Learning through clinical practice: Conceptions, evidence and prospects

1
Learning through clinical practice Conceptions,
evidence and prospects

• Stephen Billett,
• Faculty of Education,
• Griffith University

2
Structure of presentation

• Clinical workplaces as learning environments
• Assumptions about learning through clinical
  activities and interactions
• Contributions of everyday clinical experiences
• Limitations of learning through clinical work
• Developing a learning practice - guided learning
  and learning curriculum
• Co-participation and participatory practices in
  health workers work and learning
• Relational interdependence between individual and
  social agency in health work and learning

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Clinical workplaces as learning environments

• Clinical settings are useful places to learn
  clinical practice
• Workplaces are the key sites for ongoing
  vocational development throughout working lives
• Health workers need to maintain the currency of
  their clinical practice throughout working lives

Skill shortages, issues of retention and
workforce development imperatives make clinical
settings essential sites of learning
So clinical settings are important learning
environments from both workplace and worker
perspectives.
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Assumptions about learning through clinical work

• No separation between participation in work and
  learning, and also remaking practice
• Clinical practice (knowledge) is a product of
  history, culture and situation we need to
  access and engage that knowledge (i.e.
  inter-psychologically)
• Learning environments are privileged by the kinds
  of activities and interactions they afford
  individuals and their interest in engaging in
  them, not their institutional purposes
• Need to account for both personal and social
  contributions

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Findings from studies of learning in different
kinds of work and workplaces
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Learning through clinical work and in clinical
settings
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Contributions to learning through everyday work
activity include

• engagement in work tasks
• indirect guidance provided by the setting and the
  practice within that setting and
• the close guidance of other workers and experts.

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1. Engagement in work tasks (just doing it)
Engagement in and legacy of goal-directed
activities
Activity structures cognition (Rogoff Lave
1984)

• Routine activities (familiar) reinforce, refine
  and hone
• - proceduralisation (Anderson 1982) compilation
  of specific procedures
• leads to automisation in the conduct of
  procedures
• Non-routine activities (novel) new learning
• - generates new structures and categories of
  knowledge
• - can be too much

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once you seem to know the area, you don't really
seem to think about your work activities very
much. You just sort of do it. You always trying,
and you probably don't realise that you did
something. I just flows on. Automatic.
(experienced) - Patient assessments pharmacy
rounds terminology associated with medical
conditions and care, talking with patients The
more you do it just becomes second nature.
(novice)
It's the only way you can get the pressure of
grinding right. And get the knowledge of when
everything's right. After a while, with the
grinding, you can just tell by the way your
moulds slide on the pads whether it's ground
enough. It's the only way you can get to learn
this job. You can understand the job from the
books but, work activities would be one of the
only way you can learn it. It's all hands on.
(novice) - Making beds, bathing patients,
administering drugs etc
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2. Indirect guidance provided by the setting

• Learning through observation and imitation a
  potent way to learn (e.g. childrens spectacular
  learning Bransford)
• Anthropological studies (e.g. Lave 1993,
  Pelissier 1991) report this process as common
  means of learning cultural practices, such as
  paid work
• The physical and social setting is richly
  informative (e.g. clues and cues provided by
  setting and partners) (ecological psychology
  (Barker 1968, 1978)

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When Steve's talking to any of the other guys, I
sort of listen in. I normally draw something on
the board. That's got to do with the multi
hearth. I just look and listen to whatever is
going around. (novice) I'm always listening to
the two-way. And I'm always listening to, ah,
what's going on. And, ah, what they're doing to
solve the problem, and have a listen and then I
go over and ask the bloke what was going on. You
know, I say what were you doing over there. Were
you having trouble. And he'll tell me. And I
might pick something up that way. (novice)
. it only really ever makes sense when you are
actually in there, I only really understood what
happened in heart surgery when I was in theatre
and the doctor showed everything that was
happening, and even bowel surgery and everything
like that, because I view when I went in there
and they showed me what was happening, I actually
understood it, so that kind of helped me, but a
lot of the time in class it is a little bit much,
especially when we start learning about
pharmacology and things like that, I had no idea,
until you actually go there and hand out the
medication, that is how, I guess its how it
blends together. That is how I actually learnt a
lot. Toni - Monash Nursing student
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3. Close guidance of other workers and experts

• Direct guidance of a more experienced partner can
  assist access to historically and culturally
  sourced vocational knowledge
• Avoids the epistemological adventures of Robinson
  Crusoe
• Claims that the potential for individuals
  learning can be enhanced through guidance of a
  more experienced co-workers (Zone of Proximal
  Development)

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• the last places that I am still finishing I
  have had to really good preceptors, they have
  both taken the time out to sit with me a little
  bit and say Ok, Ive seen you do this, this and
  this, youve done that really well but you also
  could improve on or if you need help with this
  come and get me and I will help you and I will
  show you what to do.
• So that has been really good, they give you the
  positive and the negative criticism as well. Um,
  and they most of the time, well I have had really
  good ones.

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Learning through clinical practice
engagement in work tasks indirect guidance
provided by the setting and the practice within
that setting the close guidance of other
workers and experts.
Importance of both individual agency and
affordance of opportunities
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Um, yeah, the lessons were really good there. I
worked with a scrub nurse, an anaesthetic nurse
and a recovery nurse and they were all really
interesting, really difficult, but really
interesting and even the doctors and the
anaesthetist and everything, because I seemed so
eager because I had no idea what was going on so
I asked a lot of stupid questions, and because I
seemed so eager about it, they just put me in
positions and where like ok you can help me
intubate then and Im like what do I do? and
so I just helped them and all that kind of thing.
So, yeah, because I was so interested it,
because it was somewhere I had never been before
so everything was kind of new to me so I didnt
really know much about anything, that is why I
kind of just asked lots of questions and they
kind of put me in the spot. Like, it got to a
point in theatre where the doctors and stuff,
pulled out some of the bowel and said I think, is
it an interception when they are suction in, like
this is what it looks like and he pulled it and I
am like whoa. Because I was just so interested
and standing on a little stool and looking at
everything that they did, so I guess my eagerness
and all that kind of thing. Toni Monash student
nurse
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So what?
Importance of practise it makes possible
proceduralisation, frees up working memory,
permits near transfer etc Managing access to
highly novel experiences to avoid overload or
dissonance far transfer needs to be
guided Access to authentic work experiences
Personal dependence in terms of what constitutes
near or familiar activities Cognitive legacies
(i.e. learning) arise, albeit in different ways
for individuals Social practices become embedded
or embodied within individuals
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Limitations of learning through everyday work
activities

• learning that is inappropriate
• access to activities and guidance
• understanding the goals for workplace performance
  
• reluctance of experts to provide guidance
• absence of expert guidance
• developing understanding in the workplace
• the reluctance of workers to participate

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"You are probably shown the quickest way to do
the job, but not the correct way. They show you
the shortcuts. ....not knowing why your doing
what you've been told to do i.e. changing? a
diverter, why are you diverting material and
where to? (novice) ... not broad-based
learning skills targeted to job at hand only.
(OTJ was not useful when) attempting to deal with
unusual situations. (novice) ... (not
effective) did not provide an overall
understanding of material i.e. subject matter and
technical problems with matters, characteristics,
contaminations, etc. (novice)
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Improving clinical learning experiences

• Build on the contributions and addressing
  limitations of learning through everyday practice
• Learning curriculum
• Guided learning

20
Jean Lave an anthropologist studied how
apprentice tailors learnt tailoring in Angola
She noted that these apprentices lived with the
tailors to whom they were indentured in a street
full of tailors workshops.
They were immersed in the practice of tailoring
and learning to be a tailors.
She also noted that the apprentices learnt
without being taught observing and imitating
She also identified that their learning was
organised through participation in a sequence of
work activities that were pedagogic in their
organisation.
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Learning curriculum
Sequencing of activities to take the worker from
tasks of low accountability (e.g. error risk) to
those where consequences of errors are
great Tailors Hairdressers Production
workers Sequencing often has pedagogic qualities
and intents in ways analogous to what occurs in
educational settings (Billett 2006)
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Developing the workplace learning curriculum

• Identify
• sequencing of activities to be learnt and
• those that are hard-to-learn
• Consider frequency (daily, monthly, yearly or
  even those needed to know, but may never be
  used).
• Best informants those who have recently learnt

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Guided learning

• Learning support through guidance of more
  experienced co-workers.
• Level of guidance
• Mentoring throughout a career
• Providing experiences and monitoring progress
• Direct (proximal) guidance (e.g. strategies)

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The interest in guided learning owes much to the
legacy of the Russian scholar Lev Vygotsky
(1896-1934)
He is credited with establishing the importance
of external guidance to make available to
learners what they cannot discover for themselves.
In particular, he is held to have developed the
concept of the Zone of Proximal Development the
idea that a more experienced partners working
closely with a less experienced partners can
extend the scope of their potential learning.
This lead to an interest in reciprocal teaching
and learning, cognitive apprenticeships and
guided learning.
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Guided learning strategies

• Procedural development
• Modelling
• Coaching
• Scaffolding

• Conceptual development
• Questioning
• Diagrams
• Explanations
• Also
• Group discussion
• Extending knowledge through questioning

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-Responses to critical incidents (Billett, McCann
Scott 1998)
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Some conceptual premises
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Participation and participatory practices

• Co-participation at work (Billett 2002) - duality
  of affordances and engagement
• Affordances the invitational qualities of the
  workplace
• Engagement the degree by which individuals
  engage with what has been afforded them
• Each of the contributions and limitations to
  workplace learning experiences can be understood
  in terms of participatory practices

Two continuities social practice and individual
interplay mediated by negotiation between
affordances and individual agency (Billett et al
2004) Workplaces are contested environments
29
Conflictual relations between and among
individuals, teams and key interest groups cannot
be reduced to a mere footnote. Instead, they
pervade work, conceptions of performance and
importantly influence how individuals are able to
act, and therefore learn through work. Whether
the contestation is between newcomers or
old-timers (Lave Wenger 1991), full or
part-time workers (Bernhardt 1999) teams with
different roles and standing in the workplace
(Darrah 1996, Hull 1997) between individuals
personal and vocational goals (Darrah 1997) or
among institutionalised arrangements such as
those representing workers, supervisors or
management (Danford 1998), contestation is an
enduring feature of work practice and influences
the affordance of the workplace setting. It would
be quite derelict to view matters of engagement
in workplace activities as only cognitive tasks
and access to guidance as being benign, without
trying to understand how access to these
activities is distributed. (Billett 2001 p.24)
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Relational interdependence between individual and
social agency

• Learning and remaking culture comprises the
  relational interdependence between the social
  gift (suggestion) and individual agency (2003b
  2006a)
• This interdependence is relational not mutual,
  reciprocal or joint.
• Neither social suggestion nor individual agency
  alone is sufficient to secure either wholly
  social or individual intra-psychological outcomes
  (2006a).
• These ideas are salient because situational
  agency is privileged in theories of learning
  (e.g. communities of practice, activity systems,
  distributed cognition).

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Procedural Developing a learning practice in
workplaces

• Finding new approaches to pedagogic practices in
  workplace setting
• Not be bound to conventional classroom-based
  approaches to developing vocational knowledge
• Consider the invitational qualities of the
  workplace and how these might be improved.
• Consider, also, the epistemological agency of the
  learner and how this might be promoted in
  learners
• Assist and support guided learning reflection
• Recognise and certify workplace learnt knowledge