Making work-intensive clinical settings effective learning
environments: A forum and workshop
Stephen Billett,
Griffith University, Australia
Introduction and introductory questions
Work intensive clinical environments as sites for
learning medical knowledge
• Why is there a need to improve students’ learning
experiences in clinical settings?
• What factors currently inhibit the quality of students’
learning experiences in work intensive clinical
• What can be done to improve this situation?
The aims for this workshop are to:
• identify key tasks and professional knowledge needed to
be learnt in clinical environments;
• discuss, share and deliberate with other participants
about the qualities of work intensive clinical settings as
learning environments;
• generate pedagogic principles and practices for
maximising clinical learning in such work settings;
• generate practice-based curriculum arrangements
appropriate to such settings; and
• consider critically how best to prepare, engage and
promote students as agentic learners in these settings.
• Learning in clinical environments
• Knowledge required for work
• Learning through work
– premises and assumptions
• Work-intensive clinical settings and learning
• Engaging students in clinical settings
• Generating principles (for curriculum,
pedagogy, students’ epistemologies)
• Enacting principles - preparing
Processes and outcomes
The process will comprise:
Individual and group activities
Deliberations about formulations for improving
student learning in work intensive clinical
environments (wics)
Intended outcomes:
A set of concepts and proposed curriculum and
pedagogic practices, including those
associated with students’ engagement to
promote learning in clinical settings.
How might we address this problem: Considerations
from the learning sciences
Consideration of:
• curriculum practices (i.e. the provision of experiences for
• pedagogic practices – enriching those experiences by another
(and more informed co-worker (e.g. before, during and after
those clinical experiences))
• epistemological practices – what learners should be doing to
maximise their learning in clinical settings
Intended, enacted and experienced curriculum
Learning medicine in clinical practice settings
Practice settings are the most common site of learning (over
time and across working lives)
Medicine represents a partial exception
Yet, even here authentic experiences long valued
“The best physicians are those who have treated
the greatest number of constitutions good and bad.
From youth, they have combined with their
knowledge of their art with the greatest experience
of disease. It is better for them not to be robust of
health themselves, but to have had all manner of
diseases in the own persons. For it is not with the
body, but with the mind that they cured the body.
And thus, they infer further bodily diseases of
others from the knowledge of what has taken place
in their own bodies.” (Plato in Republic)
Yet, there are a range of limitations and strengths to learning
through practice!!!!
Everyday experiences - provide
access to novel and routine
activities through which
knowledge is constructed
Indirect guidance - observing and
listening (i.e. cues and clues)
Direct guidance - access to more
experienced co-workers
Practice – opportunities to
reinforce, refine and hone
Bad habits
Lack of opportunity to practice or
Lack of support and guidance
Doing, but not understanding
what or why
Constraining experiences
Confronting experiences
Billett 2001
Goals for this learning – the knowledge required for
work performance
Knowledge required for work: Goals for workplace learning
Expert performance is founded on securing:
• Domain-specific conceptual knowledge – ‘knowing that’
(Ryle 1939) (i.e. concepts, facts, propositions – surface
to deep) (e.g. Glaser 1989)
• Domain-specific procedural knowledge – ‘knowing how’
(Ryle 1939) (i.e. specific to strategic procedures) (e.g.
Anderson 1993)
• Dispositional knowledge - ‘knowing for’ (i.e. values,
attitudes) related to canonical and instances of practice
(e.g. Perkins et al 1993), includes criticality (e.g.
Mezirow 1985)
Dimensions of knowledge deployed and developed further through
experiencing and enacting
Conceptual knowledge
Procedural knowledge
Dispositional knowledge
These forms of knowledge are deployed and developed through experiences in both
educational and other settings, not necessarily privileged in one or the other
These capacities are more than techne - technical knowledge. There is also the
need to:
• generate and evaluate skilled performance as work tasks become complex
and as situations and processes change,
• reason and solve work problems,
• be strategic,
• innovate and
• adapt.
(Stevenson, 1994)
Indeed, professionals need critical insights and to be reflexive to both practice and learn
through practice (e.g. clinical reasoning).
Knowledge required for work comprises both:
(i) canonical occupational knowledge and
(ii) that knowledge required for situational performance
No such thing as an occupational expert, per se
Expertise arises through episodes of experiences, perhaps most
centrally authentic instances of practice
Particular experiences are likely to generate these kinds of
Task #1 – Identify the knowledge required to be learnt in
clinical settings (20 mins)
What knowledge is required to be learnt in and for clinical
Working alone, please: i) identify two or three instances of
tasks to be learnt in clinical settings that have:
Conceptual emphasis – i.e. concepts, facts, propositions
Procedural emphasis – i.e. specific - strategic procedures
Dispositional emphasis – i.e. values, attitudes
Then, ii) consider how these tasks might be best learnt in work
intensive clinical settings.
Discuss your instances and responses with another participant
Task #2 – characteristics of work intensive clinical
environments (WICS) (15 mins)
What are the characteristics of WICS as places to
learn the tasks that you have identified?
Open forum
Learning in work-intensive clinical environments
Assumptions and premises
• Learning is ongoing and across settings as we experience activities and
• Activity structures cognition (Rogoff & Lave 1984)
• Robust learning arises through experiences in both practice and
‘schooling’ settings. Experiences in educational settings are not inherently
• Key bases shaping learning:
– i) the qualities of what is experienced (i.e. activities and interactions)
– ii) how learners engage with those experiences .
• Different kinds of settings provide different kinds of experiences (e.g.
activities and interactions), and potential learning experiences.
• Yet, individuals’ process of experiencing is person-dependant and central
to what and how they learn.
• Two kinds of change: learning and the remaking of occupational tasks (i.e.
continuity and transformation)
• So, we need to identify both curriculum and
pedagogic means to for promoting effective learning
in wics
Apprentice approaches have been adopted, yet these
may inappropriate for some aspects of medical
Guided learning at work Modelling (procedural, dispositional purposes)
Coaching (procedural, dispositional purposes)
Scaffolding (procedural, dispositional purposes)
Questioning – (conceptual purposes)
Explanations – (conceptual purposes)
Diagrams – (conceptual purposes)
Analogies – (conceptual purposes)
These might be appropriate in work intensive clinical
environments (wics)
Learning curriculum
Sequencing of activities to take workers from peripheral to full
participation (Lave 1990)
From tasks of low accountability (e.g. error risk) to those where
consequences of errors are greater.
Tailors – Hairdressers – Production workers
Sequencing often has pedagogic qualities and intents in ways
analogous to what occurs in educational settings (Billett 2006)
Considerations within educational programs: reflections on
a similar process
Project: Developing higher education students as agentic
• Organising of experiences before, during and after
experiences in practice settings
Before practice experiences …
• Establishing and clarifying bases for experiences in
practice setting, including their purposes,
expectations of others and developing or identifying
capacities in practice settings (e.g. advance
• Prepare students as agentic learners (- the
importance of observations, interactions and
activities through which they learn)
• Prepare students for contestations
Newton et al – advanced organisers
Molloy – pre-practicum week
Cartmel and Thomson – learning circles…
During ………
• Direct guidance by more experienced practitioners (i.e.
proximal guidance) and sequencing of activities (i.e. ‘learning
curriculum’ - practice based curriculum)
• Identifying and utilising pedagogically rich work activities or
interactions (e.g. handovers)
• Promote effective peer interactions (i.e. collaborative
learning, e.g. use of focus groups)
• Active and purposeful engagement by learners in workplace
Glover and Sweet –
follow throughs for student midwives
After ………
Sharing and drawing out experiences (i.e. articulating, and
comparing - commonalities and distinctiveness) (e.g. identifying
the canonical and situational requirements for practice)
• Making links to what is taught (learnt) in the university setting,
securing productive critical reflections on work and learning
• Emphasising the agentic and selective qualities of learning
through practice (i.e. personal epistemologies)
Newton et al reflective learning groups
Sustaining work-intensive clinical settings as learning
Dividing into three groups – i) curriculum, ii) pedagogy and iii)
personal epistemologies
Responding to distinct questions:
• How should students’ experiences be organised for them to
effectively engage in clinical settings? (curriculum group)
• What should clinicians and others do to enrich students’
experiences? (pedagogy group)
• What should students do to maximise their learning? (personal
epistemologies group)
Task #3 – Improving student experiences in clinical
settings (45 minutes)
The process is as follows
1. Individual generation of ideas to the question
2. Capturing ideas onto a sheet of butchers’ paper
3. Nominal Group Technique process – to rank
Nominal Group Technique
NGT - a way of generating ideas and ranking those ideas without
engaging in discussion and debate, only clarification and
1. Individual and silent response to the focus question
2. Round robin process to list all ideas on butchers’ paper
3. Work through the list with each contribution being explained
4. Voting by participants to rank each set of ideas
5. Working through the list and allocating scores against them
6. Indicate the ranking on the sheet against the items
Task #4 – reporting to the entire group (15 minutes)
Each group presents their ranked listing.
Discussion about the ranked issues for pedagogy,
curriculum and personal epistemology
Task #5 - Generating principles (curriculum, pedagogy &
epistemology) (20 minutes)
Back into the three groups
Taking the first 3-5 ideas – identify 4-6 key principles for:
• organising an effective curriculum for WICS
• enacting pedagogic practices in WICS
• positioning students to engage and learn effectively in WICS
Task #6 – Enacting the principles (15mins)
Still working in the same three groups
How best to realise these goals – what needs to happen to:
• Secure the desired organisation and sequencing of
experiences (curriculum group)
• Prepare clinicians and others to enrich learners experiences
(pedagogic group)
• Prepare students for and supporting rich learning (personal
epistemologies group)
Identify 4 suggestions for implementing these goals
In sum, …………