title: Flux, questions, exclusion and compassion: collective learning in secondary care.
abstract: BACKGROUND
  Health care organisations are increasingly conceptualised as complex, indivisible entities made up of web-like networks of staff that connect to each other in changeable ways. This study draws on the theoretical framework of activity theory and the concept of knotworking to illustrate how health professionals improvise collaboratively to negotiate everyday challenges and contribute positively to patients' health priorities.
  
  
  OBJECTIVE
  The aim of this paper is to contribute to evolving ideas about collective learning, change and improvement in secondary care by exploring how health professionals work and learn together and how this compares with earlier findings from primary care.
  
  
  METHODS
  This study applied a constructionist methodology within the research paradigm of interpretivism. Qualitative data were gathered through 26 hours of observations and 17 field interviews within the natural environment of a working hospital over a 3-month period. The research site encompassed a medical receiving ward, a chronic ward, an out-patient clinic and the connecting corridors. Staff participants included a range of clinical, nursing, ancillary and clerical staff.
  
  
  RESULTS
  The study found a recurring pattern of spontaneous team forming and interprofessional shared learning to respond to care needs within the hospital as they arise. These are presented in four analytical themes: motion, flux and the unpredictability of 'team spirit'; adaptive, responsive learning through seeing, doing and asking questions; the collective learning gap between doctors and other staff; and frustration, compassion and the desire for improvement.
  
  
  CONCLUSIONS
  Health care professionals in the hospital setting both create and experience complex inclusion and exclusion behaviours that define who is empowered to act with professional authority in any given moment of care. This paper discusses issues of power, the particular exclusion of doctors from interprofessional knotworking, and the greater emphasis on questions as the pivotal aspect of shared collective learning when compared with primary care.
authors.affiliation: Department of Postgraduate Medicine, University of Glasgow, 1 Horselethill Road, Glasgow, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Bunniss
authors.forename: Diane R
authors.initials: DR
authors.lastname: Kelly
mesh_terms: D000223:Adaptation, Psychological; D003299:Cooperative Behavior; D004645:Empathy; D005069:Evaluation Studies as Topic; D005639:Frustration; D006801:Humans; D007400:Interprofessional Relations; D007858:Learning; D019370:Observation; D010348:Patient Care Team / Q000458:organization & administration / Q000639:trends*; D011209:Power, Psychological; D058996:Quality Improvement; D063127:Secondary Health Care