我们的系统:呼吁在受训人员中向系统代理转变观点。

IF 4.9 1区 教育学 Q1 EDUCATION, SCIENTIFIC DISCIPLINES Medical Education Pub Date : 2023-10-03 DOI:10.1111/medu.15242
Arden Azim, Matt Sibbald
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While this study was conducted at the height of the pandemic, the health workforce crisis continues to threaten workplace affordances of agency.<span><sup>3</sup></span> Trainees must navigate a landscape where educational and care delivery processes are increasingly centralised, and top-down crisis responses challenge agentic behaviour.<span><sup>3</sup></span></p><p>Mattick et al call for ‘urgent work […] to provide medical trainees with greater agency and favourable workplaces’.<span><sup>1</sup></span> The authors highlight learners feeling ‘disengaged [and] resigned’ and their ‘perceived powerlessness to influence a wider agenda’.<span><sup>1</sup></span> Addressing trainees' perceived lack of agency to change the system is crucial. Maximising systems agency will mitigate disengagement and leverage changes that trainees are uniquely positioned to make. 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Agency may be better interpreted as directed at activities spanning clinical care, research and learning, bridging the gap between the individual and the system.<span><sup>8</sup></span></p><p>A shift towards agency as expressed through clinical care, research and learning expands opportunity for trainees to find agency within a ‘faceless nameless entity’.<span><sup>1</sup></span> Mattick et al call for ways for trainees to ‘influence the wider policy agenda’ to combat perceived powerlessness when systems-level issues overshadow individual patient care.<span><sup>1</sup></span> They suggest ‘amplify[ing] existing positive affordances of agency; for example, when doctors-in-training collaborate positively with peers, and suggest process improvement’.<span><sup>1</sup></span> Addressing systems-levels challenges through research or quality improvement at a micro or meso systems level is a means for learners to exercise systems agency under constraining circumstances.<span><sup>4, 9</sup></span> Vipler et al discuss how recognising system failings and advocating for change allows trainees to ‘move from passive acceptance of their situation’ to ‘an active agent in constructing a different, more just reality’.<span><sup>4</sup></span> The importance of developing systems agency is reflected in physician competency frameworks, including CanMEDS, which identifies ‘advocating for system-level change in a socially accountable manner’ as an essential competency for trainees.<span><sup>10</sup></span></p><p>Next, we must consider to what extent agency can be afforded, and to what extent learners must create it—‘agency from whom?’ Through CHAT, learners can be seen as an ‘agent within an activity system’, where agency is co-constructed and negotiated within the sociocultural context, communities of practice and hierarchies.<span><sup>2, 6, 7</sup></span> Within this view, learners are not ‘mere and hapless hostages’ within the wider healthcare system.<span><sup>2, 5</sup></span> Learners are active participants in their local system and can create agency through the clinical care, research and learning activities that fall within their role.<span><sup>8</sup></span> Learners are already uniquely situated to act as ‘change agents’ through holding both a near-outsider perspective and an insider position within the system.</p><p>We agree with Mattick et al's recommendation to ‘smooth the peaks and troughs of clinical responsibility’.<span><sup>1</sup></span> Working within their zone of proximal development allows learners to co-construct greater agency through meaningful contributions to care and teaching.<span><sup>9</sup></span> Workplace systems that stretch to accommodate learners' scope of practice support the embedding of agency in workplace care and learning activities.</p><p>This brings us to the idea of an ‘agency literate’ learner. 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As stated by Watling et al, ‘agency is work’.<span><sup>5</sup></span> Cultivating agency literacy requires motivation, mentorship, support, social capital and belonging.<span><sup>5</sup></span> A paradigm shift in how trainees perceive agency must be accompanied by support from practice communities and workplaces. For example, Mattick et al suggest that supervisors could ‘facilitate this by noticing, suggesting and endorsing’ agentic activities.<span><sup>1</sup></span> We agree with the authors' call to explore how critical consciousness could offer insights into enabling trainees to act as change agents and suggest exploring how else agency literacy can be developed and maintained.<span><sup>1</sup></span> An agency literate approach may help learners move from resignation to realisation of their role as active change agents in care, learning and research. 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We see this paper not only as a call for greater workplace affordances but also as a call for a perspective shift on learner agency. Establishing greater workplace affordances for agency without empowering learners to recognise their position as active agents within the system will leave a critical aspect of agency unaddressed.<span><sup>4</sup></span></p><p>Reframing trainee perspective on systems agency requires answering two questions. First, we must consider ‘agency for what’—whether agency is directed towards personal trajectories or advancing health outcomes. 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引用次数: 0

摘要

在他们的论文“英国实习医生行使代理权的限制和负担:对话分析”中,Mattick等人呼吁迫切需要加强实习医生的代理权代理可以理解为受训者在系统内独立行动的能力,并对他们的教育轨迹、专业发展和病人护理做出决定作为一名受COVID-19影响的实习生,学习如何驾驭机构的挑战因系统压力而加剧。虽然这项研究是在疫情最严重的时候进行的,但卫生人力危机继续威胁着工作场所的服务能力受训者必须适应这样一个环境:教育和护理提供过程日益集中,自上而下的危机应对挑战了代理行为。3Mattick等人呼吁"紧急工作[…],为医疗实习生提供更大的代理权和有利的工作场所"作者强调了学习者的“脱离感和认命感”,以及他们“感觉无力影响更广泛的议程”解决受训者认为缺乏改变体制的能动性的问题至关重要。最大化系统代理将减轻脱离接触,并利用受训者独特的定位来做出改变。我们认为这篇论文不仅是对更大的工作场所支持的呼吁,也是对学习者代理视角转变的呼吁。为代理建立更大的工作场所支持,而不让学习者认识到他们在系统内作为主动代理的地位,将使代理的一个关键方面得不到解决。重新构建学员对系统代理的看法需要回答两个问题。首先,我们必须考虑“代理什么”——代理是针对个人轨迹还是促进健康结果。学习者代理通常被定义为直接针对学习者自身的专业发展,这可能与系统需求相矛盾文化历史活动理论(CHAT)将代理定位为活动系统中各种元素(包括学习者、工作场所、机构和环境)之间的协商,为理解代理目标之间的紧张关系提供了有益的视角。2,6,7 Mattick等人认为,学习者感知到的能动性缺乏可能源于将患者作为活动对象转向系统级问题如果学习者还认为能动性主要是影响其个人轨迹的能力,那么学习者可能因此认为从个人问题到系统问题的转变是缺乏能动性。代理可以更好地解释为针对跨越临床护理、研究和学习的活动,弥合个人与系统之间的差距。通过临床护理、研究和学习向能动性的转变,扩大了受训者在“无名实体”中找到能动性的机会Mattick等人呼吁让受训者“影响更广泛的政策议程”,以对抗当系统层面的问题掩盖了个人患者护理时所感受到的无力感他们建议“放大现有的能动的积极启示;例如,当培训医生与同行积极合作时,并建议流程改进通过在微观或中观系统层面的研究或质量改进来解决系统层面的挑战是学习者在受限环境下行使系统代理的一种手段。4,9 Vipler等人讨论了如何认识到系统的缺陷并倡导变革,使受训者“从被动接受自己的处境”转变为“构建一个不同的、更公正的现实的积极主体”发展系统代理的重要性反映在医生能力框架中,包括CanMEDS,它确定“以对社会负责的方式倡导系统级变革”是实习生的基本能力。接下来,我们必须考虑在多大程度上可以提供代理,在多大程度上学习者必须创造代理——代理来自谁?通过CHAT,学习者可以被视为“活动系统中的代理人”,其中代理人是在社会文化背景、实践社区和等级制度中共同构建和协商的。2,6,7在这种观点下,学习者在更广泛的医疗保健系统中不仅仅是“不幸的人质”。学习者是当地系统的积极参与者,可以通过属于他们角色的临床护理、研究和学习活动来创造代理学习者已经处于独特的位置,通过持有近乎局外人的观点和系统内部的立场,作为“变革推动者”。我们同意Mattick等人的建议,即“理顺临床责任的高峰和低谷”在他们的最近发展区域内工作,使学习者能够通过对护理和教学的有意义的贡献来共同构建更大的代理。 为适应学习者的实践范围而扩展的工作场所系统支持在工作场所护理和学习活动中嵌入代理。这让我们想到了“代理文化”学习者的概念。代理素养意味着学习者认识到自己在系统中的地位,而不是对系统无能为力。4,5具有代理文化的学习者准备通过临床护理,研究和学习来谈判代理机会。他们认识到并能够利用自己在体制内的特权地位来推动变革。机构素养使受训者能够利用机构的组织支持,包括作者所要求的变化培养机构知识将使受训者准备在复杂的系统中作为独立的从业者操作,因为系统压力将在其整个职业生涯中威胁到机构。我们认识到,向承认和制定制度机构的转变并非易事。正如Watling等人所说,“代理就是工作”培养代理素养需要动机、指导、支持、社会资本和归属感学员如何看待代理的范式转变必须伴随着实践社区和工作场所的支持。例如,Mattick等人建议主管可以“通过注意、建议和认可”代理活动来促进这一点我们同意作者的呼吁,即探索批判性意识如何能够提供洞察力,使受训者能够作为变革的推动者,并建议探索如何发展和保持代理素养一个机构文化的方法可以帮助学习者从辞职到实现他们的角色作为积极的变革推动者在护理,学习和研究。就目前而言,面对威胁机构的持续不断的系统级压力,从“我与系统”到“我们系统”的观点转变是有必要的。Arden Azim:概念化;资源;可视化;原创作品草案;写作-审查和编辑。Matt Sibbald:概念化;监督;写作-审查和编辑。
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We the system: A call for a perspective shift towards systems agency in trainees

In their paper ‘Constraints and affordances for UK doctors-in-training to exercise agency: a dialogical analysis’, Mattick et al call for urgent work to enhance agency for doctors-in-training.1 Agency can be understood as trainees' ability to act independently within the system and make decisions about their educational trajectory, professional development and patient care.2 As a trainee impacted by COVID-19, the challenges of learning to navigate agency were exacerbated by a system under strain. While this study was conducted at the height of the pandemic, the health workforce crisis continues to threaten workplace affordances of agency.3 Trainees must navigate a landscape where educational and care delivery processes are increasingly centralised, and top-down crisis responses challenge agentic behaviour.3

Mattick et al call for ‘urgent work […] to provide medical trainees with greater agency and favourable workplaces’.1 The authors highlight learners feeling ‘disengaged [and] resigned’ and their ‘perceived powerlessness to influence a wider agenda’.1 Addressing trainees' perceived lack of agency to change the system is crucial. Maximising systems agency will mitigate disengagement and leverage changes that trainees are uniquely positioned to make. We see this paper not only as a call for greater workplace affordances but also as a call for a perspective shift on learner agency. Establishing greater workplace affordances for agency without empowering learners to recognise their position as active agents within the system will leave a critical aspect of agency unaddressed.4

Reframing trainee perspective on systems agency requires answering two questions. First, we must consider ‘agency for what’—whether agency is directed towards personal trajectories or advancing health outcomes. Learner agency is often conceptualised as directed towards learners' own professional development, which can be in tension with system needs.5 Cultural historical activity theory (CHAT), which positions agency as negotiated between various elements of an activity system including the learner, workplace, institution and context, provides a helpful lens to understand tensions between the objectives of agency.2, 6, 7 Mattick et al suggest that learners' perceived lack of agency can arise from a shift away from the patient as the object of the activity towards systems-level issues.1 If learners also perceive agency primarily as the ability to influence their personal trajectory, learners may therefore perceive the shift from individual to systems issues as a lack of agency. Agency may be better interpreted as directed at activities spanning clinical care, research and learning, bridging the gap between the individual and the system.8

A shift towards agency as expressed through clinical care, research and learning expands opportunity for trainees to find agency within a ‘faceless nameless entity’.1 Mattick et al call for ways for trainees to ‘influence the wider policy agenda’ to combat perceived powerlessness when systems-level issues overshadow individual patient care.1 They suggest ‘amplify[ing] existing positive affordances of agency; for example, when doctors-in-training collaborate positively with peers, and suggest process improvement’.1 Addressing systems-levels challenges through research or quality improvement at a micro or meso systems level is a means for learners to exercise systems agency under constraining circumstances.4, 9 Vipler et al discuss how recognising system failings and advocating for change allows trainees to ‘move from passive acceptance of their situation’ to ‘an active agent in constructing a different, more just reality’.4 The importance of developing systems agency is reflected in physician competency frameworks, including CanMEDS, which identifies ‘advocating for system-level change in a socially accountable manner’ as an essential competency for trainees.10

Next, we must consider to what extent agency can be afforded, and to what extent learners must create it—‘agency from whom?’ Through CHAT, learners can be seen as an ‘agent within an activity system’, where agency is co-constructed and negotiated within the sociocultural context, communities of practice and hierarchies.2, 6, 7 Within this view, learners are not ‘mere and hapless hostages’ within the wider healthcare system.2, 5 Learners are active participants in their local system and can create agency through the clinical care, research and learning activities that fall within their role.8 Learners are already uniquely situated to act as ‘change agents’ through holding both a near-outsider perspective and an insider position within the system.

We agree with Mattick et al's recommendation to ‘smooth the peaks and troughs of clinical responsibility’.1 Working within their zone of proximal development allows learners to co-construct greater agency through meaningful contributions to care and teaching.9 Workplace systems that stretch to accommodate learners' scope of practice support the embedding of agency in workplace care and learning activities.

This brings us to the idea of an ‘agency literate’ learner. Agency literacy implies a shift towards learners' recognition of their position as embedded within the system rather than powerless against it.4, 5 Agency literate learners are prepared to negotiate opportunities for agency through clinical care, research and learning. They recognise and can leverage their privileged position within the system to drive change. Agency literacy primes trainees to take advantage of organisational affordances for agency, including the changes called for by the authors.1 Fostering agency literacy will prepare trainees to operate within complex systems as independent practitioners, as systems pressures will threaten agency throughout their careers.

We recognise that a shift towards recognising and enacting systems agency is no easy task. As stated by Watling et al, ‘agency is work’.5 Cultivating agency literacy requires motivation, mentorship, support, social capital and belonging.5 A paradigm shift in how trainees perceive agency must be accompanied by support from practice communities and workplaces. For example, Mattick et al suggest that supervisors could ‘facilitate this by noticing, suggesting and endorsing’ agentic activities.1 We agree with the authors' call to explore how critical consciousness could offer insights into enabling trainees to act as change agents and suggest exploring how else agency literacy can be developed and maintained.1 An agency literate approach may help learners move from resignation to realisation of their role as active change agents in care, learning and research. As it stands, in the face of unabating systems-level pressures that threaten agency, a shift in perspective from ‘me versus the system’ to ‘we the system’ is warranted.

Arden Azim: Conceptualization; resources; visualization; writing—original draft; writing—review and editing. Matt Sibbald: Conceptualization; supervision; writing—review and editing.

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来源期刊
Medical Education
Medical Education 医学-卫生保健
CiteScore
8.40
自引率
10.00%
发文量
279
审稿时长
4-8 weeks
期刊介绍: Medical Education seeks to be the pre-eminent journal in the field of education for health care professionals, and publishes material of the highest quality, reflecting world wide or provocative issues and perspectives. The journal welcomes high quality papers on all aspects of health professional education including; -undergraduate education -postgraduate training -continuing professional development -interprofessional education
期刊最新文献
The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review. When I say … neurodiversity paradigm. The transition to clerkshIps bootcamp: Innovative and flexible curriculum strategies post COVID-19 adaptation. Issue Information Empowering dental students' collaborative learning using peer assessment.
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