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Communities of Practice

Learning and Professional Identity Development in the Clinical Setting

Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD

CHAPTER OBJECTIVES

After reading this chapter, the reader will be prepared to:

• Differentiate between learning in the classroom and learning in the clinical setting.
  
• Recognize the complexity of teaching and learning in the clinical setting.
  
• Relate the concepts of apprenticeship learning and communities of practice to learning in physical therapy practice.
  
• Recognize the challenges that students face while learning in the clinical setting.
  
• Differentiate between personal meaning making and shared meaning making.
  
• Appreciate the importance of dialogue in the negotiation of shared meaning.
  
• Apply the concepts of communities of practice to designing effective teaching and learning experiences in the clinical setting.

As we know from previous chapters, teaching and learning in the classroom is much more complex than simply standing up in front of an audience lecturing and hoping that the audience will absorb the content. Similarly, teaching and learning in the clinic is also much more complex than simply matching a student and clinical instructor (CI) and having them work together with patients. One of the reasons why teaching and learning are so complex in the clinical setting is because one expectation of clinical education is that the learner will develop a unique professional identity, which is much more than just accumulating knowledge and skills, assimilating core values, or even simply applying their knowledge and skills to patient care. As we have tried to do throughout this text, in this chapter we provide you with a framework to help you recognize the complexity of the clinical teaching environment so that you can both engage in and design effective teaching and learning situations within the clinical setting.

This chapter emphasizes the development of professional behaviors and the affective domain as these behaviors become even more critical as students begin to interact with patients and other professionals. Professional behaviors, including communication and interpersonal skills, are emphasized because these are often the most challenging to teach and, for some, the most challenging to learn. Learning how to communicate as a professional is further complicated because some assume that communication is innate; yet, as you learned in Chapter 3, communication can be taught and is something that must be continually refined. While the focus is on communication and interpersonal skills, the concepts we present can be generalized to all aspects of learning (psychomotor and cognitive) in the clinical environment. Much of the information in this chapter is a synthesis of research and personal interviews with more than 50 students and clinicians, as well as written critical incidents from nearly another 350 students.1,2 Throughout the chapter, you will see direct quotes from students and clinicians that illustrate and reinforce the concepts being discussed. The quotes provide student and CI perspectives on how they developed their own professional identity, which is so integral to becoming a competent health care professional.

PROFESSIONALISM IN HEALTH CARE

While we know that it is critical for professionals to develop a level of expertise in their cognitive and psychomotor skills, we also know this is not enough. If you think back to Chapter 5, you will remember that learning occurs in 3 domains (cognitive, psychomotor, and affective). You will also remember that Dettmer⁴ advocates the addition of a fourth domain: the social domain. To develop high-quality, competent, caring practitioners who have assimilated the core values of the profession, we need to facilitate development in all domains of learning.

In the Stop and Reflect above, if you selected “affective skills,” you would be correct. It is truly our affective behaviors and social skills that enable us to interact effectively with patients.⁵ In any health care profession, the patient must be at the heart of all that we do. Without developing the values, attitudes, and beliefs that enable us to communicate and interact professionally and effectively with our patients, clients, and other health care providers, our own professional competence may be called into question. This is particularly true when we are interacting with laypeople who may have limited knowledge of health care in general or physical therapy specifically.^3,6–8

Beliefs, attitudes, values, norms, and standards are the noncognitive behaviors that comprise the affective domain. In the eyes of some patients, these skills may be even more important than some of the more technical skills. Laypeople assume that, because you have a license, you must be a competent practitioner. So, how do they really judge whether you are good or not? How do they determine whether you are providing quality care or not? They may very well make this judgment based solely on how you interact with them (ie, on your bedside manner).⁷ We also live in a society of consumerism, and patients are much savvier, much more informed, and more consumer-oriented than individuals from previous generations. They know that there are plenty of very smart and very skilled clinicians available, so why work with someone who does not appear to respect them or value them as individuals? Very often, it is the behaviors in the affective or social domains (your interpersonal skills) that will set you apart from other clinicians and will place you a notch above. So, professional practice is not complete without the ability to demonstrate the attitudes, values, and beliefs established by our profession.

The Code of Ethics for the Physical Therapist, the Standards of Practice, and the Core Values^9,10 of the physical therapy profession provide us with a set of expectations of professional abilities and behaviors. For some of us, these behaviors come easily; they are intuitive. Altruism, care and compassion, accountability, social responsibility, etc, are values that perhaps we grew up with and, therefore, we simply take them for granted. For others of us, these behaviors are not so simple and straightforward; they do not come so naturally. In fact, research has shown that these behaviors, while critical, have been problematic not only in physical therapy, but also throughout the medical community.11–17 It has also been shown that problems with these behaviors raise red flags for CIs. When a CI observes students having difficulty with professional behaviors, he or she often begins to question the safety and efficacy of his or her overall performance.^3,15

So, why has the development of professional behaviors been such a challenge in medicine and the health professions? Attitudes, values, and beliefs are abstract and complex concepts. They are more complex than what is written in the APTA Code of Ethics for the Physical Therapist, Standards of Practice, or Core Values documents. These behaviors are not technical skills, so they cannot necessarily be taught or measured objectively. Addressing issues of unprofessional behaviors or poor interpersonal skills can also feel very personal and uncomfortable at times. Finally, while we do have a set of standards and expectations in the profession, these standards are reinterpreted with subtle differences in each setting. For example, as a young physical therapist, I (MP)worked in 2 very different organizations. One organization was a very well-known rehabilitation setting, while the other was a well-known pediatric school setting. Expectations in each facility were quite different; behaviors and activities acceptable in the less-formal setting would likely not be acceptable in the more-formal setting. In addition, as noted in Chapter 1, we recognize that these attitudes, beliefs, and values are quite interconnected with our own histories, cultures, and generational experiences, making them ingrained and, at times, unconscious. Each clinical setting or community also has its own history and culture, which adds to the expectations of professionalism.

So, how are appropriate professional behaviors learned, and how do we teach them? Very often, it is simply assumed that, by the time you come to a professional program, you should already have the attitudes, values, and beliefs needed to be a professional or that you will learn them when you get to the clinic.3,11,18,19 However, as with any other skill, these abstract attitudes and behaviors must be practiced; to perfect them, an openness and willingness to both provide and accept feedback is essential. We know, and research has shown, that academic faculty and CIs hesitate to provide adequate feedback on affective behaviors because, as noted earlier, they often consider it too personal.^3,11,14,20 As instructors, be it in the classroom or the clinic, we often emphasize the cognitive and psychomotor domains of learning and minimize the importance of learning in the affective domain. Again, this may be because cognitive and psychomotor domains can be evaluated more easily and more objectively, while the affective domain requires substantially more subjectivity in evaluation. If you think back to Chapter 2, this is exactly what Schön referred to when he suggested that professional programs focused too much on technical rationalism almost to the exclusion of professional development. This is why it is so critical to develop the skill of creating objectives that incorporate all domains of learning.

As we noted, professional behaviors in the affective domain are not so easily defined, taught, or evaluated. We also know that, although passing the licensing examination gives us a certain degree of credibility, it does not guarantee that we have acquired the professional behaviors needed to become a fully functioning and competent therapist.²¹ We first learn about these behaviors in the abstract setting of the classroom and then we apply and continually refine them in our day-to-day experiences during our clinical internships and in clinical practice. However, as you remember, Dewey suggests that just because we have had these lived experiences does not guarantee that we will learn from them. This is particularly true now in our rapidly changing, fast-paced health care environments, where students are expected to arrive in the clinic well prepared to work collaboratively, not be a burden on their CIs, and perhaps even add to the productivity of the department. We typically expect that the students will hit the ground running as they enter the clinical setting.

THEORETICAL PERSPECTIVES ON LEARNING IN THE CLINICAL SETTING

As you will remember from previous chapters, learning is grounded in experience, and it is only through the application and interpretation of knowledge that education occurs.^22,23 Kolb²³ believes that learning is a cyclic “process whereby concepts are derived from and continuously modified by experience.” Remember from Chapter 1 that the cycle of learning starts with our concrete experiences and moves through reflection and observation, abstract conceptualization, active experimentation, and, finally, back to concrete experiences. It is this cycle that helps us to transform abstract academic theories into practical clinical application.²⁴ This is particularly relevant in physical therapy and other health care professions because we not only need to develop the knowledge, skills, and behaviors essential for practice, but we must also be able to apply them in the practice setting. Clinical internships and other clinical education experiences are what provide the real-life or contextual, social, and interactive experiences that help us to translate some of the abstract theories learned in the classroom to actual clinical practice.

In thinking about some of the questions raised above, chances are that you may have indicated that you learned through observation or by listening to, and engaging in, conversation with your parents and others. Some theorists suggest that our goals, values, interests are developed tacitly—that is, we learn them essentially through osmosis! Because professional behaviors are so complex, they cannot simply be taught through explicit instruction in an academic setting; rather, they must be experienced and learned on the job, through demonstration, practice, and indirect instruction.²⁵ In addition, as discussed earlier in this text, we know that theorists such as Schön²⁶ and Mezirow²⁷ believe that through the use of the reflective process we can make what we have learned tacitly more explicit and therefore more fully recognized and understood. Not only do students need to learn and assimilate the core values of the profession, but they also must learn the sociocultural expectations of each new setting.²⁸ While Bandura²⁹ proposes that much of this acculturation process occurs through observation within the social context, Lave and Wenger²¹ and Wenger³⁰ suggest that it takes much more than simply observation and imitation; rather, to make sense of the sociocultural expectations of each new clinical environment, active engagement in practice is critical.

This is a real paradigm shift in our thinking about how we learn. We now recognize that learning, particularly in physical therapy practice, is not simply an accumulation of facts or the processing of information, but, more importantly, it is how we apply what we have learned in a given context.21,30,31 Problem-based learning, patient simulations, and the use of cases to simulate real-world problems are examples of classroom strategies that we use to create real-life situations from which we learn to think critically, reason clinically, and solve real-world problems. In contrast, clinical practice requires us to actually function within a much more complex clinical environment. So, as authentic, or high fidelity, as we can try to make a classroom scenario, it is still quite different from what occurs in real-world situations. In simulations, we often are given the problem and asked to come up with a solution; in real-world practice, we often do not even know what problem to address. In simulations, it is the instructor’s responsibility to create the problem; as students, our role is simply to solve it. In real-world practice, we own the problem, not the instructor. It is our patient who presents with a problem and it is our responsibility to first define problem and then to develop the strategies that we might use to address that problem within the context of the unique clinical scenario.

While the differences noted earlier are substantial, perhaps the most significant difference in learning in the clinical setting vs the classroom setting is that learning takes place in a professional community of practice. Learning is no longer solely focused on gaining knowledge and skills or problem solving; rather, of equal importance is how we function effectively within the community of professionals, patients, and families. When you are in the clinical setting, you are no longer learning about physical therapy. You are learning to become a physical therapist.

If you just take a second to think about physical therapy, you will quickly realize that it is inherently a social practice and, therefore, learning must be a social process. Learning in physical therapy, or in any community of practice, is not simply the acquisition of knowledge and skills, but, rather, the development of an identity, the ability to engage, and the development of a sense of belonging within that community. Wenger³⁰ suggests that, within a community, this process is both reciprocal and evolutionary (ie, not only does the newcomer learn from those already in practice, but those in practice also learn from the newcomer). Newcomers often add different perspectives that may actually result in changes within the community (ie, an evolution). A student learns from and adds to the community as much as the community learns from and adds to the development of the student. For example, because students are required to frequently search the literature and utilize current evidence to support their work in the classroom, they bring these skills to the clinic; simultaneously, clinicians bring years of experience to bear on how that evidence is used in a given context.

COMMUNITIES OF PRACTICE

Unlike the classroom, learning in the clinical setting is improvisational or extemporaneous. It is driven by the unpredictable real-life problems that we encounter on a day-to-day basis. These problems are embedded in the complex social and physical environment within which we practice. Perspectives on how this impacts teaching and learning have evolved over time. As noted earlier, numerous educational theorists have explored the importance of different factors in the teaching-learning situation, and, because of their efforts, effective instructional strategies in professional education today include social interactions, context, and active participation in practice.^{21–23,26,30,32,33}

Active participation in practice is what helps students and novice clinicians learn how experienced practitioners act and interact throughout the day and how they interact as professionals and communicate with patients and other health care providers.³⁰ It helps to shape how they think, what they do, how they communicate and interact, and how they make sense of their experiences. Actively engaging in practice involves negotiating ways of being and interacting with one another within the community. It is through this negotiation process that students ultimately learn what it truly takes to belong and to become a fully participating member of a profession.³⁰ Each new experience reshapes how we understand practice. This continuous renegotiation of the meaning of our day-to-day experiences, which is facilitated by our own ongoing self-monitoring and reflection on what is and is not working, results in our professional identity development. Shepard and Jensen³⁴ describe this transmission of shared meanings as an acculturation process and suggest that it is the means by which students become socialized into the physical therapy profession. This renegotiation process holds true for newcomers and for those who have been in practice for some time, and forms the basis for lifelong learning in the profession. Continuous self-monitoring and self-assessment undergird this negotiation/renegotiation process.

In physical therapy, we learn from experienced practitioners much like an apprentice learns from a master craftsman. Lave and Wenger21 studied apprenticeship learning in a variety of settings. They broadened the traditional concept of apprenticeships to include communities in which increasing levels of participation lead to identity formation, much like in physical therapy and most other health care professions.³⁰ The goal of their work was to find the common threads that facilitated and inhibited learning in social practice. Common to all of these apprenticeships, as with physical therapy internships, is the concept of legitimate peripheral participation, which is a framework for understanding how newcomers learn by engaging with members of the community in progressively more complex and inclusive ways. For example, in physical therapy practice, students start by simply observing, asking questions, and, perhaps, performing a discrete component of patient management under close supervision. As they demonstrate increased competence, they gain credibility in the eyes of their CIs, who then begins to allow them to perform more and more complex skills with greater and greater independence. Over time and with additional experiences, the now novice clinician gains full membership in the community as a practicing clinician with responsibility for a total patient caseload. Throughout this transition from student to novice clinician, the learner is interacting with many individuals throughout the community of practice in the clinical setting. It is this progressively more complex engagement with other members of the community of practice that allows us, as newcomers, to continually enhance and modify our skills and interactions. Even for me, as an experienced clinician, yet as a new member of the pediatric community, I (MP) had to go through a similar process of learning about the culture of this new environment, and it reshaped the way I practiced and interacted with all members of the community, including my patients.

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