Work-Based Learning in Clinical Settings

Insights from Socio-Cultural Perspectives

Viv Cook, Caroline Daly, Mark Newman, Viv Cook, Caroline Daly, Mark Newman

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9781138443532
• eBook ISBN: 9781000419047
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The importance of learning in the workplace has long been recognised in clinical education, however the twin demands of the explosion in clinical knowledge and the changing dynamics of the clinical workplace have exposed the shortcomings of existing clinical learning practices and understandings of clinical learning in the workplace. There is a growing demand for conceptual and methodological tools that can help to develop understanding of the complex set of relationships involved in learning in professional healthcare contexts. This ground-breaking volume brings together the work of pioneering scholars of learning and is unique in providing a detailed account of socio-cultural theory in relation to clinical education. Work-based Learning in Clinical Settings clearly illustrates the potential breadth of application and the strength and diversity of research in this field. Each chapter engages with a distinct issue and follows a specific structure to present an extended case-based presentation of the research that explains the: .architecture of the concept or theory .application of the concept/theory to clinical education .methodological approaches used as well as the implications and limitations . understanding of the workplace clinical learning that emerged as a result of the research It is ideal for professionals in clinical education, healthcare policy makers and shapers, and postgraduate students who will find the thorough, innovative research enlightening.

1
Reimagining ‘the firm’

Clinical attachments as time spent in communities of practice

Clare Morris

THE WORKPLACE HAS LONG BEEN A SIGNIFICANT SITE FOR MEDICAL learning at all stages of education and training. Calls for ‘early patient contact’ (GMC, 1993) have led to a gradual demise of the traditional preclinical–clinical divide in undergraduate years, with students spending time in clinical workplaces from year one. Despite the significant investment of resource in undergraduate ‘attachments’ of this nature, there are increasing concerns about new graduates’ preparedness for professional practice and the lack of opportunities for ‘hands on’ work before graduation (Illing et al., 2008). Indeed, the relaunch of Tomorrow’s Doctors (GMC, 2009) has been accompanied with calls to reinstate the traditions of old, arguing that clinical attachments, shadowing and new ‘student assistantships’ should have greater prominence (GMC, 2009). These calls arise alongside concerns about the demise of medical apprenticeship (Dornan, 2005), the loss of the clinical ‘firm’, the impact of UK National Health Service reform on medical training and a shift toward competency-based models in postgraduate years (Tooke, 2007). There has perhaps never been a better time to research workplace-based learning in medicine; the challenge is perhaps to identify the types of conceptual and theoretical tools that best enable us to do this.

In this chapter, I explore the use of Lave and Wenger’s conceptions of communities of practice and legitimate peripheral participation as potentially useful analytical tools that offer new insights into medical students’ experiences of learning in the workplace (Wenger, 1998; Lave and Wenger, 1991). In particular, I explore the extent to which students ‘clinical attachments’ can be reconceptualised as times spent in communities of practice. In order to do this I start with an exploration of Lave and Wenger’s work, concluding with a distillation of what I see as the core underpinning tenets. This leads me to consider the ways in which these core tenets might be ‘operationalised’ to guide a socio-cultural research inquiry into medical student learning. The value of this approach is illustrated by a research study that investigated how clinical teachers support undergraduate learning in medical workplaces (Morris, 2009).

‘Rescuing the idea of apprenticeship’

The term ‘communities of practice’ is often evoked in learning literature and is gradually creeping into descriptions of medical learning and practice (PMETB, 2008). To trace its origins, it is necessary to turn to the seminal work of Jean Lave, a social anthropologist, and Etienne Wenger, a teacher and educational researcher, who set out ‘to rescue the idea of apprenticeship’ 2 decades ago (Lave and Wenger, 1991, p.29). They noted that while the term ‘apprenticeship’ was in regular use, its meaning was unclear and it was often used synonymously (and unhelpfully) with the term ‘situated learning’. Their analysis arises from a series of studies of apprenticeship, spanning Yucatec midwives, Vai and Gola tailors, naval quartermasters, meat cutters and non-drinking alcoholics. Their thesis, in essence, is that learning is an ‘integral and inseparable aspect of social practice’, characterised as ‘Legitimate Peripheral Participation in Communities of Practice’ (Lave and Wenger, 1991, p.31).

There is merit in emphasising the shifts in thinking necessary in order to fully appreciate the merit of their work, which has been argued to transform the ‘assumptions and metaphors guiding the study of learning’ (Hughes et al., 2007). Sfard (1998), in particular, contrasts the ‘dominant’ metaphor for learning (learning-as-acquisition) with the metaphor emerging from their work, that of learning-as-participation. She argues that while the perceived goal of learning-as-acquisition is the ever-greater accumulation of knowledge and skills, the goal of learning-as-participation is to become a fully participant member of a community. If the learning-as-participation metaphor is applied to the purposes and outcomes of medical students’ clinical attachments, less emphasis might be given to the acquisition of clinical knowledge or skills, and more to facilitating student participation in the medical practices of the (disciplinary) communities they join.

Sfard (1998) argues that the choice of metaphor is highly consequential with regard to the pedagogic strategies employed and the approaches to educational research and scholarship adopted. For example, the learning-as-acquisition metaphor may privilege certain types of learning experiences (e.g. lectures and clinical skills sessions) or certain types of assessments (e.g. multiple-choice questions and objective structured clinical examinations) in pursuit of this goal. In contrast, the learning-as-participation metaphor might privilege participative learning experiences (e.g. clinical attachments, shadowing, student apprenticeships) or assessment methods (e.g. workplace-based assessments or multi-source feedback). It is worth noting that Sfard (1998) cautions against the adoption of a single metaphor, a point picked up by Bleakley (2006), who argues in favour of the productive tension of these competing ideas, suggesting a need to choose those with the most explanatory power for the issues being explored.

Arnseth (2008), a key analyst in the field of socio-cultural research, argues that Lave and Wenger’s major contribution is that

they make use of this notion of practice in order to construe a reformulation of thinking and learning. Thus, they treat thinking and learning as something that is constituted in the lived-in-world – the world as it is experienced in social practice. (p.294)

This idea, that learning is an integral, inseparable part of social practice, leads us to think differently about medical thinking and learning in the workplace. When a healthcare team gather around a patient’s bed to review patient management, or a surgical team almost wordlessly move through the unchoreographed yet seamless operation, learning is happening as part of shared ‘social’ practice, whether made explicit or otherwise. Lave and Wenger (1991) offer up this analytic viewpoint by inviting us to draw upon two linked concepts: ‘legitimate peripheral participation’ and ‘communities of practice’. Taken as a conceptual ‘whole’ (they caution against deconstruction), legitimate peripheral participation becomes, in their words, ‘a descriptor of engagement in social practice that entails learning as an integral constituent’ (p.35).

Legitimate peripheral participation focuses attention on the ways in which ‘newcomers’ to a community (e.g. medical students or trainees) are invited into the community and are engaged (or otherwise) in increasingly meaningful activity that enables them to become full participants in the practices of that community. This view on learning moves us beyond understandings of learning that focus on abilities to take part in new activities or perform new tasks. As Lave and Wenger (1991) note, these activities only have meaning in relation to broader systems of relations. For example, a student’s ability to perform venepuncture is given meaning when the sample of blood they take from the consenting patient is analysed by the pathologist and the findings discussed in the wider context of a team managing that patient’s care. By being involved in discussions of patient care, the student learns not only ‘from talk’ but also ‘to talk’, being socialised into ways of thinking about and talking about patients. By inviting the student to take the blood sample, his or her practice becomes integral to the shared practice of the patient care team. Over time therefore, the student comes to belong to that community and to become a doctor through such processes. This view of learning therefore invites us to consider issues of professional identity formation. In other words, to look at the ways in which medical students are invited to take part, indeed to ‘be a part’ of the work of that community and, in so doing, start to ‘become’ a doctor.

The communities of practice concept is introduced in Lave and Wenger’s (1991) joint text, but is (as they would acknowledge) only loosely defined at this point. They argue that the term ‘community’, in this sense, is both ‘crucial and subtle’, indicating not only the shared technical knowledge and skills of community members but also the relations between community members and the activities they engage in and the world. Communities are delineated in their text on the basis of the so-called ‘reproduction cycles’ from newcomer to old-timer, as new members become full participants. In later work, Wenger (1998) offers a three-dimensional distinction, focused on ‘mutual engagement, joint enterprise and a shared repertoire’ (p.73). He also cautions against using the term synonymously with teams, groups or networks. This underdevelopment of the communities of practice concept poses some difficulties in using this idea analytically in research, particularly in relation to delineating an appropriate unit of analysis for research. It is difficult to research a community of practice if it is not clear where it begins and ends.

A full exploration or critique of the concept is beyond the scope of this chapter, and can be found elsewhere (e.g. see Hughes et al., 2007) and so only the key concepts, or ‘core tenets’, are given here: first, the view that learning is an integral part of social practice; second, that communities of practice can be identified and defined by common expertise and shared practices; third, learning has a central defining process, that of legitimate peripheral participation, a process enabling the development of the expertise necessary to enable access and full participation in a community; fourth, learning involves the construction of identities (processes of belonging and becoming); and, finally, it is recognised that language is a central part of practice, not in terms of learning from talk, but rather in terms of learning to talk – a process of talking one’s way into the expertise (Wenger, 1998; Lave and Wenger, 1991). In the rest of this chapter, the aim is to explore how these core tenets can be put to use as analytical tools to research medical learning.

Rethinking medical apprenticeship

Some commentators have been critical of the strongly individualised ‘cognitive’ conceptions of learning that appear to dominate the medical education literatures and the atheoretical nature of much medical education research (Teunissen, 2010; Norman, 2007). Bleakley (2006) and Swanwick (2005), in particular, identify the desirability of broadening the ways in which learning is conceptualised in medical education and the importance of drawing upon appropriate conceptual tools to do this. More recently, Mann (2011) has argued that socio-cultural learning theories offer the medical profession new ways to think about themselves and their practices.

In my own research work, I have drawn on Lave and Wenger’s conceptions to help me rethink medical apprenticeship. This rethinking has been part of a wider study seeking to make explicit the ways in which clinical teachers support medical student learning in the workplace. My starting premise was that Lave and Wenger’s (1991) work offered new ways into exploring learning and working relationships, practices and tools.

Their work also led me to ask different types of questions about medical student learning in the workplace. Specifically, if learning can be characterised as ‘legitimate peripheral participation in communities of practice’, to what extent can medical students’ attachments be viewed as time spent in communities of practice? Furthermore, how might the analytical lens of ‘legitimate peripheral participation’ help make sense of the learning that happens (or otherwise) on clinical attachments?

Researching medical student learning on attachments

A key concern I had when designing my research, was finding the most appropriate unit of analysis and aligned research methods. Säljö describes this as a scholarly creation, allowing researchers to put theoretical perspectives to use (Säljö, 2009, 2007). This is not a straightforward process. Matusov (2007), for example, notes that while most socio-cultural researchers would argue that the individual is not an appropriate unit of analysis, they differ in their positions on what is. If learning is seen as part of social practice, embedded in the everyday practices of a community, the chosen unit of analysis should seek to embrace and explore such complexities. Lave was a social anthropologist immersed in ethnographic studies of naturally occurring apprenticeship; tracing a full ‘transformational cycle’ from newcomer to old-timer may be possible in such circumstances. However, these methods do not readily translate to practitioner research seeking to make sense of medical student learning. Most researchers are constrained by resource issues and what is feasible in terms of access to the field. Therefore, in designing my research study, a decision was made to focus on the experiences of medical students, across all years of their course, recognising that this would potentially afford insights into a wide range of ‘communities’ and might offer some insights into the complexities of learning in clinical workplaces. At the time this research was started (in 2004), there was limited debate or exploration of research methods congruent with a socio-cultural enquiry (beyond the ethnographic work alluded to). A bespoke methodological approach was therefore developed, the goal being to make explicit the ways in which Lave and Wenger’s (1991) ideas about learning were being put to use in the design and implementation of the study. Three key methods were used: literature review and reframing, observation of medical student learning in the workplace, and interviews. Examples of these ways of working follow.

Literature review and reframing

A first step in many studies will be a review of the literature. Given the lack of research on undergraduate medical education arising from a socio-cultural tradition, there was no immediately congruent literature base on which to draw. However, there is a large literature exploring student and trainee experiences of learning in the workplace that emanates from other different theoretical traditions, but which shares similar concerns. These studies explore issues of context, of practice and of ‘cultural’ issues.

To illustrate, it is possible to take the previously articulated ‘core tenets’ arising from Lave and Wenger’s (1991) work to look anew at studies published in key medical education journals in recent years. Studies exploring the types of learning that emerge during ward rounds of different types (e.g. Kuper et al., 2010; Walton and Steinert, 2010) or in particular disciplines (e.g. Baler et al., 2010) could be seen as studies that are exploring the idea of learning being part of social practice. The emphasis given to learning in different settings (e.g. community versus hospital-based attachments) or learning within certain specialty settings (e.g. surgical versus medical attachments) can be reframed in terms of learning happening within communities of practice. These studies may well signal particular cultural tradit...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• About the editors
• Contributors
• Introduction: working to learn in clinical practice
• 1 Reimagining ‘the firm’: clinical attachments as time spent in communities of practice
• 2 Learning to teach on the job: exploring the shape and significance of learning through work activity in medical settings
• 3 Assessment in natural settings in obstetrics and gynaecology: insights from a guided learning perspective
• 4 Developing a social constructivist model of nursing’s pedagogic practice using Bernstein’s educational theories
• 5 From classroom to clinic: an activity theory perspective
• 6 ‘The hidden curriculum’: learning the tacit and embodied nature of nursing practice
• 7 Learning in the operating theatre: a social semiotic perspective
• 8 Establishing patient safety nets: how actor-network-theory can inform clinical education research
• 9 Ethnomethodological workplace studies and learning in clinical practice
• 10 Narrative methodology: understanding learning experiences in an online programme of professional development
• 11 Review: communication, knowing and being in work-based learning
• Index