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Towards the creation of learning improvement practices: Studies of pedagogical conditions when change is negotiated in contemporary healthcare practices
Linnaeus University, Faculty of Social Sciences, Department of pedagogy. Jönköping Academy, School of Health Sciences Jönköping. (Bridging the Gaps)ORCID iD: 0000-0002-3164-8462
2015 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Mot lärande förbättringspraktiker : Studier av pedagogiska villkor då förändringar förhandlas i samtida hälso- och sjukvårdspraktiker (Swedish)
Abstract [en]

In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s.

The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies.

The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press, 2015. , p. 121
Linnaeus University Dissertations ; 221/2015
Keywords [en]
quality improvement, clinical microsystem, healthcare policy, critical discourse analysis, governing mechanism, knowledge management, negotiation
Keywords [sv]
förbättringsarbete, hälso- och sjukvårdspolicy, arbetplatsrelaterat lärande, förhandling
National Category
Research subject
Social Sciences
URN: urn:nbn:se:lnu:diva-42709ISBN: 978-91-87925-61-0 (print)OAI:, id: diva2:806986
Public defence
2015-05-13, Myrdal, Hus K, Universitetsplatsen 1, Växjö, 13:15 (English)
Bridging the Gaps
Forte, Swedish Research Council for Health, Working Life and Welfare, A2007037Available from: 2015-04-22 Created: 2015-04-20 Last updated: 2015-05-06Bibliographically approved
List of papers
1. 'Money talks': En kritisk diskursanalys av samtal om förbättringar i hälso- och sjukvård
Open this publication in new window or tab >>'Money talks': En kritisk diskursanalys av samtal om förbättringar i hälso- och sjukvård
2012 (Swedish)In: Utbildning och Demokrati, ISSN 1102-6472, E-ISSN 2001-7316, Vol. 21, no 2, p. 103-124Article in journal (Refereed) Published
Abstract [en]

Based on learning as taken for granted in health care quality improvement, the aim was to identify discursive patterns in practice, and to discuss how these patterns create conditions for learning. Observations of quality improvement conversations were made at a clinic and analyzed through critical discourse analysis. Four different discursive patterns were found; a market pattern, a care-for-all pattern, a medical pattern and a value pattern. The order of discourse shows that the market pattern dominates the others while money is linked to quality control. The findings also showed a balance between discourse patterns when economical incentives were absent. In other words, the professionals can handle all complex, and sometimes contradicting, quality aspects when they don’t compete about money. We discuss that market principles impact on learning in terms of displacement effects which discourages long-term sustainable improvements.

critical discourse analysis, marketization in healthcare, quality improvement
National Category
Research subject
Pedagogics and Educational Sciences
urn:nbn:se:lnu:diva-23047 (URN)
Bridging the Gaps
Available from: 2012-12-19 Created: 2012-12-19 Last updated: 2017-12-06Bibliographically approved
2. One Lens Missing? Clarifying the Clinical Microsystem Framework with Learning Theories
Open this publication in new window or tab >>One Lens Missing? Clarifying the Clinical Microsystem Framework with Learning Theories
2013 (English)In: Quality Management in Health Care, ISSN 1063-8628, E-ISSN 1550-5154, Vol. 22, no 2, p. 126-136Article in journal (Refereed) Published
Abstract [en]

Introduction: The clinical microsystem (CMS)approach is widely used and is perceived as helpfulin practice but, we ask the question: “Is its learningpotential sufficiently utilized?” Objectives: Toscrutinize aspects of learning within the CMSframework and to clarify the learning aspects theframework includes and thereby support theframework with the enhanced learning perspectivethat becomes visible. Methods: Literature on theCMS framework was systematically searched andselected using inclusion criteria. An analytical toolwas constructed in the form of a theoretical lensthat was used to clarify learning aspects that areassociated with the framework. Findings: Theanalysis revealed 3 learning aspects: (1) The CMSframework describes individual and social learningbut not how to adapt learning strategies forpurposes of change. (2) The metaphorical languageof how to reach a holistic health care system foreach patient has developed over time but can stillbe improved by naming social interactions totranscend organizational boundaries. (3) Powerstructures are recognized but not as a characteristicthat restricts learning due to asymmetriccommunication. Conclusion: The “lens” perspectivereveals new meanings to learning that enhance ourunderstanding of health care as a social system andprovides new practical learning strategies.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2013
clinical microsystem, learning theory, quality improvement, workplace learning
National Category
Didactics Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Pedagogics and Educational Sciences, Pedagogics
urn:nbn:se:lnu:diva-26906 (URN)10.1097/QMH.0b013e31828c22e2 (DOI)000209317100006 ()2-s2.0-84879369102 (Scopus ID)
Bridging the Gaps
Available from: 2013-06-20 Created: 2013-06-20 Last updated: 2017-12-06Bibliographically approved

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