Using an action learning methodology to develop skills of health managers: experiences from KwaZulu-Natal, South Africa

Strong management skills at all levels have long been identified as key elements to improve performance of health systems, particularly in LMICs (WHO, 2009). However, many health managers are health professionals with no management experience prior to being offered a management position [1]. Effective management and strong leadership are associated with well-functioning facilities, and productive and motivated staff [2, 3]. For these reasons, it is essential that managers in the public health sector be equipped with skills to effectively perform their duties. In South Africa (SA), managers in the public health sector frequently lack skills and training to manage the daily challenges experienced in health facilities, and this has been cited as one of the reasons for poor service delivery in the public health sector [4].

Action learning is one approach that can be used to address the challenge of improving management skills. The ethos of action learning is to ‘take an attitude of enquiry’ based on the principle that experiences generate knowledge. Action learning seeks to facilitate skill development based on integration of knowledge gained from experience and knowledge gained by formal learning, underlined by critical reflection. Action learning is thus rooted in the theory and practice of adult learning [5]. This technique is well-established and has been widely used in several sectors. Action learning can be described as a continuous group-based process of engagement, learning and reflection where a group of peers meet regularly under the guidance of a trained facilitator over an extended time period. In these action learning groups, participants bring real problems to the discussion with the aim of generating innovative and creative ways of dealing with complex problems [6] and facilitating learning through the development of practical solutions that are implemented with planned intent [7]. Sessions are conducted in a socratic manner, such that participants discuss their problems in a constant back and forth questioning and answering process that elicits critical thinking, and dialogue that encourages generation of ideas and clarification of assumptions [6]. Moreover, the process of action learning encourages learners to reflect on and learn from their own experiences and those of their peers [6].

People learn more and better when learning takes place practically than when passively being provided with information [8, 9]. Action learning has been shown to be an effective method of learning and developing leadership skills particularly for senior level managers in developed countries [10]. This may be attributed to it’s less formal nature making it a practical and interactive approach that is directly related to the day-to-day problems that managers face [11]. Although the technique has been mainly used to develop the skills and competencies of senior managers, it is also used among other ranks [12]. Furthermore, although the method has been successfully used in the health sector [13, 14], it has also been implemented in other sectors such as construction [12, 15]. The action learning technique has been shown to improve confidence, resilience, conflict resolution, team work [16, 17], empowerment [18, 19], leadership skills [20], self-efficacy, critical thinking and problem solving skills [13]. All these skills are important for managers in general but more so for those who work in highly stressful environments such as the neonatal unit.

Health workers working in neonatal units in district hospitals work under extremely stressful conditions to care for critically ill infants. In the South African setting, this may be combined with daily challenges such as insufficient equipment and medication, poor transport to the referral centre, as well as shortage and burn-out of staff, making it difficult for middle management to critically develop ways of managing all the problems encountered. Neonatal units in district hospitals are run by generalist doctors and nurses, without any on-site paediatrician, and are often geographically isolated, far from specialist care. Managers of neonatal units are faced with day-to-day problems for which solutions are required. Therefore, it is important to assess whether action learning can be an effective method to improve managers’ skills to address their challenges. This paper evaluates an action learning intervention that was employed to develop the management skills among middle level health managers with direct responsibility for day-to-day management of neonatal units in district hospitals in KZN, South Africa.

A number of themes emerged from the interviews including: benefits gained from action learning within the context of their work; changes that occurred in their respective facilities as a result of implementing action plans; challenges they experienced; and recommendations on how the action learning sessions may be improved.

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.

This paper demonstrated that action learning is an effective and practical method for public health workers aiming to manage their health units despite the challenges they face. Health facilities require cadre with effective management skills for optimal service delivery in health care systems. Investing in training of middle managers to acquire necessary management skills is therefore inevitable and feasible, and accessible interventions need to be implemented to provide skills to this group of managers. Action learning could provide the solution but it requires allocation of administrative, logistical and financial resources in order for the process to yield positive outcomes for development of health workers and improvement of service delivery to public health care facility users.