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Enhancing learning through experiences in clinical practice settings

Enhancing learning through experiences in clinical practice settings. Stephen Billett , Griffith University, Australia. Case .

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Enhancing learning through experiences in clinical practice settings

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  1. Enhancing learning through experiences in clinical practice settings Stephen Billett, Griffith University, Australia

  2. Case Experiences in practice settings have particular qualities and can make distinct contributions to individuals’ learning which need to be utilised fully and integrated into medical education Optimising these contributions requires understanding the qualities, potentials and limitations of learning through practice-based experiences. We need an informed and theoretically adroit account of learning through practice, informed, but not constrained, by educational discourses Likely this account has dimensions of curriculum, pedagogy and personal epistemologies • This case is elaborated here drawing on three bodies of inquiry: • workplace learning, • learning through practice • integration of practice-based experiences in educational programs

  3. Some premises …. No separation between participating in practice and learning ……. Also, remaking of cultural practice (e.g. medical practice) Occupational (e.g. medical) knowledge is a product of history, culture and situation (e.g. locale) – it needs to be accessed and engaged with (i.e. inter-psychologically) • Rich learning of this knowledge likely dependent upon the: • i) kinds of activities and interactions available to students, and • ii) quality of students’ engagement with them. Experiences provided in educational institutions and practice settings are nothing more or less than invitations to change …….. Ultimately, how these invitations are taken up by students is most salient.

  4. Progression • Some premises • Learning through practice • Strengths and limitations of learning through practice • Learning for the professions: lessons from history and anthropology • Towards an account of learning through work • Curriculum, pedagogic and epistemological practices

  5. Learning through practice: Is the most common and sustained mode of learning occupations across human history (and across working lives) Central to humanity and human progress Similar processes for learning occurred in Europe, Asia and, elsewhere, across a range of occupations Family and local workplaces sites for that learning in Europe, India (Menon & Varma 2010), Japan (Singleton 1989) and China (Ebrey 1996) Engagement with ‘master’, yet little evidence of direct teaching This learning appears to largely progress through mimesis: observation and imitation, then practice That is - a learning process - not premised on being taught

  6. Some early accounts Mesopotamia The Talmud (i.e. Jewish book of law) ... "As it is your duty to teach your son the law, teach him a trade." the tradition was for the son to go to the rabbi's school in the morning and in the afternoon learn his father's trade. (Bennet 1938: 3 (sic)) Greece Plato noted: The son learned his trade by growing up in his father's family and participating in the family activities, imitating what he saw his father doing. At first, the imitation would be playful and childish, carried out with such toy tools as a child could handle. Later, it would become more deliberately purposive. Practice produced technical proficiency in details and the growing boy would act first as his father's ‘helper’, then as his associate, and would eventually himself become the head of family, and the centre from which further training in the family craft would radiate. (Lodge 1947: 18 (sic)) India - Similar practices occurred with pottery manufacturing (Menon & Varma 2010) Refer to curriculum of practice and pedagogic strategies

  7. The value of personal epistemologies arising from individuals’ experience is also evident in Plato’s account The best physicians are those who have treated the greatest number of constitutions good and bad. From youth up they have combined with the knowledge of their art 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 cure the body. And, thus they infer further bodily diseases of others from the knowledge of what has taken place in their own bodies. (Plato – Republic Lodge 1947: p. 42-43)

  8. Imperial China - The longest continuous culture - distinct valuing of skilled work and craft Calligraphy was required for public examinations for access to and promotion in the public service. Yet, valuing of knowledge not restricted to such declarative forms “I see things in terms of my own work. When I chisel at a wheel, if I go slow, the chisel slides and does not stay put; if I hurry, it jams and doesn’t move properly. When it is neither too slow or too fast, I can feel it in my hand and respond to it from my heart. My mouth cannot describe it in words, but there is something there. I cannot teach it to my son, and my son cannot learn it from me. So, I have gone on for seventy years, growing old chiselling wheels. The men of old died in possession of what they could not transmit. So, it follows that what you are reading are their dregs.” The Daoist philosopher Zhuangzi (369-286 BC) used a parable of a wheelwright talking to a powerful general to describe the power of personal knowledge over what is found in books. ….. an early questioning of the privileging of declarative knowledge

  9. So how did this learning through practice arise? Little written about skill development in Imperial China and other pre-modern societies: “not of interest to those who wrote” Largely arose though observation, imitation (i.e. mimesis), practice and occasionally, direct guidance Little evidence of direct teaching until era of schooling Before the ‘era of schooling’, institutionalised provisions limited to a few occupations (e.g. medicine, law, military, philosophy), even then, practice experiences central. In Hellenic Greece, anatomy classes and textbooks introduced to compensate for lack of authentic practice in medical education (Clarke 1971) So, what is known about learning through practice…its strengths and limitations?

  10. Learning through everyday practice Contributions to learning through everyday occupational practice include: i) engagement in work tasks (“just doing it”) – legacies of goal-directed activities (cognitive & socio-cultural constructivist accounts); ii) indirect guidance provided by the setting (“just being there”) – observation and imitation (cognitive & neuro-science); iii) practice within that setting – practise, rehearse, refine and associate (cognitive accounts of procedural & conceptual development); and iv) close guidance (proximal) by other practitioners and experts – assisting develop knowledge that cannot be learnt through discovery (Billett 2001). Largely arise from individuals’ intentionality and agency These contributions distinct from those educational institutions afford

  11. Limitations of learning through everyday practice • learning that is inappropriate (i.e. bad, unhelpful, wrong) • lack of access to activities and guidance • not understanding the goals for workplace performance • reluctance of experts to provide guidance • absence of expert guidance • limits in developing understanding in the workplace • reluctance of workers to participate (Billett 2001) Need to find ways of drawing on the contributions and minimising or ameliorating these limitations

  12. In all, learning arises through everyday activities or workplace interventions is a process comprising a duality of: • affordances of workplaces - (i.e. invitational qualities, can be positive or negative) and • engagement - how individuals elect to engage with what is afforded them (i.e. their intentionality, interest etc). So, how should we take forward these conceptions in informing an account learning through practice that can inform medical education? When considering them, the discourse of ‘schooling’ is not always helpful.

  13. Not captured, articulated or privileged in this discourse: • Many procedural capacities (i.e. strategic and specific) needed for work • Embodied learning (i.e. knowing through the sensory system) • Haptic qualities (i.e. feel, tactile competence) • Dispositions (i.e. values, interest, intentionality – ethical conduct, for instance) Yet, these non-declarative forms of knowledge are central to much of occupational performance Educational discourse also emphasises didactic teaching and de-emphasises learning Importantly, these claims are not anti-educational, they aim to reposition practice-based experiences within and outside of the educational scientific discourse.

  14. Elements of an account of learning through practice 1. Curriculum practices – sets of experiences, including their sequencing 2. Pedagogic practices – activities or interactions that augment learning through experiences 3. Epistemological practices – bases by which individuals construe and construct knowledge and shape their learning and development

  15. 1. Practice curriculum A way of life as an apprenticeship - Lived experiences within a community (Jordan, 1989, Rogoff 1990, Bunn, 1999) Deliberate structuring of learning experiences (Bunn, 1999) Sequencing of activities - from those of low error risk to those where consequences of errors are greater (Lave 1990) Tailors – hairdressers – production workers – room attendants -- doctors (Sinclair 1999) Leads to a consideration of the ‘learning curriculum’ (Billett 2006)

  16. Developing the workplace learning curriculum (Billett 2006) Identify: i) Sequencing of activities to be learnt and Consider frequency (daily, monthly, yearly or even those needed to know, but may never be used). ii) Capacities that are hard-to-learn Best informants – those who have recently learnt iii) Identify any ‘teachable moments’ - (e.g. nurses’ handovers)

  17. Deliberate structuring of experiences Sequencing and purpose of learners’ experiences e.g. midwifery students’ follow throughs and clinical practice (Billett, Sweet & Glover 2013) How might these experiences be ordered? Are their analogous possibilities in medical education?

  18. 2. Practice pedagogics Story telling (Jordan, 1989) Verbalisation (Gowlland, 2010) Pedagogically rich activities (Billett 2010) Proximal guidance (Rogoff 1995 Billett 2001, Gowlland, 2011) Direct instruction / ‘hands on’ (Makovicky, 2010) Indirect/distal guidance (Gowlland, 2011) Heuristics (Billett, 1997) and mnemonics (Rice 2008, Sinclair 1997) Partially worked example (Makovicky, 2010)

  19. Procedural development Modelling Coaching Scaffolding Conceptual development Questioning Diagrams Explanations Also Group discussion Extending knowledge through questioning Pedagogies for practice Billett 2001

  20. Pedagogically rich activities For example: nurses’ handovers • Patient • Condition(s) • Treatment(s) • Responses • Prognosis Need to be engaged with actively and purposefully

  21. 3. Personal epistemologies Most learning through practice arises from learners’ agency and efforts i.e. their personal epistemologies - bases of knowing, engaging and learning through practice More than epistemological beliefs – include capacities and embodied knowledge Includes sense of self (subjectivity), gaze, agency and intentionality, not to mention introspection Knowing how to act

  22. Personal epistemological practices Imitation (mimesis) (Jordan 1989, Tomasello 2004, Gardner 2004, Marchand, 2008) Ontogenetic ritualisation (Tomasello 2004) Active engagement and construction of knowledge apprehending– to seize (Webb 1999), ‘stealing’, (Marchand 2008),– Japanese word for apprentice is minarai: one who learns by observation; unobtrusive process of observation: minarai kyooiku (Singleton 1989) Importance of learner readiness (Bunn 1999, Singleton 1989) and assent (Mishler 2004) Deliberate practice (K A Ericsson, 2006, Gardner 2004, Sinclair, 1997)

  23. Whatever the origins of the didactic mode, it has always been a minor mode of knowledge acquisition in our evolutionary history. In the West, however, the didactic mode of teaching and learning has come to prevail in our schools to such an extent that is often taken for granted as the most natural, as was the most efficacious and efficient way of going about teaching and learning. This view is held despite the many instances in our own culture of learning through observation and imitation. (Jordan 1989: 932)

  24. Providing and utilising practice experiences in medical education Firstly, need to be clear about the educational purposes of these experiences Such educational purpose include: • learning about an occupation • building capacities to be effective professional practitioners • learning about some variations of that occupational practice • extending knowledge learnt in university settings • orientations to the places where the occupation is practiced • meeting requirements of occupational or professional licensing • ongoing (i.e. professional ) development (Billett 2011) Particular kinds of experiences address specific kinds of purposes

  25. Key findings about integrating practice experiences suggest: just having workplace experiences is insufficient: they need augmenting importance of preparing students for, support during and assisting connect experiences students’ readiness (i.e. interest, realism, capacities) key factor shaping their learning challenge of providing and managing experiences for students who are ‘time jealous’ salience of the ‘experienced curriculum’: how students construe and engage Incremental exposure to practice-based experience and progression (i.e. experiences being built upon, appropriate levels of support ).

  26. So what? Practice experiences go beyond just exercising, practicing and ‘contextualising’ what is learnt in educational programs. Make particular contributions and have specific qualities Need to understand how to optimise experiences in clinical settings to generate the knowledge required for medical practice Likely requires conceptions of curriculum, pedagogy and emphasise personal epistemologies, distinct from those comprising orthodoxies of educational science and practice Because experiences in educational and practice settings make particular contributions, there is the need to be utilise, augment and integrate them Thanks for your attention to this most didactic of presentations – over to Tim

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