Experiences of action learning groups for public health sector managers in rural KwaZulu-Natal , South Africa

Introduction: The World Health Organisation identifies strengthening leadership and management as an essential component in scaling up health services to reach the UN’s Millennium Development Goals. There is an identified need for informal, practically based management training programs, such as action learning, which allow trainees to reflect on their own work environment. Action learning, in essence, is learning by sharing real problems with others, as opposed to theoretical classroom learning. Methods: The objective of this study was to pilot an action learning group program with managers in a rural public health setting and to explore participants’ experience of the program. An eleven-month action learning group program was conducted for public health sector managers in a rural health district in northern KwaZulu-Natal. On conclusion of the action learning group program, a qualitative study using focus group discussions was conducted to explore participants’ experience of the action learning groups and their potential usefulness as a development opportunity. Results: Respondents’ commitment to the project was evident from the high attendance at group meetings (average of 95%). On conclusion of the program, all participants had presented a work related problem to their respective groups and all participants had developed an action plan, and provided feedback on their action plan. Ten participants were still actively working on their action plans and seven participants had completed their action plans. The main themes that emerged from the qualitative data were understandings of action learning; elements that enabled the program; perceived benefits; and reported changes over the course of


Background
Recent inquiries into health systems failures consistently point to the lack of management systems and processes.There have been no fewer than five high-level hospital inquiries in Australia since 2000 [1][2][3][4][5] .Reports published in the UK 6 , the USA 7 , New Zealand 8 and Canada 9 focused attention on the high incidence of errors and adverse events that impact on patient safety.Common themes run through many of the instances of major failure in these countries, including that health systems failures often happen in very dysfunctional organisations 10 .The pathology of failure is often organisational and concerns things such as organisational leadership, management structures and systems, organisational culture, interprofessional relationships and teamwork 11 .This suggests a need for more effective approaches to the development of management skills among health care managers 12 .
Strengthening leadership and management was also identified as a priority by the World Health Organisation (WHO) and as an essential component in scaling up health services to reach the Millennium Development Goals 13 .In 2007, WHO held an international consultation on leadership and management, involving participants from 26 countries, including South Africa.One output of the consultation was a framework to build leadership and management capacity in health 13 .The framework proposed a balance among four dimensions: (i) ensuring adequate numbers and deployment of managers throughout the health system; (ii) ensuring managers have appropriate competencies; (iii) the existence of functional critical support systems; and (iv) creating an enabling working environment 13 .
With regard to acquiring appropriate competencies, the WHO consultation found most management training was in the form of short, once-off training workshops and events 13 .The opportunity costs of this type of training are high in terms of managers being absent from their jobs, which is particularly problematic in under-resourced health settings 13 .For public health sector managers in rural areas, formal types of learning opportunities, such as attending educational or training courses, generally present challenges because of the distance between rural hospitals and academic institutions in cities.The hospital and individual need to overcome barriers such as transport, lack of funding and long periods of time away from their post.The WHO consultation concluded that traditional classroom-based learning is rarely adequate for acquiring competencies, and competencies need to be acquired through a variety of means, including coaching, mentoring and action learning 13 .A study conducted in Tonga, Uganda and South Africa made similar recommendations 14 .The researchers concluded there needs to be a balance between time spent in training courses and workshops and application of new competencies; that on-the-job support (including mentoring and learning networks) is key to improving performance; and there is potential to use a broader range of learning techniques beyond formal classroom training 14 .
With regard to the South African context, a survey was conducted in 2007 to ascertain skills and competency levels among private and public sector hospital managers in six of the nine provinces of South Africa.Despite public sector managers reporting they were significantly more likely to have attended formal training in health management, they rated themselves significantly lower than private sector managers, and generally rated themselves as 'reasonably competent, but not good' in all of the management competencies 15 .Public sector managers were also more likely than private sector managers to report they required further management development and training 15 .The study concluded that formal management programs in existence are either inappropriate or do not fully meet the needs of public sector managers, and there is a need for more informal training, based on an experiential approach, which may include mentoring and coaching, networking with colleagues and in-house programs 15 .This type of approach has benefits such as tailoring training to practices and issues relevant within the institution, exploring issues in a non-threatening environment, and increased acceptability and convenience to participants 15 .
A district management study, conducted by Health Systems Trust in 2008 in all nine provinces of South Africa, concluded that most provinces make use of a combination of training programs, from the more formal diploma-level course to the shorter once-off workshop which focus on a particular component of, or approach to, management 16 .Managers who took part in the study indicated a preference for short courses that are needs driven, participatory and aligned to work objectives 16 .The district management study recommended a mix of approaches for management development, including formal training, on the job training and action learning, but stated that action learning has high potential and merits further consideration as a strategy for management development in developing countries 16 .
With regard to competencies needing development, Pillay identified the skills and competencies that hospital managers perceive to be important for the effective management of health service organisations in South Africa 17 .Both public and private sector hospital managers felt people management and self-management skills are the most valuable 17 .People management skills include the ability to be a team player, work with people from different backgrounds, resolve conflicts, delegate tasks and share information 17 .

Action learning
Action learning is learning by sharing real problems with others, as opposed to theoretical classroom learning.Action learning is a process of reflecting on, and making sense of, past events and behaviours, so as to identify new ways of behaving 18 .Reflection is accomplished with the support of a small group of colleagues/peers (an action learning group).Individual group members each have the opportunity to present a real issue, task or problem relating to their work 19 .Others in the group help the individual to explore the challenge and identify a solution they can action in the workplace 20 .The presenter must commit to an action plan and is held responsible for its implementation.The presenter brings an account of the consequences of the action plan back to the group for shared reflection.There is an emphasis in the group on openness, support and a climate of trust 19 .
Action learning aims to help people take an active stance towards life and work, and one of its strengths is the emphasis it places on participants taking responsibility for their own learning 21 .This is in contrast to a traditional training session where the emphasis is on the transfer of knowledge from expert to learner, and the process is managed by the expert 21 .
Action learning has had a strong presence in the National Health Service in the UK, and was at the heart of the twoyear Transformational Change Programme that commenced in April 2003.An evaluation of the program found that participants saw the action learning groups as highly relevant to their development needs 22 .The approach has also been trialled with health care managers in Australia and participants reported higher levels of empowerment and selfefficacy because of the program 12 .
Despite previous studies recommending its use, action learning remains an under-utilised and, therefore, underresearched area in the South African public health context, and even more so in a rural public health setting.The objectives of the present study were to pilot an action learning group program with public health sector managers in a rural health district in KwaZulu-Natal, and to explore participants' experience of the program.This article reports on the participants' experience of the action learning group program.

Study setting
Action learning groups were established in one health district in northern KwaZulu-Natal.This district has seven hospitals and one community health centre, serves a population of approximately 840 000 people, and is approximately 80% rural.

The action learning groups
The Chief Executive Officer (CEO) and Human Resource Manager from each of the seven hospitals were invited to participate in the action learning groups, as well as the District Manager for Health, two representatives from Human Resources at the District Office, and the CEO and HR Manager of the Community Health Centre -a total of 19 possible participants.The CEO and Human Resources Manager of one of the seven hospitals chose not to participate but all other participants, 17 in total, accepted.An initial one-day workshop was held where researchers from the Centre for Rural Health (CRH) introduced participants to the methodology of action learning, and participants were divided into three groups.The three groups consisted of four, six and seven participants, respectively, and each comprised members from different institutions.Each group was assigned a facilitator from CRH.
The three groups (each with a facilitator) met regularly (approximately monthly) for 4-6 hours over a period of 11 months.For each group, meetings were held on a roundrobin basis at the institutions where the respective group members worked, with the CRH facilitators travelling from Durban each time.For all group meetings, the members sat in a circle rather than behind tables.In the first meeting with each group, participants had the opportunity to introduce themselves to the group by answering a set of four questions about themselves.Thereafter, individual group members took turns to present a real issue or problem relating to their work in their respective organisations.Generally, each meeting allowed time for one new presentation, as well as feedback on the issues presented at the previous meetings.A wide range of issues were presented, including a fire hazard at one hospital resulting from nurses cooking in their rooms because of a lack of kitchen amenities, and lack of accommodation for doctors at another institution.A number of participants presented very confidential issues related to interpersonal relationships with other managers and staff within their respective institutions.Data on attendance, which group member presented, and which group members provided feedback on action plans at each group meeting, were recorded and maintained by the facilitator of each group in a standardised spreadsheet form (Microsoft Excel 2000).

Study design
This cross-sectional study employed a qualitative design to explore fully the experience of participants in the action learning groups.Focus groups were utilised to collect data.

Participants
All 17 participants in the action learning groups were invited to participate in the focus groups, and all participants accepted the invitation.

Data collection
Written informed consent was obtained from study participants before conducting the focus groups.It was emphasised that participation was voluntary and that participants could withdraw at any time.The anonymity of participants was guaranteed, and they were assured that their information would be treated confidentially.
Three focus group discussions were conducted -one with each of the existing action learning groups.The focus groups were conducted on conclusion of the eleven-month action learning program.Participants were asked to share their experience of action learning and to reflect on its value.Each group discussion lasted approximately 2 hours and was digitally audio-recorded with the permission of participants.

Data analysis
The audio-recorded focus group discussions were transcribed verbatim.Thematic analysis was used as the primary analytic strategy.Thematic analysis means that material is searched for themes that emerge as being important to the description of the phenomenon, rather than being pre-decided by the researcher 23 .This process involves identification of themes through careful reading and re-reading of the data 24 .
Transcripts were coded by both researchers.After reading a transcript, the researchers collaboratively developed a codebook of themes around the main topics.The second transcript was then reviewed to add additional topic areas and themes that emerged.This process was repeated with the final transcript to arrive at a final coding scheme.Data were entered into NVIVO v8.0 (www.qsrinternational.com) and coded independently by the two researchers per the coding scheme.The researchers met regularly throughout the process to discuss coding, modifying the coding scheme and maintaining fidelity to the coding scheme, until consensus was reached.

Ethics approval
Ethical review was conducted by the Human and Social Sciences Ethics Committee of the University of KwaZulu-Natal.

Results
Respondents' commitment to the project was evident from the high attendance at group meetings -an average of 95% across the three groups.On conclusion of the program, all participants had presented a work-related problem, developed an action plan, and provided feedback on their action plan.Ten participants were still actively working on their action plans.This is due to two factors: first, the complexity of some of the action plans; second, some participants would only have presented their work-related problem towards the end of the program.By the end of the program, seven participants had completed their action plans.
The major themes that emerged from the qualitative data are discussed below, and enforced with quotations from the participants.

Understanding of action learning
Participants described what they understood action learning to be, including how that understanding had changed over the lifespan of the program.
Three participants initially expected the program to take the form of formal training or a workshop.

When I first heard about it, I was thinking of an ordinary workshop set-up; I was not thinking of it the way we did everything. (Focus Group 1)
There were clearly participants who were 'training fatigued'.Three participants admitted to being sceptical about the program, seeing it as yet more of the same, and something they did not have time for: I must say initially I did have reservations.I just thought not another program that we have to come and start.I was not positive initially.In my mind, I thought to myself I can't be part of this; I am too busy to be moving out and sitting in these sessions.(Focus Group 1) In contrast, some participants were positive from the outset.One participant immediately recognised the potential to learn something from interacting with more experienced managers.
With me, from the word go, I committed myself to the program.It is my first time to be involved in such a program and I looked at the people I am involved with, and they have been managers for quite some time.And from the word go, I knew I could learn from them.(Focus Group 3) After 11 months of meetings, the majority of participants saw action learning as being about teamwork.They recognised that managers 'cannot do it all alone -we need other people' (Focus Group 1), and that teamwork 'helps you to go where you want to go' (Focus Group 2).The action learning program awakened participants to the power of the collective: Previously we underestimated the power of working together as a group.I thought when we sat together as a group it would be a waste of time -it would take too long to come to a decision.But now I have seen that working as a group does wonders.(Focus Group 1) Participants also felt action learning is about capacitating one another.Group members bring different ideas on how to handle an issue.

We all come with different ideas on how to handle an issue. Maybe somebody will come with something that you did not think of. It does help a lot. (Focus Group 1)
All group members can also learn from the actions that other group members take.

You find that when a problem is presented, it is other people's problem as well, so you learn from it, and other people can learn from your activities and customise it to their own way of working. So, we are capacitating one another and we are sharing best practices. (Focus Group 1)
A number of participants commented that action learning is about realising 'you can solve your own problems, with the help of your colleagues', rather than always referring problems up the chain of command.This was experienced as empowering by the participants:

I began to realise I'm going to learn something new here. I'm going learn to solve problems on my own, or with my colleagues, or even by engaging the people back at work. I realised that if there is a challenge we have, or I am experiencing, I can now engage my colleagues and sit down, address the problem, and try different solutions until the problem is solved. So, this action learning is a good thing for us as managers of the Department of Health, and we are all surprised that we can, on our own, without involving the head office, without crying to the head office, we can solve our own problems. (Focus Group 3) Action learning was recognised as a new way of learning:
We are from the environment where you sit in a workshop and you expect somebody to give you the information.But the way the action learning was implemented was totally different.(Focus Group 2)

Elements that enabled the program
All participants commented on elements they felt were enablers of the program.The majority of respondents referred to the introductory exercise, and specifically being asked: tell us something unusual about yourself that we don't know, and that you are willing to share.In all three groups, participants shared very private feelings and experiences with their fellow group members.This sharing exercise was mentioned by the majority of participants as being vital to the formation of the group.

I think if we had not done that introductory exercise, we would have worked, but working without trust. (Focus Group 2)
Participants also mentioned the benefit of sitting in a circle at meetings.Taking participants out from behind the barrier of a desk had the effect of breaking down interpersonal barriers: The process had a very positive impact -starting from the way we are sitting in a circle.It broke down all the barriers between us.(Focus Group 1).
With sitting in a circle, there are no barriers here.We are free here; we talk freely, about everything.We start to grow as humans beings.(Focus Group 2).
Holding the meetings at the respective group members' institutions was clearly valued by the participants: It made us feel kind of at home, relaxed, no time wasted travelling, no costs.You can predict I will be here, you can plan around it.Our meetings were well planned and they were in our working environment, which put us at ease.(Focus Group 2) The CRH facilitator going to the participants' workplace also meant the facilitator saw for him/herself the reality and challenges of the participants' work settings, and could tailor his/her facilitation accordingly.

What also helped with the institutional visits by the facilitators, they tend to talk from a reality point of view. They have seen how our facilities are struggling and when a plan is put into place it is a realistic plan. (Focus Group 2)
Other elements seen as enablers for the program were: maintaining confidentiality -it was explicitly agreed at the beginning that what was said in the group stayed in the group; group members committing to being present at each meeting and always starting meetings on time; being taught the skill of writing an action plan; and being made to give feedback on their own action plan at each meeting which ensured participants took action in the interim and had something to report to the group.

Perceived benefits
The majority of participants felt their most important gain was the strong, supportive bond they formed with fellow group members.The group was seen more as a family than a working group, and participants expressed genuine affection for one another.

When we are in this group it is more than the colleagues or the co-worker; we have a family bond. (Focus Group 1)
Participants also saw their fellow group members as their first port of call for advice on problems that arise at work:

If you have a problem yourself, and when you wonder about other institutions, the first institution you think of is one of the ones in the group, and you wonder how they're coping with that problem. And you pick up the phone and ring them. (Focus Group 2)
A benefit that can't be underestimated is the enjoyment of being part of these groups that participants' reported.A number of participants reported how they 'always look forward to the meetings' (Focus Group 3).A number also described how comfortable they felt in their action learning group: In our session when we are participating I enjoy myself; I feel at home, and I am comfortable.(Focus Group 3) Because of the trust relationship that developed in the groups, participants felt free to open up to the group, to admit their weaknesses and to ask for help.At their place of work, these managers feel the need to appear in control, and tend not to ask for help, which can leave them feeling unsupported.

There are things that you cannot talk about to anyone. The environment needs to allow you to do it and you really must feel supported, and if you need help you should get that help.
This group is able do those things.I think all of us, as a group, we were able to expose our weakness, as well as whatever strengths we have.In other words, we are just ourselves.If I am not able to do something, I am able to say it outright -and say sorry I have a problem and I don't know where to start -without being afraid.At work, we've got teams.People are appointed to work with you, but usually the environment does not allow you to truly be yourself, because you are role-playing.In this group I'm not here as a manager; I am just here as a person with my issues.(Focus Group 3) Other benefits mentioned included the relief of being able to share their work-based problems: From the first day after my presentation I felt relieved, because I had shared my problem and I had got direction of how to go about it with the support of the group.I think it is the best thing that has ever happened to me in my work life.(Focus Group 2) Participants also mentioned the benefit of realising they all have the same problems, and of learning from each other's presentations.Three of the participants commented that the group also encouraged and motivated them to deliver on their action plans: And it [the group] encourages me to do the tasks that I promised them I would do; it makes me work hard in order to deliver.(Focus Group 3) Three participants commented that their involvement in the action learning groups has left them feeling more confident:

It made me feel confident in talking about my challenges and issues. I can now deal with day to day issues quicker and more effectively. (Focus Group 1)
All respondents commented explicitly on what they had learnt as a result of the program.The most frequently mentioned learnings were: the importance of trust and confidentiality; the importance of teamwork and support; the importance of consulting other people to find out how they deal with the same problems and issues; and the importance of writing an action plan, putting it into action and monitoring it to ensure you achieve your objectives.

Reported changes over the course of the program
All participants reported on what they were doing differently since their involvement in the action learning groups.Almost all reported they were making using of the principles of action learning in their place of work: I use the same approach that we have learnt in our action learning meetings; it is possible to cascade it to other projects in the institution.(Focus Group 2) Five participants mentioned that, back at their respective institutions, they are now more open with colleagues and coworkers about the problems and challenges they face: Now even back at our institution, outside of the group, we are more open.(Focus Group 1) Basically it teaches you how to share information.(Focus Group 1) Five participants mentioned they are now using teamwork more in their own institutions: I emphasise teamwork in my work place; whatever tasks we do we must work as a team.(Focus Group 1)

Discussion
The present study explored participants' experience of the action learning group program, and the potential usefulness of action learning groups as a development opportunity for managers in a rural public health setting.The 17 participants shared a comprehensive range of perspectives.From these shared perspectives, although the findings cannot be generalised, one may conclude with some confidence that action learning has the potential to serve as a learning and development opportunity for managers working in rural public health settings.
The action learning groups were seen as providing the participants with the opportunity to solve their own problems, which, according to the Health Systems Trust 16 and Pillay 17 , is a vital feature of health management training programs.The reported trust relationship that developed in the groups also allowed participants to explore their problems in a supportive, non-threatening environment.Facilitating the groups at the participants' place of work made the groups accessible and convenient to participants, which is particularly important for public health sector managers in the rural areas.Both a non-threatening environment and convenience were identified by Pillay 17 as important features of management training for hospital managers.
The participants expressed particular appreciation for the way they had learnt to be team players and to work together with people from different backgrounds.Both these aspects form part of the people management skills identified in Pillay's study as the most valuable skills needed for the efficient and effective management of hospitals 15 .When participants discussed what they had learned, the most commonly mentioned aspects were teamwork and support, the importance of trust and confidentiality, and the importance of consulting other people to find out how they deal with the same problems and issues.This valuing of others' perspectives was also evident in the study by Edmonstone and Davison in the UK's National Health Service 22 .
What was clearly of great importance to the participants was the strong supportive bond the respective groups formed.The value of this support network cannot be underestimated, as the participants in the current action learning groups operate in isolation in rural areas and do not have easy access to support and consultation from their immediate supervisors, or peers working at other institutions.As the managers in these groups all operate in the same geographically isolated, resource-poor settings, they could truly relate to the real work problems presented by other group members, and could offer insights relevant to the context.
A further benefit of action learning, which emerged in the present study, is providing participants with the tools to apply action learning principles to other challenges in their working lives -a benefit also mentioned by the participants in Edmonstone and Davison's study 22 .Their participants reported that the learning and development achieved was both specific to the problems raised and discussed, and generic and transferable to other situations.A number of participants in the current study stated they are using teamwork more in their place of work.Participants also felt they are exhibiting increased competence and confidence to discuss organisational issues in everyday working situationsanother of the people management skills identified as vital in Pillay's study 15 .Increased confidence was also reported by action learning group participants in Leggat's study 12

Limitations of the study
Although this research shows promising results, it is important to note the limitations of the study.First, it focused on one health district with a resulting small number of participants, thus raising questions around transferability.Like most qualitative research, however, this study does not make an attempt at achieving generalisability.While descriptive studies like this may not offer the highest level of evidence, they remain important in areas where there is little other research.Green and Thorogood state that in researching relatively under-researched topics, the issue of sensitising readers to new ways of thinking or participant experience is more salient than the issue of generalisability 25 .The transferability of the findings from this study will be enhanced when further comparative qualitative studies with public health managers in other districts are conducted.
It might also be regarded as a limitation that focus group discussions were conducted by CRH facilitators, although not the facilitators of the respective groups.The researchers felt, however, that having the focus groups conducted by facilitators with a solid understanding of action learning enhanced the depth of the discussions and findings.

Recommendations
Despite the above-mentioned limitations, this study has implications for rural public health settings and future research.We believe there is value in extending the use of action learning groups into other rural health districts to gain deeper insight into participants' experience of the methodology.Any possible rollout needs to be evaluated as to whether action learning is a relevant, cost-effective, sustainable learning opportunity for public sector managers in rural health settings.There is also a need to quantity the outcomes in leadership, management capacity and ultimately health delivery pre-and post-an action learning group intervention.Lastly, there is a need to compare the outcomes achieved by an action learning group intervention to those achieved by more traditional classroom-based learning, to determine whether it is a more viable development opportunity.

Conclusion
Action learning provides a practically-based learning opportunity, which allows managers to reflect on their own work environment.This study showed that the use of action learning groups may help managers resolve problems in their institutions, develop managers' skills of working within teams, and provide a vital form of support for managers.
Action learning may well be the key to improving the skills of managers in rural public health settings.
and that of Edmonstone and Davison 22 .Action learning was recognised by participants as being a different form of learning where, as stated by Bowerman and Peters 21 , the learner takes responsibility for their own learning, rather than the more formal chalk-and-talk or workshop training.Participants remarked on what they had learned because of the program and provided insight into what they are doing differently because of the program.