This chapter sets out some consideration for the application of mimetic learning to assisting and promoting the initial and ongoing development of occupational capacities through practice-based experiences. In doing so, it focuses on the organisation of experiences (i.e., practice curriculum), how these experiences can be enriched (i.e., practice pedagogies) and also the central role that personal epistemologies play in a constructive process of learning through practice. In addition, consideration is given here to how experiences in practice settings might well be integrated with those in educational programs, that is, the ways in which the contributions of both experiences in practice and in educational settings might best be aligned, ordered, organised and enacted to generate the kinds of knowledge which are required for effective occupational practice, and in preparing practitioners to be active learners themselves across their working lives.

Implications for Practice

Context Learning to prescribe is challenging for junior doctors. Significant efforts have been made to improve prescribing education, especially in view of the high rates of prescribing errors made by junior doctors. However, considerations of educational options often overlook the fact that learning to prescribe and prescribing practices rely on practice-based interactions with informed practitioners, such as pharmacists and consultants. Pharmacists have long made important contributions to developing prescribing capacities. Objectives The present study examines the potential of everyday co-working between junior doctors and pharmacists, in conjunction with consultants, as an accessible means of developing effective prescribing practices. Methods A qualitative interview study was conducted in an Australian tertiary hospital using thematic analysis to explore junior doctors', pharmacists' and consultants' perspectives on how co-working supports learning to prescribe in an acute tertiary hospital setting. Participants included 34 practitioners, comprising junior doctors (n = 11), consultants (n = 10) and pharmacists (n = 13). The thematic analysis was informed by workplace learning theory. Results Learning to prescribe was found to be a highly interdependent process. In particular, junior doctors were dependent on co-working with consultants and pharmacists. Three interrelated themes related to co-working and learning to prescribe in the workplace were identified: (i) prescribing readiness of junior doctors; (ii) need for guidance, and (iii) the challenges of pharmacists co-working as outsiders. Conclusions Co-working with pharmacists and consultants contributes positively to junior doctors' prescribing practices. However, co-working is complex and is influenced by differing understandings of prescribing practices. These insights assist in informing how co-working can be enacted routinely in hospital settings to promote safe and effective prescribing practices. Consideration should be given to when and how co-working between junior doctors and pharmacists is initiated, including during medical school. In clinical settings, strategies such as having pharmacists attend ward rounds and adopt a role of learning facilitation rather than error identification may augment everyday opportunities for co-working and learning.

Learning to prescribe through co-working: junior doctors, pharmacists and consultants.

Context
Workplace learning is optimised when learners engage in the activities of the workplace; learner engagement is influenced by workplace affordances and learner agency. Learner agency can be operationalised through achievement goal theory, which explains that students can have different goal orientations as they enter learning situations: mastery (learn and improve), performance approach (demonstrate competence) or performance-avoid (avoid demonstrating incompetence). Mastery-orientated, compared with performance-orientated, students approach curricular experiences as opportunities for developing rather than demonstrating competence. This study explored the relationships among students’ achievement goal orientations, workplace affordances and learning outcomes in the context of early clinical experiences.

Methods
Students who completed their preclerkship curricula at four medical schools answered a questionnaire about their personal goal orientation and the perceived goal structure and workplace affordances of their preceptorship experiences. All items used a 5-point scale (1 = strongly disagree/not at all true, 5 = strongly agree/very true). Students were evaluated by their preceptors and completed standardised-patient exams at the end of their pre-clerkship curricula. Analyses included descriptive statistics and mediation analysis.

Results
Of 517 students, 296 (57.3%) responded and 253 (85.5%) had linked performance data. Student goal orientation means were: mastery, mean = 4.27 (SD = 0.65); performance-approach, 2.41 (0.76); performance-avoid, 2.84 (0.88). Student goal orientation and performance on preceptor evaluations (PEval) or standardised-patient exams (SPExam) were not significantly related. Perceptions of a mastery-structured curriculum and inviting workplace were associated with higher SPExam (β = 0.28, p = 0.02) and PEval (β = 0.51, p = 0.00) scores, respectively. Student mastery goal orientation was positively associated with perceptions of a mastery-structured curriculum (β = 0.59, p = 0.00) and positive workplace affordances (β = 0.25–0.29, p ≤ 0.01).

Conclusions
Students held a predominant mastery goal orientation towards their early clinical experiences. Mastery-orientated students perceived preceptorships as mastery-structured with positive workplace affordances, and those perceiving a mastery-structured or inviting preceptorship performed better. Clinical experiences should be structured to emphasise learning rather than demonstration of skills to promote learning outcomes.

Students’ goal orientations, perceptions of early clinical experiences and learning outcomes

The entrance of newly qualified medical specialists into daily practice is considered to be a stressful period in which curriculum support is absent. Although engaging in both personal and professional learning and development activities is recognized fundamental for lifelong professional competence, research on medical professionals' entrance into practice is scarce. This research aims to contribute to the framework of medical professionals' informal learning and outlines the results of an exploratory study on the nature of learning in daily practice beyond postgraduate training. Eleven newly qualified physicians from different specialized backgrounds participated in a phenomenographic study, using a critical incident method and a grounded theory approach. Results demonstrated that learning in the workplace is, to a large extent, informal and associated with a variety of learning experiences. Analysis shows that experiences related to diagnostics and treatments are important sources for learning. Furthermore, incidents related to communication, changing roles, policy and organization offer learning opportunities, and therefore categorized as learning experiences. A broad range of learning activities are identified in dealing with these learning experiences. More specifically, actively engaging in actions and interactions, especially with colleagues of the same specialty, are the most mentioned. Observing others, consulting written sources, and recognizing uncertainties, are also referred to as learning activities. In the study, interaction, solely or combined with other learning activities, are deemed as very important by specialists in the initial entrance into practice. These insights can be used to develop workplace structures to support the entrance into practice following postgraduate training.

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Learning beyond graduation: Exploring newly qualified specialists' entrance into daily practice from a learning perspective

In our second analysis piece of Lord Darzi’s NHS review Jo Stephenson looks at the formation of a new body that will oversee all medical training in England

Medical Education England

Experiences in clinical settings have long been featured in medical education. Students engage in these experiences across their undergraduate programmes and beyond their registration as doctors during specialty training. Such is the institutional, personal and financial investment in the provision of these practice-based experiences that it is important to understand more about how they can be used to most effectively develop medical capacities and dispositions initially and then continue to support them across medical working lives. Consequently, this chapter seeks to understand more fully something of practice-based experiences’ contributions to initial and continuing medical education and learning. Quite specifically, it seeks to identify how three key educational purposes can be secured through experiences in clinical settings. These goals are those associated with assisting individuals to (1) identify whether they want to practise medicine and, if so, which specialty they wish to pursue; (2) develop the occupational capacities required to practise their preferred form of medicine; and (3) continue to learn and develop further their medical practice over lengthening professional lives. The data from interviews with new doctors beginning their second-year post-graduation clinical work in the UK medical training pathway (Foundation Year 2) are used to identify and illuminate how these experiences can be used to realise each of these three kinds of goals. The intention is to understand how best these experiences might be afforded to, and taken up by, newly qualified doctors, and in what ways practice-based experiences need to be augmented to more fully secure those medical education goals.

Joseph Leaman

Papers

Developing Medical Capacities and Dispositions Through Practice-Based Experiences