User Story: Cascading Learning [Health Care context]

In what situation? Learning trigger?

Peter is a Doctor (GP) involved in running the Diabetic Clinic at Rowland Green Medical Centre (GP Practice). He and his practice partners know (from information sent to them by professional bodies, the NHS and from their reading of professional websites) that the NHS has produced new pathway (guidelines) on how to manage a certain diabetic condition. The local Primary Care Trust has sent them an invitation to attend local training on the new guidelines. Peter discusses this with his colleagues and they decide that he and the Business Manager (Richard) will attend the training and will then cascade it to the rest of the Diabetic Clinic team and practice staff as necessary.

What happens?

  1. Richard has to arrange for Peter’s clinical work to be covered by other staff or a locum (a doctor hired to cover a specific session) whilst he is at the ½ day training session.
  2. Peter and Richard drive to the local training session, which is held in the NHS training rooms in Airedale Mill.
  3. An NHS trainer runs the session, which involves an explanation of the reason for the changes in the guidelines, a presentation of the new guidelines, some small group work to explore an example of applying the guidelines and time for questions and discussion. The trainer uses powerpoint and video in their presentation. The group work activity is written on paper and participants are given written material to take away including a link to the NICE Pathways webpage where the new pathway is set out.
  4. Peter and Richard spend time during the session talking to staff from other GP practices, sharing their experiences and discussing how they think the new guidelines will affect them.
  5. Peter and Richard drive back in Peter’s car to the practice together and continue to talk about what they learned during the session and how they think it will impact on their work.
  6. Peter feels that the time away from the practice and from the task-focused hands-on clinical or management work has given him space to step back and reflect on his work and in particular how he (and other staff) deal with this particular diabetic condition. The new guidelines seem like a good improvement and he is keen to discuss this with other staff and help them to see the benefits of the changes.
  7. Richard also feels the time has been well spent for him – both in terms of the training itself (and feeling confident that he understands the new pathway) and as an opportunity to talk through other practice issues with Peter whilst they were together.
  8. When Peter and Richard get back to the practice they are both immediately immersed in clinical and management work and do not get the opportunity to continue their discussions together or to feed back immediately to other staff.
  9. Peter plans to talk to the diabetic team about the new pathway at their next meeting, which is in two week’s time. Richard has put the new pathway on the agenda for the next whole practice education meeting (with time on its agenda) which is in a month’s time.
  10. Three days later Richard and Peter bump into each other in the coffee room and have a chat about the training and the new pathway. Peter has already had a chance to put the training into action as he had a consultation with a patient who had the relevant condition. Peter and Richard are concerned that they want to get the advice and guidelines out to other staff as soon as possible but the team meeting and the practice education meeting are still some weeks away and their allocated time slots in these meetings are short anyhow. They decide to write an email to staff summarising what they learned.
  11. Peter sends an email (using NHS Webmail ) to all relevant staff summarising the key points from the training. He also gives a very brief update on the guidelines at the next clinic team meeting and Richard gives a similar brief update at the practice education meeting.
  12. Tina (one of the Diabetic Nurse Specialists) receives the email, reads it and saves it in her email folder for Education Material. When she next comes across a patient with the relevant condition she remembers that there was some new advice on this and searches for the email. It is not that easy to find and the search does delay and disrupt the consultation with the patient a little. However she does find the advice and it has an affect on the next steps she then takes with the patient.
  13. Jane (another doctor involved with the Diabetic Clinic) receives the email and quickly scans it. Some weeks later she comes across a patient with this condition, but a lot has happened in the meantime and she does not remember that she had received this email update. She also was not present at the last Diabetic Clinic team meeting and so she did not hear Peter give the update on the guidelines. She continues to treat the patient in the way she is used to doing and does not use the new pathway.
  14. Douglas (a doctor at the practice who is not involved in the Diabetic Clinic) has also received the email but has deleted it as he is overwhelmed with emails and this one seems to be aimed at the diabetic specialists. Some months later a diabetic patient turns up for a general consultation with Douglas. Douglas feels slightly unsure about how to treat this patient. At one level he feels that the complaint they have presented with is not related to their diabetes and he should be able to treat it himself. However, he is also vaguely aware that there had been some new guidelines sent out earlier in the year about diabetics and he can’t remember if they would be relevant to this case. Given that he is already running behind with his consultations this day and it will take time for him to find and understand the new guidelines, he feels the safest thing to do would be to refer this patient to the diabetic clinic. They are the specialists and they’ll know about the new guidelines. Douglas refers the patient but feels unsatisfied in some ways with this action – he went into medicine to treat people and he enjoys understanding his patients and their conditions. Making a referral in this way leaves Douglas feeling as though he has been deskilled in some way.

What is the final result?

  • Both Peter and Richard feel enthused by the training, feel that they fully understand the new pathway, have had a chance to reflect on their practice and have gained from discussing their work with others. They consider themselves to have been actively engaged in learning. Peter will ensure he follows the new pathway in future – it is now part of his way of working. However they are both aware that their new knowledge, understanding and enthusiasm has not necessarily cascaded to everyone in the team/practice.
  • Tina feels reasonably well informed about the guidelines. She knows what to do and where to get more information and will follow the new pathway, but she does not really consider herself to have been involved in learning and wouldn’t claim to fully understand the reasoning behind the change in the guidelines.
  • Jane is not yet really aware that there has been a change and has not made a change to her working practice. At some point in the future (when she does read a relevant article, discusses a case with a colleague or her work is reviewed) this will be picked up on and she will then rapidly adopt the new pathway, but for the moment she certainly would not consider herself to have been involved in learning.
  • Douglas is vaguely aware of the new guidelines, but does not feel confident that he understands them. Due to this lack of confidence he is more likely to simply refer patients to the Diabetic Clinic. He actually feels that he is losing knowledge and skills as the specialist care is taken on by others and he has little time to keep his skills up to date and must priorities those ones that are more general. He does not consider himself to have been involved in learning.


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