Adult learning and how it applies to clinical interactions

Advanced practice nurse and trainee coach, Anna Young draws on a theory of ‘double loop learning’ – exploring how shifting from telling a patient, to curious questioning, could potentially transform clinical interactions.

I recently came across Chris Argyris’s double loop learning theory and was struck about the implications of this within our clinical interactions on a day-to-day basis.

The premise of the theory is that so often we engage in single loop learning behaviours – we tell someone the reality of a situation and expect them to change behaviour/make a decision based on this.

We do it time and time again – in chronic disease management clinics, when visiting patients at home, when doing medication reviews – updating people on their hba1c result, the implications of not making behaviour changes, explaining effect of carbohydrates on blood sugars, not taking antihypertensives medication and risk of stroke etc, the list is endless.

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Sometimes it works – we have good connection, good conversation and the patient walks away feeling empowered and we feel good about that consultation. But what about when this doesn’t work? When it’s the ‘heart sink’ visit or patient on our list? We know that we have tried everything within our toolbox to explain to them what they need to do but they don’t seem to be listening.

It’s so easy, in this situation, to turn in on ourselves, and question our own competence or get frustrated with the other. But actually, what is happening here is that the cause-and-effect learning is not working, what we need to do is start to scratch under the surface, ask some more questions, approach this with a coaching mindset and be curious.

Curiosity opens the possibilities of different answers and different conversations. We have now entered the world of double loop learning!

Rather than giving information, we start to ask open questions to the patient and their family in a non-confrontational, curious way. Questions such as ‘I’m curious about what may be stopping you from taking your tablets’ or ‘what information would be useful to help you to understand your health condition’ to ‘can you tell me what else is happening at home’ and ‘what would you like to get out of this consultation/visit today’.

By doing this, the learning process is reframed and the responsibility for engagement is handed back to the patient, it invites the other person to be a partner in their health.

These curious questions allow the patient to have ownership of their own health and wellbeing. Rather than ‘being done to’ they are partnering with us. They have the opportunity to come up with their own solutions or behaviour changes, and we become collaborators with them – providing the evidence base or signposting them to additional resources for THEIR journey.

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This journey is on their time scale though. Some people are ready to change very quickly (these are probably the ones who responded to your single loop learning) but for many others, there are a lot of small micro changes that need to happen before they are ready to engage at the level we hope they will.

But by opening up this double loop learning, we are indicating that we are here for the long haul and are applying trust and equal value to their own thoughts and opinions as to the ones we have (and are hard won through study). This doesn’t mean we can’t challenge incorrect behaviours and assumptions, but we do so through questioning and offering different perspectives – it’s a subtle, but powerful difference.

In this current climate of staff shortages and huge pressure on consultation/visit times, opening up a coaching conversation can free up space by empowering the patient to take responsibility for their own health and wellbeing with us as guides.

Anna Young is an advanced practice nurse in primary care, as well as South Yorkshire non-medical prescribing/independent prescribing development lead for primary care and an advance practice training programme director for primary care at NHS England’s Regional faculty of Advancing Practice. Ms Young is also a Professional Nursing Committee member for the Royal College of Nursing.

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