Our findings suggest that action learning can be implemented successfully among middle-level health managers in challenging resource-limited settings, benefiting the individual health worker and our findings suggest that this may have led to improvements in the daily functioning of the neonatal units. Health workers are trained to be competent clinicians, and not managers, so development of management skills is crucial when they take up management positions. Action learning participants reported that they felt empowered as a result of participating in the intervention, and that they gained practical skills to tackle their duties within the workplace. Action learning also helped to cultivate collegial relationships among the participants, who continued to seek advice and assistance from their colleagues after the groups had ended.
Action learning implementation is embedded in a cultural and social context, which determines how it is practiced. The origins of action learning lie in western developed countries, and it is strongly based on Western ideas and assumptions. Although action learning has been implemented in a wide variety of diverse cultural settings, there could be concern about adapting this approach to an African setting with a very different pedagogical tradition. In particular, action learning techniques of challenging participants may be threatening in a context where this is not common practice. This study suggested that trust was an important element of success, which took time to build, but otherwise this approach was well received and accepted, and could be more in line with traditional community based approaches to learning [25].
One of the underlying principles of action learning is that groups should be closed, that is, participants remain the same throughout the process, and discussions conducted in groups should be confidential. Therefore, participants need to be committed to the process by attending all meetings. All these aspects contributed to the development of a trusting environment. Such an environment is required to allow discussion of sensitive aspects of a problem, like conflict with colleagues in the workplace and allows group members to challenge each other. The same sorts of trusting relationships may not be easy to achieve using other approaches, particularly in our context where colleagues frequently work in close-knit, isolated communities, making it challenging to ask for advice or to reveal a lack of skills to direct colleagues. Action learning promotes peer learning between members which can be a powerful and accessible tool. Similarly, Leggatt et al. (2011) also found that a psychologically safe environment is key to enabling participants to freely voice their thoughts in the action learning group.
Additionally, our findings indicated that action learning created a support network for participants such that they built relationships that encouraged peer learning [26], maintained contact and continued to support and advise one another beyond the problems addressed in the group meetings. To the authors’ knowledge, this is a new and interesting finding within the realm of action learning and shows that this method is effective and may be sustainable with participants from different geographical settings. Although one of the requirements for a functional action learning group is to have a trained facilitator, sustainability could be achieved as the group becomes more familiar and confident with the action learning process so that they take over the facilitation of the group themselves. In this way, this type of learning promotes self-direction and independence rather than reliance on experts that are percieved as more knowledgeable [27].
Another critical finding from this study is that participants expressed that participation in the action learning groups gave them a sense of empowerment to tackle challenges. Health workers further developed a sense of resilience and problem-solving as a result of many critical problems that were resolved.
Action learning takes on a socratic approach which involves an iterative and reflective process of one’s challenges and the possible solutions. By employing this method, action learning allowed the participants to think critically about issues and come up with solutions on their own. These are generic skills that can be applied to any work situation and can be anticipated not only to lead to changes in the work place during implementation of the action learning groups but to provide skills that will promote personal development of participants, allowing them to be more effective beyond the lifetime of the group.
For any skills development intervention to be successful, particularly when participants are working in isolated areas, considerable time and resources have to be spent, and using action learning as a method to develop skills for health managers is no different. Furthermore, the development of management competencies is complex but the action learning approach may provide immediate benefits in terms of addressing practical workplace challenges. However, actions could be taken to reduce costs, for example meetings could be held at internal venues and conducted at the same time as other routine district management meetings. Using action learning more broadly could allow for different cadres of health workers to use the method, and for the method to be used as a generic process that can be applied to resolving various challenges within the health system. Action learning faciltators could be trained among Department of Health staff but would have to be carefully selected to maintain the trusting relationships within the action learning groups. Implementation of action learning could contribute towards shifting some of the practices and perceptions related to training programmes so that these are considered an integral part of health workers’ jobs rather than being regarded as external, unnecessary and time-consuming activities.
Participants expressed lack of support from senior management as one of the challenges they encountered with regards to attendance of sessions, especially during the initial stages of the intervention. Participants also stated that they needed the support of their managers for the problems identified during action learning to be resolved. SA Nelson and RK Yeo [12] state that ‘the success of action learning programmes will depend heavily on senior management support and the preparedness to commit to longer term learning programmes rather than two-day “sheep dip” training sessions, which accomplish very little at great expense’ (p. 305). This is essential if quality of care is to be improved in such a way that staff are competent and have the support required to provide good standards of care.
Orientation of senior management to action learning as a skills-development tool ahead of implementation could address many concerns that senior managers may have regarding action learning and resolve some of the logistical barriers identified, like obtaining permission to attend the action learning sessions. An additional role for action learning facilitators, if trained within the Department of Health, to improve success and sustainability could be to establish the principles of action learning in each site, improve linkages and communication with senior managers, and advocate for support for action learning at all levels of the health system. Additionally, this could be used as an opportunity to advocate for senior managers to use action learning themselves especially considering its successful use among this group of managers [9]. Furthermore, a reporting tool could be developed in order to track participants’ progress and for senior management to have a good sense of action learning outcomes.
Limitations
Our study attempted to illustrate how action learning can be used as a method to develop skills among middle managers in resource-limited health facilities. The results of our study are not intended to be generalizable, however through rich accounts, they provide important insights into the outcomes of action learning in our context. Our intervention had limitations in terms of sustainability because it was conducted by external facilitators at venues that were provided. Further research could look at ways of improving sustainability by increasing involvement of senior managers, using internal Department of Health facilitators and promoting the eventual independence of the action learning groups.