Training and the dental team – or how to get the best from your staff

What sort of a workforce do you want?

The annual Gallup poll of employees has regularly identified some key issues which gives an interesting set of results (Table 1). The question is what can an employer do to try and encourage the staff to do their best and how can he/she help them to be more effective?

The key to being more effective lies in the culture of the practice. Edgar Schien, Professor at MIT School of Management, defined the culture of an organization as:

The key aspects of Professor Schien's definition are the words – learned basic assumptions – as the group solved problems that are then – taught to new members – of staff.

If the culture is one of fear, where staff are told what to do and when, they are likely to be reactive and only do things when they have to; as are the 50% in the Gallup survey just working hard enough not to get fired. On the other hand, if the culture is one of sharing, helping each other, where ideas are encouraged, then staff are more likely to be proactive in dealing with problems and thinking ahead; these are the 88% and 75% respondents in the survey.

There are several important aspects to developing an effective and proactive culture in any business or organization. But learning is fundamental to all of them. We cannot simply assume that current knowledge, however impeccable and well earned, will always be sufficient. Tomorrow's problems are unlikely to be solved using yesterday's understanding. The really sustainable source of competitive advantage (and, perhaps, even survival) lies in an organizational environment that encourages thinking ahead, curiosity, healthy levels of feedback and experimentation. Essentially, a passion for trying to think or do things differently.

Now, this requires learning and practice, but it also acknowledges the need to be able to make mistakes and learn from them. All too often we recruit smart people with the idea that they will ‘hit the ground running’. We provide incentives for doing what they already know how to do, and then we ask them to do it a bit faster (or more efficiently). This is considered a performance gain and, understandably, is looked upon with favour. We frown upon dips in performance.

Unfortunately, learning (to do things differently, more effectively, or in an entirely original way) is invariably accompanied by just that sort of dip in performance. It takes a heroic and keenly committed professional to risk credibility (let alone any bonuses) all in the name of trying something new ‘that just might work’.

Education is acquiring new, or modifying existing, knowledge, behaviours, skills, attitudes.

Training refers to the acquisition of knowledge, skills and competencies.

Learning is the habit of engaging with new knowledge, skills and experiences with the aim of changing one's behaviour or stance. It can be achieved through either of the previous methods, but it invariably requires the support and feedback of others.

The difference between the first two is more related to the outcome – training is usually concerned with achieving particular predictable and practical results (like a competency or requirement – meeting the HTM0105 standard for cross-infection control, for example).

What options for education and training are available for practices?

Formal training – courses, study days, meetings, structured learning. The proof of which may result in examinations, certificates and qualifications (Table 2).

Informal – this is where learning takes place, usually in short bursts associated with solving a particular problem, eg an experienced receptionist showing a new member of staff how to cash up the till at the end of the day. This type of learning tends to be unplanned and responds to events, but is highly effective, as the learner identifies a learning need and has it met soon after the event, and so it is likely to be implemented.

Informal is in many ways an opportunist form of learning, when a member of staff takes personal responsibility for resolving a query or dilemma. Its power lies in the almost arbitrary variety of possible enquiries – and of the learning generated. The key is to ensure that the practice has ways of capturing that learning and circulating it amongst other members of staff. All too often, individual insights are lost to the group because there is no mechanism for sharing them.

Learning can be either by solitary study or group/team learning. Solitary learning is effective for learning facts as one can test one's own progress. Group learning tends to be more effective for skills, behaviour and attitude learning as learners can share in the experience and views of other members of the group. There is also the potential benefit of having others (colleagues, managers, owners) to encourage and support the individual (perhaps even learning alongside them) as they make inevitable errors and mistakes en route to learning new skills.

Argyis and Schon1 suggested that people used one of two models to solve a problem. This provides us with a useful insight into why we sometimes learn the wrong things or keep repeating the same mistakes (Table 3).

In Model 1, a manager focuses on the problem and fixes the problem, the consequence of such action is then fed back to the action and may or may not solve the problem in the long term.

Model 2 focuses on understanding why the problem occurred in the first place and what the underlying issues were. The first model depends on feedback from the action to see if the problem is solved; this is known as a single feedback loop. Model two feedback from the results is to both the action taken and changes to the underlying cause – double loop feedback (Figure 1).

Action learning

This is where groups of people (eg a practice team) get together to discuss real issues at work and find solutions to try out solutions between meetings. The action learning set may need facilitation to get started, but anyone who is good at asking appropriate questions will do. The key is to get groups to explore the issues from different perspectives and to try to get ever closer to the underlying issues at the heart of a problem (Table 3: Model 2).

Action learning is useful in bringing about improvement in individual and organizational performance. Action learning is often a voluntary, individually-focused process to solve real and unresolved organizational problems in the workplace. It works because it generates (and relies on) the mutual support of the others in the team in an environment of trust and openness.

Reg Revans2 (and later Michael Marquardt3) developed a formula that describes the action learning process. It looks like this: L = P + Q + R, where Learning equals Programmed Instruction plus Questioning plus Reflection. Here, the meaning of programmed instruction represents the knowledge currently being used in the organization (or passed on in the form of training). It could be in books, in one's mind, or evident in the culture and practice of the organization. The important thing is that once the ‘Programming’ is recognized, then it can be challenged through a process that combines good old fashioned curiosity with determined questioning. Questioning means continuously seeking fresh insight into what is not yet known about why the system is not working and why the organization is not continuously learning. Reflection simply means rethinking, taking apart, putting together, making sense of facts, and attempting to understand the problem.

Following the use of the formula, action steps are planned and carried out with constant feedback and reflection as the implementation takes place. The spirit of inquiry does not stop at this point, but the use of the formula becomes embedded in the culture and continues as part of the solution.

How can learning and development best be achieved in practice?

There are two main routes:

Having key targets and direction of travel identified in the business plan should feed into annual staff appraisals where one can review the skills the staff have and identify what knowledge and skills are needed to deliver the plan. One can then discuss with staff how these can best be acquired, whether through formal or informal learning. We need to be imaginative here: courses are often necessary, but can be costly in both cash and resource terms. Learning in situ can be an effective alternative for some subjects, but it needs to be taken seriously. Action learning, for example, is very cost-effective, but it needs to be both relevant and carefully structured. Getting the means of learning right is as important as finding the right course or workshop.

The internet also provides an accessible, informal route to learning. It can be a useful support for individual learning and problem solving. Don't forget the value of other informal methods (Table 5).

Maximizing success

If one is keen to have effective learning and development, not only should it be planned, monitored and evaluated, but it must also be valued. This means that we have to be active in giving praise when things work well, seeking feedback from staff when they have been on courses, and working with them to apply new ideas and share new insights. Sharing of information can be a very powerful form of learning. Fundamentally, we need to be partners in enquiry: co-learners and challenging collaborators. We must seek out every opportunity to appreciate learning and to give constructive feedback. We must encourage people to be curious and to go beyond the first ‘right answer’. If people aren't making calculated mistakes (as opposed to careless ones), then they are unlikely to be taking enough risks to learn much of value. Learning is a habit, but it needs to be cultivated in an environment that nurtures and supports it.

Conclusion

There are many areas where the learning is common to all groups and the only difference may be the depth of knowledge. Many subjects could be covered in team learning activities in the practice (like a regular action learning set), or as part of a more formal course or workshop that the team could attend together.

Practices that have well planned training and development as an integral part of their business processes are more likely to succeed in delivering the quality of care they wish. They will have developed a kind of learning ‘culture’ that will anticipate changes in customer needs and wishes and will have the resilience and imagination to adapt. This will lead to good things, like higher levels of patient satisfaction, greater business success, happier and more motivated staff members and lower staff turnover rates.

The key to making all this happen is a clear and energetic commitment, on behalf of the owners and managers of the practice, to encourage everyone to learn. Sharing knowledge, encouraging curiosity, providing constructive feedback, valuing effort and seeking out diverse perspectives are the hallmarks of tomorrow's successful business.