- Email: [email protected]
Work-based learning in health care environments
NEPR-03.QXD
3/17/01 10:12 AM
Page 12
Article
Work-based learning in health care environments Jenny Spouse
In reviewing contemporary literature and theories about work-based learning, this paper explores recent trends promoting life-long learning. In the process the paper reviews and discusses some implications of implementing recent policies and fostering learning in health care practice settings. Recent Government policies designed to provide quality health care services and to improve staffing levels in the nursing workforce, have emphasized the importance of life-long learning whilst learning-on-the-job and the need to recognize and credit experiential learning. Such calls include negotiation of personal development plans tailored to individual educational need and context-sensitive learning activities. To be implemented effectively, this policy cannot be seen as a cheap option but requires considerable financial resourcing for preparation of staff and the conduct of such activities. Successful work-based learning requires investment in staff at all levels as well as changes to staffing structures in organizations and trusts; changes designed to free people up to work and learn collaboratively. Creating an organizational environment where learning is prized depends upon a climate of trust; a climate where investigation and speculation are fostered and where time is protected for engaging in discussions about practice. Such a change may be radical for many health care organizations and may require a review of current policies and practices ensuring that they include education at all levels. The nature of such education also requires reconceptualizing. In the past, learning in practice settings was seen as formal lecturing or demonstration, and relied upon behaviourist principles of learning. Contemporary thinking suggests effective learning in work-settings is multi-faceted and draws on previously acquired formal knowledge, contextualizes it and moulds it according to situations at hand. Thinking about work-based learning in this way raises questions about how such learning can be supported and facilitated. © 2001 Harcourt Publishers Ltd
Introduction Jenny Spouse, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA, UK. Manuscript accepted: 3 December 2000
For many people work reflects their identity, often providing a meaning to their life that is reflected in social interactions. When first meeting a stranger, the nature of their work is often amongst the first questions asked and places individuals within a social framework. Identity is often reflected in ancient family names derived from work origins, such as butcher, baker, cantor and so on. Increasingly
12 Nurse Education In Practice (2001) 1, 12–18
people anticipate a long working life with satisfaction to be gained from undertaking meaningful activities, where artistry and skill can be invested and problem-solving becomes an enjoyable component (Csikszentmihalyi & Csikszentmihalyi 1988). By creating work that engages people in learning, in problem solving activities and in negotiating meaning, humans are exercising their unique characteristics (Buch 1999). Developing professional awareness can be personally challenging.
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0003, available online at http://www.idealibrary.com on
NEPR-03.QXD
3/17/01 10:12 AM
Page 13
Work-based learning in health care environments
In workplace situations where learning is viewed as an admission of un-knowingness, the learner–worker risks loss of status as an authority amongst colleagues. Without opportunities to question practice, the learner–worker becomes stifled and work becomes repetitive and ritualized. By contrast, work settings where learning is part of the culture and structures are in place to provide support and learning opportunities either formal or informal, then everyone gains.
Conditions for workplace learning Successful work-based learning needs a sophisticated community of practitioners able to recognize learning opportunities, and who are willing as well as able to communicate their professional knowledge. Many practitioners have not acquired the necessary language to describe their taken-for-granted practices, and need opportunities to reformulate their practice in preparation for sharing it. Supervision can be one medium for learning such skills but has had mixed success in health care settings. In many instances this is because it is seen as a bolt-on activity resulting from insufficient numbers of suitably experienced and prepared staff who are left to cope with clinical workloads that often fail to reflect their educational responsibilities. Another issue for work-based learning is the way in which supervision and work-based tutoring have been conceptualized. Many strategies used in work settings are derived from behaviourist approaches. In prequalification programmes, models of traditional apprenticeship have been favoured where students learned from peers and through trial and error (Spouse 2000). Quality concerns about fitness for practice means organizations providing institutional care cannot afford to sustain or risk such practices where litigation or professional investigation may result. On a personal practical level, practitioners may face conflict between best practice advocated by research-based evidence and the custom-and-practices used in their work-place setting. This is particularly true for novices (White et al. 1993,
© 2001 Harcourt Publishers Ltd
Watson & Harris 1999). Such practices may have little evidence-base and may not conform to ‘best’ practice. With rapid changes to health care, staff need access to resources and skills to maintain and develop their professional knowledge through use of data bases that can inform best practice and this incurs further training need and resource provision.
Incentives to promote work-based learning Government concerns to safeguard public spending and deliver quality services have led to increasing centralized control of professional activities. This is reflected in the establishment of two Government watchdogs and advisory bodies: the Commission for Health Improvement (1999) and the National Institute of Clinical Excellence (NICE). These two organizations are charged with ensuring equitable and high standards of health care delivery across the nation through standardsetting and monitoring. Since April 1999, ensuring professional management, efficient resource use, risk management and patient satisfaction have been the statutory duty of all National Health Service agencies. Implementation of these duties is through a system of Clinical Governance that touches every practitioner throughout the service with final accountability resting with the Chief Executive of the NHS (Department of Health 1997). Subsequent documents from the Secretary of State for Health have reinforced the Government’s agenda for quality (Department of Health 1998a; Department of Health 1998b) and emphasize personal accountability as well corporate responsibility (Department of Health 1999). Clinical governance comprises several processes including programmes of quality improvement activities concerned with staffing and service delivery. Staffing activities are concerned with workforce planning and development including regular monitoring of continuing individual professional development programmes designed to meet the needs of the organization. Working in a post-industrial
Nurse Education In Practice (2001) 1, 12–18 13
NEPR-03.QXD
3/17/01 10:12 AM
Page 14
Work-based learning in health care environments
society where global market economies influence national wealth and expenditure, these policies acknowledge the need for investment in staff working in the NHS. If services are to be maintained and developed to meet rapidly changing needs, staff are the key resource that requires continuous development and investment. To meet these changes, staff are expected to become flexible and efficient workers. They need to be able to respond to technological changes by developing attitudes and ways of thinking that regard change as an evolutionary process and by developing ability to problem solve and negotiate their work environments (Garrick & Usher 1999, Department of Health 2000). This transition in workforce requirements from skilled technical workers to active problem solvers able to negotiate their organizational culture and develop knowledge of the organization and ‘how things work’. Such knowledge permits organizations to function effectively, and has been conceptualized as intellectual capital (Marsick & Watkins 1999), emphasizing that such knowledge carries economic benefits and is an important resource, taking years to develop. Conceptualizing staff in such a way makes investment in staff education essential to any political strategy. In times of competing job interests, recruitment difficulties and demographic changes leading to a subsequent shrinking of the labour force, developing strategies for enhancing work-place settings and retaining staff in jobs they find stimulating and rewarding, becomes a mandate far organisational survival. Recent Government proposals (Department of Health 2000) demonstrates a commitment to this kind of investment in NHS staff.
Promoting life-long learning in practice Establishing organizational structures on a national scale, such as the National Institute of Clinical Excellence and the Commission for Health Improvement, ensures information is accessible. Strategies mandating local staff support through clinical governance and personal supervision make it possible to support staff development and provide
14 Nurse Education In Practice (2001) 1, 12–18
resources designed to ensure that effective practices become commonplace. Such structures can facilitate life-long learning and continuous development. However, they can only be effective in organizational cultures where staff are encouraged to feel secure in their role and status, and have the energy to be receptive and supportive of further education and training without loss of status or authority (Barnett 1999). Where there is an organizational ethos of mutual regard, equity and value, it is possible to institute such social and educational activities (Billett 1999). As a result, commonplace traditional assumptions of knowledge and authority become outmoded and everyone becomes a learner. Local and national policies for continuing development are further supported by professional statutory organizations, which also have responsibility for protecting the public by developing professional standards of performance and for ensuring they are maintained. Whilst none of this can take place effectively without full collaboration from all the employees some professions have introduced mandatory professional refreshment as a requirement for re-registration. The United Kingdom Central Council for Nurses, Midwives and Health Visitors have a 3-yearly registration process based on evidence of continuing professional development, and this provides a model for all workers in the health service.
Professional development Development is concerned with individual personal growth. It deals with feeling and thinking and has practical application to life activities. This definition uses a more holistic form of learning involving personal and interpersonal skills such as problem-solving, initiative, efficiency, interactional and communication skills. Professional development moves this person-centred approach towards a more sophisticated level of incorporating knowledge, skills and attitudes necessary for effective practice. It prepares individuals to work in environments that are uncertain and changing rapidly. It helps people to develop skills that can be used in a range of settings both at home and at work. They are
© 2001 Harcourt Publishers Ltd
NEPR-03.QXD
3/17/01 10:12 AM
Page 15
Work-based learning in health care environments
the skills that enable practitioners to be self-directed, to take the initiative, to work with others, to communicate clearly, to take informed but calculated risks, to make judgements, to be responsible and assertive. These are the characteristics of empowered human beings and the way professionals are expected to act.
Complexity of practice development Professional practice is a dynamic activity that reflects individual encounters. Patient conditions and problems may bear similar characteristics, but individuals do not. Thus the idiosyncratic nature of professional practice is its fascination and also its challenge. Ovretveit’s (1992) arguments that practitioners need the necessary professional knowledge and skills to be effective, communicates that such knowledge is not static but needs refreshment and development on a continuous basis. It also assumes that practitioners have undertaken sufficient preparation to fulfil their role effectively; to be able to learn continuously and to recognize their own limitations. This continuous development of professional knowledge and understanding can be most effective when carried out under guidance and support from more experienced colleagues. This requires a complex range of professional skills and knowledge that marries both science and art in skilful, expert practice. Such expertise takes years to accumulate and can not be acquired after a few years training and education. Both opera singers and athletes are acknowledged to need a minimum of 8–10 years to reach their peak of performance. Ericsson and his colleagues (1993) investigating expertise, found like other researchers (for example Dreyfus & Dreyfus 1986) that practitioners require repeated exposure and feedback to develop complex skills. They found that it took an average of 10 years to become an expert. With all its complexity and high-risk management health care practice must rank as highly in developmental need as opera singers. These research findings raise questions about what can be reasonably expected of newly qualified practitioners and
© 2001 Harcourt Publishers Ltd
the kinds of post-qualification support and development needed to achieve their potential. Baseline profiles for newly qualified staff working in a range of settings describe the kinds of work they may reasonably be expected to undertake (NBS 2000). Based on recent research into newly qualified nurses it demonstrates the importance of further and continuing support and education. Titchen’s (2000) concept of critical companionship provides one model that goes a long way towards promoting such development. Successful professional development takes place in cultures that value education as an essential and continuous process rather than a luxury or a bonus. With Clinical Governance, learning and continuous development becomes part of the fabric of organizations, built into their policies and procedures. The rapid pace of technological development means knowledge quickly becomes outdated. This was a key concern of the National Committee of Inquiry into Higher Education (Dearing Report 1997). The Report emphasised a need for high quality education that supports learning as a life-long process. Recognition of the importance of affective and practical or experiential knowledge has grown with increasing research into learning and exposure to multi-cultural approaches to learning. As a result, learning in workplace settings is becoming recognized and the value of effective supervisory support from a colleague able to facilitate learning has become increasingly important. This requires adequate numbers of staff who have the time, interest and ability to provide such support.
Nature of work-based learning Throughout work settings, practical judgement is the mainstay of professional practice. This may not always be the case where work has become routinized and mundane. To survive unrelenting workloads, staff develop schema of practices that bypass questioning or problematizing practice and provide ready solutions or recipes. Experienced practitioners hold in their minds a range of such schema and can mentally flick through suitable ones to find a solution to their problem at hand (Benner
Nurse Education In Practice (2001) 1, 12–18 15
NEPR-03.QXD
3/17/01 10:12 AM
Page 16
Work-based learning in health care environments
1996). As a result, practical judgement may only be called to use when faced with the unexpected or problematic. Newcomers, unfamiliar with everyday situations of a setting encounter work as a series of problems to be resolved. Problematizing their practice in such a manner provides a model of practice that promotes person centredness (Argyris 1982) and has potential to enhance the quality of care. Collaborative problem-solving, preferably with colleagues or alternatively through journal writing, provides opportunities for existing knowledge and practices to be challenged and to generate new understandings. Practitioners with limited knowledge or understanding of the environment often have difficulty recognizing their environmental landscape as everything appears like a blur of activity, with few boundaries between the routine and the mundane and between the exceptional and the challenging. Not possessing informed sight newcomers require guidance from an experienced ‘local’ to make practice visible and to highlight the normal from the abnormaI or unusual. Novices may lack the vocabulary to talk about what is observed or to understand the everyday language of practitioners. These two categories of practitioners, the novice and the newcomer, who may be the same or different groups of people, need careful guidance until they have learned to read and talk about practice as old timers within the community (Lave & Wenger 1991). At another point in the continuum of practice are those who are experienced practitioners and whose judgements are based on routines and ritual. Often their vision of practice has become dulled by repetition and amongst the work objects of daily routines and unrelenting workloads they have forgotten to recognize the individual. As a result they may not recognize the significance of signs exhibited by their patients or clients. Collaborative work alongside skilled practitioners provides opportunities to review their own approaches to practice in an environment that can be both supportive and challenging (Daloz 1986). Challenges to their judgement of this kind are posed by what Burbules (1996) identifies as exposure to difference, exposure to power (of disruption) and exposure to alternative
16 Nurse Education In Practice (2001) 1, 12–18
discourse. By having to navigate these challenges, practitioners have to find alternative modes of action and as a result begin problem solving. In situations where knowledge or actions are not ready-to-hand, alternative strategies have to be developed and as a result judgement-making has educational significance (Hager & Beckett 1998). In developing judgements actors come to use a range of practical knowledge, skills and attitudes that have become integrated within a personal framework of understanding. Individual progress depends upon capacity to make sense of the environment and its challenges (Vygotsky 1930). This is where having a supportive supervisor able to assess capacity and potential for development makes work-based learning most effective. Through assessment of capability and knowledge, practitioners can be supported by their supervisors to undertake practices that challenge their thinking and promote further problem solving and learning (Spouse 1998). Understanding and professional knowledge can be supported and developed further through strategies such as debriefing, questioning, project work or journal keeping. By supporting learners in this manner insights and understandings can be mentally integrated alongside existing knowledge in a manner described by Piaget (1972). Such understanding can be consolidated and further developed over time through exposure to multiple examples of practice whilst supported by members of their community of practice (Rogoff 1990). Winch (1998 cited by Beckett 1999) describes human learning as flowing from attention to tasks at hand. This learning is accomplished by engaging in unfamiliar activities and learning to read them as problems worthy of investigation. In the process learners can extend their repertoire of knowledge. This reflects assertions that learning comes from research, theory and practice (Argyris 1982, Kolb 1985, Schön 1984, Usher & Bryant 1989) where to make sense of concrete experiences further investigation and propositional knowledge needs to be acquired. Working collaboratively in identified and legitimate activities and roles newcomers as well as old timers can assimilate new understandings. Newcomers can learn the
© 2001 Harcourt Publishers Ltd
NEPR-03.QXD
3/17/01 10:12 AM
Page 17
Work-based learning in health care environments
language and culture of their community of practice until they are able to fit comfortably within their new community (Lave & Wenger 1991).
Learning as informal, incidental or formal Marsick and Watkins (1990) describe learning in work-settings as informal or incidental. In both forms of learning the practitioner is an autonomous learner gaining understanding from experience. Incidental learning is more likely to be unnoticed, arising from brief exchanges of narratives or stories of practice such as during handover sessions, report writing or during social interactions at meal breaks where problems are shared and explored and can lead to sudden insights. Informal learning is defined as taking place outside formal educational settings but is planned or tailored to the learner’s identified needs such as debriefing or journal discussion activities, or specific practice experiences designed to meet predefined learning needs. Whilst Informal learning is planned it often draws on knowledge learned from formal educational activities, such as journals reading or classroom discussions and contextualizes it. Learning to recognize the saliency of formal, theorized information is challenging and often requires guidance from more knowledgeable practitioners. Drawing on the earlier discussion of learning arising from research, theory and practice, formal knowledge comes into play when practitioners identify limits to their understanding and ask questions about why or what they are doing in practice and look for answers. By modifying formal knowledge that has been decontextualized to the situation-at-hand informal learning can be supported. This is particularly important for novices embarking on their career and needing to apply their formal know-how to practical situations. Such learning can best take place in environments where everyone is an active learner engaged in problem solving and redefining routine activities. Such learning works best in environments where there is trust and a sense of companionship, and where there is time to engage in knowledge generation through reconstruction and
© 2001 Harcourt Publishers Ltd
reinterpretation of practice according to what has been seen as a problem(s) at hand (Spouse 1996). Such learning activities arise from recognizing practice as having potential to generate its own curriculum for learning and development. In settings where staffing levels are poor and there are insufficient experienced or knowledgeable practitioners able to guide learners (who are all the staff), such learning and knowledge transmission may be difficult to establish and support.
Conclusions and recommendations This paper highlights the importance of learning in the workplace and the crucial role that practitioners have in supporting each other’s professional development. Such learning does not depend upon lectures or tutorials, but it does rely on practitioners looking at their practice with fresh eyes. It needs them to see every act as worthy of scrutiny and reconsideration. It needs them to think whether they could do it differently and better in a way that is tailored specifically for the needs of each of their patients or clients. Learning in the workplace needs practitioners to draw on knowledge to be gained from evidence and this may be lodged in texts or with other colleagues. Crucially, learning in the workplace requires practitioners to share their expertise, to identify their learning needs and to plan how such needs can be met. It can only be achieved in settings where workloads do not drain staff of all their time and energy but leaves them thinking time and collaborative working time. Under the requirements of Clinical Governance such conditions will have to be provided. When such conditions are achieved learning and working become twinned making them natural and enjoyable processes. Acknowledgements
This paper is based on one presented at the conference: Dilemmas 2000, 1–3 September 2000 at the University of East London, Docklands; with Jill Reynolds, my colleague in SHSW at the Open University. My thanks go to her for the stimulation and support she generated.
Nurse Education In Practice (2001) 1, 12–18 17
NEPR-03.QXD
3/17/01 10:12 AM
Page 18
Work-based learning in health care environments
References Argyris C 1982 Reasoning, learning and action: Individual and organisational. Jossey Bass, San Francisco Argyris C, Schön D 1978 Organisational learning: a theory of action perspective. Jossey Bass, San Francisco Barnett R 1999 Learning to work and working to learn. In: Boud D, Garrick J (eds) Understanding learning at work. Routledge, London, Chapter 3, pp. 29–45 Benner P, Tanner CA, Chesla CA (eds) 1996 Expertise in nursing practice: caring, clinical judgement and ethics. Mass. Springer Publishing Company, Cambridge Billett S 1999 Guided learning at work. In: Boud D, Garrick J (eds). Understanding learning at work. Routledge, London, Chapter 10, pp. 151–164 Buch A 1999 Life, work and identity: the mapping of learning. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 49–52 in proceedings of conference Burbules N 1996 Post-modern doubt and philosophy of education. In A. Neiman (ed) Philosphy of education 1995. Urbana, Illinois, Philosophy of Education Society. pp. 39–48; cited by Beckett, D. (1999) Researching workplace learning amidst post-modern tensions. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 13–22 in proceedings of conference Csikszentmihalyi M, Csikszentmihalyi SI (eds) 1988 Optimal experience: psychological studies in the flow of consciousness. Cambridge University Press, Cambridge Daloz LA 1986 Effective teaching and mentoring. Jossey Bass, San Francisco Department for Education and Employment 1999 Learning to Succeed. White Paper, DfEE. Department of Health 1997 The New NHS: Modern Dependable. HMSO, London Department of Health 1998a A First Class Service: Quality in the new NHS. HMSO, London Department of Health 1998b Working together: securing a quality workforce for the NHS. HMSO, London Department of Health 1999 Continuing Professional Development: Quality in the new NHS. Department of Health (http://tap.ccta.gov.uk/doh/coin4.nsf), London Department of Health 1999 Quality and performance in the NHS: Clinical indicators. HMSO, London Department of Health 2000 The NHS Plan, London, Department of Health. Chapter 5: Investing in NHS staff Dreyfus HL, Dreyfus SE 1986 Mind over machine: The power of human intuition and expertise in the era of the computer. Basil Blackwell, Oxford Ericsson KA, Krampe RTh, Tesch-Romer C 1993 The role of deliberate practice in the acquisition of expert performance. Psychological Review 100(3):363–406 Garrick J, Usher R 1999 Flexible learning, contemporary work and enterprising selves. Paper presented at Researching Work and Learning. A first international conference. Trinity and All Saints College, University of Leeds. 10–12 September 1999. pp. 61–69 in proceedings of conference
18 Nurse Education In Practice (2001) 1, 12–18
Hager P, Beckett D 1998 What would life long learning look like in a workplace setting? In: Holford J, Jarvis P, Griffin C (eds). International perspectives on lifelong learning. Kogan Page, London, Chapter 19 Kolb, DA, 1985 Experiential learning. Prentice-Hall, NJ Lave J, Wenger E 1991 Situated learning: legitimate peripheral participation. Cambridge University Press, Cambridge Marsick VJ, Watkins KE 1999 Envisioning new organisational learning. In: Boud D, Garrick J (eds), Understanding learning at work. Routledge, London. Chapter 13, pp. 199–214 Marsick VJ, Watkins K 1990 Informal and incidental learning in the workplace. Routledge, London National Advisory Group for Continuing Education and Lifelong Learning 1997 Learning for the Twenty First Century: first report of the National Advisory Group for Continuing Education and Lifelong Learning, DfEE. Chair: Sir Ron Dearing National Board for Nursing Midwifery and Health Visiting for Scotland 2000 The Work of Newly Qualified Nurses: Adult Nursing, Core skills and Competencies. National Board for Nursing Midwifery and Health Visiting for Scotland, Edinburgh National Committee Inquiry into Higher Education 1997 Higher Education in the learning society. Summary report. HMSO, London NHS Executive 1999 The NHS performance Assessment framework. NHS Executive, Leeds Ovretveit J 1992 Health service quality an introduction to quality methods in health services. Blackwell Science, Oxford Piaget J 1972 Intellectual evolution from adolescence to adulthood. Human Development 5:1–12 Rogoff B 1990 Apprenticeship in thinking: cognitive development in social context. Oxford University Press, New York Schön D 1983 The reflective practitioner: How professionals think in action. Arena Ashgate Publishing Ltd, Hants Spouse J 1996 The Effective Mentor – a model for student centred learning in clinical practice. Nursing Times Research 1(2):120–133 Spouse J 1998 Scaffolding student learning in clinical practice. Nurse Education Today 18:259–266 Titchen A 2000 Freedom to practice. Heinemann, Oxford Usher R, Bryant I 1989 Adult education as theory, practice and research: The captive triangle. Routledge, London Vygotsky L, Luria A 1930 Tool and symbol in child development. In: Van der veer R, Valsiner J (eds). The Vygotsky Reader. Blackwell, Oxford, 7:99–174 Watson H, Harris B 1999 Supporting students in practice placement in Scotland. Glasgow Caledonian University, Department of Nursing and Community Health. Research commissioned by the National Board for Nursing, Midwifery and Health Visiting Scotland Winch C 1998 The philosophy of human learning. Cited by Beckett D 1999 Researching workplace learning amidst post-modern tensions. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 13–22 in proceedings of conference
© 2001 Harcourt Publishers Ltd
3/17/01 10:12 AM
Page 12
Article
Work-based learning in health care environments Jenny Spouse
In reviewing contemporary literature and theories about work-based learning, this paper explores recent trends promoting life-long learning. In the process the paper reviews and discusses some implications of implementing recent policies and fostering learning in health care practice settings. Recent Government policies designed to provide quality health care services and to improve staffing levels in the nursing workforce, have emphasized the importance of life-long learning whilst learning-on-the-job and the need to recognize and credit experiential learning. Such calls include negotiation of personal development plans tailored to individual educational need and context-sensitive learning activities. To be implemented effectively, this policy cannot be seen as a cheap option but requires considerable financial resourcing for preparation of staff and the conduct of such activities. Successful work-based learning requires investment in staff at all levels as well as changes to staffing structures in organizations and trusts; changes designed to free people up to work and learn collaboratively. Creating an organizational environment where learning is prized depends upon a climate of trust; a climate where investigation and speculation are fostered and where time is protected for engaging in discussions about practice. Such a change may be radical for many health care organizations and may require a review of current policies and practices ensuring that they include education at all levels. The nature of such education also requires reconceptualizing. In the past, learning in practice settings was seen as formal lecturing or demonstration, and relied upon behaviourist principles of learning. Contemporary thinking suggests effective learning in work-settings is multi-faceted and draws on previously acquired formal knowledge, contextualizes it and moulds it according to situations at hand. Thinking about work-based learning in this way raises questions about how such learning can be supported and facilitated. © 2001 Harcourt Publishers Ltd
Introduction Jenny Spouse, School of Health and Social Welfare, Open University, Milton Keynes MK7 6AA, UK. Manuscript accepted: 3 December 2000
For many people work reflects their identity, often providing a meaning to their life that is reflected in social interactions. When first meeting a stranger, the nature of their work is often amongst the first questions asked and places individuals within a social framework. Identity is often reflected in ancient family names derived from work origins, such as butcher, baker, cantor and so on. Increasingly
12 Nurse Education In Practice (2001) 1, 12–18
people anticipate a long working life with satisfaction to be gained from undertaking meaningful activities, where artistry and skill can be invested and problem-solving becomes an enjoyable component (Csikszentmihalyi & Csikszentmihalyi 1988). By creating work that engages people in learning, in problem solving activities and in negotiating meaning, humans are exercising their unique characteristics (Buch 1999). Developing professional awareness can be personally challenging.
© 2001 Harcourt Publishers Ltd doi:10.1054/nepr.2001.0003, available online at http://www.idealibrary.com on
NEPR-03.QXD
3/17/01 10:12 AM
Page 13
Work-based learning in health care environments
In workplace situations where learning is viewed as an admission of un-knowingness, the learner–worker risks loss of status as an authority amongst colleagues. Without opportunities to question practice, the learner–worker becomes stifled and work becomes repetitive and ritualized. By contrast, work settings where learning is part of the culture and structures are in place to provide support and learning opportunities either formal or informal, then everyone gains.
Conditions for workplace learning Successful work-based learning needs a sophisticated community of practitioners able to recognize learning opportunities, and who are willing as well as able to communicate their professional knowledge. Many practitioners have not acquired the necessary language to describe their taken-for-granted practices, and need opportunities to reformulate their practice in preparation for sharing it. Supervision can be one medium for learning such skills but has had mixed success in health care settings. In many instances this is because it is seen as a bolt-on activity resulting from insufficient numbers of suitably experienced and prepared staff who are left to cope with clinical workloads that often fail to reflect their educational responsibilities. Another issue for work-based learning is the way in which supervision and work-based tutoring have been conceptualized. Many strategies used in work settings are derived from behaviourist approaches. In prequalification programmes, models of traditional apprenticeship have been favoured where students learned from peers and through trial and error (Spouse 2000). Quality concerns about fitness for practice means organizations providing institutional care cannot afford to sustain or risk such practices where litigation or professional investigation may result. On a personal practical level, practitioners may face conflict between best practice advocated by research-based evidence and the custom-and-practices used in their work-place setting. This is particularly true for novices (White et al. 1993,
© 2001 Harcourt Publishers Ltd
Watson & Harris 1999). Such practices may have little evidence-base and may not conform to ‘best’ practice. With rapid changes to health care, staff need access to resources and skills to maintain and develop their professional knowledge through use of data bases that can inform best practice and this incurs further training need and resource provision.
Incentives to promote work-based learning Government concerns to safeguard public spending and deliver quality services have led to increasing centralized control of professional activities. This is reflected in the establishment of two Government watchdogs and advisory bodies: the Commission for Health Improvement (1999) and the National Institute of Clinical Excellence (NICE). These two organizations are charged with ensuring equitable and high standards of health care delivery across the nation through standardsetting and monitoring. Since April 1999, ensuring professional management, efficient resource use, risk management and patient satisfaction have been the statutory duty of all National Health Service agencies. Implementation of these duties is through a system of Clinical Governance that touches every practitioner throughout the service with final accountability resting with the Chief Executive of the NHS (Department of Health 1997). Subsequent documents from the Secretary of State for Health have reinforced the Government’s agenda for quality (Department of Health 1998a; Department of Health 1998b) and emphasize personal accountability as well corporate responsibility (Department of Health 1999). Clinical governance comprises several processes including programmes of quality improvement activities concerned with staffing and service delivery. Staffing activities are concerned with workforce planning and development including regular monitoring of continuing individual professional development programmes designed to meet the needs of the organization. Working in a post-industrial
Nurse Education In Practice (2001) 1, 12–18 13
NEPR-03.QXD
3/17/01 10:12 AM
Page 14
Work-based learning in health care environments
society where global market economies influence national wealth and expenditure, these policies acknowledge the need for investment in staff working in the NHS. If services are to be maintained and developed to meet rapidly changing needs, staff are the key resource that requires continuous development and investment. To meet these changes, staff are expected to become flexible and efficient workers. They need to be able to respond to technological changes by developing attitudes and ways of thinking that regard change as an evolutionary process and by developing ability to problem solve and negotiate their work environments (Garrick & Usher 1999, Department of Health 2000). This transition in workforce requirements from skilled technical workers to active problem solvers able to negotiate their organizational culture and develop knowledge of the organization and ‘how things work’. Such knowledge permits organizations to function effectively, and has been conceptualized as intellectual capital (Marsick & Watkins 1999), emphasizing that such knowledge carries economic benefits and is an important resource, taking years to develop. Conceptualizing staff in such a way makes investment in staff education essential to any political strategy. In times of competing job interests, recruitment difficulties and demographic changes leading to a subsequent shrinking of the labour force, developing strategies for enhancing work-place settings and retaining staff in jobs they find stimulating and rewarding, becomes a mandate far organisational survival. Recent Government proposals (Department of Health 2000) demonstrates a commitment to this kind of investment in NHS staff.
Promoting life-long learning in practice Establishing organizational structures on a national scale, such as the National Institute of Clinical Excellence and the Commission for Health Improvement, ensures information is accessible. Strategies mandating local staff support through clinical governance and personal supervision make it possible to support staff development and provide
14 Nurse Education In Practice (2001) 1, 12–18
resources designed to ensure that effective practices become commonplace. Such structures can facilitate life-long learning and continuous development. However, they can only be effective in organizational cultures where staff are encouraged to feel secure in their role and status, and have the energy to be receptive and supportive of further education and training without loss of status or authority (Barnett 1999). Where there is an organizational ethos of mutual regard, equity and value, it is possible to institute such social and educational activities (Billett 1999). As a result, commonplace traditional assumptions of knowledge and authority become outmoded and everyone becomes a learner. Local and national policies for continuing development are further supported by professional statutory organizations, which also have responsibility for protecting the public by developing professional standards of performance and for ensuring they are maintained. Whilst none of this can take place effectively without full collaboration from all the employees some professions have introduced mandatory professional refreshment as a requirement for re-registration. The United Kingdom Central Council for Nurses, Midwives and Health Visitors have a 3-yearly registration process based on evidence of continuing professional development, and this provides a model for all workers in the health service.
Professional development Development is concerned with individual personal growth. It deals with feeling and thinking and has practical application to life activities. This definition uses a more holistic form of learning involving personal and interpersonal skills such as problem-solving, initiative, efficiency, interactional and communication skills. Professional development moves this person-centred approach towards a more sophisticated level of incorporating knowledge, skills and attitudes necessary for effective practice. It prepares individuals to work in environments that are uncertain and changing rapidly. It helps people to develop skills that can be used in a range of settings both at home and at work. They are
© 2001 Harcourt Publishers Ltd
NEPR-03.QXD
3/17/01 10:12 AM
Page 15
Work-based learning in health care environments
the skills that enable practitioners to be self-directed, to take the initiative, to work with others, to communicate clearly, to take informed but calculated risks, to make judgements, to be responsible and assertive. These are the characteristics of empowered human beings and the way professionals are expected to act.
Complexity of practice development Professional practice is a dynamic activity that reflects individual encounters. Patient conditions and problems may bear similar characteristics, but individuals do not. Thus the idiosyncratic nature of professional practice is its fascination and also its challenge. Ovretveit’s (1992) arguments that practitioners need the necessary professional knowledge and skills to be effective, communicates that such knowledge is not static but needs refreshment and development on a continuous basis. It also assumes that practitioners have undertaken sufficient preparation to fulfil their role effectively; to be able to learn continuously and to recognize their own limitations. This continuous development of professional knowledge and understanding can be most effective when carried out under guidance and support from more experienced colleagues. This requires a complex range of professional skills and knowledge that marries both science and art in skilful, expert practice. Such expertise takes years to accumulate and can not be acquired after a few years training and education. Both opera singers and athletes are acknowledged to need a minimum of 8–10 years to reach their peak of performance. Ericsson and his colleagues (1993) investigating expertise, found like other researchers (for example Dreyfus & Dreyfus 1986) that practitioners require repeated exposure and feedback to develop complex skills. They found that it took an average of 10 years to become an expert. With all its complexity and high-risk management health care practice must rank as highly in developmental need as opera singers. These research findings raise questions about what can be reasonably expected of newly qualified practitioners and
© 2001 Harcourt Publishers Ltd
the kinds of post-qualification support and development needed to achieve their potential. Baseline profiles for newly qualified staff working in a range of settings describe the kinds of work they may reasonably be expected to undertake (NBS 2000). Based on recent research into newly qualified nurses it demonstrates the importance of further and continuing support and education. Titchen’s (2000) concept of critical companionship provides one model that goes a long way towards promoting such development. Successful professional development takes place in cultures that value education as an essential and continuous process rather than a luxury or a bonus. With Clinical Governance, learning and continuous development becomes part of the fabric of organizations, built into their policies and procedures. The rapid pace of technological development means knowledge quickly becomes outdated. This was a key concern of the National Committee of Inquiry into Higher Education (Dearing Report 1997). The Report emphasised a need for high quality education that supports learning as a life-long process. Recognition of the importance of affective and practical or experiential knowledge has grown with increasing research into learning and exposure to multi-cultural approaches to learning. As a result, learning in workplace settings is becoming recognized and the value of effective supervisory support from a colleague able to facilitate learning has become increasingly important. This requires adequate numbers of staff who have the time, interest and ability to provide such support.
Nature of work-based learning Throughout work settings, practical judgement is the mainstay of professional practice. This may not always be the case where work has become routinized and mundane. To survive unrelenting workloads, staff develop schema of practices that bypass questioning or problematizing practice and provide ready solutions or recipes. Experienced practitioners hold in their minds a range of such schema and can mentally flick through suitable ones to find a solution to their problem at hand (Benner
Nurse Education In Practice (2001) 1, 12–18 15
NEPR-03.QXD
3/17/01 10:12 AM
Page 16
Work-based learning in health care environments
1996). As a result, practical judgement may only be called to use when faced with the unexpected or problematic. Newcomers, unfamiliar with everyday situations of a setting encounter work as a series of problems to be resolved. Problematizing their practice in such a manner provides a model of practice that promotes person centredness (Argyris 1982) and has potential to enhance the quality of care. Collaborative problem-solving, preferably with colleagues or alternatively through journal writing, provides opportunities for existing knowledge and practices to be challenged and to generate new understandings. Practitioners with limited knowledge or understanding of the environment often have difficulty recognizing their environmental landscape as everything appears like a blur of activity, with few boundaries between the routine and the mundane and between the exceptional and the challenging. Not possessing informed sight newcomers require guidance from an experienced ‘local’ to make practice visible and to highlight the normal from the abnormaI or unusual. Novices may lack the vocabulary to talk about what is observed or to understand the everyday language of practitioners. These two categories of practitioners, the novice and the newcomer, who may be the same or different groups of people, need careful guidance until they have learned to read and talk about practice as old timers within the community (Lave & Wenger 1991). At another point in the continuum of practice are those who are experienced practitioners and whose judgements are based on routines and ritual. Often their vision of practice has become dulled by repetition and amongst the work objects of daily routines and unrelenting workloads they have forgotten to recognize the individual. As a result they may not recognize the significance of signs exhibited by their patients or clients. Collaborative work alongside skilled practitioners provides opportunities to review their own approaches to practice in an environment that can be both supportive and challenging (Daloz 1986). Challenges to their judgement of this kind are posed by what Burbules (1996) identifies as exposure to difference, exposure to power (of disruption) and exposure to alternative
16 Nurse Education In Practice (2001) 1, 12–18
discourse. By having to navigate these challenges, practitioners have to find alternative modes of action and as a result begin problem solving. In situations where knowledge or actions are not ready-to-hand, alternative strategies have to be developed and as a result judgement-making has educational significance (Hager & Beckett 1998). In developing judgements actors come to use a range of practical knowledge, skills and attitudes that have become integrated within a personal framework of understanding. Individual progress depends upon capacity to make sense of the environment and its challenges (Vygotsky 1930). This is where having a supportive supervisor able to assess capacity and potential for development makes work-based learning most effective. Through assessment of capability and knowledge, practitioners can be supported by their supervisors to undertake practices that challenge their thinking and promote further problem solving and learning (Spouse 1998). Understanding and professional knowledge can be supported and developed further through strategies such as debriefing, questioning, project work or journal keeping. By supporting learners in this manner insights and understandings can be mentally integrated alongside existing knowledge in a manner described by Piaget (1972). Such understanding can be consolidated and further developed over time through exposure to multiple examples of practice whilst supported by members of their community of practice (Rogoff 1990). Winch (1998 cited by Beckett 1999) describes human learning as flowing from attention to tasks at hand. This learning is accomplished by engaging in unfamiliar activities and learning to read them as problems worthy of investigation. In the process learners can extend their repertoire of knowledge. This reflects assertions that learning comes from research, theory and practice (Argyris 1982, Kolb 1985, Schön 1984, Usher & Bryant 1989) where to make sense of concrete experiences further investigation and propositional knowledge needs to be acquired. Working collaboratively in identified and legitimate activities and roles newcomers as well as old timers can assimilate new understandings. Newcomers can learn the
© 2001 Harcourt Publishers Ltd
NEPR-03.QXD
3/17/01 10:12 AM
Page 17
Work-based learning in health care environments
language and culture of their community of practice until they are able to fit comfortably within their new community (Lave & Wenger 1991).
Learning as informal, incidental or formal Marsick and Watkins (1990) describe learning in work-settings as informal or incidental. In both forms of learning the practitioner is an autonomous learner gaining understanding from experience. Incidental learning is more likely to be unnoticed, arising from brief exchanges of narratives or stories of practice such as during handover sessions, report writing or during social interactions at meal breaks where problems are shared and explored and can lead to sudden insights. Informal learning is defined as taking place outside formal educational settings but is planned or tailored to the learner’s identified needs such as debriefing or journal discussion activities, or specific practice experiences designed to meet predefined learning needs. Whilst Informal learning is planned it often draws on knowledge learned from formal educational activities, such as journals reading or classroom discussions and contextualizes it. Learning to recognize the saliency of formal, theorized information is challenging and often requires guidance from more knowledgeable practitioners. Drawing on the earlier discussion of learning arising from research, theory and practice, formal knowledge comes into play when practitioners identify limits to their understanding and ask questions about why or what they are doing in practice and look for answers. By modifying formal knowledge that has been decontextualized to the situation-at-hand informal learning can be supported. This is particularly important for novices embarking on their career and needing to apply their formal know-how to practical situations. Such learning can best take place in environments where everyone is an active learner engaged in problem solving and redefining routine activities. Such learning works best in environments where there is trust and a sense of companionship, and where there is time to engage in knowledge generation through reconstruction and
© 2001 Harcourt Publishers Ltd
reinterpretation of practice according to what has been seen as a problem(s) at hand (Spouse 1996). Such learning activities arise from recognizing practice as having potential to generate its own curriculum for learning and development. In settings where staffing levels are poor and there are insufficient experienced or knowledgeable practitioners able to guide learners (who are all the staff), such learning and knowledge transmission may be difficult to establish and support.
Conclusions and recommendations This paper highlights the importance of learning in the workplace and the crucial role that practitioners have in supporting each other’s professional development. Such learning does not depend upon lectures or tutorials, but it does rely on practitioners looking at their practice with fresh eyes. It needs them to see every act as worthy of scrutiny and reconsideration. It needs them to think whether they could do it differently and better in a way that is tailored specifically for the needs of each of their patients or clients. Learning in the workplace needs practitioners to draw on knowledge to be gained from evidence and this may be lodged in texts or with other colleagues. Crucially, learning in the workplace requires practitioners to share their expertise, to identify their learning needs and to plan how such needs can be met. It can only be achieved in settings where workloads do not drain staff of all their time and energy but leaves them thinking time and collaborative working time. Under the requirements of Clinical Governance such conditions will have to be provided. When such conditions are achieved learning and working become twinned making them natural and enjoyable processes. Acknowledgements
This paper is based on one presented at the conference: Dilemmas 2000, 1–3 September 2000 at the University of East London, Docklands; with Jill Reynolds, my colleague in SHSW at the Open University. My thanks go to her for the stimulation and support she generated.
Nurse Education In Practice (2001) 1, 12–18 17
NEPR-03.QXD
3/17/01 10:12 AM
Page 18
Work-based learning in health care environments
References Argyris C 1982 Reasoning, learning and action: Individual and organisational. Jossey Bass, San Francisco Argyris C, Schön D 1978 Organisational learning: a theory of action perspective. Jossey Bass, San Francisco Barnett R 1999 Learning to work and working to learn. In: Boud D, Garrick J (eds) Understanding learning at work. Routledge, London, Chapter 3, pp. 29–45 Benner P, Tanner CA, Chesla CA (eds) 1996 Expertise in nursing practice: caring, clinical judgement and ethics. Mass. Springer Publishing Company, Cambridge Billett S 1999 Guided learning at work. In: Boud D, Garrick J (eds). Understanding learning at work. Routledge, London, Chapter 10, pp. 151–164 Buch A 1999 Life, work and identity: the mapping of learning. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 49–52 in proceedings of conference Burbules N 1996 Post-modern doubt and philosophy of education. In A. Neiman (ed) Philosphy of education 1995. Urbana, Illinois, Philosophy of Education Society. pp. 39–48; cited by Beckett, D. (1999) Researching workplace learning amidst post-modern tensions. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 13–22 in proceedings of conference Csikszentmihalyi M, Csikszentmihalyi SI (eds) 1988 Optimal experience: psychological studies in the flow of consciousness. Cambridge University Press, Cambridge Daloz LA 1986 Effective teaching and mentoring. Jossey Bass, San Francisco Department for Education and Employment 1999 Learning to Succeed. White Paper, DfEE. Department of Health 1997 The New NHS: Modern Dependable. HMSO, London Department of Health 1998a A First Class Service: Quality in the new NHS. HMSO, London Department of Health 1998b Working together: securing a quality workforce for the NHS. HMSO, London Department of Health 1999 Continuing Professional Development: Quality in the new NHS. Department of Health (http://tap.ccta.gov.uk/doh/coin4.nsf), London Department of Health 1999 Quality and performance in the NHS: Clinical indicators. HMSO, London Department of Health 2000 The NHS Plan, London, Department of Health. Chapter 5: Investing in NHS staff Dreyfus HL, Dreyfus SE 1986 Mind over machine: The power of human intuition and expertise in the era of the computer. Basil Blackwell, Oxford Ericsson KA, Krampe RTh, Tesch-Romer C 1993 The role of deliberate practice in the acquisition of expert performance. Psychological Review 100(3):363–406 Garrick J, Usher R 1999 Flexible learning, contemporary work and enterprising selves. Paper presented at Researching Work and Learning. A first international conference. Trinity and All Saints College, University of Leeds. 10–12 September 1999. pp. 61–69 in proceedings of conference
18 Nurse Education In Practice (2001) 1, 12–18
Hager P, Beckett D 1998 What would life long learning look like in a workplace setting? In: Holford J, Jarvis P, Griffin C (eds). International perspectives on lifelong learning. Kogan Page, London, Chapter 19 Kolb, DA, 1985 Experiential learning. Prentice-Hall, NJ Lave J, Wenger E 1991 Situated learning: legitimate peripheral participation. Cambridge University Press, Cambridge Marsick VJ, Watkins KE 1999 Envisioning new organisational learning. In: Boud D, Garrick J (eds), Understanding learning at work. Routledge, London. Chapter 13, pp. 199–214 Marsick VJ, Watkins K 1990 Informal and incidental learning in the workplace. Routledge, London National Advisory Group for Continuing Education and Lifelong Learning 1997 Learning for the Twenty First Century: first report of the National Advisory Group for Continuing Education and Lifelong Learning, DfEE. Chair: Sir Ron Dearing National Board for Nursing Midwifery and Health Visiting for Scotland 2000 The Work of Newly Qualified Nurses: Adult Nursing, Core skills and Competencies. National Board for Nursing Midwifery and Health Visiting for Scotland, Edinburgh National Committee Inquiry into Higher Education 1997 Higher Education in the learning society. Summary report. HMSO, London NHS Executive 1999 The NHS performance Assessment framework. NHS Executive, Leeds Ovretveit J 1992 Health service quality an introduction to quality methods in health services. Blackwell Science, Oxford Piaget J 1972 Intellectual evolution from adolescence to adulthood. Human Development 5:1–12 Rogoff B 1990 Apprenticeship in thinking: cognitive development in social context. Oxford University Press, New York Schön D 1983 The reflective practitioner: How professionals think in action. Arena Ashgate Publishing Ltd, Hants Spouse J 1996 The Effective Mentor – a model for student centred learning in clinical practice. Nursing Times Research 1(2):120–133 Spouse J 1998 Scaffolding student learning in clinical practice. Nurse Education Today 18:259–266 Titchen A 2000 Freedom to practice. Heinemann, Oxford Usher R, Bryant I 1989 Adult education as theory, practice and research: The captive triangle. Routledge, London Vygotsky L, Luria A 1930 Tool and symbol in child development. In: Van der veer R, Valsiner J (eds). The Vygotsky Reader. Blackwell, Oxford, 7:99–174 Watson H, Harris B 1999 Supporting students in practice placement in Scotland. Glasgow Caledonian University, Department of Nursing and Community Health. Research commissioned by the National Board for Nursing, Midwifery and Health Visiting Scotland Winch C 1998 The philosophy of human learning. Cited by Beckett D 1999 Researching workplace learning amidst post-modern tensions. Paper presented at the Researching Work and Learning. A first international conference. Trinity and All Saints College University of Leeds. 10–12 September 1999. pp. 13–22 in proceedings of conference
© 2001 Harcourt Publishers Ltd