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

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.

Keywords: Change Laboratory; activity systems analysis; cultural historical activity theory; medical education; methodology.

Figure 1

Diagram of the minimum unit of analysis from 2nd generation CHAT.

Figure 2

Diagram demonstrating the distinctions between operation, action, and activity as described by Leontiev. Note: Data from Leontiv.

Figure 3

Diagram of 3rd generation CHAT, adapted from Engeström. The diagram demonstrates that neighbouring activity systems may have outcomes which may or may not be aligned.

Figure 4

Example of the outcome of activity systems analysis. In this case ASA was applied to data generated from interview with newly graduated (FY1) UK doctor exploring experiences of caring for patients approaching the end of life in the hospital workplace.