Learning through health care work: premises, contributions
and practices
Author
Billett, Stephen
Published
2016
Journal Title
Medical Education
Version
Accepted Manuscript (AM)
DOI
https://doi.org/10.1111/medu.12848
Copyright Statement
© 2016 John Wiley & Sons Ltd. This is the peer reviewed version of the following article:
Learning through health care work: premises, contributions and practices, Medical Education,
Volume 50, Issue 1, January 2016, Pages 124–131, which has been published in final form at
10.1111/medu.12848. This article may be used for non-commercial purposes in accordance
with Wiley Terms and Conditions for Self-Archiving (http://olabout.wiley.com/WileyCDA/Section/
id-828039.html)
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Learning through healthcare work: Premises, contributions and practices
Stephen Billett, Griffith University, Australia
Abstract
Learning through work has long been important for the development of healthcare workers’
occupational competence. Yet, to effectively utilise this mode of learning, its particular qualities and
contributions need to be understood and optimised and its limitations redressed. By optimising the
experiences healthcare workplaces provide, augmenting their learning potential and promoting
workers’ engagement with them can, together, assist these workers’ ability to respond to future
occupational challenges. Importantly, such considerations can be used to understand and appraise
workplaces as learning environments on their own terms. Here, the concepts of practice curriculum
and pedagogies, and workers’ personal epistemologies (i.e. what individuals know, can do and value)
are described and advanced as practical bases for optimising learning in and for healthcare
workplaces now and for the future. Such bases seem salient given the growing emphasis on practice-
based provisions for the initial preparation and on-going professional development of healthcare
workers’ capacities to be effective in their practice, and responsive to occupational innovations that
need to be generated and enacted through practice.
Learning through health care work
As long recognised, experiences in work settings can make distinct contributions to healthcare
workers’ learning, both in their initial professional preparation and ongoing development across
professional working lives(1, 2). Yet, to effectively utilise workplace experiences for these purposes
and advance innovation and efficacies in healthcare practice requires the contributions and
limitations of these experiences be understood, and used to inform practical actions for their
effective utilisation(3, 4). This goal requires drawing on accounts of learning informed, but not
constrained, by educational science as much of its assumptions are founded in ‘schooling’ (i.e.
taught experiences in educational institutions).
In addressing these concerns, empirically-based inquiries of learning in workplaces and
relevant literature are drawn upon to inform how everyday experiences in healthcare work can be
positioned as educationally worthwhile, including addressing future challenges. Whilst not always
founded in healthcare occupations, these inquries offer insights that can potentially translate to
clinical settings about: i) how learning through those settings arises, ii) the potential and limitations
of these learning processes and outcomes, and iii) how learning and innovation can be promoted in
and through work. Foundationally, they explain effective learning through healthcare work as arising
through a duality between the activities and interactions afforded in clinical settings, on the one
hand, and how healthcare workers elect to engage with them, on the other(5). This is the case
whether that learning arises through everyday work activities or interventions, such as clinical
teaching.
In principle, therefore, there is no difference between accounts of learning through
experiences in educational institutions and in clinical settings(
6). Both afford experiences and
individuals (i.e. students, workers) elect how they engage with what is afforded them. However,
qualitatively, clinical settings with their distinctive physical and social environments, activities and
interactions afford access to experiences and make contributions aligned with learning healthcare
practices. The clues and cues provided by those settings, and their occupationally-authentic goal-
directed activities and interactions grant access to and assist securing the kinds of knowledge
required for effective healthcare work and in ways that classroom-based experiences alone
cannot(7). There is, however, clear evidence of limitations, shortcomings and risks associated with
learning through workplace experiences(7). Hence, these experiences need to be valued in terms of
their potential for realising the desired kinds of learning outcomes required for workplace
performance that extends to efforts to redress their limitations. Elaborating these qualities and
advancing how they can address healthcare workers’ learning now and for the future is the central
focus here. The increasing role of workplace experiences in both initial occupational and ongoing
development in healthcare and the growing requirement for innovation and efficacies in practice
makes such understandings particularly important.
Four premises for understanding learning through work
The precepts, practices and focuses of ‘schooling’ (i.e. those of educational institutions and
practices) whilst essential in their own right, currently dominate and can distort considerations of
what constitute effective learning experiences. This can lead to the ignoring or downplaying of
learning arising outside of intentional educational programs and experiences(6). Therefore,
processes supporting learning through work need to be understood on the own premises, which can
then inform how they can be best ordered, supported and augmented. Four such premises are now
advanced.
Firstly, learning occurs all the time. It is an inevitable consequence of human thinking and
acting(8, 9). When practitioners engage in work activities and interactions, more than completing
tasks, changes have been shown to arise in what they know, can do and value(i.e. learning) (7).
Hence, learning is not reserved for or necessarily privileged by intentional educational experiences.
Indeed, rather than where they occur, it is the kinds and qualities of everyday work experiences and
individuals’ responses to them that shape what is learnt(10). Engaging in clinical tasks or activities
that are novel to individuals offer the potential for new learning. Novel experiences, if effectively
engaged with and adequately supported, can lead to developing further clinical capacities. However,
activities beyond the scope of individuals’ existing competence or readiness (i.e. their zone of
potential development(11) can lead to limited or negative outcomes: e.g. confusion or frustration(7).
Hence, there can be a need for guidance by more experienced co-workers. Importantly, routine or
familiar clinical activities can also lead to more effective practice through honing and refining their
procedures and establishing causal links and associations of the kind required for clinical
reasoning(12). This incremental learning often arises without conscious awareness and can be
difficult to recall by practitioners and capture by researchers. So, changes in what individuals know,
can do and value (i.e. learning) are ongoing across working lives and are not dependent on
educational programs or teacherly interventions.
Secondly, studies indicate that as workers engage in work activities they also remake(13),
and potentially, transforming their occupational activities(14). So, as healthcare practitioners enact
their clinical work at particular moments in time and circumstances as directed towards specific
goals, they are engaged in remaking their occupations, thereby sustaining and, incrementally,
transforming them. Sometimes, that remaking extends to the transformation of occupational
practice. Worldwide, healthcare workers are currently changing their infection control practices to
contain the Ebola virus. As existing protocols have failed, new procedures are developed, trialled and
enacted, thereby transforming healthcare practice. So, more than changes arising in individuals (i.e.
learning), occupations also change through workers’ enactment. Hence, identifying, enacting and
evaluating future clinical procedures and securing innovations are inevitably linked to the co-
occurrence of healthcare work and learning.
Thirdly, as clinical knowledge (e.g. that for medicine, radiography, etc.) is a product of
history, culture and situational requirements, it has to be accessed and engage with to be secured by
workers. Workplace settings have been shown to provide access to aspects of that knowledge
through physical and social environments, and activities and interactions that comprise authentic
instances of occupations(8). Yet, more than individuals’ accessing these experiences, their active
engagement with these environments is required for effective learning to arise, including their
appraisals of the worth of what is experienced. This engagement arises through everyday thinking
and acting through work, and emphasises individuals’ learning and development as personally
mediated.
Fourthly, learning and development are two separate, but interdependent, processes.
Moment-by-moment learning or micro-genetic development continually occurs as individuals learn
through their experiencing(15). Yet, this learning is premised on what they already know, can do and
value which are legacies of earlier experiences and learning (i.e. their ontogenetic development)(15).
So, individuals’ personally-particular development means they may learn differently from the ‘same‘
experience(6, 16). Hence, the interlinking between learning and development are person-
dependent, by degree. All this suggests that positioning individuals as meaning-makers and
constructors of knowledge is central to promoting how learning through clinical practice might best
progress and be supported.
From these premises, learning through work is seen as a normal outcome of everyday
thinking and acting at work. Factors comprising the social and physical environment, and their
activities and interactions shape that learning and its efficacy. Also, the experiences afforded
learners and how they engage with them are central to the kinds and extent of knowledge learnt
through healthcare work. Having outlined these premises for considering workplaces as learning
environments on their own terms, it is necessary to elaborate the particular qualities of learning
through work.
Learning through work
Across human history, participating in work activities is the commonest mode of learning
occupations (17). Most of it has likely arisen through observation, imitation, practice (i.e. mimesis)
and, occasional direct guidance, but only rarely teaching(8). Until relatively recently, this was the
only means through which most occupations were learnt. Before the ‘era of schooling’, that arose
with the formation of modern nation states and industrialisation, very few occupations (e.g.
medicine) had educational provisions. Yet, even those occupations relied on practice-based
experiences. Indeed, in Hellenic Greece, anatomy classes and textbooks were introduced in medical
education to compensate for lack of student access to authentic medical experiences (
17). Processes
of observation and imitation are central to much learning across individuals’ lives, including that at
work, which largely proceeds without being taught or guided(18, 19). Such claims may seem
contentious to those living in schooled societies where educational provisions are ubiquitous and
orthodox. Yet, Jordan(19) notes teaching has always been a minor mode of knowledge acquisition in
human history. She advises,
… 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, … 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." (19) (932)
Therefore, given its significance to healthcare work and workers across human history(4), the
characteristics and contributions of these experiences are worthy of a brief elaboration.
Using observations, interviews and recall through critical incidents and across a range of
industries, studies of how workers’ learn through and for their work have identified four key
contributing factors to that learning(7). Firstly, through workers engagement in goal-directed work
activities and interactions – ‘just doing it’ – procedural, conceptual and dispositional knowledge is
learnt. Engagement in work activities requires individuals to utilise what they know, can do and
value and through completing those activities these can change. Secondly, workplaces’ social and
physical environments afforded clues and cues about performing and learning those activities.
Across a range of occupations, workers consisted reported the importance of observation and
hearing others as being salient for their learning. This ‘indirect’ guidance was found to generate goal
states (i.e. what needs to be achieved) that guide and permit monitoring of work and learning
processes. Thirdly, work activities afford opportunities for practise thereby honing abilities to enact
tasks effectively and building causal and propositional links amongst concepts of the kind required
for tasks such as clinical reasoning(12). Fourthly, close guidance by more experienced workers assists
in accessing and securing knowledge that is difficult to learn and would not be best learnt through
trial and error(7).
Noteworthy, three of these four contributions are primarily based on learners’ actions,
agency and intentions. They emphasise active engagement with what is experienced, including those
with more expert workers. An interview based study of medical students in longitudinal rural
placements found that their engagement in clinical decision-making through parallel consultations
was held to be generative of richer and more applicable medical knowledge than their peers who
engaged in more restricted activities in a teaching hospital (20). So, the combination of authentic
activities and interactions, interest and focused intentional engagement are held collectively as key
contributions to effective workplace learning experiences.
However, potential limitations of learning through work are evident across these studies(7).
Workers report a lack of access to required activities and the direct guidance needed for effectively
learning occupational knowledge in those settings. When they are not explicit and/or accessible,
individuals report difficulty in understanding the goals for their work and learning, and how to
achieve some work goals. Also, what is learnt through practice can be inappropriate (i.e. bad,
unhelpful, perilous habits or practices). In addition, workers can be reluctant to participate in ways
generative of adaptive learning(7). So, in appraising how workplace experiences can assist learning
in healthcare settings, measures to redress these potential limitations are required.
Yet, considerations for effectively utilising their potential and redressing limitations needs to
go beyond the orthodoxies and conceptions of educational programs, their assumptions and
practices (i.e. teaching) and discourse, can be constraining and unhelpful. Much of the strategic and
specific procedures required for work are not expressible or captured by the declarative (i.e.
stateable) forms of knowledge privileged in those institutions. Embodied ways of knowing (i.e. such
as in auscultation (21), are also not accommodated by such forms, nor is haptic engagement (i.e.
feel, tactile competence) that is essential to some healthcare diagnoses and treatments. With its
reliance upon declarative forms, this discourse also struggles to accommodate dispositions (i.e.
values, interest, intentionality) – ethical conduct, for instance. The educational discourse also