Workplace learning and communities of practice for medical professionals 1

Essay for the “Developing supervisory and professional practice” workshop at Institute of Education, London (Master of Arts in Clinical Education) Workshop tutor: Dr. David Guile

(3227 words) Title
Learning as the development of expertise for medical professionals in their clinical workplace Akira Naito

… “innovation” in organizational practice can be understood not as some extraordinary marginal feature of the changing social organization of work but within the “commonplace” of improvisation that occur[s] in ordinary everyday practice. (p. 252) David Middleton, 1998

Although concerned with the continuity of that practice or community, rather than individual learning, the structuring of these experiences [i.e. their workplace activities] is often inherently pedagogic … that is how individuals engage in the inter-psychological process of thinking-acting-learning through (workplace) activities. (p.115-116) Stephen Billett, 2004

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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 of their time, and where most ongoing learning occurs.

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 strategies that are integrated within the workplace.

In addition to several structures of formal learning arrangements (such as conferences, workshops, institutional-meetings and ward rounds), the process of professional development 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 [Evans et al., 2006; Rainbird et al., 2004].’

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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 learning as the development of one’s expertise in the workplace alongside professional practice.

Learning in and through the workplace

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 possible. It is mandatory for every member of the healthcare community to make a contribution to this project, in other words, all practitioners are inevitably required to participate and be engaged in their clinical practice.

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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, ‘old-timers (experienced workers)’ as well as ‘new-comers’ within their communities of 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]: (1) Practice [cognitive and behavioural assets] - operating shared processes/procedures, problem-solving strategies, and implementing shared goals; (2) Community [socio-cultural and managerial assets] – belonging to a community as a member, and acquiring cultural attributes in order to communicate with each other; (3) Meaning [attitudinal and affective assets) – experiencing/negotiating shared values, beliefs, priorities, and common stories; and (4) Identity [ontological and pragmatic assets] – becoming an independent professional self and specifying a role in one’s community. 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

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human capacities.” (p.15) Therefore, it was indicated that an individuals’ learning as ‘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 the development of expertise in the workplace’ in each domain.

Practice as a teamwork in the workplace

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 and involves multidisciplinary professionals across a variety of professional specialities and 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 of practice, which necessitates and employs a range of collaborative teamwork activities [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

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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, ‘workplace affordance.’ By this affordance he means the capability of living in tensions, particularly the capability of being able to reconcile contestations between their interests and to negotiate amongst affiliate members, which constantly generate conflicts between power and personal politics in the workplace.

The reconciling process is a necessary component of maintaining and improving one’s performance in the workplace. Middleton (1998) also reported observations of the process of negotiation on various conflicts, and analysed those clinical multi-professionals’ talking including their unplanned ‘corridor talks’:

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 particular cases and in terms of team procedures in general. (p.252)

Middleton concluded that this informal process is essential for team to progress their practice, and therefore is imperative for individuals’ learning.

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Community as a learning environment

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. Therefore, ‘knot-working’ is a task-oriented combination of people and contents of tasks, and 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 involvement change over the course of workplace activities.

Engeström emphasised the importance of the nature of the change/dynamism (and frangibility/frailty) in workplace activities as part of ongoing learning, and highlighted this by 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 enhance employees’ knot-working collaborations in a constant process of the changes/coconfigurations, he also introduced the concept of ‘expansive learning environment’. This notion of ‘expansive learning’ was proposed from his “activity theory (third generation)” originated from Vygotsky’s model of cultural ‘mediation of action’, expressed as an interdependent triadic relationships between subject, object, and mediating artefact [Engeström, 2001].

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Fuller and Unwin (2004) have utilised the notion of ‘expansive learning’ and extended this with the opposed notion of ‘restrictive learning’ to create a continuum to describe an individual professional’s learning as a development of his/her expertise:

In contrast to Engeström’s concentration on organizational learning, the focus of our conceptualization of expansive - restrictive approaches … is on ‘people’ and ‘learning (workforce development)’. (p.131)

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:

1. Chance to engage in multiple and overlapping communities of practice at and beyond the workplace; 2. Chance to pursue underpinning and theoretical knowledge through participation in one’s practice and by formal off-the-job trainings; and 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 an adequate learning environment. The next section summarises, as an example, an approach that uses this continuum as a methodology to examine and improve learning environment.

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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 better workforce development. As they note,

… Evidence from empirical research suggests that an expansive approach to workforce development is likely to increase the quantity and range of opportunities for participation and for employee learning. (p.131)

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 narrow view of learning.

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Evans and colleagues (2006) also summarised the primary organizational and cultural barriers for workplace learning:

A heavy reliance on economy-of-scale advantages, i.e. cost-based competition, which may promote low trust relationships;

People-management systems that emphasize command, control and surveillance, i.e. an underlying belief that people are a cost or a disposable factor of production;

Standardized products and services with hierarchical management structures, which enhance a culture of blame, where mistakes are punished, and which also lead to have little slack or space for creativity.

Having identified and summarised these key empirical findings, they then proposed a fivestage 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 environment [Evans et al., 2006: 169-172]:

1. Identify dimensions/categories (and sub-categories) for the target group of individual workers to examine and to improve their learning environment; 2. Identify the current position of the workplace in the continuum against those determined dimensions separately; 3. Identify potential dimensions for improving learning environment and possible changes within and across those dimensions;

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4. Identify the balance of advantages and disadvantages against each possible changes/effects on each levels of both parties, i.e. employees and employers, to find mutual benefits; and 5. Implement a plan for improvement, and monitoring the course of changes, althoug assessment should be performed in a long-term timeframe and a wide view of learning.

Meaning of knowledge: horizontal vs. vertical discourses

The process of learning in an expansive approach has been described as ‘horizontal or 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 viewed as advancing/climbing-up the ladders of knowledge/expertise which has a hierarchical 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

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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]:

… a new generation of expertise … not based on ‘supreme and stable individual knowledge and ability’ but on ‘the capacity to cross boundaries and to negotiate and improvise “knots” of collaborations in meeting constantly changing challenges ...’ (p.143)

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 form of a coherent, explicit, and systematically principled structure, hierarchically organised, as in the sciences, or … a series of specialised languages with specialised modes of interrogation and specialised criteria for the production and circulation of texts as in the social sciences and humanities. [Bernstein, 1999: 4]”

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In summary, it may be useful to consider the learning as development of expertise in two 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 relatively recently, particularly in a modern interactive society where multi-disciplinary professionals collaborate. These conceptions provide new ways of learning and therefore embrace a large spectrum of professional learning/development, and also serve as a useful perspective to help create more effective strategies for learning as developing expertise in the workplace.

Specifying identity in learning/participating as a role in the community of practice

In discourses of ‘expansive learning’, the importance of ‘contradictions’ is emphasised as a 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 learning process … is the conflictual “questioning” of the existing standard practice. … This led to deepening “analyses” of the cases, and eventually to sharpener and more articulated questioning. (p.151)

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Engeström noted that the process of resolving contradictions comprises of four steps in the course of expansive learning:

(1) A need to be explicit in clarifying contradictions by a series of questionings; (2) Creating double-bind structure through historical (conceptual) and empirical analyses; (3) Resistance against proposed changes emerges when a new model is presented; (4) Realignment with neighbours occurs alongside implementation and reflections, leading to consolidation into a new practice.

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 configurations in their community to become an independent professional self and to specify his/her own role.

Evans et al. (2006) also pointed out the importance of one’s personal history of accesses/exposures to learning opportunities since that is a unique and different individual’s 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 opportunities, and which can be divided into regions and frameworks.

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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 ‘horizontal or sideways’ (socio-cultural) viewpoint; and (2) qualification-related, interestrelated, power-related or relationship-related (motivation-oriented) division of framework in 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, and thereafter they result in new configurations.

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 coherent course of actions in reconciliation and configurations of (cognitive/intra-personal and social/inter-personal) conflicts and contradictions he/she encountered.


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 dimensions Evans et al. (2006) proposed, with an emphasis on ‘participation’ as an important

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learning process. The discussions also considered in terms of two dominant perspectives - a ‘cognitive’ (content-based) and ‘socio-cultural’ (context/interaction based) perspectives. However, most of the discussion focused on the latter perspective. Analytical approaches directing both perspectives, in vertical and horizontal knowledge in the Bernstein’s nomenclature, were suggested as a way to embrace the bigger picture of

learning/development in the workplace. Further consideration regarding ‘vertical’ approaches and discussion on ways to take into account both directional approaches concurrently, however, may be necessary to attain this ultimate goal.


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Lave, J., and Wenger, E. (1991). Situated learning : legitimate peripheral participation. Cambridge [England] ; New York: Cambridge University Press. Middleton, D. (1998). Talking work: Argument, common knowledge, and improvisation in team work. In Engestroem, Y. and Middleton, D. (Eds.), Cognition and communication at work (Pbk. ed., pp. ix, 346 p.). Cambridge ; New York, NY, USA: Cambridge University Press. Rainbird, H., Fuller, A., and Munro, A. (Eds.). (2004). Workplace learning in context. London: Routeledge. Smith, L. (2006). Workload, sleep loss and shift work. In Cox, J., King, J., Hutchinson, A. and McAvoy, P. (Eds.), Understanding Doctors' Performance (pp. 134-151). Oxford: Radcliffe Publishing Ltd. Wenger, E. (1998). Communities of practice : learning, meaning, and identity. Cambridge, U.K. ; New York, N.Y.: Cambridge University Press. West, M., and Borrill, C. (2006). The influence of team working. In Cox, J., King, J., Hutchinson, A. and McAvoy, P. (Eds.), Understanding Doctors' Performance (pp. 106-122). Oxford: Radcliffe Publishing Ltd.

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