akelly@rcseng.ac.uk

1. Institute of EducationResearchingMedical Learning & Practice16 November 07Crossing boundaries: how refugee surgeons learn to work in the NHS akelly@rcseng.ac.uk

2. 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

3. 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

4. One surgeon’s story: “you can’t 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

5. … continued • Glasgow bombs – pathologising refugees • Refugees’ contribution: different experience • Uprooting/families/networks • Professional identities – what happened to my colleagues • Stress – PTSS • “there’s no plan, there’s no pathway …”

6. The key question … … what pedagogy fits with Stefan’s story – and with other refugee surgeons learning to work in the NHS? …

7. A case study • Context • Theoretical field/literature • Empirical setting/methodology • Some questions

8. The context

9. 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

10. 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

11. 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

12. How Stefan’s story compares with the larger picture … • Refugee Doctors: support, development and integration in the NHSNeil 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

13. Effect of uncertainty on learning? • Maslow’s hierarchy: - physical needs/survival - security - social needs - recognition/success - self-actualisation/desire for self-fulfilment • Impact of high degree of self-motivation

14. The theoretical field/literature

15. 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

17. 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

18. 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)

19. 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?

20. Cox, K. (1992). What Surgeons Know. Australian & New Zealand Journal of Surgery, 62, 836-840 • One surgeon’s 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?

21. Empirical setting/methodology

22. 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?

23. 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 surgeon’s sense of professional and learning identities?

24. 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)

25. 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)

26. 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)

27. Research design • Role of the researcher • Ethical issues • Sample • Data sources • Data collection & analysis • Validation • “Naturalistic generalisation” • Reporting

28. Workshop questions • How can the study be structured to be of most use to participants? • Which aspects of the refugee surgeon’s experience of transition should be prioritised? • Might the study be relevant to other groups in transition?