Institute of Education Researching Medical Learning

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Institute of EducationResearchingMedical
Learning Practice16 November 07Crossing
boundaries how refugee surgeons learn to work in
the NHS
akelly_at_rcseng.ac.uk
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Generations of refugees

• A Guide for Refugee Doctors
• Published by the Jewish Council for Racial
  Equality
• Dr Franz L Neumann, refugee doctor from Germany,
  1937
• Dr Nayeem Azim refugee doctor from Afghanistan,
  2002

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BMA Refugee Doctors Database

• 1,118 refugee/asylum seeking doctors
• 77 surgeons establishing eligibility
• 25 eligible to apply for consultant post
• 13 refugee surgeons practising in NHS
• how many undeclared in London alone?
• Afghanistan, Iran, Iraq, Pakistan, Sudan

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One surgeons story you cant go back

• Belonging or not belonging?
• DSS/humiliation
• Difficulty of access to clinical experience
• Mentoring social professional
• Social values work, colleagues, the group and
  the individual
• Adapting to local/national issues culture

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continued

• Glasgow bombs pathologising refugees
• Refugees contribution different experience
• Uprooting/families/networks
• Professional identities what happened to my
  colleagues
• Stress PTSS
• theres no plan, theres no pathway

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The key question

• what pedagogy fits with Stefans story and
  with other refugee surgeons learning to work in
  the NHS?

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A case study

• Context
• Theoretical field/literature
• Empirical setting/methodology
• Some questions

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The context
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Policy perspectives

• Report of the Working Group on Refugee Doctors
  and Dentists, DoH, 2000
• Refugee Health Professional Steering Group, 2001
• 2M project to support refugees in their efforts
  to seek NHS employment
• A cost-effective source of staff for NHS seeking
  to modernise its workforce
• Most recently changes in UK work permits

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Refugee Doctors Programme Queen Mary, University
of London

• Advice/orientation to living in UK
• Mentoring/professional life in the UK
• Support/high standard of medical English
• Updating/professional knowledge/skills
• Adjustment/UK learning teaching styles, and
  assessment methods
• Access/clinical practice in the UK

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The significance of work placements for refugee
doctors

• Experience of patient interaction in UK
• UK clinical practice/terminology
• Working in multicultural teams
• Knowledge of NHS practices/protocols
• Knowledge of career paths
• Access to vacancies within the NHS
• Improved psychological health/well being

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How Stefans story compares with the larger
picture

• Refugee Doctors support, development and
  integration in the NHS Neil Jackson and Yvonne
  Carter, (2004).
• Asylum application process
• Financial hardship
• Adjusting to training mode in order to acquire
  UK registration
• Previous interruption of training
• Lost/destroyed documentation
• Securing references
• Medical English
• No contact with family members or other support
  networks
• Accessing appropriate information
• Trauma experienced in personal lives

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Effect of uncertainty on learning?

• Maslows hierarchy
• - physical needs/survival
• - security
• - social needs
• - recognition/success
• - self-actualisation/desire for self-fulfilment
• Impact of high degree of self-motivation

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The theoretical field/literature
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Macro-analysis external factors

• Butler, C. Eversley, J. (2007). Guiding their
  way assisting refugee health professional.
  Clinical Teacher,
• 4, 146-152.
• Context analysis
• - Social
• - Economic
• - Technological
• - Political
• - Ethical
• - Environmental
• - Legislative

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Identity

• Identity represents the process by which the
  person seeks to integrate his sic various
  statuses and roles, as well as his diverse
  experiences, into a coherent image of self
  (Epstein, 1978)
• Different traditions experimental sciences,
  literature, social sciences
• identity is a storied process (Frank, 1995)
• Multiple identities
• - social
• - learning
• - professional
• - organisational

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Transitions

• The ways in which people transfer knowledge and
  skills between different contexts and roles
  constitute a transition (Eccleston et al, 2005)
• Navigation of old and new identities
• implies reconstruction of identity narratives
  
• Role of learning in different kinds of transition
  Learning will more often flow from transitions
  and life events than cause them (ibid)

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Work-based learning

• Concerning the learner identity is integral
  (Wojecki, 2007)
• Constructing identity as work Learning
  implies becoming a different person and
  involves the construction of identity (Lave
  Wenger, 1991)
• What pedagogy fits with professionals identity
  narratives?

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Cox, K. (1992). What Surgeons Know. Australian
New Zealand Journal of Surgery, 62, 836-840

• One surgeons personal taxonomy of his clinical
  working knowledge covering a range of different
  kinds of knowledge and practical reasoning
  processes
• How do refugee surgeons translate these
  capabilities into a new setting?

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Empirical setting/methodology
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Research questions

• What (dis)continuities do refugee surgeons
  experience between induction into the profession
  in their home country the UK?
• What changes in professional practice are
  necessary for a refugee surgeon moving into UK
  practice?What has to be learnt/unlearnt?
• Who and what assist the learning process?

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Research questions, cont

• What is the significance of
• - mentoring?
• - work-place attachments?
• What are the barriers to the learning process?
• How does the experience of transition affect the
  refugee surgeons sense of professional and
  learning identities?

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Research paradigm

• Seeking meanings
• Social constructivist approach
• Case study/in-depth interviewing
• The tradition of medical narrative
• Greenhalgh Narrative-based medicine in an
  evidence-based world (1998)

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Case Study

• An empirical enquiry that investigates a
  contemporary phenomenon within its real-life
  context, especially when the boundaries between
  phenomenon and context are not clearly evident
• (Yin, 1994)
• Appropriate to
• the real world of clinical practice,
  involving intentions, meanings,
  intersubjectivity, values, personal knowledge and
  ethics
• (Miller Crabtree, 1998)

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Narrative professional judgement

• The irrevocably case-based (ie narrative-based)
  nature of clinical wisdom is precisely what
  enables us to contextualise and individualise the
  problem before us. Far from obviating the need
  for subjectivity in the clinical encounter, the
  valid application of empirical evidence requires
  a solid grounding in the narrative-based world.
  (Greenhalgh 1998)

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Research design

• Role of the researcher
• Ethical issues
• Sample
• Data sources
• Data collection analysis
• Validation
• Naturalistic generalisation
• Reporting

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Workshop questions

• How can the study be structured to be of most use
  to participants?
• Which aspects of the refugee surgeons experience
  of transition should be prioritised?
• Might the study be relevant to other groups in
  transition?