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Developing professional competence: Lessons from the emergency room

Valerie Wilson a; Anne Pirrie b
a
The Scottish Office Education & Industry Department Educational Research Unit, Edinburgh, UK b Moray
House Institute of Education, University of Edinburgh, Edinburgh, UK

Online Publication Date: 01 January 1999

To cite this Article Wilson, Valerie and Pirrie, Anne(1999)'Developing professional competence: Lessons from the emergency
room',Studies in Higher Education,24:2,211 — 224
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URL: http://dx.doi.org/10.1080/03075079912331379898

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 Studies in Higher Education Volume 24, No. 2, 1999 211

Developing Professional
Competence: lessons from the
emergency room
VALERIE W I L S O N
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The Scottish Office Education & Industry Department Educational Research Unit, Edinburgh,
UK

A N N E PIRRIE
Moray House Institute of Education, University of Edinburgh, Edinburgh, UK

ABSTRACT This article begins by reassessing the nature and value of practice-based learning in the
health professions. The role and status of work-based learning are then examined in the context of
recent policy developments in the field of health care. The authors report the findings from a 1-year
qualitative study of clinicians' perceptions of the workplace as an environment for learning, funded
by the Scottish Council for Postgraduate Medical and Dental Education (SCPMDE). Focusing in
particular upon in-depth interviews with junior and senior clinicians in two hospital specialties, they
explore the process through which novice clinicians become part of a "community of practice" and
their senior colleagues continue to learn in an environment which poses fewer professional challenges.
Finally, the implications for the development of competent professionals are discussed.

Introduction

The development, maintenance and assessment of professional competence have long been
the subject of debate in higher education (Eraut, 1985, 1994; Barnett et al., 1987; Barnett,
1994; Gear et at., 1994; Becher, 1994; Hytand, 1994; Rolls, 1997). As Wolf (1995) points
out, the medical profession 'is also moving towards increasing use of competence-oriented
assessment, with the development of complex problem-solving scenarios and simulations' (p.
94). (See also the recommendations in Lowry, 1993.) However, opportunities for profession-
als to learn are not restricted to formal settings within higher education institutions [1]. It is
also widely acknowledged (see Eraut, 1994) that learning from experience is as much a part
of becoming a proficient (and subsequently, perhaps, an expert) practitioner as assimilating
propositional knowledge [2]. However, as those involved in health care rarely exercise their
profession in isolation, 'learning from experience' implies learning from one's colleagues. The
recognition that practitioners working in parallel fields (for example, nursing, physiotherapy
and occupational therapy) deploy a range of skills which are complementary and overlapping
has found its ultimate expression in the development of National Occupational Standards,
e.g. National Vocational Qualifications, (NVQs) and Scottish Vocational Qualifications
(SVQs) for the health care professions [3]. The role of NVQs/SVQs in promoting the
development of a 'seamless' service, supported by various forms of 'shared learning' has been
widely documented (see Hevey, 1992; Barr, 1994; Mathias & Thompson, 1997).

0307-5079/99/020211-14 © 1999 Society for Research into Higher Education

 212 V. Wilson & A. Ih'rn'e

T h e notion of 'apprenticeship' is frequently adduced as one way of explaining how

professionals learn in the context of the workplace. Yet as Lave & Wenger (I 991) point out,
the term is in danger of becoming 'yet another panacea for a broad spectrum of learning-
research problems, and [is] in danger of becoming meaningless' (p. 30). By exploring the
relationship between the largely metaphorical use of the term in educational research and
historical forms of apprenticeship, they develop the notion of 'legitimate peripheral partici-
pation' to explain how professional learning occurs. T h e radical feature of this concept is its
holism, and its reconceptualisation of learning as a social process. T h e distinctions between
formal and informal fall away; the individual, their activity, and the context in which they
operate are viewed as mutually constitutive. T h e now almost hallowed distinction between
'knowing how' and 'knowing that' (Ryle, 1962; Kolb, 1984; Dreyfus & Dreyfus, 1986) also
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begins to look less persuasive.

Lave & Wenger's conceptualisation of 'learning in doing' overcomes the distinction
posited by Barnett (1994) between a version of competence based upon knowledge of
disciplines, which has been displaced in many higher education institutions by a newer
version characterised by know-how, competence and skills. It would appear that the twin
processes of modutarisation and credit accumulation and transfer have fragmented the
learning experiences of many students in higher education. As Barnett (1994) notes, there are
'no credit points from attempting to bring one's separate units into a relationship with each
other; so why do it?' (t9. 129). Thus, learners" active engagement with their educational
experiences, which provides the key to transforming both the experience and themselves
(in our case into competent doctors) is discouraged by a system which atomises those
experiences.
How, then, are we to make sense of developing professional competence? One of the
criticisms of 'learning-on-the-job' in the context of health care delivery is that the demands
of service provision are paramount, and that this in itself prejudices the quality of learning.
H o w can opportunities to acquire knowledge, practise developing skills--to become, in short,
'part of a community of practice' (Lave & Wenger, 1991, p. 29) be reconciled with the busy
schedules of health professionals, particularly when the context in which they learn has for so
long been dominated by the overarching concept of an internal market? These are some of
the issues which a team of researchers from the Scottish Council for Research in Education
(SCRE) addressed in an exploration of learning in a sample of health care organisations in
Scotland during 1996. Before we turn to our findings, let us briefly oufline the broader
context in which the professional development of those involved in health care is located.

Background to the Study

As patients, and prospective patients, of the,National Health Service (NHS), we cannot but
he aware of the radical changes which it has undergone in the past decade. The genesis of
many of the changes is associated with Allan Enthoven, a professor of economics at Stanford
University. He once described himself as 'a visitor from M a r s ' - - a n interesting metaphor for
a consultant to a former Minister of H e a l t h - - a n d was tasked with conducting 'a sympathetic
review of some problems of organisation and management in the National Health Service'
(Enthoven, 1985, p. 1). H e suggested that the N H S was caught in a 'gridlock' of forces that
made change exceedingly difficult to bring about. Nevertheless, proposals for radical change,
such as conversion to a private insurance-based scheme for financing health care, were both
totally unrealistic and politically unacceptable, given the current level of popularity of the
Health Service. However, he recommended the adoption of a modified market model:
 Developing Professional Competence 213

I believe that the Internal Market Model [between purchasers and providers of
health care] offers substantial improvements over the present N H S structure ...
When all the alternatives have been considered, it becomes apparent that there is
nothing like a competitive market to motivate quality and economy of service. (p.
42)

Such suggestions clearly caught the imagination of politicians because they appeared to offer
solutions to intractable problems. They also reflected the beliefs about the market which were
so pervasive at the time. As Gewirtz et al. (1995) point out, the 'market solution currently
holds politicians around the world in its thrall' (p. 1). This was largely because it appeared
to offer them all the benefits of being seen to act decisively, but without the risk of being
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blamed when things went wrong.

It is assumed that the market is a mechanism which will produce its own order.
Consumers purchase goods and services from providers, who in turn produce more goods
and services to meet the demands and expectations of consumers. Those who cannot
produce sufficient goods of the requisite quality will cease to trade. Can this theory, however,
be applied to services which have previously been organised according to a public service
ethos? In a different area of social policy, Gewirtz et al. (1995) note that while schools in
England have been forced to accept the 'paraphernalia of a market system' (and we would
also suggest the discourse of a market analogue), the reality is somewhat different. Implemen-
tation is strongly politically regulated, giving rise to 'quasi-markets'. Additionally, there is no
evidence that managed markets actually produce the predicted economies and quality
standards. With specific reference to health care, Enthoven (1985) admits that the USA,
where health care is funded largely by private insurance schemes, spends 11% of its gross
national product on health care, compared with only 5.5% in Britain. Claims that the market
per se wilt inevitably produce economies begin to look specious.
It is not our intention here to debate the efficacy of the 'internal market' in health care
created by the White Paper Working for Patients (Department of Health, 1989), but rather to
note its implications for continuing professional education. First, the principle of a managed
market, manifest in the 'purchaser-provider' split, constitutes the dominant paradigm in
which this research is sited. Staff at all levels have been affected: a new 'managerialism'
pervades the system. As Calnan & Williams (1995) argue, there is now greater emphasis on
the planning of policy and the setting of targets, managing and facilitating the implemen-
tation of policy, and monitoring performance. All of these developments have their analogues
in the education sector. In health care, what this 'market' amounts to is that:

G P fundholders are encouraged to compete for patients and to bargain with

hospitals and other provider units, thereby creating competition between these
providers of health care for G P contracts. (Calnan & Williams, 1995, p. 221)

Second, structural changes in the system, together with an emphasis on consumer rights
(see, for example, The Patient's Charter, [Scottish Office, 1990]), represent a challenge to the
dominance of the medical profession: a shift from a culture based upon medical authority to
'articulate consumerism'. T h e implications for staff development and training are obvious.
N o t only does the adoption of a market model carry a heavy political agenda, namely the
deconstrnction of the principles of collective responsibility embedded in the welfare state (see
Ball, 1991), but also the replacement of professional control by managerial control. Service-
level agreements link purchasers to providers in a chain of performance management in which
junior hospital doctors are the mainstay of service delivery. We see from our research that this
may be inimical to their role as learners. It has also given rise to a growing unease at the
 214 [7. Wilson & A . Pirrie

process by which junior doctors, who are learning how to be competent professionals, are
trained and employed. F r o m a researcher's point of view, we had to remind ourselves that our
respondents, often bleary-eyed senior house officers at the end of a night shift, were actually
professionals in training 'apprenticed' to more senior colleagues. In a study of senior house
officers' perceptions of formal postgraduate education, Grant et al. (1992) identified a cluster
of interrelated factors which inhibited continuing education. These were encapsulated by the
central dilemma, a 'conflict between the demands of clinical work (patient care) on the one
hand, and the need for education and training on the other' (p. 43). T h e following quotations
from junior and staff grade doctors clearly demonstrate the deleterious effects of this potential
conflict of interest:
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... if y o u ' d been psychologically beaten up in hospital ... well you're supposed to be
open and honest [educationally] ... when a hospital environment is very m u c h cover
up what you d o n ' t know ...

... the way we work ... with shifts and a heavy on-call c o m m i t m e n t ... I've got to
be aware that m y enthusiasm for being out of m y bed at night may wane ...

However, these structural changes to the service have implications not only for junior
doctors; the role o f more senior clinicians is also affected. Consultants have been required to
add managerial responsibilities to their traditional clinical and teaching roles. This clearly has
an impact u p o n the a m o u n t of time they are available for teaching. I n addition, the European
Commission expressed its concern about the U K system of training for, and recognition of,
specialist medical qualifications. This led directly to the establishment of a committee to
consider the present training arrangements (Department of Health, 1993 [The Caiman
Report]). T h e committee r e c o m m e n d e d that specialist training should have a defined starting
and finishing date; structured curricula; and that a range of fundamental principles encom-
passing flexibility, choice~ completion and assessment on merit, should be built into new
training programmes. These changes were to be determined by T h e Medical and Surgical
Royal Colleges and the regional Postgraduate Deans and implemented as soon as possible.
T h e research reported here is a reflection of continuing medical education in a period of
transition. We were witnessing the gradual evolution from a system predicated on 6-monthly
rotations, u n d e r which junior doctors could be employed on a series of short contracts often
within various specialties in different hospitals, towards one based on specialist training.
These changes were clearly evident in some sites. Some hospital-based respondents were
employed in new career grade training posts, while others were forced to seek new posts every
6 months. T h e sense of discontinuity that this entailed was a marked feature of their
experience.

The Research Project

This is the background against which the research reported here was commissioned. T h e
main aims of the study were to explore the concept of a 'learning organisation' within a
sample of community and hospital-based organisations; and to identify the structures, values,
behaviours and activities which support continuing professional development. T h e funder,
the Scottish Council for Postgraduate Medical and Dental Education ( S C P M D E ) , antici-
pated that the results would be of interest to a disparate range of organisations including
universities, health care trusts and others with responsibility for continuing professional
development in health care.
T h e research was sited within 10 health care organisations in Scotland, which were
 Developing Professional Competence 215

selected as five matched pairs. These included examples from each of the following: general
medical practice, general dental practice, accident and emergency (A & E), obstetrics and
gynaecology, and laboratory medicine. The methodology was qualitative, which stands in
marked contrast to the dominant paradigm in medical research. We adopted a two-stage
approach. This included observations, and in-depth interviews with a random sample of staff
in the 10 sites. The fieldwork was conducted by three researchers between October 1995 and
April 1996. This process yielded a total of 72 interviews, each of which was fully transcribed
and analysed with the aid of a computer package (Hypersoft). During the second phase of the
study, conducted in June 1996, emerging issues were fed back to respondents as a means of
respondent validation (Cohen & Manion, 1989). This offered participants the opportunity to
comment on the researchers' perceptions and provided feedback to participating organisa-
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tions. The findings from both stages are reported here.

Working with Experienced Colleagues

Despite attempts to restructure and ibrmalise continuing education and training for medical
staff (Department of Health, 1993), data from our research suggest that learning within
health care is still dominated by traditional models of 'apprenticeship' and serendipity. These
two factors were identified by many respondents. Encouragingly, most junior staff recognised
the necessity of continuing education and the paucity of the 'front-end' model of education:
registration and/or graduation were perceived as the end of one stage, essentially based upon
the acquisition of theoretical knowledge (see Ryle, 1962) and marked the beginning of
another distinct phase. As one dental associate reported, 'There are so many things that you
don't know about when you come into practice'. In this situation, the role of more
experienced colleagues is crucial. However, being under close scrutiny could lead to feelings
of uncertainty and an increasing awareness of deficiencies in both knowledge and skill. One
general medical practitioner referred to such continuous scrutiny as "just a nightmare having
people watching you'. Being aware of the limitations of one's own knowledge was a pervading
theme in the data. For example, a junior doctor in obstetrics and gynaecology described how
as a trainee she could: 'always pop out of the surgery on the pretext of I just need to check
something and then you could just phone one of the others [medical partners]'. The theme
of uncertainty was graphically recorded by another senior house officer (SHO) as 'going
through terrors and horrors' of being pressured into making decisions beyond her com-
petence. She attributed this to her initial training, when she and her peers had 'sort of looked
at consultants a little bit like gods and maybe we were a bit afraid to approach them and ask
them questions'.
There is some evidence that these stereotypical views are beginning to break down in
practice. A number of junior staff in five sites perceived their senior colleagues to be not only
'good clinicians', who were able to model 'good practice', but also 'very approachable'. One
SHO in obstetrics and gynaecology recalled how:

... if you have a question to ask about a patient, you can ask it. If they're
[consultants] in their office you can ring them. They don't say 'why didn't you go
through the registrar?' There's no upper channel. If it's about a patient and you've
a question to ask, you can ask.

Respondents reported learning from a variety of colleagues: senior members of their own
profession, 'middle graders', peers and members of other professions. However, in most
cases, traditional models, based upon notions of 'apprenticeship' and 'learning by watching'
senior colleagues in the same profession were evident. A number of senior medical staff
 216 V. Wilson & A. Pirrie

articulated the medical variant of the 'apprenticeship model' of learning. Although they
acknowledged its limitations, in particular its capacity to generate uncertainty and a debilitat-
ing awareness of deficiencies in knowledge, they basically considered that what had been
good enough for them was good enough for the junior doctors in their charge. The spurious
legitimacy of the model was thus perpetuated and reinforced. One consultant in laboratory
medicine recalled his own training as "being apprentice to this person [a national expert] ...
the deal was then that I was shown the material [samples] and very much apprenticed ... for
what turned out to be a large number of years until she retired'. 'Situated learning' is the term
used by Lave & Wenger (1991) to describe a stage on the way to 'legitimate peripheral
participation'. In the first case, cognitive processes (and thus learning) are primary, although
the novice may be called upon to assist. In the second, clinical (and social) practice is the
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primary phenomenon, and learning is an integral part of this. There is, however, no
straightforward binary opposition between legitimate and illegitimate, peripheral and central,
participation and non-participation. There are as many intermediate states as there are
clinical circumstances, and the demands of the service are a significant determinant of the
degree of participation.
There is evidence to suggest that professions learn not only from members of their own
profession but also from others (see Jones, 1986). In the study we report here, experienced
nurses played an important, but not necessarily formally recognised, rote in the education of
junior doctors. The presence of more experienced nurses was welcomed by a number of
junior doctors. One in obstetrics and gynaecology suggested that experienced nurses on the
ward are vital to SHOs because their knowledge and experience helped inexperienced doctors
develop a sense of 'what's mundane and routine and what's essential to get on top of or else
it can get out of hand'. Very occasionally, experienced nurses were the only source of advice:
an S H O in A & E recalled a situation in which 'it was only the nurses you could ask, because
they were the only other people who were there'. Serendipity--simply being in the right place
at the right time--also played a part in providing novice practitioners with opportunities to
develop their clinical acumen.

Availability of Consultants
In the course of their training, junior doctors are exposed to the differing practice of several
consultants in a variety of hospitals. Some younger respondents had already formed very firm
opinions about what makes a 'good' consultant. For example, a registrar in obstetrics and
gynaecology was able to compare current conditions within a Scottish hospital with her
previous experiences in England:
In the other hospitals, they [the consultants] were all too busy and they didn't have
teaching time and some people didn't really like teaching ... and maybe they have
too much private work.
T h e lack of consultant time has potentially serious consequences--not only for patients, in
that survival rates improve if seriously injured people are seen by senior staff--but also for
junior doctors' career progression. One registrar in obstetrics and gynaecology reported
having received no help with Royal College examination preparation in her previous hospital.
Nevertheless, many respondents, both senior registrars and consultants, had a well
developed sense of responsibility for the education of junior staff. This was demonstrated in
numerous ways, including the amount of time they devoted to formal teaching; preparation
for teaching; modelling approachable behaviours; and demonstrating open attitudes towards
their own and other people's learning.
 Developing Professional Competence 217

A number of consultants in A & E emphasised the importance of their continuing

presence in the department so that, as one put it, 'they [SHOs] are not totally on their own'.
This had the effecx of initiating new SHOs into the ways of that particular department. As
one consultant told us, it means that 'things are done the right way from the start'. However,
as Dreyfus & Dreyfus (1986) point out, understanding rules and abiding by set procedures
are very important for novice practitioners. 'A very heavy consultant presence on the floor'
ensured that consultants were perceived to be approachable: there were no awkward silences;
nor were junior doctors 'forced to make decisions beyond their level of competence'. Silence,
however, was a very powerful weapon: a registrar in obstetrics and gynaecology recalled her
previous experience in an English hospital:
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Well when you ring [the consultant] at 2 o'clock in the morning and so there's a
'silence' ... and if you say 'she has foetal distress and needs a section, and I can do
it', then you can hear the relief, they're happy.

In contrast, a consultant in A & E who described himself as a 'player manager', recognised

that not only his presence, but also his attitude, encouraged junior staff to consult him
frequently. He was able to make the most of teaching opportunities as they presented
themselves because 'you were not in some distant office, t h e y [ S H O s ] come to you ... and
you can put up an X-ray and say this is how we look at a wrist X-ray'.

Teamwork
There is a considerable literature on how changes in patterns of health care delivery, and in
the s~ucmre of the N H S itself, have impacted upon the development of the health profes-
sions (see, for example, Pringle, 1993; Biggs, 1993; Shaw, 1993; Poulton & West, 1993;
Leathard, 1994; Weinstein, 1994; Mackay et al., 1995; Hugman, 1995; Tope, t996). It is
beyond the scope of this article to document these changes in detail. Nevertheless, it is dear
that the development of a primary-care-led NHS, which looks set to continue under the
present government, has led to a significant reappraisal of working practices and a renewed
emphasis on collaboration and teamwork between health and social care professionals in the
best interests of the patient.
There were certainly frequent references to working and learning in teams in our
research, and such experiences were not confined to junior staff: a number of senior doctors
also reported relying on other team members to maintain their own knowledge base. As one
consultant in laboratory medicine reported, junior staff bring more recently acquired and
up-to-date theoretical knowledge to the team. He described the contribution of his more
junior colleagues in the following terms: 'you guys [sic] are reading books for examinations,
and I haven't opened a book since 1975 (that's an exaggeration but, you know, just for effect)
... so you'll keep me up to date with the latest information ... but I've got all the experience'.
The notion of a symbiotic relationship between various team members was echoed by other
respondents. Interestingly, night time was perceived to offer both challenges and opportuni-
ties for teamworking. An SHO in A & E described how professional relationships within the
multiprofessional team developed during the night shift when 'we can be incredibly busy here
sometimes and quite a low number of doctors and the amount of work, they [nurses] do ...
there's just you and the nurses and they do everything just very quickly'. The particular
exigencies of the specialty appeared to encourage teamwork. As one consultant in the same
department argued:

A & E again lends itself to working as a team. A lot of us have been here a long time
 218 V. Wilson & A. Pirrie

and were able to help them [junior doctors] quite a bit ... they can't go back and
see that patient three hours later because they have forgotten something ... so you've
got to try and say to them look your patient is here 15 minutes.

However, team roles were rarely static and numerous references were made to ways of
introducing innovative teamwork, including feedback on performance. It is to this that we
now turn.

Feedback on Performance

Models of adult learning (Knowles, 1975; Mezirow, 1981; SchOn, 1983) assume that
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reflection is an essential part of becoming a self-directed learner. This can be encouraged by

learners sharing insights with others. From our data, it emerges that staff received feedback
on their performance at work through a number of discrete channels: through written
memoranda; formal appraisal schemes; and informally from both senior staff and other
colleagues. On the basis of the data, we developed a matrix of overlapping factors which
appeared to influence learning. Perhaps not surprisingly, 'feedback on performance' are
words which respondents rarely used. A variety of euphemisms was preferred: 'a chat';
'various comments'; 'talk together' and 'doing well'. Despite these semantic differences, there
is unanimity on the usefulness of feedback: staff in all professions, and in most grades,
appreciated informal feedback.
Interestingly, a number of junior staff claimed to know, almost intuitively, when things
were either 'going right' or conversely 'going wrong'. The same theme of self-assessment was
echoed by a registrar in obstetrics and gynaecology who claimed that 'the general attitude of
the midwives, the staff and the SHOs themselves because they seem to like working with you'
was an indicator of competent performance. Colleagues in another specialty (A & E) reported
receiving 'feedback on a daily basis'. The need for feedback did not appear to diminish with
experience. In laboratory medicine, consultants liaised closely with medical colleagues who
could be construed as their 'clients'. As one explained, 'this isn't research: this is actual
routine work [diagnosis of samples] for the patient and if any mistakes are made at all, we are
told about it'. Significantly, in an environment now dominated by a market model, the voice
of the patient as customer was rarely heard in our data. Only in two cases (one general
practice and the other laboratory medicine) did respondents report patients' views.

Rotation
Unlike many other professionals, health care practitioners are required to provide a continu-
ous service throughout the year. This requirement is met through a complicated pattern of
shifts, rotations and on-call work: some practices have historical antecedents, while others
have been more recently introduced. All impact upon education and training. Respondents
used the term 'rotation' in two ways: firstly, to describe the process by which junior medical
staff are engaged on 6-monthly contracts, often in different hospitals and specialties; and
secondly, to denote the organisation of work within a particular department according to a
'rota'. Both had positive and negative effects on individual learning.
The 'rota' within some hospital departments appeared to be more problematic than in
others. For example, junior doctors in an A & E department reported that it interfered with
their sleep and study patterns in ways that they had not experienced in other locations.
Tiredness affects motivation: a staff nurse in obstetrics and gynaecology had noted a
reluctance on the part of junior staff to attend normal births at night.
 Developing Professional Competence 219

Junior doctors have traditionally rotated from one hospital to another throughout
training. Continuity and progression, which should underpin learning, are thus disrupted.
This arrangement had its supporters as well as its critics. For those who had had a specialist
training post in the wake of the Calman Report (Department of Health, 1993)~ a learning
structure has been provided. As a consultant in laboratory medicine reported, it was thus
hardly surprising that:

... they [SHOs] have sufficient experience so that when they go up to the exam
[Royal College of Pathologists] they are confident. They have a reasonable chance
of getting through, and most of our candidates get through, usually in the first time
of asking.
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For others, changing jobs every 6 months was a negative experience. Junior doctors reported
a lack of continuity. A registrar in obstetrics and gynaecology felt that he was taking 'a step
or two steps backwards every time' he changed jobs.
There was also a tendency to rationatise traditional work patterns, implying that they
provided not only variety, but also encouraged adaptability. However, the downside of
rotation was evident. As a staffgrade doctor in A & E pointed out, 'you've suddenly got a new
group of people [SHOs] all at once who really don't have much idea about a lot of things they
are going to be faced with right from day one'.

Supported Autonomy
Theories of adult learning (Knowles, 1975; Mezirow, 1981; Brookfield, t 986), sometimes
referred to as andragog35 stress the importance of autonomy. Adults learn best when they are
actively involved in determining their own learning goals; perceive the content to be relevant
to their current needs; and recognise that the timing and methods are appropriate. A number
of our respondents described instances in which they had actively pursued a problem, or set
personal learning goals to 'challenge' themselves. The desire to pursue professional knowl-
edge by self-directed inquiry was described by a senior registrar in A & E in the following
terms:

Someone comes in and you think this could be this, this or this so you do your tests
and refer them on to the specialist and then go and read it up. That's certainly the
way people continue learning in all medical specialties.

Staff in several sites described encountering work-based problems; seeking and assessing
solutions (with or without the help of senior staff); and visualising future adaptations in
practice. Inadvertently, respondents had discovered an experiential learning cycle (Kolb,
1984) which seemed to work for them.
The application of new knowledge was perceived to be a crucial step in the developmen-
tal learning process. For example, a number of respondents described the first time they had
carried out procedures without supervision as the time when they felt they had 'really
learned'. A phased movement towards complete autonomy is an essential component of
supported learning (see Dreyfus & Dreyfus, 1986). One registrar described having a consult-
ant assist in his first 10 Caesarean sections, then undertaking the procedure himself with a
consultant 'just watching over the shoulders'. In the end, the consultant would only enter the
theatre if requested to do so by the registrar.
 220 1I. Wilson & . 4 . Ih~rie

Vision and M o d e l s o f G o o d Practice

Other researchers (Peters & Waterman, I982) have identified that successful organisations
develop with employees a shared vision of the organisation's future. These scenarios stress
organisational goals and emphasise the importance of learning at both individual and group
levels. Data from our research highlighted the role which vision plays in individual learning.
There were several examples of individuals who were both committed to, and motivated by,
learning. In departments where a strong vision was evident, respondents described the
increased confidence and inspiration to learn which resulted from the example set by
committed skilled clinicians. Working closely with other staff gave senior clinicians opportu-
nities to share their vision. The role of 'hands on clinicians' was often identified as an
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important element in creating a learning culture. Staff were encouraged to ask questions. A
consultant in A & E described how this role of 'player manager' was central to his vision for
his department:
I try and spend 50% of my time.actually on the shop floor just seeing patients as
they come through in turn .... I think that is important, presumably gaining respect
from each of your staff if they see that you can do a good job.
In the other A & E department, a registrar described how '[the consultants] are not off
doing private work or anything like that, they are always there and around. They are not
afraid to get their hands dirty doing boring routine stuff and they are keen on teaching'.
Respondents used a variety of terms to describe the behaviour of these 'learning leaders'.
Some were called 'good clinicians'; others practised 'excellent medicine'; or kept 'at the
forefront of learning'. In one case, the practice's ethos was composed of two key elements:
sharing an ideal; and positive attitudes to new challenges and learning.

Conclusions
The main focus of this research is continuing professional education in a health care context.
It is an environment dominated by myths about the behaviour of different professionals, the
territory they share, and their experiences of disparate undergraduate or pre-registration
education en route to qualified professional status. This has encouraged the development of
separate professional identities, reinforced by exclusivity and status. However, following the
reorganisation of the Health Service, there is increasing pressure for all to work in multidis-
ciplinary groups in order to deliver effective patient care. In these changing circumstances,
respondents identified a range of learning opportunities within their own organisations which
were critical to their own learning, and a more complcx picture of the relationship between
experience and learning emerged. In general, a series of interrelated factors appear to
influence continuing professional development in health care. These include: the experiences
of work; organisational structures and systems; the availability of resources; the role of the
individual; and external or statutory changes. Although in general, nothing appears to prepare
health care professionals better for the complexities of practice than the complexities of
practice, the relationship between work experiences and learning is complex and not clearly
understood. It is influenced by:
• the presence, attitudes and behaviour of experienced colleagues who can support novice
practitioners;
s the opportunity to work within well-established, supportive teams;
• approachable senior and middle grade staff who can encourage questioning and reflective
practice;
 Developing Professional Competence 221

• allocation, rotation and development of team roles which prevent role confusion and
overload, and ensure comprehensive coverage of the different aspects of professional work;
• opportunities to practise developing skills under supervision;
• an environment which encourages learning from mistakes as an essential step in the
development of reflective practice;
• the practice of open communication among different grades and professions;
• timely, informal feedback on performance, especially from senior staff and other
colleagues; and finally
• a work rota which allows staff to benefit from the preceding points.

Adequate resources are essential to successful continuing professional education. It is highly

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improbable that professionals in understaffed departments will be predisposed to update their

practice through continuing education. However, despite the positive impact of resources,
and the corresponding deleterious effects of their absence, it cannot be assumed that learning
is unaffected by individual actions. Individuals can, and do, influence the learning process.
Our respondents identified factors which encouraged them actively to pursue their own
learning goals. In addition, they also spoke of the positive effects of the vision of, and example
set by, senior staff as 'expert practitioners'.

Implications
Developing Professional Knowledge
We have presented a detailed analysis of respondents' accounts of how they learned in
a clinical setting. These are particular 'stories', snapshots in time, but they also carry
implications for the organisation and delivery of continuing professional development. T h e
distinction between propositional knowledge ('knowing that') and procedural knowledge
('knowing how') posited by Ryle (1962) is significant by its absence:

... learning how or improving in ability is not like learning that or acquiring
information. Truth can be imparted, procedures can only be inculcated, and while
inculcation is a gradual process, imparting is relatively sudden. (p. 59)

Perhaps not surprisingly, these are not the distinctions which health care professions make.
Most respondents differentiated between what they described as 'relevant' knowledge, gained
largely in the workplace, and decontextualised 'academic' knowledge from lectures in higher
education. However, they did not consider that all knowledge gained in the workplace is by
definition 'practical' knowledge. They appeared to have an integrated notion of professional
development which included skills and knowledge rooted in situated activity. What the5' were
describing was the complex and highly interactive process through which they acquired the
confidence and the clinical acumen to participate more fully in a 'community of practice'
(Lave & Wenger, 1991, p. 47). They were also initiated into the values which were an integral
part of that particular community of practice. This type of situated teaming entails what
Rowland (1993) describes as 'a process of evaluation as they [the learners] seek to give
meaning to these experiences and relate them to the work of others' (p. 123).
It is hard to underestimate the role of positive role models in an individual's professional
development. Given that this appears to be the case, then the role of universities in
continuing professional education for health care professional must perforce be limited. Eraut
(1994) argues that the development of practical knowledge integrates 'complex understand-
ing and skills into a partly routinized performance, which then has to be deconstructed and
 222 V. Wilson & A. Pirrie

deroutinized in order to incorporate something new' (p. 20). Whether this can be achieved
within institutions which espouse discipline-based knowledge is debatable.

Developing Knowledge and Skills

Competence-based systems of education and training differentiate between skill acquisition
and underpinning knowledge (Miller, 1988). It is implied that 'underpinning knowledge' can
be acquired independently from the contexts in which professions practise. Competent
professionals are expected to integrate the separate strands: demonstrate 'skitfut' behaviour;
take cognisance of an appropriate body of knowledge and demonstrate situational under-
standing. However, there is no logical reason to assume that professional skills and knowledge
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develop concurrently on parallel tracks. As Eraut (1994) points out, the problem may be that
competence is assessed on a binary rather than a progressive scale: individuals are judged to
be either competent or not competent to make professional judgements, when in reality
professional development is far more complex.
Evidence from our research shows that respondents did not equate becoming competent
with one point in time--for example, passing a qualifying examination--which legitimised
their professional status. The rite of passage was perceived as a lengthy process. In fact, on
numerous occasions respondents indicated that the qualifying examination signified the
beginning, rather than the end, of the process of becoming a competent professional.
Paradoxically, respondents were able to differentiate and integrate these processes, thus
creating a unique epistemology. They differentiated between levels of competent perform-
ance but integrated skills and relevant knowledge. They rejected 'academic' knowledge as
irrelevant to their current practices because it was 'out of date' or failed to take account of
resource implications. This differentiation between knowledge which informs and extends
practice, and knowledge which practitioners consider irrelevant is indicative of a more
complex perception of professional knowledge than the simplistic dichotomy between theory
and practice assumed in experiential learning theory. Therefore, analyses of continuing
professional development which perpetuate this false division misrepresent the learning
process.
Most educational decisions are now inextricably linked with resource issues. The
language of health care has changed, and the mechanism of the internal market imposes its
own order. Into this debate of economy, efficiency, effectiveness and consumer choice, it is
in no one's interest that continuing professional development should remain random or
unsystematic. It is only by disentangling the factors which support continuing professional
development within the milieu of the actual organisations in which professionals work that
there is hope of building an effective system for educating professionals. Learning may be
complex, but as we have seen, those who participate in it have no difficulty identifying the
necessary and sufficient conditions for its development. We must listen to their voices.

Acknowledgements
This article could not have been written without the support of a number of people. Our
thanks, first of all, to those who gave of their valuable time to be interviewed. We are also
indebted to our former colleagues, Jan Finnigan and Elizabeth McFall, for their invaluable
assistance with data collection and analysis. Our thanks also to Dr Graham Buckley,
Executive Director of the Scottish Council for Postgraduate Medical and Dental Education
(SCPMDE) for his many helpful insights into the working lives of health care professionals.
The views expressed are those of the authors, and are not necessarily those of the
 Developing Professional Competence 223

S c o t t i s h C o u n c i l for R e s e a r c h in E d u c a t i o n ( S C R E ) , t h e S c o t t i s h C o u n c i l for P o s t g r a d u a t e
M e d i c a l a n d D e n t a l E d u c a t i o n ( S C P M D E ) , t h e S c o t t i s h Office or M o r a y H o u s e I n s t i t u t e o f
Education.

Correspondence: D r Valerie W i l s o n , E d u c a t i o n a l R e s e a r c h U n i t , T h e S c o t t i s h Office E d u -

c a t i o n & I n d u s t r y D e p a r t m e n t , 2B Victoria Q u a y , E d i n b u r g h E H 6 6 Q Q , U K .

NOTES
[1] We note, however, that formal provision is easier to document for accreditation purposes (see Crossley
& ToghilI [1997]), who record the number of hours/days undertaken by members of the Royal College
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of Physicians),
[2] Dreyfus & Dreyfus's (1986) theory of expertise, which is premised almost entirely on learning by
experience, encompasses a model of competence in which the novice practitioner progresses in a unilinear
fashion through competence towards proficiency and expertise. We would argue that 'progress' is as more
likely to be made by taking two steps forward and one back as by marching steadily onwards and upwards.
This notion of competence does not preclude excellence, as some critics of competence-based assessment
(e.g. Bridges, 1996) have suggested.
[3] These developments have not affected the medical profession, which as Eraut (1994) points out, has
'remained firmly in the ascendant in the health sector' (p. 4).

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