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Cited by 39Innovative Education and Learning PracticesInnovations in Medical EducationHealth and Medical Education

Cultural Historical Activity Theory for Studying Practice-Based Learning and Change in Medical Education

Open access
Qureshi, Shaun Peter·2021·Advances in Medical Education and Practice
DOI 10.2147/amep.s313250PMC PMC8390886
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Abstract

Cultural historical activity theory (CHAT) is a social theory which is useful as a methodological framework for the vital task of studying practice-based learning in complex learning environments. CHAT is an apparatus considering learning as occurring through practice, through collective activity, and mediated by culturally specific instruments. Because CHAT is increasingly drawn upon in medical education academia, it is necessary for medical educationalists to be familiar with this theory. This methodology article explains how CHAT theorizes learning in dynamic workplaces within an activity system comprising multiple practitioners engaged in activity, which is collaborative, multi-voiced, and bounded by a shared intended object. It provides an accessible overview of the central concepts within CHAT and a description of a methodological strategy (activity system analysis) to incorporate CHAT into one's own work. CHAT also theorizes where tensions lie within and between activity systems, causing difficulties in achieving the intended object, defining such tensions as contradictions. It is through the overcoming of past contradictions that activity has come to exist in its current form, abiding by social norms of the present time, and CHAT allows consideration of how practice within a system may be changed through resolution of contradictions. For example, the Change Laboratory is a contrived intervention where practitioners consciously contribute to developing and embedding new, improved ways of practicing using CHAT principles. This allows practitioners to have agency in improving their own areas of learning and practice. Throughout this article, examples are provided of how CHAT has been usefully applied to various aspects of medical education research, including undergraduate education, postgraduate education, and continuous professional development. By building on the introduction to CHAT provided in this article, the reader can start to use CHAT methodologically to describe complexity, identify practice-based contradictions, and develop improved forms of practice-based learning, in his/her own context.

AI snapshot

Written from the paper’s full text.

TL;DR

This methodology article provides an accessible introduction to cultural historical activity theory (CHAT) as a framework for studying practice-based learning and change in complex medical education workplaces. It explains central CHAT concepts, describes activity systems analysis as a practical method, and illustrates how CHAT has been applied across undergraduate, postgraduate, and continuing professional development contexts.

Key findings

  • CHAT conceptualizes learning and practice as inseparable, occurring through collective, object-oriented activity mediated by culturally specific instruments; the activity system is the basic unit of analysis, comprising a subject aiming to bring about an object.
  • Contradictions (classified as primary, secondary, tertiary, and quaternary) are tensions within and between activity systems that block achievement of the intended object and are the main driver of development; overcoming them constitutes expansive learning.
  • Engeström's expansive cycles are described as having seven typical steps: questioning, analyzing, modelling, examining the model, implementing the model, reflecting/evaluating, and consolidating outcomes.
  • The Change Laboratory is presented as a formative intervention; cited examples include a Danish pediatric department using six reflective meetings with doctors, and UK Change Laboratories with three hospital teams for student assistantships and in obstetrics and gynaecology training.

Methods

  • Design: a methodology/conceptual article, not an empirical study; it aims to explain CHAT and its use as a theoretical framework in medical education research.
  • Content: describes CHAT's place among socio-cultural and socio-material theories, defines key terms (Table 1), and presents activity systems analysis (ASA), including the Eight-Step-Model (Table 2) for mapping data to activity system components.
  • Illustrations: draws on published medical education studies (eg, Cleland et al's surgical boot camp ethnography, Lingard et al's transplant department study, Archer et al's three-year GMC-commissioned revalidation investigation, de Feijter et al, Klitgaard et al) and the author's own doctoral research on newly qualified doctors caring for patients approaching the end of life.

Limitations

  • Stated: CHAT is complex and gaining proficiency may be off-putting; researching practice-based learning requires workplace data with ethical and practical challenges, including power imbalances between participants and researcher (especially with students and doctors in hierarchies), balancing researcher immersion against patient confidentiality and disruption to care, and logistical/organizational confidentiality issues in accessing historical documents; the work is time consuming and requires careful governance and ethical approvals.
  • Stated: CHAT has faced criticism for privileging the social over the individual, and critics state it only considers learning as part of group practice; the author suggests incorporating another cognitive-based framework to explore individual learning and reflexivity.
  • Evident from the text: the article is explicitly "not intended to be exhaustive" and offers an overview rather than a systematic review; the empirical illustration (Figure 4) is from the author's own doctoral data, with further details and results stated to be published elsewhere.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2147/amep.s313250

Cites

31 of 31 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 93 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Applying CHAT as a framework allowed the author to identify factors involved in a newly graduated doctor's workplace practice in enacting care for patients approaching the end of life, including tangible instruments, intangible instruments, rules and division of labour.

    “applying CHAT as a framework allowed me to identify factors involved in this doctor’s workplace practice in enacting this role, for example, tangible instruments (eg, documentation), intangible instruments (eg, awareness of the patient’s age), rules (eg, FY1s should know the limits of their competency), division of labour (eg, FY1 must first assess sick patients before calling for senior input).48”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] Qureshi SP. Explaining how medical doctors learn about and understand the approach to the end-of-life in the workplace; 2020.

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  • Interpretationcitation

    These studies exemplify how CHAT is a suitable theory for studying complex learning and workplace environments.

    “These studies exemplify how CHAT is a suitable theory for studying complex learning and workplace environments, as it views work as constantly changing mix of actors over long periods of time, and widely distributed in space.7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] 1987

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  • Premisecitation

    Practice is learned by practicing.

    “practice is learned by practicing.18,19”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [18] Dornan, 2012, Perspect Med Educ source

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    • cites [19] Kahlke, 2019, Med Educ source

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  • Premisereasoning

    Contradictions in activity systems provide barriers to practice and learning.

    “Contradictions in activity systems provide barriers to practice and learning.”
    Quote in the paperSubstantial claim
  • Premisecitation

    Socio-cultural perspectives view workplaces as environments where there is no separation between participation in work and learning.

    “Socio-cultural perspectives differ by viewing workplaces not only as environments where people can learn but indeed where there is no separation between participation in work and learning:17 practice is learned by practicing.18,19”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] 2008

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  • Classified as probably not a substantial claim. 54
  • May combine two claims. 35

  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning

    CHAT emphasises that many social voices are in dialogue with one another (multi-voicedness), and each part of the activity system influences the others.

    “CHAT emphasises that many social voices are in dialogue with one another (multi-voicedness), and each part of the activity system influences the others.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    One learns to be a doctor through entering the workplace, through interactions with others, and by taking on the role of the doctor.

    “It is through entering the workplace, through interactions with others, and by taking on the role of the doctor, that one learns to be a doctor.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    If contradictions are severe, the activity may collapse, and the subject may not be able to attain the object which is meant to be directing the activity.

    “If contradictions are severe, the activity may collapse, and the subject may not be able to attain the object which is meant to be directing the activity.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] 2010

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  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    In CHAT terms, there is no distinction between learning and doing.

    “Medical educators are likely to be interested in individual human learners in the workplace environment, and, in CHAT terms, there is no distinction between learning and doing.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The hospital workplace is recognised as an important site of learning for medical students and doctors.

    “For example, for the learners in medical education contexts (medical students and doctors) the hospital workplace is recognised as an important site of learning.10”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] 2015

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Neglecting materials may put patient safety at risk.

    “This is relevant to medical practice where a variety of tools inform medical practice and design23 and neglecting materials may put patient safety at risk.24”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Bleakley, 2012, Med Teach source

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  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    CHAT allows consideration of how and why an activity system occurs in its current form, and how it may be changed in the future to overcome tensions within the system.

    “Furthermore, CHAT allows consideration of how and why an activity system occurs in its current form, and how it may be changed in the future to overcome tensions within the system, as described below.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CHAT embraces the concept of distributed learning, i.e., knowledge construction through interactions between living beings.

    “As such, it embraces the concept of distributed learning ie knowledge construction through interactions between living beings.14,15”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [14] Fenwick, 2010, Eur J Res Educ Learn Adults source

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    • cites [15] Liljedahl, 2018, Perspect Med Educ source

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    Premisecitation

    Rules, community, and division of labour are heavily shaped by cultural expectations, which are different at different times in history.

    “Rules, community, and division of labour are heavily shaped by cultural expectations, which are different at different times in history.7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] 1987

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  • May combine two claims.

    Premisereasoning

    CHAT does not assume the dualist (mind v. body) view assumed in acquisitive perspectives of learning, and instead views professional learning as participational, without a disparity between knowing and doing.

    “It does not assume the dualist (mind v. body) view assumed in acquisitive perspectives of learning, and instead views professional learning as participational, without a disparity between “knowing” and “doing”.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisereasoning

    Knowledge is practical, embodied, and social: it does not only exist in the mind as a thing to be transmitted from one person to the next.

    “Knowledge is practical, embodied, and social: it does not only exist in the mind as a thing to be transmitted from one person to the next.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Contradictions must lead to change and so are the main cause for development in activity systems.

    “Contradictions therefore must lead to change and so are the main cause for development in activity systems.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Within CHAT, the activity cannot be understood only by looking at its individual constituent parts.

    “Within CHAT, the activity cannot be understood only by looking at its individual constituent parts.29”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [29] 2014

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    People learn through activity and through working collaboratively.

    “It is through activity and through working collaboratively that people learn.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    CHAT considers the individual and environment together, and postulates that human consciousness is co-created through participation in activity.

    “CHAT considers the individual and environment together, and postulates that human consciousness is co-created through participation in activity.9,26”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [9] 2010

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    • cites [26] 1978

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  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisecitation

    Knowledge is not a body of knowledge but an activity that is both individual and collective.

    “Socio-cultural and socio-material theories align with Gheradi’s25 description of “knowing-in-practice”: knowledge is not a body of knowledge but an activity that is both individual and collective.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] 2012

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  • Classified as probably not a substantial claim.

    Premisenone given

    Within the activity system, knowledge is co-constructed between the learner and their social world.

    “Within the activity system, knowledge is co-constructed between the learner and their social world.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    CHAT is a socio-cultural and socio-material theory.

    “CHAT is a socio-cultural and socio-material theory.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    When tensions occur, the community is not integrated and working harmoniously, and there are multiple conflicts.

    “When tensions occur, the community is not integrated and working harmoniously, and there are multiple conflicts.8”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] 2012

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    Premisecitation

    In the British system, the doctor graduates from medical school and becomes a postgraduate trainee, working and learning simultaneously.

    “In the example of the British system, the doctor graduates from medical school and becomes a postgraduate trainee, working and learning simultaneously.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] British Medical Association. Medical Training Pathway [Internet]; 2020. Available from: https://www.bma.org.uk/advice-and-support/studying-medicine/becoming-a-doctor/medical-training-pathway. Accessed May 15, 2021.

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The importance of making theory explicit in medical education research is recognised.

    “The importance of making theory explicit in medical education research is therefore recognised.11–13”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [11] Rees, 2010, Med Educ source

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    • cites [12] Sandelowski, 1993, Res Nurs Health source

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    • cites [13] 2014

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  • Classified as probably not a substantial claim.

    Premisecitation

    Within CHAT, the subject of activity does not act directly on their environment, but always indirectly through action mediated by instruments, which may be tangible or intangible and have culturally specific meanings.

    “Within CHAT, the subject (individuals, groups or organizations) of the activity does not act directly on their environment, but always indirectly in some way, through action which is mediated by the use of instruments, which may be tangible or intangible, and have culturally specific meanings.8,9”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] 2012

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    • cites [9] 2010

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    Premisecitation

    Medical training and practice occur within healthcare organizations that are undergoing constant change.

    “Medical training and practice occur within healthcare organizations which are undergoing constant change.1,2”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] Lingard, 2012, Med Educ source

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    • cites [2] Reid, 2015, Adv Heal Sci Educ source

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    CHAT considers the fundamental unit of life to be activity, which is collective and requires communication and interaction between practitioners.

    “CHAT considers the fundamental unit of life to be activity, which is collective and requires communication and interaction between practitioners.6,7”
    • Also stated in: § Learning Through Activity · plain
      “Within CHAT, learning and development occur through practice, and the fundamental unit of the life of an organism is not individual behaviour, but activity which is collective and requires communication and interaction between people.6”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [6] 1999

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    • cites [7] 1987

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    Premisecitation

    CHAT is attracting increasing interest in medical education for studying dynamic systems in change.

    “Cultural historical activity theory (CHAT) is a social theory for studying social practice, and is attracting increasing interest in medical education for studying dynamic systems in change.3–5”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [3] Larson, 2019, Acad Med source

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    • cites [4] Engeström, 2021, Med Teach source

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    • cites [5] Morris, 2021, Med Teach source

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  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisereasoning

    Socio-materiality differs from and complements socio-cultural theory: understanding the relationship between individuals and the social world is important for understanding learning, but this also includes the vital role of matter and the material in how entities relate to each other and learn.

    “Socio-materiality differs from and complements socio-cultural theory: understanding the relationship between individuals and the social world is important for understanding learning, but this also includes the vital role of matter and the material in how entities relate to each other and learn.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Work is not the application of acquired knowledge, but through work knowledge is used as a resource in the production of further knowledge.

    “Work is not the application of acquired knowledge, but through work knowledge is used as a resource in the production of further knowledge.25”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] 2012

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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    The theoretical stance of the researcher influences all aspects of the conduct of research and what the researcher believes is possible to achieve through research.

    “The theoretical stance of the researcher will influence all aspects of the conduct of research, and, more fundamentally, what the researcher believes is possible to achieve through research.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The purpose of CHAT is not simply to display practice in an activity system, but to understand where conflicts and tensions lie as a basis for improved forms of activity.

    “The purpose of CHAT is not simply to display practice in an activity system, but to understand where conflicts and tensions lie as a basis for improved forms of activity.7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] 1987

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    Premisecitation

    In the future there will be further evolutions to systems through discovering new ways of doing things, coming from currently un-thought space.

    “In the future, there will be further evolutions to systems through discovering new ways of doing things, coming from currently un-thought space.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] 2014

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    Premisecitation

    Dynamic research is required to progress, mediate, record and analyze cycles of expansive change.

    “Engeström identified that dynamic research is required to progress, mediate, record and analyze cycles of expansive change.7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] 1987

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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    To adopt ASA usefully without the process becoming overwhelming, it is necessary to focus on and present only the most salient and essential aspects of activity systems.

    “In order to adopt ASA usefully, and so that the process does not become overwhelming, it is necessary to focus on and present only the most salient and essential aspects of activity systems.9”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] 2010

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Yamagata-Lynch provides a practical and accessible description of the method for analysing data using CHAT to study complex learning environments: activity systems analysis (ASA).

    “Yamagata-Lynch9 provides a practical and accessible description of the method for analysing data using CHAT to study complex learning environments: activity systems analysis (ASA).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] 2010

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    ASA allows the researcher to map data from their area of study to the components of the activity system and express complex practice in CHAT terms.

    “ASA allows the researcher to map data from their area of study to the components of the activity system, and express complex practice in CHAT terms.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Complex healthcare environments inevitably experience challenge, including tensions in providing quality education and meeting service demands for adequate patient care, and the need to adapt to emergent challenges.

    “Such complex environments inevitably experience challenge, including tensions in providing quality education and meeting the service demands for adequate patient care, and the need to adapt to emergent challenges.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Through the learning process, learners begin to question why things are done the ways they are (externalization).

    “Furthermore, through this learning process, learners will also begin to question why things are done the ways they are (externalization).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Researchers facilitated practitioner-led change laboratories which developed new ways of working to improve the training experience and lead to safer patient care.

    “Researchers facilitated practitioner-led change laboratories which developed new ways of working to improve the training experience and lead to safer patient care.5,42,43”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [5] Morris, 2021, Med Teach source

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    • cites [42] Royal College of Obstetrics and Gynaecology. Obstetrics and gynaecology workforce Report 2017 [Internet]; 2017. Available from: https://www.rcog.org.uk/globalassets/documents/careers-and-training/workplace-and-workforce-issues/rcog-og-workforce-report-2017.pdf. Accessed March 28, 2021.

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    • cites [43] Royal College of Obstetricians and Gynaecologists. Improving workplace cultures and behaviours [Internet]; 2020. Available from: https://www.rcog.org.uk/en/careers-training/workplace-workforce-issues/supporting-our-doctors/culture-behaviours/. Accessed February 2, 2021.

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  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    By incorporating CHAT, researchers can describe complexity and identify contradictions in the system which cause the activity to suffer and cause the desired object to not be achieved.

    “By incorporating CHAT, researchers can describe complexity and identify contradictions in the system which cause the activity to suffer and cause the desired object to not be achieved.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Theory can be employed in research in a variety of ways and may be explicit or implicit.

    “Theory – propositions which are logically aligned and are used to explain the relation(s) between different constructs44 – can be employed in research in a variety of ways and may be explicit or implicit.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Sandelowski, 1993, Res Nurs Health source

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    Interpretationnone given

    Practitioner-researchers can gain insights into the inner workings of a system; components of an activity system such as mediating instruments, rules and division of labour are likely to be more apparent to and better understood by someone working in that environment than by an outsider.

    “As a practitioner-research, insights can be gained into the inner workings of a system, eg, necessary components of an activity system like the mediating instruments, the rules, and the division of labour are likely to be more apparent to and well understood by someone working in that environment compared to an outsider.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    CHAT may be particularly helpful for practitioner-researchers, i.e. practitioners conducting research within their own field of practice.

    “CHAT may be particularly helpful for practitioner-researchers5 ie, practitioners who are conducting research within their own field of practice.45”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Morris, 2021, Med Teach source

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    • cites [45] 2002

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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    It may be challenging for a researcher to begin working with CHAT.

    “It may be challenging for a researcher to begin working with CHAT.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Theory can help researchers increase understanding of phenomena under study.

    “Theory can help researchers increase understanding of phenomena under study.31”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Gormley, 2020, Adv Simul source

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  • Classified as probably not a substantial claim.

    Premisecitation

    Expansive learning involves changing entire activity systems or fields of activity.

    “Expansive learning therefore involves changing entire activity systems or fields of activity.7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] 1987

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Activity systems occur in their present form because of historicity: past events that have influenced them and how past contradictions have been overcome.

    “Activity systems occur in their present form because of historicity: past events which have influenced them to do so, and how past contradictions have been overcome.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Newly graduated doctors entering the hospital workplace experience four key 'struggles'.

    “Using thematic analysis, these researchers identified four key ‘struggles’ which newly graduated doctors experience when entering the hospital workplace”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Klitgaard et al35

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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    In the busy hospital workplace with several interacting workers carrying out multiple actions, the system is complex.

    “Clearly, in the busy workplace of the hospital with several interacting workers carrying out multiple actions, the system is complex.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    CHAT is a socio-cultural and socio-material theory which can be used to describe activity in a collaborative, dynamic environment with multiple voices, where the entire activity is bounded by a shared intended object.

    “CHAT is a socio-cultural and socio-material theory which can be used to describe activity in a collaborative, dynamic environment with multiple voices, where the entire activity is bounded by a shared intended object.7,9,10”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [7] 1987

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    • cites [9] 2010

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    • cites [10] 2015

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Yamagata-Lynch advocates for ASA to allow users to convey the essence of complex data in a model that can be communicated with others.

    “Yamagata-Lynch advocates for ASA to allow users to convey the essence of complex data in a model that can be communicated with others.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] 2010

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  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The purpose of studying workplace practice using CHAT is to identify where the contradictions lie and how they may be overcome to lead to expansive learning.

    “Ultimately, the purpose of studying workplace practice using CHAT is to identify where the contradictions lie and how they may be overcome to lead to expansive learning.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Using change laboratories with three hospital teams, Reid et al facilitated professionals in identifying cultural and historical influences on current practice and developing a new structure of practice so that final year medical students could take on more active clinical roles.

    “Utilizing change laboratories with three hospital teams, Reid et al2 facilitated professionals in identifying cultural and historical influences on current practice, and developing a new structure of practice so that final year medical students could take on more active clinical roles.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Reid, 2015, Adv Heal Sci Educ source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationown data

    Applying CHAT as a framework allowed the author to analyze and present the complexity of this area of practice.

    “This approach allowed me to analyze and present the complexity of this area of practice.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Healthcare organizations are dynamic workplaces comprised of multiple people with different perspectives, interacting with one another and with non-human tools to carry out their work and to learn.

    “Healthcare organizations are dynamic workplaces comprised of multiple people with different perspectives, interacting with one another and with non-human tools to carry out their work and to learn.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In Denmark, researchers used the Change Laboratory to develop innovative change in a pediatric department and new ways of learning and practice, conceptualizing the conflict between learning and patient care as two contradicting activity systems.

    “In Denmark, researchers utilized the Change Laboratory to develop innovative change in a pediatric department and develop new ways of learning and practice. The conflict between learning and patient care were conceptualized as two activity systems contradicting each other.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Skipper, 2016, BMC Med Educ source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    CHAT is useful for considering where tensions lie in a system of practice.

    “CHAT is useful for considering where tensions lie in a system of practice.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Generating change is challenging and may require multiple small cycles of innovation, during which changes are evaluated and refined.

    “Generating change is challenging, and may require multiple small cycles of innovation, during which changes are evaluated and refined.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    Over time, learners identify where the contradictions exist in their activity, and by reflecting on these contradictions, expansive learning (developmental changes in activity systems) may occur.

    “Over time, learners identify where the contradictions exist in their activity. By reflecting on these contradictions, expansive learning may occur ie developmental changes in activity systems.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Consideration of power imbalances between participants and researcher is especially important when researching medical students and doctors, who already may be operating within a hierarchical structure.

    “Like all research, there must be consideration of power imbalances between the participants and researcher, and this is especially important when researching medical students and doctors, who already may be operating within a hierarchical structure.46,49”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [46] Qureshi, 2019, Adv Med Educ Pract source

      Not checked in the free run.

    • cites [49] Lempp, 2004, BMJ source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    To explore individual learning and reflexivity, it is likely to be more appropriate to incorporate another framework with a cognitive basis.

    “To explore individual learning and reflexivity, it is likely to be more appropriate to incorporate another framework with a cognitive basis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These factors mean the research is time consuming and requires careful planning and dialogue with organizations to reach a satisfactory research agreement involving local governance and ethical approvals.

    “These factors will mean that the research is time consuming, and will require careful planning and dialogue with organizations to reach a satisfactory research agreement involving local governance and ethical approvals.50–53”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [50] Perlman, 2000, Paediatr Child Health (Oxford) source

      Not checked in the free run.

    • cites [51] 2020

      Not checked in the free run.

    • cites [52] 2020

      Not checked in the free run.

    • cites [53] NHS Health Research Authority. Planning and improving research. NHS Health Research Authority; 2018. Available from: https://www.hra.nhs.uk/planning-and-improving-research/. Accessed May 16, 2019.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Workplace learning theories differ in how they incorporate the role of individual agency, and CHAT has faced the criticism of privileging the social over the individual.

    “Additionally, workplace learning theories differ in how they incorporate the role of individual agency54 and CHAT has faced the criticism of privileging the social over the individual.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [54] Sukhera, 2018, Adv Heal Sci Educ source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    CHAT is complex and the effort required to gain proficiency with the theory may be off-putting.

    “CHAT is complex and the effort required to gain proficiency with the theory may be off-putting”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Considering all components of CHAT requires exploration of the cultural and historical reasons why practice occurs in its current form, which may be logistically difficult and raise organizational confidentiality issues.

    “Furthermore, considering all components of CHAT will require exploration of the cultural and historical reasons why practice occurs in its current form, for example, necessitating access to historical documents for analysis. This may be logistically difficult and have issues around organizational confidentiality.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Generating appropriate data will likely involve immersion of the researcher in the medical workplace, which must be balanced against maintaining patient confidentiality and not disrupting patient care.

    “Generating appropriate data will also likely involve immersion of the researcher in the medical workplace, which must be balanced against the need to maintain patient confidentiality and not be disruptive to patient care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationnone given

    Researching practice-based learning will require data generated through and in the workplace, and in the medical context there are likely to be ethical and practical challenges to achieving this.

    “Researching practice-based learning inevitably will require data generated through and in the workplace, and in the medical context there are likely to be ethical and practical challenges to achieving this.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Activity systems analysis provides a logical process by which researchers may begin to describe activity in terms of CHAT.

    “In particular, the reader may wish to do this by using activity systems analysis which provides a logical process by which researchers may begin to describe activity in terms of CHAT.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] 2010

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    CHAT is a distributed learning theory and critics have stated that CHAT only considers learning as part of group practice.

    “CHAT is a distributed learning theory and critics have stated that CHAT only considers learning as part of group practice.55”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [55] 2004

      Not checked in the free run.

67 of 67

  • The paper relies on this without support.

    The cited studies are genuine and successful applications of CHAT in medical education, whose reported findings can be taken as given.

    “This article has provided examples of how CHAT has been usefully incorporated in the theoretical frameworks of medical education studies.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • CHAT is concerned with qualitative transformations in human practice and views education and practice as inseparable, so it is suitable for simulation-based interprofessional training in the workplace.

    “CHAT is concerned with qualitative transformations in human practice and views education and practice as inseparable so is suitable for simulation based interprofessional training in the workplace (Qureshi, 2021).”

    From SimLab: an intervention to promote expansive learning and organisational change in team-based emergency care simulation (2025) · cites this paper as Qureshi, 2021

  • A theory-guided interventional approach to ISS moves beyond describing an intervention to provoking change in collective activities by supporting agency to enable the interprofessional team to collaboratively design future change in their local setting.

    “A theory guided interventional approach to ISS moves beyond describing such an intervention to provoking change in collective activities by supporting agency to enable the interprofessional team to collaboratively design future change in their local setting (Qureshi, 2021).”

    From SimLab: an intervention to promote expansive learning and organisational change in team-based emergency care simulation (2025) · cites this paper as Qureshi, 2021

Cites

Flagged first, then by citations

Research works printed but not linked: 23

  1. 1999, Activty Theory and Social Practice
  2. 1987, Learning by Expanding: An Activity-Theoretical Approach to Developmental Research
  3. 2012, Practice Theory, Work and Organization: An Introduction
  4. 2010, Activity Systems Analysis Methods: Understanding Complex Learning Environments
  5. 2015, Researching Medical Education
  6. 2014, Understanding Medical Education
  7. 2014, Reconceptualising Professional Learning
  8. 2008, Contemporary Theories of Learning: Learning Theorists … in Their Own Words
  9. Fenwick, 2010, J Work Learn, 22, 114
  10. 2017, Sociology and the New Materialism: Theory, Research, Action
  11. 2015, Researching Medical Education
  12. 2012, How to Conduct a Practice-Based Study. Cheltenham: Edward Elgar
  13. 1978, Mind in Society: The Development of Higher Psychological Processes
  14. 1978, Activity, Consciousness, Perosnality
  15. 2014, Critical Realist Activity Theory
  16. 1999, Activty Theory and Social Practice
  17. Kerosuo, 2010, Cent Eur J Public Policy, 4, 110
  18. Crossley, 2015, Adv Med Educ Pract, 6, 447
  19. Varpio, 2019, Acad Med, 1
  20. 2002, Real World Research
  21. 2020, Handbook of Research Ethics and Scientific Integrity
  22. 2020, Handbook of Research Ethics and Scientific Integrity. Cham: Springer
  23. 2004, Doing-Thinking-Activity-Learning

Cited by

Sorted by citations

Related

Authors
Qureshi, S. P.
Affiliations
NHS Greater Glasgow and Clyde (GB)
Corresponding author
Qureshi, Shaun Peter
ORCID
Qureshi, Shaun Peter
Venue
Advances in Medical Education and Practice
Publisher
Informa UK Limited
Published
2021-08
Volume
Volume 12
Pages
923-935
ISSN
1179-7258 (ISSN-L)
DOI
10.2147/amep.s313250
PMC
PMC8390886
OpenAlex
W3195301460
Semantic Scholar
139020dc4901f33462a5daa92ae8eca8cc0115ca
Cited by
37
References
31
Citations by year
2026: 11 · 2025: 10 · 2024: 9 · 2023: 4 · 2022: 3
FWCI
7.47
Type
journal article
Language
en
Open access
Licence
Locations
  • Advances in Medical Education and Practice (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Dove Medical Press (Taylor and Francis Group) (submittedVersion, cc-by-nc)
Topics
  • Social Sciences › Human Factors and Ergonomics › Innovative Education and Learning Practices
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
  • Health Sciences › Health Professions › General Health Professions › Health and Medical Education
Keywords
cultural-historical activity theory, hands-on learning, medical education, contradiction, Change Laboratory, practice change, workplace learning, continuing professional development, graduate medical education, undergraduate medical education, learning from practice

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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