and change needs, so that people don't feel this is an additional layer of work. So, what we have found sometimes is that when we can communicate change efforts to people in a way that helps them see how it helps with the problems they have identified, and not just with the problem, someone out there has identified, that really helps with the motivation for people to take part.
[00:11:40] Cheryl: I think that's a really good point. It's about internalizing it and making sure the individual can see the benefit of that organizational change. So, I think that is a really important part and one of the fundamental things that potentially can go wrong, because if you can't see the benefit of change why change it?
[00:11:57] Riikka: Absolutely. And especially in hierarchical organizations, they tend to be some people whose viewpoints are more likely to be heard than others. So, it's really thinking, have we thought through the impact of this and all levels. And what it is, in a healthcare organization, everybody wants patients to get better. Or if patients can't get better, people want them to have a good quality of life.
[00:12:23] But actually that's far too broad a goal to guide anyone's practice and anyone's normal to normal practice in their workplace. So, I think one of the things is that we need to think of much more concrete and specific goals that people are working from day to day and from hour to hour in their workplace and how to link with those.
[00:12:42] The final thing that links really closely with that, that I wanted to mention is that increasingly in healthcare settings, as patients’ challenges get more complicated, we have aging populations, we have increasing comorbidities. Of course, the pandemic has exacerbated some of the problems, for example, around healthcare challenges and, demographic challenges in the population.
[00:13:05] Riikka: Increasingly a lot of healthcare professionals, including, medics have to work more and more across professional boundaries. That can include doctors working with doctors from other specialities, secondary care doctors working with primary care doctors, but also doctors working with other healthcare professionals and nursing practitioners, advanced nursing practitioners, physiotherapists, clinical scientists, and so forth. And we tend to assume that that is something people can do if they choose to do so. And when it doesn't work, people are being difficult or something like that.
[00:13:38] And, what a lot of practitioners will know and what we know really well from research, that actually to work effectively across professional boundaries requires its own knowledge and competence that we need to really focus on in our training.
[00:13:51] And there are two things that I wanted to mention from research in relation to this, is one of them, is that when people want to make change happen in the workplace, We have seen in our research that typically they tend to think about other people in terms of how can I bring them on board with my change efforts? How can I avoid resistance? How can I persuade the troublemakers? And that really loses the opportunity to draw on other people as a resource for change and not just to see them as a barrier for change.
[00:14:22] So when we've looked at clinical leadership development and what people learn taking part in that, in terms of making their change efforts more effective, is that they come to see other people in a much broader range of ways. So, they come to start thinking about who has the kind of knowledge I would need that could help me, which really often leads them to a much broader range of people within their organization that they might've thought of previously. It's not just medics, it's not even just nurses; it could be IT professionals, it could be admin professionals, custodians, people who know how their organization works.
[00:14:56] Secondly, people start thinking about the, like, when should I involve other people? Whom should I bring on board right from the beginning? Whom should I just ask when I need to speak to them now? How do I use my resources effectively? Whom should I be training as part of my change efforts, so that next time around, I don't need to be doing this by myself?
[00:15:15] And really thinking of other people in a much broader range of ways and when we bring on the people who are a great resource for us because they have knowledge we need, or because they will champion our efforts or because they will persuade people. Then it becomes much easier for us to deal with those people who might post a challenge.
[00:15:34] Cheryl: And that's a good point, I like the way that you've also reflected that it's individuals throughout the organization. I think quite often we forget that the organization is made up from such a diverse range of professionals. And everybody's a professional in their own right and they all have something to bring to the table. And it's really important to include everyone when you're looking at an organizational change. So, I think that's really helpful to, to highlight that as well.
[00:16:00] Riikka: It is. And when we think, particularly for example, a patient's perspectives of what has been happening in hospital settings, it may sometimes be surprising groups of people whom they may have spoken to, you know, that are not our usual suspects that we draw on in our staff meetings. You know, that who may have perspective where the buildings are difficult to navigate, whether waiting rooms feel safe and comfortable to people. You know, what is it that makes people feel better if they're having to wait for a long time? You know there might be quite different people who might have those conversations.
[00:16:33] Cheryl: Absolutely. So, it's the person who brings a cup of tea that can quite often be the most important person they've seen that morning.
[00:16:40] Riikka: Absolutely. And the person who moves someone around the building, a difference that can make in a situation to make someone feel comfortable so that they can actually maybe settle down and better communicate what's going on. And, what some of our research has looked at and many colleagues in the field have looked at is this idea that people also need to develop shared knowledge. One of the academics in my field talks about, Anne Edwards, talks about, is common knowledge among professionals. That professionals need to develop enough common knowledge to be able to communicate with one another effectively to make change happen. And that we see that particularly, not just between different professional groups, but between primary and secondary care and also between different specialties and their different expertise and communicative cultures in hospital settings. Sometimes people don't get their message through simply because they don't share a language with the other professional group.
[00:17:38] But it's not just about a matter of terminology, its understanding what issues are of consequence to that other professional group so that we can understand why they might be unwilling to take our patient over, to do some investigative tests, even though from our professional expo, our specialties’ perspective, that seems really important. So that we can then communicate the aspects that are going to be most important for that other team and negotiate with them our and their priorities and where those might meet.
[00:18:07] So I think given that we've got lots of really specialist expertise working in healthcare settings, we don't always in practical terms, the research suggests, appreciate the huge added expertise that is required to work effectively in a relational manner, across silos.
[00:18:26] Cheryl: I think that's right. And, and patients often see that, and that is a concern.
[00:18:32] Riikka: They do.
[00:18:33] Cheryl: Yeah, so I think it's something that perhaps we need to look into a bit more and perhaps either more research or actually see what sort of educational methods in terms of communication between the silos could be beneficial. So, it's a good point.
[00:18:50] Riikka: And how we can spread good practices, always lots of examples of great practice in big healthcare organizations as well. How can we make sure that that spreads and is shared across the organization, including with more junior members?
[00:19:05] Absolutely, that's been really insightful. Thank you for that. I'm going to move on to something slightly different. So, I know quite often in healthcare, we set up all sorts of different programs or a project that we want to explore X, you know whatever that may be in terms of patient care.
[00:19:26] Cheryl: And you always hear, oh, we must evaluate that, that big, really good idea, if we evaluate that program or project, whatever it may be. So, it's almost sometimes feels like it's a buzzword rather than an actual we're going to do this. Can you tell us why evaluating a project is so important?
[00:19:45] Riikka: I think that's an incredibly important question and I'm so glad you've asked it because you're absolutely right evaluation has to become a bit of a buzz word and it's something like a tick box that people have to do and evaluating something in a really controlled lab setting has its challenges. But once it's been set up, if we have a lot of control, we know how to do that kind of thing.
[00:20:09] But evaluating how change happens in a real practice setting, is actually quite challenging. And we don't have that control and all those kinds of features that make our lab studies really, really well managed and controlled. So, then it's good to think about why are we actually evaluating, what is the purpose of this exercise, so that we put our resources in the right place.
[00:20:30] And I think the key reason why we need to evaluate, is that we often talk about change as it's something that's automatically agreed. Which it, of course, may not be… change may not be good. It may lead to things that are not good, it may have unintentional consequences, and the biggest reason, probably why we evaluate, is this principle of do no harm.
[00:20:50] So the biggest reason why we evaluate first of all, is to ensure that our change efforts are not making things worse or not having unintended consequences for certain outcomes. So that will be our very basis. So, we could at least establish that our new practice is no worse than our previous practice and that's ethically really, really important.
[00:21:13] Of course, we want to go beyond that because given that, we've just been saying for all of this time, that making change happen is quite difficult. We really wouldn't want people putting in all of that effort and it just be just the same or as good as before.
[00:21:25] So the other thing I think we need to evaluate is that there are trade-offs and opportunity costs to all change efforts. And sometimes we need to consider whether as we achieve small improvements, but actually we may have lost something else as a trade-off. Or the opportunity cost of staff spending time on this, is then that they aren't spending time on something else that may have gone, you know, out of the way, because of that.
[00:21:50] We really want to know that our change efforts are worth the trade-offs and the opportunity costs in terms of what is achieved. So effectively, then the reasons why we want to evaluate it are that we all accountable to something, you know. We are accountable for the resources that we spent, be it people's time, be it finances, you know actual money, be it equipment, beds, whatever it might be and, and also, we are accountable for the purposes of what our organization is trying to achieve, the outcomes from our practice.
[00:22:26] So we want to know that our change efforts are improving what we are trying to do on the things that we're wanting to achieve. We want to be able to monitor as we go on with it, we don't want to have to wait until a point at which we will naturally find out if things got better or worse. We want to have a tool that can show us all along the way that if we have some negative unintended outcomes or harm is happening, we know that that information will come to us really, really quickly so that we can stop and pause and think. So, we want to build that evaluation into our change efforts and not use it as something that we do in the end.
[00:23:06] And really, so it's about risk management and also evaluation is important for motivating people. So, we said making change happen is hard. And we need to think about what matters to people. And sometimes what we've achieved, isn't immediately obvious. Because it may either be something really broad or something really specific. So, we want to be able to have something to show to people who've gone into this extra effort or what it is that we have collectively achieved.
[00:23:32] Cheryl: You're right. I think that's really helpful to allow people to see the achievement in a positive way and or as you say, we don't want to do any harm. So, if we see the harm, let's stop it, let's change it, let's do what have to do. It's not just a buzzword, it's important. I think that's a good message to make sure we all understand that. But you also talked about making change for change’s sake or, is it something we should do? We recently had this thing called the pandemic, change was brought upon us, whether we liked it or not.
[00:24:03] Riikka: Yes.
[00:24:04] Cheryl: In terms of thinking about the impact that that's had, has that made it different in terms of how you would evaluate a programme?
[00:24:13] Riikka: So, I think it has created some really significant differences from my perspective and my collaborative work, conducting research, as well as evaluations in healthcare settings and particularly medical education and medical training settings.
[00:24:31] One of those is that the appetite to evaluate what we do in medical education and medical training in particular. And the interest to do that has grown, if anything, you know, that people really want to know. One of the reasons for that I think is because there are many things that we hadn't done in training previously, because there was an assumption that we couldn't do them they'd be too hard or they wouldn't be a good idea. Or there was a resistance, or we wouldn't like them, or we didn't have the time.
[00:25:03] And simply when the pandemic arrived, there was no option but to do whatever it was that we were actually able to do. And that's really shown, while some of that was reactive, it wasn't all good. We aren't going to necessarily want to keep all of it, but it really showed to people that were able to make change happen, much more than we had thought previously.
[00:25:22] So I think there is a real excitement to try and build on that. I think because that didn't happen based on evidence, although there is evidence behind some of it, but there was no time for people to be trying out what works and reading papers and so forth. We simply had to react literally pretty much overnight. There's a real appetite in trying to understand which of those things do we want to keep. And they weren't just because we had to do it that way, but it was an opportunity for us to do new things that we would really want to keep. And which of things; where do we want to go back to how we used to do things previously, even though that might be more resource intensive, where it's really important to go back.
[00:26:00] And I think the final thing, whether it's a real impact from the pandemic to thinking about evaluation, is that we've also got a gap in our generation of outcome data, exams changed, assessments changed during the pandemic. And many of the kinds of data that we collect from people in organizations, there is a gap or it wasn't the same data being collected.
[00:26:23] So we don't necessarily have good baseline data to compare a change or trainee or student learning to. And if we compare it to what happened before the pandemic, it's a little bit unfair given the disruption that people have had to their practice, to their training, to their clinical work, to their education.
[00:26:43] So one of the things I think there is good understanding out there for, is that we need a new baseline. We need an understanding of where people are currently at, what are the analogies, what are the gaps that have emerged during the pandemic. So that whatever we do in the coming months and years, we can compare to a relevant and credible baseline and not to the world that we had before the pandemic which isn't quite the world we are in now.
[00:27:09] Cheryl: Yeah. That's really interesting. Cause I hadn't thought about it in terms of before and after from an evaluation point of view and the way the worlds changed. I know we talk about it a lot, oh, we do this differently now or, you mentioned earlier consultations being different when you call a medical professional. So that's different. Is it good? Is it bad? You know those are questions that we may ask, but there's a before and an after. We did do some of that before, but how we conducted those consultations may have been different to what, when we had to do it and we had no other choice.
[00:27:45] So I think that's really interesting to think about that in terms of a before and after, and also how we would evaluate it and try to pull out the pros and the cons going forward. Thank you, I mean, this has been really interesting to talk to you and take a step back and think about practices in a different way.
[00:28:03] Why is evaluation so important? And to think about our organizational behaviours and those points that you pulled out earlier. I thought that was really interesting and thinking about internalizing the behaviours, but also thinking about what are our normal behaviours, that maybe not everybody recognizes.
[00:28:24] So, I think that was really interesting to take onboard. From my perspective, I've learned a lot today. What would be your three takeaway points or from today that you would say, you know what I want as a listener, I think it's really important to take away these particular points.
[00:28:44] Riikka: I think from my perspective, I suggest that we try and think about trying to make change happen in the workplace based on new policies, based on new evidence, based on research. Through thinking of it as having three sides, so kind of thinking of it as a triangle.
[00:29:04] So, first of all, we do need to think about what the evidence is that's calling us to change something in our practice and what is it that it's calling us to change? Sometimes its clear clinical evidence coming from the work of NICE, for example, that's suggests this practice needs to change. Sometimes it's things to do with organizational culture, so the evidence may take a different nature, but it's saying, what is it that we need to change? And what is the evidence to support that goal?
[00:29:35] And that's typically the one aspect that we think about that's where everything starts from. You know, that's what we need to change here is the evidence. But change efforts often tend to stop with that and then there is an assumption, as I said, at the very beginning that we do just need to get people to agree and they will be compliant and they will put that into place and it will be a good thing. It will happen and it will be a good thing. And as I've been saying that we can't assume either of those two things.
[00:30:02] So the second side of the triangle is then thinking about implementation. What is going to be involved in making this change happen? Which groups of people are going to be involved, how will they need to change their practice? What will that involve?
[00:30:16] And that means looking at the kind of research that tells us can tell us about how to make organizational change happen. What professional learning is involved? What organizational learning is involved? And they said the kinds of ideas I talked about earlier in this podcast.
[00:30:31] So for example, thinking what are the norms that are going to have to change for us to implement this new practice? Who are they going to involve? Who is going to have to work with whom? And what competencies are they going to need to be able to do that effectively? And how do we link this desire to change to what people in our organization are trying to do and what motivates them?
[00:30:53] And then the third side or the bottom of the triangle, if you like is the last conversation we had. So, we've talked about evidence, what is the evidence for the change we need to do? What is the implementation that's going to be required and how can we understand better how that might happen?
[00:31:08] And the third line is the evaluation, the managing of the risk involved in the change efforts and monitoring what's happening and understanding are we achieving our outcomes. And there really thinking, and this may well be the topic of another podcast, what are the tools that we could use from research and evaluation practice in their clinical practice setting? That could tell us how might we evaluate these kinds of practice-based change efforts and what might the outcomes be that we are trying to achieve? And how could we capture those?
[00:31:40] Cheryl: Great summary, thank you for that. And I liked the fact that you've mentioned another podcast. That would be fantastic to have you back again because this has been really interesting. And, just going back to the first comment about the triangle, thank you for bringing out the fact that it may be others that require the change.
[00:32:00] So when you talked about NICE, or the National Institute for Clinical Excellence, sometimes they come out with the changes that practitioners need to do and how are we going to implement that? So, I like your description of the triangle, it was really helpful. Great summary. It's been really, really interesting to talk to you today.
[00:32:16] Riikka: It's been really lovely to talk to you as well. Cheryl.
[00:32:19] Cheryl: Thank you, Dr Riikka Hofmann. It's been fantastic and I do hope that you'll come again.
[00:32:24] Riikka: Thank you very much.
[00:32:25] Cheryl: Thank you, if listeners are interested in learning more about medical education and evaluation in health or educational settings, please contact us via the CUMEG website. You'll also find our other podcasts on the website at www.CUMEG.cam.ac.uk, or look for us wherever you get your podcasts.
[00:33:00] We are grateful to you, our listeners. Thank you for taking the time out of your busy schedules to listen to us today. If you would like to hear more from our series, please like and subscribe to our podcast.
[00:33:12] Next week, we will be talking to Dr Anna Spathis, who will be talking to us about palliative care and the different approaches that one can take.
We look forward to you joining us next time.
