Abstract
Background & Purpose The critical nature of emergencies requires general practice teams to provide a prompt patient-centred collaborative approach. Paediatric emergencies are challenging, and General Practitioners (GPs) report they often feel unprepared to manage these scenarios. However, given their critical nature and benefits that timely interventions can confer it is important that general practice teams are prepared for such eventualities.In-situ simulation (ISS) is well placed to train for high acuity, low opportunity events such as medical emergencies. ISS training is documented in literature as an acceptable and feasible way of developing interprofessional skills in a primary care setting, yet more needs to be known its impact and how it achieves its effects(1).
Existing research has evaluated the emerging potential of ISS but has been limited by outcome measures such as improved confidence of participants. There is a lack of research exploring a theoretical approach to learning from ISS(2). Cultural Historical Activity Theory (CHAT) is a useful methodological framework to study practice-based learning in complex learning environments such as clinical practice(3). This social cultural research aimed to bring to the surface many of the nuances and contextualised factors in the complex world of general practice to guide us in the best direction of providing team-based response to managing paediatric emergencies.
Methodology Change Laboratory (CL) is “a formative intervention method developed for studying workplaces in transition and generating improved, shared patterns of activity”(4). A smaller scale adaptation of a CL, ‘SimLab’ was developed by our research team for the busy general practice workplace. This longitudinal programme of ISS consisted of four workshops and scaffolded the process of Transformative agency by Double Stimulation (TADS) by introducing CHAT to participants as a potential mediating artefact for problem solving to issues raised in the ISS.
In workshop 1, participants engaged in an ISS (paediatric anaphylaxis), afterwards they reviewed the ISS video footage and mapped workplace activity to CHAT framework. In workshop 3 they participated in a different ISS (meningitis) followed by a discussion to explore if the changes had enhanced their emergency response. Workshop 2 and 4 involved in depth CHAT guided discussions.
The lens of CHAT was applied to the case study to gain a deeper understanding of organisational change brought about by the ISS training model of emergencies. The TADS model was used to demonstrate and explain participants’ development of agency in the context of ISS paediatric emergency care. The expressions of transformative agency were mapped as they emerged from the SimLab and evolved over time.
Results CHAT enabled participants to take a systemic perspective of workplace learning exploring the complexity of clinical practice through the use of theory guided ISS(5, 6). Collaboratively participants identified accumulated historical tensions in their activity system, these becamepotential levers for effective organisational change and devised a future orientated model to resolve contradictions. . Learners exhibited six types of expressions of transformative agency; resisting, criticising, explicating, envisioning and committing to actions which evolved through collective activity(7).
Discussion & Conclusions This research used simulation as a mirroring tool to lead to organisational change at systems level. The use of ISS provided real life contextuality, identified latent threats and has the potential to transfer well into practice enhancing the degree of preparedness for such time-critical, low-frequency, and high-morbidity events. Simulation and theory were used to narrow the gap between constructed reality and the real reality. This research demonstrates how CHAT can provide a theoretical lens and approach to guide ISS in healthcare(2) to bring about organisational transformation for emergency care. This research offers rich insights into the emerging potential of ISS to stimulate individual and organisational change in response to highly complex, contextualised patient safety problems.
Thesis is embargoed until 31 July 2027.
| Date of Award | Jul 2025 |
|---|---|
| Original language | English |
| Awarding Institution |
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| Sponsors | KN Cheung and SK Chin QUB InterSim Bursary Award & Health and Social Care (Northern Ireland) Research and Development |
| Supervisor | Richard Conn (Supervisor) & Gerard Gormley (Supervisor) |
Keywords
- Cultural Historical Activity Theory
- in-situ simulation
- interprofessional learning
- general practice emergencies
- double stimulation
- transformative agency
- , expansive learning
- organisational change