Facilitating learning in the workplace - Faculty Development ...

Clinical Teaching Made EasyFacilitating learning in the workplaceWorkplace-based learning has been at the heart of medical education and training for centuries. However, radicalreform of the NHS means we have to re-think traditional approaches to apprenticeship and find new ways toensure that students and trainees can learn ‘on-the-job’ while doing the job.This article explores contemporaryperspectives on workplace-basedlearning and considers how theyguide learning in medical workplaces.Ways to create an environment wherelearning happens in parallel with working,are explored. In addition, strategies tomaximize workplace-based learning areidentified.Learning in the workplaceChallenges and opportunitiesClinical teachers identify the followingchallenges to workplace-based learning:• Available time and resources• Competing demands and priories• Increased paperwork for training andassessment• Changing expectations• Concerns about the risks involved indelegating clinical work.Students and trainees report concernsabout lacking a clear role, knowing what isexpected of them, limited opportunities tobe observed and receive feedback on performanceand, increasingly, being unclearabout the inherent learning value of dailywork activity.The workplace offers rich opportunitiesfor learning, enabling learners to developprofessional knowledge, skills, behavioursand attitudes and work collaboratively todeliver patient care. Critically, it is the site ofprofessional socialization, where professionalidentity is shaped. Finding ways to supportsuch development while meeting patientneeds is a challenge for clinical teachers.One way to address this is to put aside thetypes of teaching developed for the classroomand provide learning opportunitiesthat are compatible with the workplace.Learning as participationIt is helpful to distinguish conceptions oflearning as ‘acquisition’ (of knowledge orMrs Clare Morris is Associate Dean,Bedfordshire and Hertfordshire PostgraduateMedical School, University of Bedfordshire,Luton LU2 8LEskills) from those that see learning as ‘participation’in workplace practices and cultures(Bleakley, 2002; Swanwick, 2005).Learning as acquisition drives learnersfrom the workplace into classrooms andleads to clinics and theatre lists over-runningas clinicians attempt to ‘teach’ studentsbetween patients or procedures.Learning as participation opens up newopportunities for learning while working.In the 1980s, Kolb represented this type oflearning as a cycle (Figure 1) which focussedon the types of experiences learners hadand how they made sense of these experiences(Koln, 1984). The influence of thistype of thinking can be seen in the increasinguse of case-based discussion as anassessment tool and in the wholesale adoptionof ‘reflective portfolios’ in training.Kolb’s cycle provides a framework toconsider what needs to happen beyond‘doing something’ for learning to takeplace. This model poses two risks: implyingthat experiential learning is an individualpursuit divorced from context anddownplaying the complexity of learning inand through experience and the role playedby the clinical teacher.Sociocultural learning theoriesMore recently, attention has turned tosociocultural theories of learning and conceptssuch as ‘communities of practice’ and‘situated learning’ (Wenger, 1998; LaveFigure 1. Kolb’s learning cycle. From Kolb (1984).Abstract conceptualizationActive experimentationReflective observationand Wenger, 2003). These theories seelearning not as an individual pursuit but assomething that happens through engagementin shared activities and practices.Drawing on this viewpoint, distinctionsbetween medical learning and working areartificial creating implications for thosewho support learning in the workplace(Bleakley, 2002, 2006; Swanwick, 2005).So, for example, when clinicians gatherround the bedside to talk to patientsand discuss their progress and managementwith members of the team, theyare engaged in both a working and learningactivity. Their understandings of oneanother, their patients and their illnessesare influenced by the conversationsaround the bed and by the notes made,which become part of workplace-basedlearning.Clinical teachers therefore need to makethis learning more explicit to trainees, tohelp them recognize that they are learning‘how to do the job’ by ‘doing the job’. Theextent to which it is possible to learnthrough work activity is influenced byrecognizing and making explicit the learningembedded in everyday practice.Facilitating learning in theworkplaceIn the following sections, key ideas arisingfrom these theories are identified and theimplications for practice explored.Concrete experience48 British Journal of Hospital Medicine, January 2010, Vol 71, No 1BJHM_48_50_CTME_Workplace.indd 48 23/12/09 16:50:44

Clinical Teaching Made EasyLearning is part of everyday lifeIf learning is seen as an integral part ofworking, clinical teachers need to makethe learning more explicit by identifyingspecific workplace cultures and practicesand helping learners ‘make sense’ of whatthey see, hear, sense and do. Strategiesinclude:• Label the learning opportunity, e.g. ‘wehave a theatre list this afternoon and weneed to consent patients this morning. Itwould be a great opportunity for you tolearn more about how to explain proceduresand gaining patient consent.’• Establish prior experience and negotiatea learning goal, e.g. ‘so, you haveexperience of consenting patients forroutine procedures, so why don’t wework together this morning to consentpatients about to undergo more complexprocedures, with the aim beingthat you will be able to do this independentlynext time?’• Prime for learning through observing,e.g. ‘in clinic this morning we are likelyto see patients who are booked in forcaesarean section. While you observe,notice the reasons given for requestingelective section and consider how youwould respond if in my shoes.’• Workplace-based assessment tools canbe used to identify opportunities forlearning and development throughworkplace-based activity, e.g. ‘I noticedyou were struggling with putting inthat line, why don’t you arrange towork with one of the anaesthetists forthe day and get some extra experiencein theatre?’Workplaces need to be madeinvitational for all learnersStudents and trainees who are made to feelwelcome are more likely to actively engagein the full range of learning opportunitiesprovided and to seek to play an active rolein the team. Simple strategies like ensuringstudents are introduced by name, have aperiod of orientation to the workplace andthe roles of other team members can makea big difference. Billett (2002, 2004) suggeststhat workplaces are not necessarily‘invitational’ to all learners, and may beshaped, for example, by students’ priorexperiences, their gender, socioeconomicbackground or apparent differences inmotivation, enthusiasm or interest.Clinical teachers need to create the rightconditions for learning and ensure certaintypes of learners are not disadvantaged.For example, trainees who seem to lackinterest, confidence or capability for aparticular specialty need just as muchopportunity to participate (if not more)than those who have a natural flair orinterest.Learning happens in acommunity of practiceTeams can be seen as potential ‘communitiesof practice’ (Lave and Wenger, 2003),identified by common interests and sharedexpertise. To make the most of that expertise,all members of the community shouldbe engaged in supporting learning.Learners readily identify colleagues, teammembers, patients and carers who helpthem ‘fit in’ to new settings and who makepositive contributions to their learning.These individuals may not have a formallyrecognized teaching role, for example:• Patient feedback is very powerful inreinforcing practice or seeking newways to do things• Students and trainees learn from eachother (‘I find it helpful to hold it thisway’) and share experiences (‘I saw agreat case in theatre yesterday’)• Junior medical staff guide less experiencedcolleagues in ways of examiningpatients, interpreting charts or testresults and prioritizing workloads• Nursing colleagues help newcomers getto grips with ward procedures and protocolsand identify ways to effectivelywork with particular team members.By acknowledging the role played by allmembers of your community and valuingit explicitly, learners are encouraged tolook beyond their immediate supervisorfor guidance.Learning happens throughparticipationLearning is most effective when learnersare given opportunities to engage activelyin real workplace activity. Such opportunitiesare bounded by competing demands,concerns and priorities, the complexity ofthe activity, the potential risks involved,the competence and confidence of thelearner, the time available and the willingness(and consent) of patients to beinvolved. With adequate preparation and‘safety netting’, clinical teachers can delegatesome complete tasks to learnerswhereas other opportunities require teachersto work in parallel with learners, delegatingappropriate aspects of work in orderto increase confidence and competence.One of the ways in which teachers can‘safety net’ is through learning needs analysis(McKimm and Swanwick, 2009). Abrief yet really focussed conversation witha trainee can inform decision makingabout what to delegate and appropriatesupport strategies. This will usually includefinding out what the trainee knows, whathe/she has done before that is of relevance,any concerns or anxieties he/she has aboutwhat is proposed and an offer of back-upsupport (a rescue strategy) to be used ifthings don’t go according to plan.For example, a trainee might not yet beready to perform a complete surgical procedure.He/she may, however, be ready totake the history, perform the examination,consent the patient, prep the patient andperform one part of the procedure, monitorin recovery and write up the charts.This gives the trainee a sense of takingresponsibility for the patient’s managementand time to focus his/her attentionfully on the aspects he/she is not yet doing,but might do next time.Workplace-based assessments provide aprofile of trainee performance, enablingthe clinical teacher to spot obvious gaps ineither experience or competence. Thesegaps can become the focus on clinicalteaching, with the trainee being guided toexperiences that help meet their developmentneeds.Fostering ‘horizontal’ learning‘Learning in work-based contextsinvolves students having to come toterms with a dual agenda. They notonly have to learn how to draw upontheir formal learning and use it tointerrogate workplace practices; theyalso have to learn how to participatein workplace activities and cultures’(Griffiths and Guile, 1999).Formal education tends to focus on ‘vertical’learning, the accumulation of knowledge.In the workplace, ‘horizontal’ learning,taking what you know to make senseof the situations you encounter or adaptingwhat you can already do to fit anunexpected presentation is just as impor-British Journal of Hospital Medicine, January 2010, Vol 71, No 1 49BJHM_48_50_CTME_Workplace.indd 49 23/12/09 16:50:45

CliniCal TeaChing Made easytant. Medical students and trainees moverapidly from one workplace to another andneed to identify and respond to the nuanceddifferences between one setting or teamand another. For example, all doctors routinelytake a history from their patients,but there are significant differences inapproach across specialties and settings.Clinical teachers can help this process bymaking expectations explicit (e.g. preferredstyles of dress, ways of addressing colleaguesand patients, format for writing innotes or constructing letters).Horizontal learning also needs to helplearners activate their formal learning(gained in the classroom) to make sense ofclinical encounters. Viewing teaching as adialogue (rather than a monologue) andusing appropriate questioning strategies isparticularly effective. Socratic questionscan be used to explore what learners knowand help them make connections to whatthey see. Heuristic-type questions, designedto promote the student’s own self-directedlearning, are also important.Learning through talkingSocial learning theorists suggest that ‘talk’is a central part of practice. Learners needto ‘learn to talk their way into expertise’rather than just learn from the talk of anexpert (Lave and Wenger, 2003).Many aspects of medical practice areunseen, taking place in the minds of practitioners,engaged in an internal dialogueKEY POINTS• Make sure your workplace is invitational for all students and trainees.• Make opportunities for learning from everyday work explicit.based around differential diagnosis, clinicalreasoning, management planning andexploring prognosis. Clinical teachers needto find ways to make their thinking accessibleto the trainee and access the trainee’sthinking as a way of ensuring he/she is ontrack. Strategies include:‘Thinking aloud’Narratives can be provided as we teach askill or procedure, or along the lines of‘what I am struggling with here is…’ or ‘Iam weighing up the options of x vs ybecause...’.Trainee talkMany clinical teachers have set ways theylike trainees to present patients, reflectingways in which thoughts are organized inorder to formulate a diagnosis or managementplan. By being clear with trainees thatthis talking prompts a way of thinking, youare labelling it as a teaching strategy ratherthan a personal quirk and helping learnersto gain insight into how medicine is practisedin specific contexts. These ways oftalking about patients reveal cultural practices.For example, the way a patient ispresented in surgery is different from medicinewhich is different from psychiatry.Case-based discussionThis is designed to explore the thinkingbehind practice. It provides an opportunityfor learners to make their thinking explicit• Provide opportunities for learners to be actively involved in all aspects of patient care.• Value and make use of the expertise of all members of your community, including patients.• Help trainees to learn from your talk and to learn to talk medicine.and develop ideas. Clinical teachers canmake the most of these opportunities byusing questions that require the trainee toprovide a rationale for decision-making.For example, ‘you decided to admit thispatient, can you tell me more about thefactors that you took into account… howmight you justify sending this same patienthome… who else in the team did youinvolve or could you involve in that decision-makingprocess?’ConclusionsWorkplace-based learning might be underthreat, but it has never been more important.By drawing upon contemporary viewson workplace-based learning, clinicians canbuild upon the sound traditions of apprenticeshipand value the workplace as a key sitefor medical learning and practice. BJHMConflict of interest: none.Billett S (2002) Toward a workplace pedagogy:guidance, participation and engagement. AdultEducation Quarterly 53(1): 27–43Billett S (2004) Workplace participatory practices:conceptualising workplaces as learningenvironments. Journal of Workplace Learning16(6): 312–24Bleakley A (2002) Pre-registration house officers andward based learning: a new apprenticeship model.Med Educ 36: 9–15Bleakley A (2006) Broadening conceptions oflearning in medical education: the message fromteam-working. Med Educ 40(2): 150–7Griffiths T, Guile D (1999) Pedagogy in workbasedcontexts. In: Mortimore P, ed. UnderstandingPedagogy and it’s impact on learning. Sage,London: 155–74Kolb D (1984) Experiential Learning. Prentice Hall,Englewood Cliffs, NJLave J, Wenger E (2003) Situated Learning:Legitimate Peripheral Participation. CambridgeUniversity Press, CambridgeMcKimm J, Swanwick T (2009) Assessing learningneeds. Br J Hosp Med 70(6): 290–3Swanwick T (2005) Informal learning inpostgraduate medical education: from cognitivismto ‘culturism’. Med Educ 39(8): 859–65Wenger E (1998) Communities of Practice: Learning,Meaning and Identity. Cambridge University Press,CambridgeThis series of articles for clinical teachers was originally commissioned as a suite of e-learning modules for the London Deanery. Both the series and e-learningmodules were designed and edited by Judy McKimm and Tim Swanwick. The London Deanery e-learning modules for clinical teachers are open access andavailable at www.londondeanery.ac.uk/facultydevelopmentEach module takes 30–60 minutes to complete and proof of completion is available in the form of a printed certificate. Forthcoming articles in this series include:Teaching clinical skills Simulation Involving patients in clinical teachingInterprofessional education Managing poor performance Introduction to educational researchDiversity, equal opportunities and human rights50 British Journal of Hospital Medicine, January 2010, Vol 71, No 1BJHM_48_50_CTME_Workplace.indd 50 23/12/09 16:50:51