Professional Documents
Culture Documents
Essay for the “Developing supervisory and professional practice” workshop at Institute of
(3227 words)
Title
Learning as the development of expertise for medical professionals in their clinical workplace
Akira Naito
Although concerned with the continuity of that practice or community, rather than
Introduction
Alongside their professional practice, practitioners need to continually update their knowledge
and skills in their specialised area and to develop their professional expertise in order to
maintain accountability. Although formal trainings outside of practice have been developed
their effectiveness, their efficiency is still considered as limited due to the lack of time available
for medical professionals to take such formal opportunities in addition to their clinical
commitment. Thus, the workplace remains the primary place where professionals spend most
Medicine has become a discipline that provides patient care 24 hours a day, seven days a week.
Its augmented workload and associated time pressures have been increasingly recognised as
key factors that can negatively impact on clinical performance [Smith, 2006]. This is an
additional factor that highlights the need for medical professionals to develop learning
is also supposed to emerge and evolve informally and concurrently with one’s practice. The
adage of “learning by doing” is often cited to depict this concept, and it has been developed by
a number of writers, labelling the concept as ‘experiential learning [Kolb, 1984]’, ‘situated
learning [Lave and Wenger, 1991]’, ‘informal learning [Garrick, 1998]’ and ‘workplace learning
Theories endorsing the concepts of workplace learning focus on ways in which previous
knowledge and skills can be linked and instigated in the process of innovative knowledge
construction, and in which people learn through purposeful interactions in their social settings.
Moreover, these theories explore ways in which one’s knowledge and understanding can be
further advanced through structured teaching and learning [Evans et al., 2006]. This essay aims
to develop this premise further by reviewing and discussing these discourses with a particular
focus upon the quest for the most effective strategies and settings that facilitate individual
practice.
In the workplace, the first priority is always given to the maintenance and improvement of the
level of performance associated with a specific project. For medical professionals, the shared
goal for the project is to provide and deliver the highest quality of patient care and safety
contribution to this project, in other words, all practitioners are inevitably required to
Billett (2004) noted that the basic process of participation in practice can be a useful and
effective way of learning on its own. This notion of ‘participation-as-learning’ has explored
from what Lave and Wenger (1991) called ‘legitimate peripheral participation’, and utilised in
the context of ongoing (continuous) professional development for both, Lave and Wenger’s,
practice [Wenger, 1998]. In this way, learning in the clinical workplace can be re-defined as
developing one’s expertise by participating in, and (at the same time) contributing to, clinical
practice.
Evans et al. (2006) utilised this expanded notion of ‘participation/participating in’ their
communities of practice and defined dimensions or domains of what individuals can learn by
participating in a project [the following assets are labelled by the author of this essay]:
member, and acquiring cultural attributes in order to communicate with each other;
Although these four domains are inter-dependent and overlapping, but they were suggested
as one way to offer an “… enhanced view of individuals’ competences, embodying the mental,
emotional and physical processes that are integral to the development and expansion of
Workplace learning and communities of practice for medical professionals
5
‘participation’ can be evaluated more fully by using these domains as a methodology. This
essay employs this suggestion and the following sections discuss the premise of ‘learning as
Clinical practice, particularly in the management of chronic diseases and co-morbidities (which
are increasing in our aging society worldwide especially within developed countries), requires
institutional boarders [West and Borrill, 2006]. Such professionals, including medical, nursing,
psychological, other healthcare and administrative workers, collaborate with each other in the
same project sharing the same goal; that is, to provide the best patient care and safety. Hence,
medical practice can be considered as a relevant and significant example of the communities
[Engestrom, 2004].
To maximise effective teamwork, Garrick (1998) suggested that all workers, at every operative
level in communities of practice, need ‘… more power and choice in the work of the enterprise
and greater opportunities for learning.’ (p.44-45) For the purpose of this learning, he
suggested that the ability to be flexible in different working situations and settings is essential.
Garrick defined this flexibility as the ability to transfer previously acquired knowledge and skills
Workplace learning and communities of practice for medical professionals
6
to use in unfamiliar and different settings and circumstances. This process of transferring one’s
knowledge and expertise into a new situation does not occur in a social vacuum. Billett (2004)
labelled the relationships and interactions between a learner and his/her work environment,
particularly the capability of being able to reconcile contestations between their interests and
to negotiate amongst affiliate members, which constantly generate conflicts between power
performance in the workplace. Middleton (1998) also reported observations of the process of
The arguments people have in their attempts to resolve or evade the dilemmas that
emerge in representing and accounting for their working life appear crucial to the
coordination of team practice, as are the maintenance of past experience as the working
intelligence for that practice, and the definition of appropriate ways forward in
Middleton concluded that this informal process is essential for team to progress their practice,
From the standpoint of viewing the community as a learning environment, Engeström (2004)
introduced the notion of the ‘knot-working’ environment. His concept of the ‘knot’ is not as a
single action, but rather a hub that inter-connects a number of related actions, each one of
which is constituted by relatively stable but transient objects, motives and divisions of labour.
the combination changes constantly [Engeström, 2004]. A single person can participate in
several ‘knot-workings’ in various levels of engagements at different times, and these levels of
mentioning that “… we must learn new forms of activity which are not yet there, they are
literally learned as they are being created [Engeström, 2001: 138]”. In order to
analyse/describe the degrees of possibility for the environment (of organisation) to realise and
notion of ‘expansive learning’ was proposed from his “activity theory (third generation)”
dependent triadic relationships between subject, object, and mediating artefact [Engeström,
2001].
Workplace learning and communities of practice for medical professionals
8
Fuller and Unwin (2004) have utilised the notion of ‘expansive learning’ and extended this with
According to Fuller and Unwin, the criteria define these expansive learning environments
comprise three availabilities that help to co-construct knowledge and expertise for employees:
the workplace;
3. Chance to obtain qualifications for one’s own career progression in one’s profession.
Each of these availabilities can be assessed and measured in the light of expansive - restrictive
continuum in order to judge the level of appropriateness (or ability) of a workplace to provide
that uses this continuum as a methodology to examine and improve learning environment.
Workplace learning and communities of practice for medical professionals
9
An example for analysis using a method of the expansive - restrictive learning environment
Although restrictive learning environment is not necessarily ineffective, Fuller and Unwin
(2004) believe that making a work environment more expansive than restrictive in the
continuum promotes better participation for individual workers in general, and therefore
Evans et al. (2006) also supported this idea in their review of research findings in the light of
the expansive - restrictive continuum measurement. They reported four key and common
indicative conditions under which organisational interventions were likely to be most effective
(p.168):
(1) Addressing needs (for both employees and employers) in the workplace;
(2) Valuing and making the best use of employees’ voice and reassuring employees that
the improvement in productivity will not threaten their employment or condition of it;
(3) Integrating work activities with both formal and informal learning opportunities; and
(4) Not judging workforce learning and performance in a short-term timeframe and in a
Evans and colleagues (2006) also summarised the primary organizational and cultural barriers
enhance a culture of blame, where mistakes are punished, and which also lead to have
Having identified and summarised these key empirical findings, they then proposed a five-
stage process (strategy) to analyse and improve the above opportunities for expansive learning
by using a method of the continuum of expansive - restrictive measures for the learning
2. Identify the current position of the workplace in the continuum against those
changes/effects on each levels of both parties, i.e. employees and employers, to find
5. Implement a plan for improvement, and monitoring the course of changes, althoug
sideways learning and development’ and explained as one in contrast to the traditional
concept of learning where the learning process is seen as progressing in a ‘vertical’ direction
[Engeström, 2001]. By a vertical direction, Engeström means that a learning process can be
and stable infrastructure. Francis Bacon’s notion of “knowledge is power” may symbolize part
of this vertical (and prepositional) knowledge. The development of this model of knowledge is
well-depicted in the individual learner’s stages, such as Dreyfus brothers’ perspective of the
levels of expertise. That is, from the level 1 as a novice, level 2 an advanced beginner, level 3 a
competent individual, level 4 a proficient, to the level 5 as an expert [Dreyfus et al., 1986].
Although Lave and Wenger’s notion of the development across a continuum from a
‘newcomer’ to an ‘old-timer’ may be viewed as having equivalent ladders, in this case the
Workplace learning and communities of practice for medical professionals
12
direction of progress is what Engeström called ‘horizontal or sideways.’ This horizontal learning
represents the process of gaining and sophisticating ‘distributed and shared knowledge
[Hutchins, 1995]’ where contrasting differences, described before, could generate conflicts
and contradictions [Fuller et al., 2005]. Engeström suggested that the process of resolving
those generated contradictions is the key activity in the ‘knot,’ and indicated the objectives for
the ‘horizontal or sideways learning and development’ creates a new type of expertise
[Engestrom, 2004]:
knowledge and ability’ but on ‘the capacity to cross boundaries and to negotiate and
Similarly, the contrast between (traditional) vertical and (emerging) horizontal learning can
also be labelled as the ‘standard (cognitive) paradigm’ and ‘emerging (socio-cultural) paradigm
of learning,’ respectively (p246) [Hager, 2004]. In this regard, Bernstein (1999) made a
distinction describing that the horizontal type as a “… this form has a group of well-known
features: it is likely to be oral, local, context dependent and specific, tacit, multi-layered, and
contradictory across but not within contexts”, as opposed to a vertical type that “… takes the
interrogation and specialised criteria for the production and circulation of texts as in the social
general areas, namely vertical and horizontal. Analyses and discourses regarding the latter
direction (which generate the key concept to discuss in this essay that “participation as
learning” leading to introducing the notion of ‘expansive learning’) has emerge and evolved
professionals collaborate. These conceptions provide new ways of learning and therefore
perspective to help create more effective strategies for learning as developing expertise in the
workplace.
driving force of change in an activity system where some old elements (the rules and the
division of labour, for example) collide with new elements [Engestrom, 2001]:
In contrast [to the Nonaka and Takeuchi’s knowledge creation model, which consists of
smooth and conflict-free socialising steps], a crucial triggering action in the expansive
This led to deepening “analyses” of the cases, and eventually to sharpener and more
Engeström noted that the process of resolving contradictions comprises of four steps in the
(2) Creating double-bind structure through historical (conceptual) and empirical analyses;
(3) Resistance against proposed changes emerges when a new model is presented;
Experiencing this four-step process a number of times would help to clarify each individual
worker’s own professional identity for himself or herself. Because each time a worker goes
through this process, it results in a coherent outcome after new configurations (of judgements
and decision-makings) within him/her-self and between other members occur. The process of
these configurations coincides with their developing one’s professional expertise and defining
his/her role of participation for their practice. In other words, a worker learns in the
Evans et al. (2006) also pointed out the importance of one’s personal history of
history of ‘becoming’ heretofore. They then referred this process as a ‘learning territory’,
which is determined by one’s both history of the exposures, and current access, to learning
As discussed and summarised in the previous section, one way to think about and classify
one’s learning experience is to think of it as falling along two directions; that is ‘horizontal or
sideways’ and ‘vertical’ approaches. For example, the ‘learning territory’ may be categorised as
(1) class-based, home-based or work-based (place-oriented) division of region that falls along
the vertical (cognitive) viewpoint. These ‘learning territories’ likely influence individual
professionals in the ways in which conflicts within a self and between other workers emerge,
In summary, this section discussed the process of sophisticating professional identity and
defined as that one’s identity is consolidated by a series of experience (i.e. personal history) of
Conclusions
This essay outlined the a model for understanding and classifying workplace learning for
medical professionals. Learning approaches in the workplace were discussed for each of four
learning process. The discussions also considered in terms of two dominant perspectives - a
However, most of the discussion focused on the latter perspective. Analytical approaches
and discussion on ways to take into account both directional approaches concurrently,
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