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 environments?
• 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.

Progression
• 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 practitioners/students/learners

Processes and outcomes
The process will comprise:
Presentations
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 learners)
• 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!!!!
Strengths
Weaknesses
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 extend
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
Importantly,
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 knowledge

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 settings?
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 interactions
• Activity structures cognition (Rogoff & Lave 1984)
• Robust learning arises through experiences in both practice and
‘schooling’ settings. Experiences in educational settings are not inherently rich.
• Key bases shaping learning:
– i) the qualities of what is experienced (i.e. activities and interactions) and
– 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 education

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 learners
• 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 organisers)
• 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 settings
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 environments
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 responses

Nominal Group Technique
NGT - a way of generating ideas and ranking those ideas without engaging in discussion and debate, only clarification and weighting.
Process
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, …………