Extraordinary Learning in the Workplace

Extraordinary Learning in the Workplace

Innovation and Change in Professional Education VOLUME 6

Series Editor: W.H. Gijselaers, School of Business and Economics, Maastricht University, The Netherlands Associate Editors: L.A. Wilkerson, David Geffen School of Medicine, University of California, Los Angeles CA, USA H.P.A. Boshuizen, Center for Learning Sciences and Technologies, Open Universiteit Nederland, Heerlen, The Netherlands Editorial Board: H. Barrows, School of Medicine, Southern Illinois University, Springfield IL, USA T. Duffy, School of Education, Indiana University, Bloomington IN, USA K. Eva, Faculty of Health Sciences, McMaster University, Hamilton ON, Canada H. Gruber, Institute of Educational Science, University of Regensburg, Germany R. Milter, Carey Business School, Johns Hopkins University, Baltimore MD, USA

SCOPE OF THE SERIES The primary aim of this book series is to provide a platform for exchanging experiences and knowledge about educational innovation and change in professional education and post-secondary education (engineering, law, medicine, management, health sciences, etc.). The series provides an opportunity to publish reviews, issues of general significance to theory development and research in professional education, and critical analysis of professional practice to the enhancement of educational innovation in the professions. The series promotes publications that deal with pedagogical issues that arise in the context of innovation and change of professional education. It publishes work from leading practitioners in the field, and cutting edge researchers. Each volume is dedicated to a specific theme in professional education, providing a convenient resource of publications dedicated to further development of professional education.

For further volumes: http://www.springer.com/series/6087

Janet P. Hafler Editor

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Editor Dr. Janet P. Hafler Yale School of Medicine New Haven Connecticut USA [email protected]

ISBN 978-94-007-0270-7 e-ISBN 978-94-007-0271-4 DOI 10.1007/978-94-007-0271-4 Springer Dordrecht Heidelberg London New York © Springer Science+Business Media B.V. 2011 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Overview: The Reasons for Writing This Book Janet P. Hafler

Just prior to a recent American Educational Research Association (AERA) annual meeting, leaders of AERA Division I (Education for the Professions) met at a pre-conference session to explore important educational topics and issues that cut across the professions. From the discussion, a proposal was put forward for the Springer series “Innovation and Change in Professional Education” and this volume – “Extraordinary Learning in the Workplace” – is one of the fruits of that effort. We seek to inform the work of educators for the professions in curriculum design, instruction, and assessment by focusing on professional education in the practice settings of the workplace during the degree program stages of professional education. Our synthesis applies to a wide variety of professions and professionals who are trying to understand how to teach and how to promote learning in the workplace. First among the fundamental issues that need to be discussed when looking at workplace education and when seeking to make workplace learning extraordinary is to clarify the meanings of “workplace” and of “extraordinary learning.” As to the first, we use the term “workplace” when referring to “the site where work is done by professionals while students are participating in providing service.” As to the second, we start with the word “extraordinary,” which Merriam-Webster (2009) defines as “going beyond what is usual, regular and customary,” and then move to “extraordinary learning,” which Hafferty and Hafler, in one of the chapters, put forth as follows: [W]e take as our primary thesis that workplace learning truly is extraordinary when it is marked by structural congruence and a positive synergy among the intended and formal preparation of professionals (the formal curriculum); the tacit learning that takes place within the hidden curriculum; and the subsequent demands, both formal and tacit, that are embedded in subsequent workplace settings.

J.P. Hafler (B) Yale School of Medicine, New Haven, CT, USA e-mail: [email protected]

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To arrive there, authors explored the research and practice literature related to curriculum, instruction, and assessment of professionals’ learning in the workplace and the implications for best practices. What was added – and what is therefore unique to our volume – is that we examined that literature in the context of four professions (education, nursing, medicine, and clergy) at the point in those professions where students are learning during the degree program stages of their education. And so our students are student-teachers learning how to teach; student-nurses learning nursing; student-doctors learning how to provide care; and student-clergy learning the elements and practice of their profession. One assumption we hold is that for extraordinary learning to take place, throughout lifetimes of practice, professionals-as-educators must not only continue learning but must do so in the context of their practice, utilizing such methods as self-directed and practice-based learning. Though it is not the focus of this book, ongoing professional development is essential to our discussion because educators in the workplace need to be role models of effective practice if they are to make workplace learning extraordinary. Further, our examination of the current literature and relevant developments in teaching and learning across the professions have led us to explore how students can best learn in the workplace. We draw on that research, add what we found across selected professions, and highlight the questions that can guide continued research on how learning can be made extraordinary. The purpose of the book is to lay out the issues associated with extraordinary learning in the workplace, so that professionals who are educators may be aware of them and of best practices and, so, be equipped to facilitate extraordinary learning in the workplace. How do we teach in the workplace so that extraordinary learning can truly occur, even when it involves what Hawkins (1974) so beautifully refers to as “messing about?” Should not our curriculum capture and reflect the process of learning – the “messing about” – while still giving the other, perhaps more obvious, elements their due in planning for student learning: curriculum design, teaching methods, and assessment strategies, all of which are key structural components of education programs that promote learning. That assumes that attention has been paid to the curricular issues, the teaching challenges, the relevant assessment methods, and the much-needed preparation of the faculty members involved in workplace learning. Many of our authors argue that there has been a lack of attention in the past to the programmatic context of learning in the workplace. Each contributor was tasked with carefully reviewing the literature and each has presented an excellent synthesis of the current status of the field as well as possible strategies to help foster extraordinary learning in the workplace. How different is learning in the workplace from learning in the classroom? Shulman and his colleagues, working in the context of the Carnegie Foundation study of education for the professions (Shulman, 2005), conceptualize professional development in terms of professional socialization and development of moral integrity, professional or clinical skills, and specialized knowledge through what they refer to as signature pedagogies. In education for the professions, learning in the practice settings of the workplace is the signature pedagogy and it is in

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those environments that novices most profoundly experience entry into a community of practice as they develop professional skills through observation, coaching, mentoring, and supervision, and as the situations of practice provide meaning and motivation for abstract learning. Much of such learning occurs in the workplace. The authors in this book argue that attention to both the formal and the hidden curricula of the workplace, as well as preparing teachers to be effective educators in the context of a complex environment, forms the crucible where extraordinary learning can take place.

The Structure of the Book After a careful analysis of the literature and numerous discussions with all the contributing authors, we decided to structure the book in four sections: 1. Curriculum, addressing both the Formal and the Hidden Curriculum; 2. Learning and Instruction; 3. Assessment, addressing emerging changes and practical strategies in the Assessment Paradigm for Professionals; 4. Implementation, addressing Faculty Development issues and a synthesis of what we have learned from our work. To help understand terminology across the professions, Table 1 provides an overview of the different terms used to describe workplace learning in each of the four professions that were selected. To simplify the terminology throughout the book, we will use student, faculty, and workplace to refer to all of the professions. Although we are examining one aspect of student learning – in the workplace – we fully acknowledge that learning is developmental and progresses on a continuum (Table 1).

The Issues Addressed in Part I: Curriculum From the perspective of workplace learning we begin with Harris highlighting three predominant traditions in curriculum studies: the systems approach, the reconceptualist approach, and the approach of deliberative curriculum inquiry (Harris, 1993). She has skillfully synthesized the literature and showed how the three traditions are relevant to professional education. She suggests that the systems approach has provided professional education with, as she states, “its principal and most enduring edifice for curriculum development and evaluation.” She argues that Tyler’s (Tyler, 1949) paradigm for curriculum work, an exemplar of the systems approach that focuses on needs, purposes, objectives, organization of learning experiences, and assessment of students’ performances, provided the foundation for Blooms’ behavioral approach to assessment (Bloom, 1956), but only partially addresses the full range of issues in professional education in the workplace.

Ministry supervisor usually with a faculty rank

Ministry supervisor

Student MDiv – (post-baccalaureate) ~4 years to ordination Clergy are placed throughout curriculum; internship experiences prior to ordination Broad variety of training environments (hospitals, prisons, community organizations, church environments, schools, etc.) Clinical pastoral education or ministry training

Attending physician, Preceptor,

Clerkship (medical student), residency (post graduate) Attending physician, preceptor, resident

Medical student MD (post-baccalaureate) – licensure 3–5 years required training Typically medical school year 3 (with some experiences in years 1 and 2) Hospitals, operating rooms, outpatient clinics, emergency rooms, private offices, etc.

Medicine

Nurse preceptor

Clinical supervisor

Clinical rotations; clinical preceptorship

Hospitals, nursing homes, outpatient clinics, schools

Student nurse ADN (associates) 2–4 years; BSN (baccalaureate) Usually clinical begins year 1

Nursing

in the field placement/in the school where the student teacher is placed. for grading the student teacher, must conduct observations in the cooperating teacher’s classroom.

b Responsible

a Teacher

Title of teacher/mentor/supervisor in workplace Title of faculty or university-based teacher/mentor/advisor

Name of workplace learning experience

Site/type of workplace used for training

Title of learner Length of total training/required credentials When clinical/practical training occurs

Clergy

supervisor – faculty member

b University

Student teaching, internship, practicum, field placements a Cooperating teacher

Often as part of a 5th year teacher certification or as a field placement in a 4-year program The classroom

Student teacher BA + masters degree, 4–6 years

K-12 education

Table 1 The following chart helps to clarify some of the terminologies used in the four professions that we are highlighting in this volume

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The systems approach to curriculum design tends to ignore the nature of the informal and hidden curricula present in every institution of professional education and work. Harris then explores the reconceptualist approach to curriculum work, developed by a group of curriculum scholars, who sought to reconfigure how we think of the curriculum. The reconceptualist approach includes perspectives from a broad range of disciplines with a focus on the relationships between curricula and the cultural, social, political, and economic structures of the professional school and workplace setting; on the personal experiences of the curriculum; and on the hidden curriculum of role modeling and professional socialization (Harris, 1991a; Harris, 1993). Lastly, Harris completes her discussion on curriculum as it relates to the hidden curriculum via a discussion of the deliberative curriculum inquiry approach to curriculum work that focuses on group processes of reflective inquiry in curriculum development. This tradition has its origins in work done by Schwab at the University of Chicago in the early 1970s (Schwab, 1978). She explores how processes in curriculum design in the deliberative inquiry approach, involving diverse stakeholders that include preceptors and mentors in workplace settings, have the potential to create curricula suitable for education in the setting of the workplace, while considering both the formal and the hidden curricula. In Chapter 2, Hafferty and Hafler, in their chapter, “The Hidden Curriculum, Structural Disconnects, and the Socialization of New Professionals,” provide a paradigm of the reconceptualist approach to curriculum work in their analysis of the hidden curriculum – which refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors – which they view through the lens of socialization theory (Freidson, 1970a, 1970b). Hafferty and Hafler use Freidson’s basic arguments about training and work to explore several issues facing professional education in the twenty-first century. The basic argument is that the more highly siloed the training experience, and the more highly disconnected or pedagogically fractured that experience, the more likely the current work setting will trump prior socialization in determining how one performs in the workplace. The logic for those conclusions is as follows: the more disconnects there are in training, whether they be with respect to sites of training or the number of role models encountered, the more likely trainees will experience not one but several different and potentially countervailing experiences of socialization and professional inculcation. The disconnects, in turn, generate a hidden curriculum of professional preparation whereby trainees learn (and are tacitly taught) to adopt a chameleon-like approach to their professional preparation. The authors argue that to attain extraordinary learning in the workplace, the curriculum, formal and hidden, need to be considered in tandem and synergistic, in order to develop an extraordinary learning environment.

The Issues Addressed in Part II: Learning and Instruction Part II focuses on conceptions and theories of learning and instruction and is intended to inform the work of educators with regard to components of professional

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education that occur in the practice settings of the workplace. As Shulman (2005) has described, in education for the professions learning in the practice settings of the workplace is perhaps the signature pedagogy. As such, the authors explored the range of learning theories to assess their applicability in the workplace. Harris integrates the many theories into clusters, and Henry and Malu present “effective teaching practices for the workplace.” Schön’s (1983, 1987, 1991, 1995) influential epistemology of professional practice, encapsulated in the term “reflective practice,” is imbedded in all of our chapters, from learning to teaching to assessing students. Harris writes that his “work is grounded in important philosophical traditions,” most notably Dewey’s conceptions of the role in learning of reflection on experience (Dewey, 1938). She comments that [Schön’s work] “is based on empirical analyses of case studies, across the professions, of professional practice and education for professional practice. Moreover, it is supported by studies in cognitive psychology and the development of expertise.” In exploring what makes learning extraordinary in the workplace, Harris comments that Schön acknowledges the role of specialized knowledge in the competent and wise action that characterizes effective professional practice. But equally important for effective professional practice is the demonstration of “practical knowledge” or “know-how,” which Schön refers to as “knowing-in-action,” and of reflective competencies, which he refers to as “reflection-in-action” and “reflection-aboutaction.” Rounding out Part II, Henry and Mahu explore how coaching, mentoring, and supervision are strategies for workplace learning environments. As Svinicki and Wilkerson suggest, when teachers are prepared and trained for the workplace, they can effectively help the student “reflect in action” and “reflect about action” as issues in professional practice emerge.

The Issues Addressed in Part III: Assessment Galbraith et al. report on changes in the assessment of students in the workplace, arguing that “assessment has remained largely unchanged. . . and the multiple choice question (MCQ) tests introduced originally in the 1950s have become the de facto gold standard for ‘quality’ assessment.” They move the thesis forward by using medicine as the main example, but enjoin readers to examine their own profession’s assessment in a new light, saying for example: “Given the current level of patient dissatisfaction with communications skills and professionalism, the introduction of organized assessment could do much to assure patients that relevant proficiencies are being acquired and maintained.” The same arguments would be valid for nursing, teacher education, and education for the clergy, they posit. Galbraith et al. explore the concept of a broad base of assessment. Rather than focusing primarily on knowledge and its application, they propose that assessment also include the domains of professionalism, reflective competencies, and functioning within systems of professional practice. In addition, the discussion of the movement toward lower stakes assessment that includes one’s professional

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development and attitudes is becoming more prominent in the literature and the authors push us to explore new methods to assess the important leaning that actually occurs in the workplace, once again contributing to learning that can be extraordinary. Clifton and Mylona review research into the methods of assessment during workplace training for each of the four professions: medicine, nursing, theology, and education. The literature review is structured around practical assessments in three domains: knowledge, skills, and attitudes. They acknowledge that many of the methods integrate one or two of these domains but are able to help us see how we can advance our thinking of assessment in the workplace.

The Issues Addressed in Part IV: Implementation The central argument in this book is that teachers need to learn how to be effective educators in the workplace, to include curriculum design, teaching, and assessment. The focus of faculty development (also called staff development or educational development in different countries and disciplines) is to educate the teachers for the professions. As Svinicki and Wilkerson state, “To use the more familiar workplace learning denotation, the faculty developers are the trainers who train the trainers.” The focus of that effort and of this chapter is the workplace instructor,1 and the goal of such training is to make the workplace instructors more effective at helping students. If a teacher understands the range of factors that influence learning in the workplace, he or she will be able to develop strategies that will help move toward extraordinary learning in the workplace. O’Brien has successfully organized the final chapter into three themes: relationships, activities or tasks, and work practices. She writes that these themes can constitute a synthetic framework for workplace learning. She references the literature and points out how the themes can enhance or interfere with learning. The critical synthesis moves us forward to identify future directions for research in workplace learning environments. The questions they pose (such as “Do students have a clearer sense of expectations, receive more guidance and constructive feedback, have a better sense of their level of performance, or feel more motivated to improve their performance if they have a longitudinal relationship with a workplace instructor?” or, “How can relationships beyond the instructor-student, be developed to enhance learning?”) begin to guide future directions for research that can be addressed across professions. In pursuing further research it is best, she suggests, to

1 To clarify the workplace settings that we have researched for this chapter, we are studying clinical settings for the medical and nursing professions, student teaching in real schools and classrooms for the teaching profession, and placements in congregations and other social service settings for the pastoral profession. This means that we are targeting attending physicians, clinical nursing supervisors, cooperating teachers, and clinical pastoral education supervisors.

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use general principles rather than to focus on capturing the nuances of particular settings and professions and to search for tighter connections between “the classroom” and “the workplace.”

Summary Many themes reappear in this book, but the overarching one is that as educators, regardless of profession, we must ensure we are teaching to promote learning and not just helping students acquire a knowledge base that has stochastic relevance to their professions. We not only aim to extend knowledge but also seek to develop the skills and the attitudes that are the backbone of each of our professions. Where we tackle the definition of learning from a broad array of theories and explore how we can prepare for our role as teachers in providing extraordinary learning in the workplace, we are not directly writing for any one profession but for many, citing four that are relevant and provide cogent examples. Although many chapters focus on the literature of medicine, we aim to integrate the literature from education, nursing, and clergy as we believe our effort is essential and relevant to all educators who teach in the workplace.

References Bloom, B. S. (1956). Taxonomy of educational objectives: Cognitive domain. New York: McKay. Dewey, J. (1938). Experience and education. New York: Kappa Delta Phi, Touchstone. Freidson, E. (1970a). Profession of medicine: A study of the sociology of applied knowledge. New York: Harper & Row. Freidson, E. (1970b). Professional dominance: The social structure of medical care. New York: Atherton Press. Harris, I. (1991a). Contributions to professional education from the field of curriculum studies: Research and practice with new traditions of investigation. Professional Education Research Quarterly, 13, 3–16. Harris, I. (1991b). Deliberative inquiry: The arts of planning. In E. C. Short (Ed.), Forms of curriculum inquiry (pp. 287–321). Albany NY: State University of New York Press. Harris, I. (1993). Perspectives for curriculum renewal in medical education. Academic medicine, 68, 484–486. Hawkins, D. (1974). The informed vision: Essays on learning and human nature: Messing about in science (p. 63). New York: Agathon Press. Merriam-Webster Online Dictionary (2009). From http://www.merriam-webster.com/ dictionary/extraordinary. Accessed August 1. Schwab, J. J. (1978). The practical: A language for curriculum. In I. Westbury, N. Wilkof (Eds.), Science, curriculum and liberal education: Selected essays (pp. 287–321). Chicago: University of Chicago Press. D. A. Schön. (Ed.). (1991). The reflective turn: Case studies in and on educational practice. New York: Teachers College Press. Schön, D. A. (1983). The reflective practitioner: How professionals think in action. New York: Basic Books.

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Schön, D. A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco: Jossey Bass. Schön, D. A. (1995). The new scholarship requires a new epistemology. Change, 27(6), 26–34. Shulman, L. S. (2005). Signature pedagogies in the professions. Daedalus, 134, 52–59. Tyler, R. (1949). Basic principles of curriculum and instruction. Chicago: University of Chicago Press.

Contents

Part I

Curriculum

1 Conceptual Perspectives and the Formal Curriculum . . . . . . . Ilene B. Harris 2 The Hidden Curriculum, Structural Disconnects, and the Socialization of New Professionals . . . . . . . . . . . . . . . . . . Frederic W. Hafferty and Janet P. Hafler Part II

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Learning and Instruction

3 Conceptions and Theories of Learning for Workplace Education . Ilene B. Harris

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4 Coaching, Mentoring, and Supervision for Workplace Learning . Beverly W. Henry and Kathleen F. Malu

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Part III

Assessment

5 Conceptual Perspectives: Emerging Changes in the Assessment Paradigm . . . . . . . . . . . . . . . . . . . . . Robert Galbraith, Stephen G. Clyman, and Donald E. Melnick 6 Assessment: Practical Strategies Applied to the Professions . . . . Maurice Clifton and Elza Mylona Part IV

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Implementation

7 Faculty Development for Workplace Instructors . . . . . . . . . . Marilla D. Svinicki and LuAnn Wilkerson

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8 Envisioning the Future . . . . . . . . . . . . . . . . . . . . . . . . Bridget O’Brien

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Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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From the Series Editors

About the Book Series The overall purpose of the Book Series “Innovation and Change in Professional Education” (ICPE) is to promote innovation in the field of professional education based on current research and thinking in the learning sciences. We provide a platform for exchanging experiences and knowledge about educational innovation and change in professional education and post-secondary education (engineering, law, medicine, management, health sciences, etc). The series provides an opportunity to publish reviews, issues of general significance to theory development and research in professional education, and critical analysis of professional practice to the enhancement of educational innovation in the professions. The series promotes publications that deal with pedagogical issues that arise in the context of innovation and change of professional education. It publishes work from leading practitioners in the field, and cutting edge researchers. Each volume is dedicated to a specific theme in professional education, providing a convenient resource of publications dedicated to further development of professional education.

About This Book The 6th volume – edited by Janet Hafler from Yale University – in our book series presents a broad perspective on how various professions are more and more focusing on capturing the importance of professional practice in curricula for professionals. It provides a synthesis of topics that support educators to improve learning experiences for students in the professions when dealing with program design, learning and instruction, and assessment. It furthers our understanding how learning at the workplace can become central in the training of professionals and how learning in the workplace can be an extraordinary learning experience for students. The idea for the present and several forthcoming volumes in this book series was initiated by Marcia Mentkowski from Alverno College, Milwaukee Wisconsin, when she served as Vice President of Division I (Education in the Professions) of the American Educational Research Association (AERA). She encouraged the editor xvii

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and authors to continue their hard work and cooperative effort to write this important volume. The editorial board of the ICPE book series wants to express their gratitude to all people who made this volume possible. Wim H. Gijselaers, Editor-in-Chief Maastricht University, Maastricht, The Netherlands Henny Boshuizen, Associate Editor Open University, Heerlen, The Netherlands LuAnn Wilkerson, Associate Editor University of California, Los Angeles, CA, USA

Contributors

Maurice Clifton Mercer University School of Medicine, Macon, GA, USA, [email protected] Stephen G. Clyman National Board of Medical Examiners, Philadelphia, PA, USA, [email protected] Robert Galbraith National Board of Medical Examiners, Philadelphia, PA, USA, [email protected] Frederic W. Hafferty Mayo Medical School, Rochester, MN, USA, [email protected] Janet P. Hafler Yale School of Medicine, New Haven, CT, USA, [email protected] Ilene B. Harris College of Medicine, University of Illinois, Chicago, IL, USA, [email protected] Beverly W. Henry Northern Illinois University, DeKalb, IL, USA, [email protected] Kathleen F. Malu William Patterson University, Wayne, NJ, USA, [email protected] Donald E. Melnick National Board of Medical Examiners, Philadelphia, PA, USA, [email protected] Elza Mylona State University of New York, Stony Brook University Medical Center, Stony Brook, NY, USA, [email protected] Bridget O’Brien San Francisco School of Medicine, University of California, San Francisco, CA, USA, [email protected] Marilla D. Svinicki The University of Texas, Austin, TX, USA, [email protected] LuAnn Wilkerson David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, [email protected]

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Part I

Curriculum

Chapter 1

Conceptual Perspectives and the Formal Curriculum Ilene B. Harris

Overview This chapter is intended to inform the work of educators for the professions about conceptual perspectives related to the curriculum and will focus on the formal curriculum, particularly as it relates to those components of professional education that occur in the practice settings of the workplace. In Chapter 2, Hafferty and Hafler focus on the informal curriculum of the workplace. In Part I, we will present a definition of the concept of curriculum. We will also discuss the rationale for the pervasive inclusion in professions education curricula of learning in the practice settings of the workplace, typically very early in the preservice curriculum. In Part II, we will discuss the implications for learning in the workplace of three predominant traditions of scholarship and practice in curriculum studies – the systems approach, deliberative curriculum inquiry, and reconceptualist approaches (Harris, 1993a).

Part 1: Definition of Curriculum and Rationale for Learning in Practice Settings of the Workplace for Education for the Professions Consistent with current curriculum scholarship and practice, we espouse a broad and comprehensive conception of the curriculum. “Curriculum” refers not only solely to the content or subject matter of education but also importantly to the planning and implementation of education programs, including needs assessment for programs, formulation of goals and objectives, selection of approaches and methods of instruction, consideration of the teaching and learning environment, assessment of learners, and evaluation of the curricula (Pinar, Reynolds, Slattery, & Taubman, 1996; Schubert, Shubert, Thomas, & Carroll, 2002). Curriculum also I.B. Harris (B) College of Medicine, University of Illinois, Chicago, IL, USA e-mail: [email protected] J.P. Hafler (ed.), Extraordinary Learning in the Workplace, Innovation and Change in Professional Education 6, DOI 10.1007/978-94-007-0271-4_1,  C Springer Science+Business Media B.V. 2011

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I.B. Harris

encompasses the concepts of the “intended curriculum” – the formal plan; the “enacted curriculum” – the actual implementation of the plan, which may or may not be consistent with the plan; and the “experienced curriculum” – what learners experience in education settings (Billet, 2006; Hafferty & Hafler, 2010). Furthermore, curriculum includes the “hidden curriculum,” the “unintended curriculum,” and the “informal curriculum” (Pinar et al., 1996; Lave & Wenger, 1991) – all referring to the unplanned, but “experienced,” curriculum, which may or may not be consistent with the planned, formal curriculum, and which may or may not be viewed as positive and efficacious. It is well known that curricula for professions such as medicine, nursing, and teaching, as organized in academic institutions, typically include learning in the practice settings of the workplace, early in the formal curriculum, as early as the first year. For example, medical students participate in preceptorships and clerkships, in hospital and community clinic settings, supervised by physicians in practice, as an integral component of their education, typically beginning in their first year of training. Medical residents have three or more years of supervised experience in medical practice settings following graduation from medical school, prior to being licensed to practice independently. Student nurses participate in clinical rotations and preceptorships, in hospitals, private practices, and school clinics, supervised by nurses practicing in those settings, again typically beginning during their first year of training. Student teachers, preparing to teach in K-12 (kindergarten through 12th grade) settings, engage in practice teaching in classrooms, in what are referred to as internships, practicums, or field placements. They are supervised both by “cooperating teachers,” responsible for these classrooms, and by university faculty members, responsible for placements and oversight. These practice teaching experiences are typically in one school and for a semester near the completion of their formal training. During the 1990s, “professional development schools” (PDSs) were formed through partnerships between professional education programs and P-12 schools to function like teaching hospitals: hybrid institutions focused on preparation of new teachers, faculty development, and inquiry for improvement of practice in the venue of teaching actual students (Clark, 1999; Darling-Hammond, 1994; Holmes Group, 1990). Divinity students have internship placements throughout their 4-year curriculum, guided by a “ministry supervisor,” in practice settings such as hospitals, community organizations, prisons, schools, and church environments. In these settings, divinity students are socialized to the roles, the pastoral and education functions, and ways of thinking of religious leaders. They learn to help individuals and communities respond to the events in their lives, based on insights from their religious traditions; they also develop skills of communication, transformation, and even skills of managing organizations (Foster, Dahill, Goleman, & Tolentino, 2006). Why do curricula for the professions characteristically include placement in workplace settings as an integral part of preservice education? One reason the curricula include such “apprenticeship” experiences, in that they are part of several vaunted traditions. In addition, it has come to be recognized that “clinical”

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experiences in workplace settings, even early in professional education, are very important for achieving essential goals of education for the professions. Shulman (2005, 2007), in his work on the Carnegie Foundation study of education for the professions, conceptualized professional development in terms of inextricably intertwined processes of professional socialization, development of professional or clinical skills, and development of specialized knowledge through what are referred to as signature pedagogies – the pedagogies that are special, often unique in a domain of education. In education for the professions, learning in the practice settings of the workplace is the signature pedagogy, where novices experience professional socialization as they enter into a community of practice and develop professional or clinical skills through observation, role modeling, practice, reflection and feedback, and specialized knowledge as the situations of practice provide both motivation and a context for deeper understanding in classroom settings. From a related perspective, evolving conceptions of the nature of professional practice provide a solid grounding for this tradition. As discussed in Chapter 3 (Harris) of this book, professional practice requires specialized knowledge from various disciplines. For example, medicine and nursing require pertinent knowledge from the basic and clinical sciences, as well as the social sciences. Teaching requires knowledge of the subject matter taught and of the body of scholarship related to curriculum, instruction, assessment, and evaluation. Divinity requires knowledge and skills in exegesis and biblical interpretation. Furthermore, actual professional practice situations are characterized by conditions of complexity, uniqueness, uncertainty, ambiguity, and conflicting value and ethics orientations. Effective professional practice requires the development of “practical knowledge” for applying a repertoire of formal knowledge to a specific situation and for transfer of formal knowledge to a variety of related situations (Bransford, Brown, & Cocking, 1999). It also requires reflective competencies, which Schön (1983, 1987, 1991, 1995) refers to as “reflection-in-action,” in the midst of practice; and “reflection-about-action,” in the postmortem, for selfcorrection and development of professional practice. Based on case studies across the professions, Schön observes that these competencies are learned principally in practice, through experience with the actual problems of practice. From another related set of perspectives, an evolving array of learning theories, discussed in Part II (Chapter 3 by Harris) of this book, justifies and validates the inclusion of learning in the workplace as a component of the curriculum of education for the professions, even early in in-service training. Behavioral learning theories focus on the importance for professions education of opportunities for practice, with supervision, and specific and timely feedback in relation to observation of learners’ performance in practice (Wilkerson & Irby, 1998). Conceptions of “adult learning” and constructivist theories of learning suggest the importance for professional education of active learning by self-directed learners in relation to authentic problems, with opportunities to practice and gain experience in multiple situations, to reflect upon their experiences and formulate principles for practice based on their reflections, and to apply these principles to practice in new situations (Gagne, 1985; Kolb, 1984; Schön, 1983, 1987, 1991; Shuell, 1986; Sternberg & Wagner, 1986).

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Social learning theories also emphasize the importance of active learning by selfdirected learners, but add to these processes the importance of constructing meaning through observation and collaboration with others in a social context (Bandura, 1986; Salomon & Perkins, 1998, Vygotsky and Cole, 1978). Other investigators in the social learning tradition focus on the importance of learning in, and being initiated into, communities of practice and of situated learning in the authentic context of practice settings (Brown, Collins, & Duguid, 1989; Collins, Brown, & Newman, 1989; Lave & Wenger, 1991; Wenger, 1998). It should be noted that “social learning” is related to, but distinct from, “communities of practice.” Social learning focuses on learning in any social context, while learning in a “community of practice” focuses on learning in situations where community norms have developed. Lave and Wenger (1991) describe a trajectory of learning and development as professionals, beginning with legitimate peripheral participation, that is, performing less essential tasks, to increasingly full participation in the central work of the community of practice. Vygotsky and Cole (1978) describe a zone of proximal development, a space where aspiring professionals learn the knowledge, skills, and values of the community, in their social and cultural context, through observation and interaction with more experienced professionals, opportunities to practice, with increasing responsibility and autonomy, and feedback based on observation of practice. Thus, the array of learning theories, in the behavioral, the constructivist, and the social-cognitive traditions, justifies and validates the inclusion of learning in the workplace as a component of the curriculum of education for the professions, however early in in-service training. In this section, a broad and comprehensive definition of curriculum was presented. We also discussed the rationale for the pervasive inclusion of learning in the practice settings of the workplace in education for the professions, typically very early in the preservice curriculum, in terms of traditions, of evolving conceptions of the nature of professional practice, and in terms of evolving learning theories. In Part II, we will discuss the implications for learning in the workplace of three predominant traditions of scholarship and practice in curriculum studies – the systems, deliberative curriculum inquiry, and reconceptualist approaches (Harris, 1993a).

Part 2: Traditions of Scholarship and Practice in Curriculum Studies: Implications for Learning in the Workplace There are three predominant traditions in curriculum studies: the systems approach, the reconceptualist approach, and the deliberative curriculum inquiry approach (Harris, 1993a). The systems approach focuses on the systematic selection and alignment, among various components of curricula, to include educational goals and objectives, instructional and learning methods, assessment methods, and evaluation methods. Reconceptualist approaches use perspectives and methods from a broad range of disciplines, such as ethnography, politics, and economics, to focus on (1) the relationship between curricula and their economic, political, social, and

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cultural contexts and (2) the experiential, personal, and hidden meanings associated with the experienced curriculum. The deliberative curriculum inquiry approach focuses on group processes of reflective inquiry in curriculum development.

Systems Approach The systems approach to curriculum development has provided professional education, and education in general, with its principal and most enduring edifice for curriculum development and evaluation. Synthesized by Tyler (1949), this paradigm focuses on the systematic analysis of needs; systematic formulation of purposes, goals, and objectives; selection and organization of teaching and learning experiences; assessment of students’ performance; evaluation of the curriculum; and concordance among these components of the curriculum. The systems approach has been translated into a quasi-technology, firmly grounded in the ideal of using specific behavioral objectives (Bloom, 1956; Gronlund, 1991: Krathwohl, 1964; Mager, 1984; Popham & Baker, 1975), chosen based on needs assessment (Witkin & Altschuld, 1995), as a basis for selecting aligned instructional (Dick & Carey, 1990) and assessment approaches. The actual curricula in education for the professions typically include “classroom” components, designed to develop in aspiring professionals specialized knowledge pertinent to each profession, such as in medicine and nursing, of the basic and clinical sciences. Curricula for the professions also include, as we have discussed, learning in the workplace, which is intended to serve multiple purposes – to develop professional skills, to provide for initiation and socialization into a community of practice, to provide motivation for classroom learning, and to provide an authentic context for understanding implications for professional practice. The history of curricula for professions education has been characterized by an increasing emphasis early in the curriculum on the actual problems of practice (Harris, 1993b) – whether in classroom instruction, with the widespread implementation of instructional strategies such as problem-based learning (Neville & Norman, 2007), or in the practice settings of the workplace (Harris, 1993b). The systems approach to curriculum design has clear implications for learning in the practice settings of the workplace. It suggests consideration, first, of which goals and objectives are most appropriate for learning in the practice settings of the workplace and, second, of the optimal use of the practice settings of the workplace to achieve these goals and objectives. With regard to goals and objectives, we ask: which are most appropriate for learning in the practice settings of the workplace? In turn, we ask: What are the resources for such learning available in the workplace? Most fundamentally, the workplace provides a venue where, ideally, master professionals engage with “clients” (broadly conceived) to address their problems and achieve their goals, using appropriate resources, in a community of practice, which will include other professionals and perhaps other students. Ideally, these practice settings provide venues where novices can observe the “best practices” of master practitioners;

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reflect with these professionals about the practices they have observed; engage in practices themselves at a level appropriate to their training; and reflect on their own practice efforts, with feedback from master practitioners. These practice settings may have “academic resources.” Hospitals and community clinics, for example, may have regularly scheduled rounds and conferences. However, the unique contribution of the workplace for education of novices is the venue provided for novices to observe “best practices” and, for themselves, to practice with feedback. Therefore, the goals and objectives best served by placement in the practice settings of the workplace are goals in the domain of professional skills and professional socialization, rather than purely cognitive knowledge goals, which are well served by such methods as the use of case studies and simulations in classroom settings. What, then, is the optimal use of the practice settings of the workplace to achieve these goals and objectives in the domain of professional skills and professional socialization? Ideally practice settings should exemplify “best practices” for the profession – such as exemplary doctoring, nursing, teaching, or pastoral care. Second, ideally the practice settings should be prepared for the involvement of students in what is primarily a work situation. Third, workplace supervisors should also demonstrate “best practices” – in teaching. The various theories of learning discussed in Part I provide clear guidelines for effective teaching in the practice settings of the workplace. Behavioral learning theories focus on the importance of opportunities for practice, with supervision, and specific and timely feedback in relation to expectations, goals, objectives, and observation of learners’ performance in practice. Conceptions of adult learning, and constructivist theories of learning, suggest the importance of active learning by selfdirected learners in relation to authentic problems in practice; with opportunities to practice and gain experience in multiple situations; to reflect upon their experiences and formulate principles for practice based on their reflections; and to apply these principles to practice in new situations. Social learning theories add to these processes the importance of constructing meaning through observation and collaboration with others in a social context, and initiation into communities of practice. Perhaps most important, Lave and Wenger (1991) describe a trajectory of learning and development as professionals, beginning with legitimate peripheral participation that starts with novices performing less essential tasks to their increasingly full participation in the central work of the community of practice. Vygotsky and Cole (1978) describe a zone of proximal development, a space where aspiring professionals learn the knowledge, skills, and values of the community, in their social and cultural context, through observation and interaction with more experienced professionals, opportunities to practice, with increasing responsibility and autonomy, and giving and receiving feedback based on observation of practice. These learning theories have different emphases, but they converge on a set of straightforward recommendations for optimizing learning in the practice settings of the workplace. Specifically, workplace supervisors should engage collaboratively with learners in identifying their learning needs, formulating appropriate goals and objectives, selecting appropriate learning experiences and resources, assessing their

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performance in relation to these goals and objectives, and reflecting on their experiences. Learners should be provided with opportunities to observe role models and to reflect on their observations; to practice, with problems appropriate to their level; to reflect on their rationales and strategies for practice; and to develop principles for practice that they then test in practice – all with timely feedback. The systems approach has served professional education well in providing systematic methods for curriculum development (Kern, Thomas, Howard, & Bass, 1998); moreover, as demonstrated in our discussion, it provides a basis to conceptualize the role of learning in the practice settings of the workplace in curricula for the professions, in terms of purposes, goals, and objectives and optimal methods for achieving these goals and objectives. However, the systems approach has limitations to conceptualizing the curriculum, when applied to workplace learning. First, it does not clearly acknowledge that professional practice, learned ultimately in the workplace, fundamentally involves exercising judgment and acting wisely in complex, unique, and uncertain situations. In addition to theoretical and technical knowledge, professionals need reflective and practical competencies for dealing with problems in the indeterminate zones of practice that do not yield to technical or familiar solutions (Schön, 1987). Such competencies, which are difficult to describe in behavioral objectives, need to be observed and practiced and appear to be ever more important in the development of professionals, given the current climate of rapid technological, cultural, and economic changes. Second, the systems approach does not explicitly take into account that curricula are embedded in complex institutional settings with intertwined missions of service provision, education, and very often research and scholarship. Institutions have multifaceted relationships with society, which depends on them to serve vital missions. There are also intricate relationships internally within a professional school’s administration and externally with the institutions of professional practice – the workplace. Third, the systems approach to curriculum design tends to ignore the nature of the informal and “hidden” curricula present in every institution of professional education and work. Examples include the socialization processes through which professional competencies and values are developed and the role modeling by professionals in these settings, which may or may not be consistent with “best practices,” recommended practices, or even appropriate practices.

Reconceptualist Approach An approach to curriculum scholarship and practice that does address these issues is what has been referred to as the reconceptualist approach. This approach derives its name from a group of curriculum scholars who sought to reconceptualize how we think about the curriculum (Schubert et al., 2002; Pinar et al., 1996). Reconceptualist thinking involves the use of perspectives from a broad range of

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disciplines, such as ethnography, sociology, political science, and economics, to focus on the relationships between curricula and the cultural, social, political, and economic structures of the professional school and workplace setting; the hidden curriculum of role modeling and professional socialization; and the curriculum that students actually experience (Harris, 1991a, 1993b). There is an increasing number of studies and essays that explore these aspects of professional development. For example, a number of investigators have persuasively discussed the powerful role of the hidden curriculum in the professional development of health professionals, both in academic institutional settings and in the practice settings of the workplace (Castellani & Hafferty, 2006; Goold & Stern, 2006; Hafferty & Franks, 1994; Hafferty, 1998, 1999, 2000; Hundert, Hafferty, & Christakis, 1996; Stern & Papadakis, 2006). Moreover, there have been studies showing that the professional values espoused in the formal curriculum may not, in fact, be demonstrated in the practice settings of the workplace. For example, Stern (1998) reported a study comparing the “recommended curriculum” of medical values with the values actually demonstrated, and thereby taught, in hospital-based internal medicine teams at an academic medical center. The recommended curriculum was identified through content analysis of curriculum documents and interviews with individuals responsible for directing education programs within the formal curriculum. The “taught” curriculum of values in the workplace was identified through naturalistic but systematic observation and audiotaping of interactions in inpatient internal medicine teams. Among the professional values intended to be taught were self-policing and the importance of public health. However, these values were less emphasized in the “taught” curriculum of the workplace – in the actual learning environment of inpatient internal medicine teams. Other professional values targeted for teaching were the importance of interprofessional respect and service, but naturalistic observations revealed that interprofessional disrespect and the burden of service were prevalent in the “taught” curriculum. Using scholarship in the field of curriculum studies as a resource (Schubert et al., 2002; Pinar et al., 1996), Hafferty and Hafler, in the next chapter of this book, provide an extended example of a reconceptualist approach to thinking about the curriculum that focuses on curricula for medicine. They examine issues of the hidden curriculum through the lens of socialization theory. Starting from Freidson’s (1970a, 1970b) argument that the current work setting is more important than prior preparation or socialization in explaining professional performance, they point to the impact on professional development of students’ experiences in different work settings, each with different practices and standards – many of which demonstrate a disconnect with recommendations for the formal curriculum. They conclude, “These disconnects . . . generate a hidden curriculum of professional preparation, whereby trainees learn (and are tacitly taught) to adopt a chameleon-like approach to their professional preparation. As a consequence, trainees come to define – and approach – each clinical experience or classroom setting as a distinct book of expectations (e.g., learning) in which the lessons learned in one become site-specific points of engagement with only ancillary application to other situations” (p. 10).

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In turn, drawing on historical sources, Hafferty and Hafler (2010) describe three movements for best practices in medicine, stimulated by clear evidence of problems in the actual practice of medicine – the professionalism movement, the evidencebased medicine movement, and the patient safety movement. With reference to these movements, they point to issues in the relationships of the institutions of medicine with the pharmaceutical industry, which present challenges to professionalism and potential conflicts of interest. Furthermore, they discuss issues connected with implementing the 80-hour workweek for residents in training, mandated by the Accreditation Council for Graduate Medical Education (ACGME), stemming from widespread concerns about patient safety. They observe that while these movements have had significant influence on recommendations for the formal curriculum, students experience wide discrepancies between recommendations for best practices and what they are actually taught – the hidden curriculum, in the variety of role models and workplace settings where they are placed for their “clinical education.” Moreover, they observe that a “culture of silence” dominates the medical workplace about deviations from best or even appropriate practices. As a result, rather than being in an environment that serves as a resource for collaborative reflection (Schön, 1987), students adapt to the culture of silence, which becomes an influential part of the hidden curriculum, affecting their professional development. In analyzing the relationship between the formal curriculum, and learning in the practice settings of the workplace, Hafferty and Hafler (2010) and others as well ( Billet, 2006) argue for increasing the congruence between the formal curriculum of recommended “best practices” and the hidden and enacted curriculum that students experience in the workplace. They conclude their analysis, commenting, “Workplace learning is truly extraordinary when it is marked by structural congruence and a positive synergy between the intended and formal preparation of professionals (the formal curriculum), the tacit learning that takes place within the hidden curriculum, and the subsequent demands, both formal and tacit that are embedded in subsequent workplace settings” (p. 30). We have been exploring the implications for learning in the practice settings of the workplace of two predominant traditions of investigation in curriculum studies. The systems approach focuses on the systematic selection, and alignment, among various components of curricula – educational goals and objectives, instructional and learning methods, assessment methods, and evaluation methods. Reconceptualist approaches use perspectives and methods from a broad range of disciplines, such as ethnography and sociology, to focus on the relationship between curricula and their social, cultural, political, and economic contexts and on the experiential, personal, and hidden meanings associated with the experienced curriculum. Use of reconceptualist approaches in constructing arguments, and in empirical studies, most typically demonstrates a disconnect between the formal curriculum, derived using systems approaches to curriculum development, and the practices experienced by students in workplace settings – which have been referred to as the taught curriculum, the enacted curriculum, or the hidden curriculum (Billet, 2006). There is another tradition in curriculum studies, referred to as “deliberative curriculum inquiry,” that addresses this disconnect, by focusing on group

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processes of reflective inquiry in curriculum development (Harris, 1991a, 1991b, 1993a, 1993b).

Deliberative Curriculum Inquiry Work done in the tradition of deliberative curriculum inquiry addresses the problems identified previously, by presenting alternative perspectives on the nature of curriculum issues and by recommending specific processes for curriculum deliberation and decision-making – group processes of reflective inquiry. This tradition has its origins in work done by Schwab (1978) at the University of Chicago in the early 1970s. He viewed curriculum problems as fundamentally practical problems about making choices; taking action; formulating educational policy; and practicing within complete, unique, and complex situations in which values and belief systems play a central role. He argued that curriculum problems should be addressed by methods appropriate to issues of choice and action, namely deliberation among stakeholders who, by bringing to the discussion diverse perspectives and values, about what to teach, and why and how to teach it, reach a consensus about how to solve education problems in particular situations. Schwab and others have characterized various processes and “arts” (Harris, 1991b) needed for both leading and participating in productive curriculum deliberations. The fundamental process for group deliberation is a systematic method by which groups formulate and consider an adequate variety of alternative perceptions and formulations of problems, as well as an adequate variety of alternative solutions to those problems. Discussion is directed toward making decisions about what and how to teach in a particular context. Deliberation among members of properly constituted groups is essential for achieving the purposes of effective curriculum decision-making. These purposes are to bring together diverse values and sources of evidence and expertise, to reach justified decisions, to educate participants through exploration of diverse perspectives, and to achieve personal and political commitment to decisions. Given the purposes of curriculum decision-making, it follows that the most important curriculum deliberations for professional education take place at each professional school and involve those who “live in” or are strongly affected by the education process: faculty members in the academic setting; representatives from the practice settings of the workplace, including workplace supervisors; administrators and education leaders; students; and a chairperson. Curriculum deliberation groups so constituted would first identify what curriculum problems need to be addressed in their particular situation, such as a disconnect between the formal curriculum and the enacted curriculum in the practice settings of the workplace. They would consider the nature of the problems. For example, given the perception of such a disconnect, is the vision of “best practices” formulated in the formal curriculum unrealistic or inaccurate with respect to the complexities of actual workplace practice? Or, is the system within which professionals practice a dysfunctional one for achieving what all agree are “best practices”? Deliberative

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groups would bring to bear on the problems identified an eclectic array of values, perspectives, and experiences, each with its own light to shed on the problems at hand. Heuristics have been developed to facilitate the phases of deliberation. These heuristics include preplanning evaluation, a process of preliminary data-gathering that informs all phases of deliberation (Curry, 1992). Another heuristic is the use of nominal group technique, a structured group process approach developed in management sciences for expeditiously conducting the problem identification and solution phases of deliberations (Hegarty, 1971). Specific principles and methods for deliberative curriculum inquiry are more completely described elsewhere (Harris, 1991b). What perspectives should inform the process of curriculum deliberation? First and foremost, the group should consider the curriculum already in place and the local circumstances: the missions, goals, and objectives of the institution; the characteristics of students; the orientations of faculty members; the resources available; the social, economic, and political context; and the strengths and pressing problems – all based on the diverse perspectives of the deliberative group, informed by curriculum evaluation data. Second, the group should have knowledge of effective processes of curriculum design, including principles and strategies for curriculum implementation, curriculum deliberation, and alignment of educational goals, methods, and assessment, embedded in the systems approach to curriculum design (Tyler, 1949; Kern et al., 1998). It should be understood that in using the structure of this traditional systems framework for curriculum design, goals need not necessarily be expressed in terms of behavioral objectives; the methods of education clearly extend to learning in the practice settings of the workplace; and assessment encompasses the very broadest goals for professional education. Third, the group should be knowledgeable about current thinking regarding the nature of professional practice, such as Schön’s (1983, 1987) work on reflective practice and studies of the development of expertise and professional competence, indicating the importance of learning in the authentic settings of the workplace (Bandura, 1986; Brown, Collins, & Duguid, 1989; Lave & Wenger, 1991). Fourth, the group should consider perspectives in the national arena for their particular profession, such as the movements in education for medicine and nursing related to professionalism, evidence-based health care, and patient safety. Fifth, the group should consider, of course, perspectives and evidence related to the hidden curriculum, the experience of professional education in the practice settings of the workplace. These processes, if conducted well, serve multiple purposes. This process has the potential to bring together diverse values and sources of evidence and expertise, to reach justified decisions, to educate participants through exploration of diverse perspectives, and to achieve personal and political commitment to decisions. Clearly, these processes, by involving diverse stakeholders – including preceptors and mentors in workplace settings – have the potential to create curricula suitable for education in the setting of the workplace, whether the formal

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curriculum, the informal curriculum, or the “hidden” curriculum of professional socialization.

Conclusion This chapter was intended to inform the work of educators for the professions about conceptual perspectives related to the curriculum. We focused on the formal curriculum, particularly as it relates to those components of professional education that occur in the practice settings of the workplace. In Part I, we presented a broad definition of the concept of curriculum. We then discussed the rationale for the pervasive inclusion of learning in the practice settings of the workplace in education for the professions, typically very early in the preservice curriculum. We discussed this rationale in terms of traditions as well as in terms of evolving conceptions of the nature of professional practice and evolving theories of learning. In Part II, we discussed the implications for learning in the workplace of three predominant traditions of scholarship and practice in curriculum studies – the systems approach, deliberative curriculum inquiry, and reconceptualist approaches (Harris, 1993a). It is clear that these approaches are complementary. Each contributes to our understanding of the formal curricula of education for the professions and the role in these curricula of learning in the practice settings of the workplace. The systems approach enjoins us to consider the education purposes best served by learning in the practice settings of the workplace, and the instructional methods most appropriate for optimizing the value of learning in the workplace. The reconceptualist approach helps us to understand the potential disconnect between the formal curriculum and the curriculum enacted in the practice settings of the workplace. The deliberative inquiry approach suggests strategies for engaging important stakeholders, in any curriculum for the professions, in a process that is designed to provide for input into justified decisions; for stakeholder commitment, buy-in, and political support; and perhaps equally important, for an educational process in curriculum, instruction, assessment, and evaluation – for all participants. This education process can be seen as an approach to faculty and institutional development, which has the potential to result in more effective educators, both in classroom settings and in the practice settings of the workplace.

References Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Billet, S. (2006). Constituting the workplace curriculum. Journal of Curriculum Studies, 38, 31–48. Bloom, B. S. (1956). Taxonomy of educational objectives: Cognitive domain. New York: McKay. Bransford, J. D., Brown, A. L., & Cocking, R. R. (1999). How people learn: Brain, mind, experiences and school. Washington, DC: National Academy Press. Brown, J. S., Collins, A., & Duguid, P. (1989, January). Situated cognition and the culture of learning. Educational Researcher, 18, 32–42.

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Castellani, B. & Hafferty, F. (2006). Professionalism and complexity science: A preliminary investigation. In D. Wear, J. M. Aultman (Eds.), Medical professionalism: A critical review (pp. 3–23). New York: Springer. Clark, R. W. (1999). Effective professional development schools. San Francisco: Jossey Bass. Collins, A., Brown, J. S., & Newman, S. E. (1989). Cognitive apprenticeship: Teaching the crafts of reading, writing, and mathematics. In L. B. Resnick (Ed.), Knowing, learning and instruction: Essays in honor of Robert Glaser (pp. 453–494). Hillsdale, NJ: Lawrence Erlbaum Associates. Curry, L. (1992). Deliberative curriculum inquiry and its application in the education of health service administrators. Journal of Health Administration Education, 10, 519–526. Darling-Hammond, L. (1994). Professional development schools: Schools for developing a profession. New York: Teachers College Press. Dick, W. & Carey, L. (1990). The systematic design of instruction (3rd ed.). Glenview, IL: Scott Foresman. Foster, C. R., Dahill, L. E., Goleman, L. A., & Tolentino, B. W. (2006). Educating clergy: Teaching practices and pastoral imagination. San Francisco: Jossey-Bass. Freidson, E. (1970a). Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Harper & Row. Freidson, E. (1970b). Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press. Gagne, E. D. (1985). The cognitive psychology of school learning. Boston: Little, Brown. Goold, D. S. & Stern, D. T. (2006). Ethics and professionalism: What does a resident need to learn? American Journal of Bioethics, 6, 9–17. Gronlund, N. E. (1991). How to write and use instructional objectives. New York: MacMillan. Hafferty, F. W. (1998). Beyond curriculum reform: Confronting medicine’s hidden curriculum. Academic Medicine, 73, 403–407. Hafferty, F. W. (1999). Managed medical education. Academic Medicine, 74, 972–979. Hafferty, F. W. (2000). In search of a lost cord: Professionalism and medical education’s hidden curriculum. In D. Wear, J. Bickel (Eds.), Educating for professionalism: Creating a culture of humanism in medical education (pp. 11–34). Iowa City: University of Iowa Press. Hafferty, F. W. & Franks, R. (1994). The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 69, 861–871. Hafferty, F. W. & Hafler, J. P. (2010). The hidden curriculum, structural disconnects, and the socialization of new professionals. In J. P. Hafler (Ed.), Extraordinary learning in the workplace. The Netherlands: Springer. Harris, I. (1991a). Contributions to professional education from the field of curriculum studies: Research and practice with new traditions of investigation. Professional Educational Research Quarterly, 13, 3–16. Harris, I. (1991b). Deliberative inquiry: The arts of planning. In E. C. Short (Ed.), Forms of curriculum inquiry (pp. 287–321). Albany, NY: State University of New York Press. Harris, I. (1993a). Perspectives for curriculum renewal in medical education. Academic Medicine, 68, 484–486. Harris, I. (1993b). New expectations for professional competence: Reflective practice and selfcorrection. In L. Curry, J. Wergin (Eds.), Educating professionals (pp. 17–51). San Francisco: Jossey-Bass. Hegarty, E. (1971). The problem identification phase of curriculum deliberation: Use of the nominal group technique. Journal of Curriculum Studies, 9, 31–41. Holmes Group (1990). Tomorrow’s schools: Principles for design of PDSs: A report of the Holmes Group. East Lansing, MI: Author. Hundert, E. M., Hafferty, F., & Christakis, D. (1996). Characteristics of the informal curriculum and trainees’ ethical choices. Academic Medicine, 71, 624–642. Kern, D. E., Thomas, P. A., Howard, D. M., & Bass, E. B. (1998). Curriculum development for medical education: A six-step approach. Baltimore: Johns Hopkins University Press. Kolb, D. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall.

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Krathwohl, D. R. (1964). Taxonomy of educational objectives: Affective domain. New York: David McKay. Lave, J. & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press. Mager, R. F. (1984). Preparing instructional objectives. Belmont, CA: David S. Lake Publishers. Neville, A. J. & Norman, G. R. (2007). PBL in the undergraduate MD program at McMaster University: Three iterations in three decades. Academic Medicine, 82, 370–374. Pinar, W. F., Reynolds, W. M., Slattery, P., & Taubman, P. M. (1996). Understanding curriculum. New York: Lang. Popham, J. H. & Baker, E. (1975). Establishing instructional goals. Englewood Cliffs, NJ: Prentice Hall. Salomon, G. & Perkins, D. N. (1998). Individual and social aspects of learning. In P. D. Pearson, A. Iran-Nejad (Eds.), Review of Research in Education. Washington, DC: American Educational Research Association. Schön, D. A. (1983). The reflective practitioner: How professionals think in action. New York: Basic Books. Schön, D. A. (1987). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco: Jossey Bass. D. A. Schön (Ed.) (1991). The reflective turn: Case studies in and on educational practice. New York: Teachers College Press. Schön, D. A. (1995). The new scholarship requires a new epistemology. Change, 27(6), 26–34. Schubert, W. H., Shubert, A. L., Thomas, P., & Carroll, W. M. (2002). Curriculum books: The first hundred years (2nd ed.). New York: Lang. Schwab, J. J. (1978). The practical: A language for curriculum. In I. Westbury, N. Wilkof (Eds.), Science, curriculum and liberal education: Selected essays (pp. 287–321). Chicago: University of Chicago Press. Shuell, T. J. (1986). Cognitive conceptions of learning. Review of Educational Research, 56, 411–436. Shulman, L. S. (2005). Signature pedagogies in the professions. Daedalus, 134, 52–59. Shulman, L. S. (2007). Cascades: Report of the president. Carnegie Foundation for the Advancement of Teaching. Available at http://www.carnegiefoundation.org/about-us/aboutcarnegie?key_501. Accessed October 27, 2007. Stern, D. (1998). Practicing what we preach? An analysis of the curriculum of values in medical education. American Journal of Medicine, 104, 569–575. Stern, D. T. & Papadakis, M. (2006). The developing physician – becoming a professional. New England Journal of Medicine, 355, 1794–1799. R. J. Sternberg, R. K. Wagner (Eds.) (1986). Practical intelligence: Nature and origins of competence in the everyday world. New York: Cambridge University Press. Tyler, R. (1949). Basic principles of curriculum and instruction. Chicago: University of Chicago Press. L. S. Vygotsky, M. Cole (Ed.) (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press. Wenger, E. (1998). Communities of practice: Learning, meaning and identity. New York: Cambridge University Press. Wilkerson, L. & Irby, D. (1998). Strategies for improving teaching practice: A comprehensive approach to faculty development. Academic Medicine, 73, 387–396. Witkin, B. R. & Altschuld, J. W. (1995). Planning and conducting needs assessment: A practical guide. Thousand Oaks, CA: Sage Publications.

Chapter 2

The Hidden Curriculum, Structural Disconnects, and the Socialization of New Professionals Frederic W. Hafferty and Janet P. Hafler

Now there is no question at all that the education in attitude and skill that the physician obtains in medical school and in the hospital . . . is an absolute source of much of his performance as a practitioner . . . Nonetheless, I argue that education is a less important variable than work environment. There is some very persuasive evidence that ‘socialization’ does not explain some important elements of professional performance half so well as does the organization of the immediate work environment. (Freidson, 1970a, pp. 88–89)

Introduction Over the past 30 years, educators have come to understand the importance of differentiating between the formal and alternative forms of learning such as the hidden curriculum. We now recognize how necessary it is to account for the unstated, but never the less vital, curriculum that is operational in schools and in workplaces. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational practices (Hafferty & Franks, 1994; Hafferty & Levinson, 2008; Hafferty, 1998; Sullivan, 2005; Sullivan, Colby, Wegner, Bond, & Schulman, 2007). In this chapter, we will attempt to peel back the frequently under-examined dynamics between these two sources of “instruction” and explore how the stated intentions of professional training (the formal curriculum) intersect with the actual practices within that training (the curriculum “in action”), to impact on professional identity formation. In particular, we will wrestle with the impact of the hidden curriculum on the developing professional as they learn in the workplace (Gherardi, 2005; Hoff, Pohl, & Bartfield, 2004). We will examine how the curricula experiences offered to students often fail F.W. Hafferty (B) Mayo Medical School, Rochester, MN, USA e-mail: [email protected]

J.P. Hafler (ed.), Extraordinary Learning in the Workplace, Innovation and Change in Professional Education 6, DOI 10.1007/978-94-007-0271-4_2,  C Springer Science+Business Media B.V. 2011

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to establish a faithful bridge between the classroom and the workplace and thus follow the lead of Wear & Kuczewski (2004) who urge us “. . . to pay more attention to the academic environment in which students are educated” (p. 1). In this chapter, we argue that how we structure the educational enterprise through a mixture of formal and informal instructional practices has critical implications for the type of professional we produce, and that the types and amount of this variability become more evident as we examine different types and sites of professional preparation – such as the occupational groups (clergy, education, medicine, nursing) addressed in this book. In turn, these variations also have implications for how we think about a core theme of this book – extraordinary workplace learning. We also will examine issues of the hidden curriculum through the lens of socialization theory (Gofton & Regehr, 2006; Hafferty, 2008; Haidet & Stein, 2006) with particular attention to how we can use this framework as one way of thinking about the relationship of learner and teacher (Grusec & Hastings, 2006; Harvill, 1981; Inkeles, 1969; Van Maanen, 1976; Weidman, 1992). We begin by reviewing Eliot Freidson’s challenge to medical educators as reflected in the quote that opens this chapter.

Freidson’s Challenge As educators, we have much to learn from Eliot Freidson’s attempt to rescue both sociology and medicine from the normative clutches of structural functionalism, which includes his efforts to elevate the explanatory power of social structure over that of normative values and individual motives (Freidson, 1970a, 1970b). Freidson’s ongoing interest in exploring how environmental and organizational factors constrain social action placed him squarely in the crosshairs of an ongoing conundrum within the social sciences – the relative impact of place and structure versus that of person and agency in explicating the human condition. For Freidson, current work setting was more important than prior socialization and how doctors “apply their skill not many years after graduation does not reflect the academic standards of their teachers” (Freidson, 1970b, pp. 16–17). Rather, Freidson insisted that much of individual behavior is situationally determined and that scientists seeking to understand “the major sources of variation in professional performance” (Freidson, 1970a, p. 90) should focus more on the organization of medical care settings than “the attributes of personnel – their training, devotion, and sensitivity” (Freidson, 1970a, p. 32). Freidson’s partiality for structure over motives and current work settings over prior experiences presents us with a number of challenges as we seek to conceptualize extraordinary workplace learning. First, and perhaps most important, Freidson’s elevation of structure and recency over what we routinely designate as “professional preparation” challenges the often unexamined assumption that what we formally present students during their training (in terms of the formal curriculum) is both necessary and sufficient for entry into the workplace. What if this is not the case? What

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if practice behaviors are determined more by current setting and the demands of the immediate work environment than prior preparation? And if so, what does this say about the veracity and validity of all those requirements educators formally deem necessary for entry into the workplace? Freidson’s challenge is anything but trivial. Second, Freidson’s differentiation between prior training and the workplace raises questions as to whether the two should be considered phenomenologically equivalent entities. Traditional models of professional preparation uncritically assume that students “learn by doing” and do so within “real-life” work situations. In short, educators routinely assume that the clinic, classroom, or “confessional” used for training purposes are experiential replicates of work settings not used for this purpose. But what if this is not the case? What if teaching hospitals, for example, are fundamentally different in terms of the structure, process, and content of work than facilities not used for training purposes? If so, then training within the former might not be authentic preparation for the latter. Even more phenomenologically problematic is a corollary assumption that the clinic, classroom, and confessional awash with trainees are the same clinic, classroom, and confessional when students are not present. Here the distinction is not teaching versus nonteaching hospital, for example, as it is the assumption that the work performed in teaching hospitals when trainees are present is the same work when they are absent. But are these assumptions true? Perhaps “the workplace” is fundamentally altered by the presence of trainees and therefore what is learned in these settings does not seamlessly translate into workplace settings post training? Third, and related, casting “the workplace” and “prior training” as distinct and potentially antithetical domains of influence raises the possibility that we may have distinctive types of influence as well. Much of the literature on professional preparation, including most of the classic sociological studies on medical training such as Becker, Geer, Hughes, & Strauss’ (1961) Boys in White and Merton, Reeder, & Kendall’s (1957) The Student Physician, treat “the medical school” and “the hospital” as highly commingled and even indistinct sites of cultural influence and therefore are not treated as distinctive for the purposes of understanding issues such as professional preparation. Nonetheless, how various occupations define and negotiate the boundaries between the workplace as a site of work and the workplace as a site of formal and informal learning is both highly problematic and quite variable across professions. Furthermore, there are considerable tensions within this duality for both the learner and the teacher. Both faculty and students know that the novice is not the most qualified to teach the class, perform the appendectomy, or counsel the parishioner, yet virtually all professions have trainees “practice on” often-unsuspecting clients. Part of the ritual and lore of professional preparation is that learners will immerse themselves in a series of “firsts” (e.g., lumbar puncture) even as more highly skilled others hover (sometimes quite distantly) in the background. Physician autobiographies routinely function as a window into this divine comedy as trainees rocket between terror and triumph and patients oscillate between the dual status of “care recipient” and learning tool (Gawande, 2002; Shalof, 2008). Fourth, and due to emergent concerns about quality of care and patient safety issues (ABIM Foundation, ACP-ASIM Foundation & European Foundation of

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Medicine, 2002; Lopez & Katz, 2009), the demands of pedagogy are beginning to take a back seat to the demands of work, whether that be in the clinic, classroom, or confessional. Thus, while it is well established that learning must take place alongside, or even within, the responsibilities for delivering services, it also is held to be true that the need to train future practitioners must not unduly disrupt the essential nature of that work. Thus, the role of the patient, parishioner, or pupil – as an object of work – is elevated to a status above that of the patient, parishioner, or pupil as a learning tool. This represents a profound shift in the nature of professional preparation. In short, and due to concerns about issues of privacy, autonomy, and safety, we are beginning to frame our models of professional preparation so that students are injected into a system without substantially altering the essential nature of that system. What does this new standard do to traditional practices of “learning while doing” as well as distinctions between “prior training” and the kinds of continuing professional development that is supposed to occur after entering the workplace? Professions, after all, define themselves as engaged in a process of lifelong learning, thus rendering the preparatory years as “just one” of many. So, what is the problem? Why don’t we just throw ourselves into the task of creating exemplary workplace settings – which will then function, almost by definition, as venues of extraordinary learning? Once again, there are reasons to pause and give continued considerations to Freidson’s basic reservations. First, and again using medicine and nursing as our examples, the work of providing patient care services is by no means a rule-driven and unambiguous undertaking. Despite healthcare’s claim to be scientifically grounded, many of the services delivered to patients are not evidence based. Moreover, there is considerable debate as to whether they should be (De Simone, 2006). Finally, and even when there are established “best practices,” it is often a tossup as to whether providers will practice based on these “standards” (McGlynn et al., 2003). All of these tensions, and their underlying causes, have important implications for training, not the least of which is that the experience of learning across the different sites and settings of healthcare work thus are rendered highly context dependent. During the course of training, students may find themselves exposed to half a dozen different ways to evaluate and treat epigastric pain, inflammatory arthritis, or the diagnosis of heart murmurs – each of which is performed as an example of “quality,” or perhaps even as “state of the art.” So what are learners supposed to internalize from these different experiences and practices? Is everyone (or no one) right? Are some “more right” than others? Whom do you listen to or role model? In the words of Christakis & Feudtner (1997), “temporary matters” as students recoil through their transient and time-limited exposures to faculty, patients, and each other – all the while developing a professional identity that depends more on current place and setting than on some underlying and shared experience. Thus, when students exit their formal training, it is quite understandable if they readily adapt to the practice norms and culture of their newest job setting – if only because there are appreciable differences in the cultures and work demands of training (the “then and there”) versus current work (the “here and now”). Moreover, the highly siloed and truncated nature of medical training and the transitory nature of healthcare relationships

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(including peer relationships) teach students – in a highly invisible and tacit way – to value temporary adaptation over internalized identity formation. Conversely, the more consistent and integrated the learning environments, the less distance there is between the formal and the hidden curriculum, and the greater the internalization of a consistent professional identity. While none of this consistency guarantees the absence of conflicts between the demands of training and the workplace, the presence of integration and a striving for pedagogical uniformity across training experiences will establish that there can be continuity of experience based on overarching practices and principles and that learning can (and should) become something more than situational adaptation (Hirsh, Ogur, Thibault, & Cox, 2007). Perhaps these tensions and disjunctures are why Freidson identified current work setting as being the most influential – if only by virtue of being the most recent, and therefore the most demanding, in terms of what it asks of that role occupant. If so, then we have several important challenges to our call to establish extraordinary workplace learning. In the text that follows, we will continue to explore these (and related) issues by using Freidson’s basic arguments about training and work to explore several issues facing professional education in the twenty-first century. Our basic argument is simple, if nuanced. The more highly siloed the training experience, and the more highly disconnected or pedagogically fractured that experience, the more likely current work setting will trump prior socialization in determining how one performs in the workplace. The logic for our conclusions is as follows. The more disconnects there are in training, whether those be with respect to sites of training or the number of role models encountered, the more likely trainees will experience not one, but several different, and potentially countervailing, experiences of socialization and professional inculcation. These disconnects, in turn, generate a hidden curriculum of professional preparation, whereby trainees learn (and are tacitly taught) to adopt a chameleon-like approach to their professional preparation. As a consequence, trainees come to define – and approach – each clinical experience or classroom setting as a distinct block of expectations (e.g., learning) in which the lessons learned in one become site-specific points of engagement with only ancillary application to other situations. In a perverse sense, and if only as a defense mechanism, learners carry the concepts of situated learning and situated cognition to an extreme (Lave & Wenger, 1991). We begin our exploration of disjunctures and their impact on learning with a brief and selective history of professional preparation and occupational practice. In this history, we stress the nature of professions as an occupational group characterized (at least internally) by an ethic of occupational autonomy. This autonomy is reflected at the practitioner level by how much discretionary decision-making the learner enjoys in terms of how they organize and carry out their work. The result, at least historically, has been considerable variability in the practice patterns – and even underlying standards – of that work (Liang, 2007). More recently, and using medicine as our example, this variability has come under increasing criticism (Dilts, 2005; Schaeffer & McMurty, 2004). One consequence (although highly contested) has been efforts to reduce the amount of practice variability. These efforts have

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been shaped by three major social movements within contemporary medicine, namely professionalism, evidence-based medicine (EBM), and patient safety, as well as two contemporary crises reflecting these movements, namely conflicts of interest and resident “duty hour” limits. In keeping with the organizing theme of this volume, extraordinary workplace learning, we will briefly examine each of these five sites of systems change as points of possible impact on formal education and workplace learning. Throughout this discussion, we take as our primary thesis that workplace learning truly is extraordinary when it is marked by structural congruence and a positive synergy between the intended and formal preparation of professionals (the formal curriculum), the tacit learning that takes place within the hidden curriculum, and the subsequent demands, both formal and tacit that are embedded in subsequent workplace settings. In short, we will argue that workplace learning in the past, including when Freidson was shaping his ideas about the relative impact of training versus current work setting, was substantively scarred by disjunctures not only within the context of formal training, but between that training and what learners were called upon to do when they graduated and entered their chosen profession. In turn, we will argue that the potential to reduce this “bad learning” exists when certain intermediary crises (identified below) are overcome.

Extraordinary Workplace Learning: A Normative Framing Before moving on, it might be helpful to pause and conceptualize extraordinary workplace learning across two intersecting planes: (1) role models (and thus role modeling) and (2) the workplace setting itself. As noted above, there is appreciable variability across the professions addressed in this book, as to how they are prepared for the workplace in terms of these two dimensions. Figure 2.1 represents how we might conceptualize workplace learning along these two dimensions using a common metric – frequency or amount. Trainees (theoretically) can find themselves learning from a single role model or many role models. Similarly, they can learn within a single work setting to multiple workplace settings. Historically, the traditional apprenticeship model falls into the lower corner of these two intersecting vectors. A master would adopt (sometimes literally) a trainee, the two of whom would function within a single shop or place of work (e.g., one role model, one work setting). At the other extreme (upper right), trainees would encounter multiple role models with most of these exposures taking place across a variety of work settings (many role models, multiple work settings). In terms of the professions reviewed in this book, this latter configuration is best represented by medicine – with some types of medical training fitting into the outer reaches of this figure. As students move, first through their clerkship and preceptorship experiences (at the undergraduate level), and then through their graduate (residency) rotations, they rotate through dozens of work settings populated by literally hundreds of (potential) role models.

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4 Medicine/Nursing 3 Educators

Role Models

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Clergy

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Fig. 2.1 The relationship of role models and workplace settings

Other types of professional training fall elsewhere within this figure. Some professionals encounter a variety of role models, but do so within a relatively small number of workplace settings (e.g., nursing). Conversely, others (e.g., clergy) may encounter (relatively) few role models but do so across multiple settings. In all instances, the further one moves from the intersection of these two dimensions, the more extreme the combining of these two factors. There are efforts under way to alter training along both of these dimensions. For example, within medicine there is growing movement to establish a longitudinal and integrated model of clerkship and residency training – a model that deliberately minimizes the stress generated by the traditional “block” form of clinical experiences (e.g., 4–8-week exposures to – in no particular order – surgery, internal medicine, pediatrics). Instead, the goal is to establish continuity among patients, faculty, and trainees (Bell, Krupat, Fazio, Roberts, & Schwartzstein, 2008; Hirsh et al., 2007). Finally, we can imagine, but will not explore here, other dimensions of the training experience including time (how long will a student remain in a given setting or exposed to a given role model), the number of trainees (does one train alone or with other peers), or the “intensity” or “stress” of the experience itself – all varying along a range from low to high, and always with an eye for its impact on workplace learning. For example, the archetype apprenticeship model posits a oneon-one mentor–trainee relationship, with no other trainees in the picture. However, adding peers to any workplace setting dramatically alters the dynamics of learning as well as the process of professional socialization – and thus adds to the kinds of informal learning covered within the theoretical framework of the hidden curriculum (Hafferty & Castellani, 2009).

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Medical Education and Work: A Brief History As we approach the hundredth anniversary of the Flexner Report, it is important to recall how the action steps most often tied to this report, in particular the drastic reduction in the number and types of medical schools, were of secondary historical importance to the almost wholesale reorganization of the medical school as a learning environment. Medical schools were transformed and relocated from largely freestanding educational enterprise units into academic units within the American university system (Ludmerer, 1999). Mimicking their across-campus brethren, these newly relocated medical schools began to offer a curriculum delivered by ever more specialized faculty from within ever more independent academic units. Clinical departments created their own fiefdoms of power and influence. Experts and expertise thus came to rule both the classroom and the clinic. As a consequence, medical students began to encounter a topic-by-topic, clerkship-by-clerkship menu of pedagogical experiences as courses and clinical experiences were delivered by dozens of faculty, each with their particular piece of an increasingly complex pie. Silos grew in depth and concrete-ness. Integration of experiences and materials, if it was a goal at all, was most likely to take place at the individual student level. Thus, although the transplantation of the medical school from freestanding unit to university setting had its desired effect in strengthening medicine’s identity as a scientific discipline, this shift also set in motion a number of subsequent transformations, including still unfolding processes of internal differentiation, which have tended to bury the educational mission of the medical school under the newer, yet increasingly important missions of research and clinical care (Angell, 2000; Watson, 2003). By the 1960s and the 1970s, forces for change within the broader social milieu (e.g., the civil rights, the women’s movement, Vietnam war, information technology, the consumer movement) were beginning to work their way into the fabric of medical education. Medicine was becoming less male, less white (slightly), and less hierarchical (ever so slowly). Access to care, via the passage of Medicare and Medicaid legislation, was becoming more egalitarian – even as this leveling helped spawn a new type of disenfranchisement, the “uninsured patient.” In the 1980s, organized medicine launched the first of what would become three broad, and somewhat interrelated, movements. The first was a professionalism movement. Medicine’s modern-day professionalism movement first appeared in the mid-1980s driven by medicine’s concerns over its loss of social trust and the deterioration of its social contract with society, and the increasing influence of industry over clinical decision-making and the practice of medicine (Lundberg, 1985; Relman, 1987). One expression of these concerns was the realization that much of what medical students had been learning about professionalism took place not within medicine’s formal curriculum but within other domains of learning (variously labeled as the informal, the hidden, the tacit, or shadow curriculum (Hafferty & Franks, 1994; Hafferty & Levinson, 2008)). As a consequence of these concerns, medicine began to develop professionalism codes and charters (ABIM Foundation et al., 2002), formal coursework on professionalism for undergraduate medical students (Whitcomb, 2007), and to craft new professionalism standards at the level of undergraduate

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(e.g., new LCME accreditation standard MS-31-A) and graduate (e.g., ACGME core competencies) medical education. Issues of identity, practice, and professionalism were joined in the 1990s, by a second social movement within medicine – this one focusing on the degree to which medical practice was indeed underscored by rigorous scientific evidence (Evidence-based Medicine Working Group, 1992; Rosenberg & Donald, 1995; Sackett, 1995; Smith, 1991). In the late 1980s and the early 1990s, the emergence of sufficient information technologies, along with data fueled by Medicare and Medicaid payment records, began to document how little of what took place in clinical medicine actually was informed by scientific evidence (Timmermans & Mauck, 2005; Traynor, 2008). This emergent concern was labeled “evidence-based medicine” (EBM), and even though this movement is less than two decades old, it has its own internal evolution, in terms of both clinical practice (Doherty, 2005; Lake, 2006; Woolf, 2001) and medical education (Green, 1999, 2000). Concerns about what is considered “evidence” and its application to the complexities of clinical care have emerged as well (Henry, Zaner, & Dittus, 2007; Moussa, 2008; Safford, Allison, & Kiefe, 2007; Upshur, 2005). The EBM movement was quickly joined by a third, this one focusing on patient safety (American Society for Healthcare Risk Management, 2006; Mathews & Pronovost, 2008). Although there had been precursor studies documenting a startlingly high prevalence of “adverse events” (Brennan et al., 1991; Leape, Brennan, & Laird, 1991), it took reports by the Institute of Medicine (Committee on Quality of Health Care in America, 2001; Kohn, Corrigan, & Donaldson, 2000) and considerable media coverage about the large number (e.g., 98,000) of preventable deaths per year (Davis & Appleby, 1999) to galvanize national attention. Taken together, these concerns over issues of professionalism, EBM, and patient safety can be consumed under a more general “quality of care” label.

A Pedagogical Conundrum If medicine indeed is riddled with pockets of unprofessionalism; if much of what is represented as “scientific” lacks the necessary evidence; if many patients are the object of unsafe medical practices including such “basic” things as hand washing (Berens, 2002; Cantrell et al., 2008; Gawande, 2004; van de Mortel, Bourke, McLoughlin, Nonu, & Reis, 2001); if patients are undertreated, overtreated, and mistreated (e.g., errors); if practitioners “turf” patients to other services to reduce workload (Caldicott, 2007; Shem, 1978); if practice variations and unsubstantiated “styles” represent more the norm than the exception; and if patients have no better than a 50–50 chance of receiving what the profession itself labels as “best practices” and/or “standards of care” (McGlynn et al., 2003; Parker-Pope, 2009), then what does this say about health professions’ education and the training of future healthcare providers? And how does this variability in practice patterns and standards impact the workplace training experiences in all professions?

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The answer should be obvious and troubling. To the degree that students, as future professionals, acquire their training across a vast number of informal settings, and alongside a variety of role models and mentors, and to the degree that “professional standards” function more as “suggestions” than as normative mandates, then what students in fact participate within, in terms of learning environments, are sites of educational chaos oftentimes (and additionally) riddled with unprofessional practices (Ginsburg, Regehr, Stern, & Lingard, 2002). The scope of this problem, along with its evolving impact, remains vastly underappreciated. To the degree that much of professional training occurs in the workplace where the hidden curriculum is often central to that learning, then development of programs to educate instructors becomes important. There actually are several problems. First, “substandard” or “bad” practices (of whatever ilk) rarely are considered or labeled as such within the cultures in which they are practiced (Groopman, 2007; Wusthoff, 2001). Most clinical faculty, for example, see their workplace activities as hallmarks of scientific effectiveness, and the vast majority of providers do not consider themselves to practice ad hoc, harmful, or unprofessional medicine – regardless of whether they fail to wash their hands, neglect to examine the feet of a diabetic patient, or talk about patient confidences with their spouse. Second, a culture of silence continues to dominate the medical workplace, as does some religious denominations (Plante, 2004). Thus, even when colleagues see practices that are unsafe, harmful, unprofessional, or against religious teachings or scientific evidence, they often turn the other way and adopt a culture of “there but for the grace of God go I” (Bosk, 1979; Gawande, 2002). Practices of social control often are informal, with professionals avoiding the messiness of confrontation rather than engaging in adjudication and remediation. Third, and even among professionals who historically have promised to police themselves, there is an extraordinary degree of defensiveness and denial about unprofessional or marginal practices (Chimonas, Brennan, & Rothman, 2007). Fourth, even when someone recognizes that they have acted unprofessionally they rarely point any of this out to their trainees (Kushner & Thomasma, 2001). Fifth, and related, trainees rarely are exposed to the uncertainties and ambiguities that plague the profession. Sixth, and overshadowing all, trainees encounter, in the course of their learning, an almost unlimited range of “usual” and “acceptable.” Although these examples are in medicine, learner exposures to the vagaries, vacuities, and margins of professional practice can happen in other professions as well. In short, students are not always being exposed, whatever the practices, to “good medicine,” “good teaching,” “good nursing,” and “good clergy” and thus they respond accordingly – in terms of learning.

Two Modern-Day Arenas of Pedagogical Conflict Among the various types of practice variations medical students encounter are relations with industry. Some healthcare providers eschew all contacts while others seek out the opportunity to closely work with pharmaceutical and medical equipment

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companies. These variations, in turn, stand in some relief to a diversity of institutional practices as schools of health education and healthcare delivery organizations establish a variety of standards or conflict of interest (COI) policies. What then is a student to believe – policy or practice? If policy, whose policy? If practice, what practice? Who is the best role model – the physician who distances himself/herself from industry or the one who courts that relationship? Far from being unusual or fringe, relations with industry are ubiquitous within healthcare. The vast majority of clinicians (94%) report some kind of relationship with the pharmaceutical industry, although types and intensity of relations do vary by specialty, practice type, and professional activities (Campbell et al., 2007a). Similarly, most academic health centers hold equity interest in companies that sponsor research at their institution, with large numbers of department chairs, members of expert panels, experts who write clinical guidelines, and FDA advisory committees having industry relations (Angell, 2009; Campbell et al., 2007c; Ehringhaus et al., 2008; Stolberg, 2002). Medical journals have difficulty finding experts without conflicting industry relations to write a particular commentary piece or editorials on a given issue (Angell, 2000; Associated Press, 2002). To complicate matters further, and in what might be labeled the “conceit of professionalism,” while many researchers, practitioners, and administrators will acknowledge having relationships with industry, most do not believe that their work is influenced by those relationships (Avorn, Chen, & Hartley, 1982; Backer, Lebsack, Van Tonder, & Crabtree, 2000; Dana & Lowenstein, 2003; McKinney et al., 1990). At best (and with some degree of irony here), physicians acknowledge the problem in the abstract, but insist that colleagues are the ones being influenced, not them (Brett, Burr, & Moloo, 2003; Steinman, Shlipak, & McPhee, 2001). Physicians also employ elaborate and head-scratching “denials and rationalizations” as they attempt to “manage the cognitive inconsistencies within their relationships with drug representatives” (Chimonas et al., 2007). Among the array of disclaimers and distancing strategies used was a rationale that yes, industry representatives did seek to influence the clinical decisions of physicians, but because there were so many, individual attempts cancelled each other out – yielding no net influence. The number and type of cognitive squirreling strategies used led the authors to conclude that voluntary and internal guidelines would be inadequate and that the only effective solution would be a prohibition of physician–industry interactions. On a related dimension, one national survey found that while most physicians agreed with core professional principles, their clinical behavior was not always consistent with the standards they endorsed (Campbell et al., 2007b). Similar to their role models, most medical students also report receiving gifts from industry, and likewise feel that gifting will not affect their future prescribing behavior (Fein, Vermillion, & Uijtdehaage, 2007; Sierles, Brodkey, & Cleary, 2005). In some instances, students feel that gifting not only is normal, but expected and something they are due given the “sacrifices” they feel they are making in terms of their education (Moynihan, 2003).

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There also is considerable debate within the education community between “banning” and “managing” COIs. Medical schools are aware that industry now provides more than half of its research dollars and much of the support of continuing medical education. There is concern that efforts to combat COI can “go too far,” damage research and/or clinical activities, or create an artificially sterile learning environment (Lee, 2008; Stossel, 2008). As a consequence, many E-COI reports extol the beneficial relations between industry and medical schools and conclude that what is needed is better “transparency” or better “management” of relations (Martin & Kasper, 2000). Muddying the waters even further is the existence of an appreciable psychological and cognitive science literature on gifting and norms of reciprocity that documents how much of these phenomena operate at an unconscious level (Association of American Medical Colleges, & Baylor College of Medicine, Department of Neuroscience and Computational Psychiatry Unit, 2007). Not only are individuals unaware of how much they are being influenced, but also common solutions such as disclosure have been found to increase – not decrease – COI behaviors. All of this influence thus becomes part of a hidden curriculum of professional education, and thus presents us with a rather formidable conundrum. On the one hand, exposure to influences is so ubiquitous and relentless as to become “normal,” expected, and even “due.” Furthermore, gifting comes in a myriad of forms and disguises, making it difficult to identify and label. Finally, and regardless of its form or intensity, clinicians, researchers, department chairs, members of expert panels, and students believe they operate above the fray. They are not influenced – making the entire issue moot. How then are educators to respond to this overall tacit learning environment? Again, our review of the issues, and using medicine as our case-in-point, is more superficial than substantive. It is intended to raise, but not settle, the issue of how the variety of COI practices and policies impact workplace learning. The fact that there has been widespread internal condemnation of certain COI practices, such as self-referral and physician ownership of lucrative surgical and diagnostic facilities yet without a seeming end to such practices, only results in greater confusion for trainees as they attempt to navigate the treacherous cognitive territory between what their profession says (in principle) and what it does (or does not do). The second example of challenges to workplace learning is resident work hour restrictions. In 1984, following the death of 19-year-old Libby Zion in a New York City hospital, both the profession and the public had become increasingly concerned about issues of resident sleep deprivation and fatigue, work errors, substandard faculty supervision, resident stress, and concerns about work–life balance (Goitein, 1996). In 2003, the Accreditation Council for Graduate Medical Education (ACGME) placed limits on the number of hours residents could be in the hospital. Their primary concern was patient safety – along with the threatened external regulation of medical training by Congress. In the fall of 2008, and following a report on work hours from the Institute of Medicine (IOM), the ACGME announced new standards. In turn, old debates about resident exhaustion, patient safety, the rise of a “shift mentality” among residents, the coordination of patients (e.g., “handoffs”) across shifts, and faculty time for teaching were revisited and reenergized

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(Parker-Pope, 2008a, 2008b). Although the IOM did not call for any additional duty hour cuts, the fact that even more stringent work hour limits for residents and faculty (48 hours per week or less as of 2009) have been adopted in the United Kingdom and European countries (Mommaerts, 2009; Woodrow, Segouin, Armbruster, Hamstra, & Hodges, 2006) remains an omnipresent challenge to medical educators as they struggle to balance the competing demands of work hour limits, patient care needs, and the time available for student learning. Limits to the number of hours residents can be in the clinic and hospital represent one of the most profound challenges to medical workplace learning in the past 100 years. There is no parallel in clergy, education, or other professions such as law or engineering. Even the shifting nom de plume of “duty hour” versus “work hour” limits reflects the continuing tension between service and learning within the culture of medicine – just as it represents a continued confusion over what exactly is being restricted. Do restrictions in “work time” automatically translate into restrictions in what can be learned? When work is equated with learning, the answer must be “yes.” But, must the two be unequivocally linked? The conundrums that exist between professional preparation and workplace learning remain a moving target. While it is far too early to disentangle the still rapidly evolving changes in the organization of work and the impact of these changes on student learning, there is no dispute that changes in the structure, process, and content of work represent a threat to current educational practices – and thus a threat to the current culture of professional learning (Nuthalapaty, Carver, Nuthalapaty, & Ramsey, 2006). Faced with the new accreditation standards, residency programs, nursing schools, and schools of education are being forced to reexamine and restructure how they link learning to work demands. It is not altogether clear, at least to us, what extraordinary workplace learning will look like within these tensions. What we are sure of, given the disjunctures documented above, is that there are grave threats to extraordinary learning currently taking place (systemwide) at this time.

Conclusions Although the issues covered in this chapter point to a picture that remains in flux, there are some conclusions we can draw – all couched within the context of socialization as a process of deep learning and identity formation. First, and with respect to medicine, the shift from professionalism “curriculum” where professionalism lessons largely were delivered from within an informal, tacit, and hidden curriculum to a more structured and formal curriculum has produced a learning crisis – however unintentional. As all US medical schools and residency programs came to adopt some version of a formal professionalism curriculum, students found themselves “caught” between what they were being formally taught about professionalism as codified in key documents, such as the Physician Charter and in the language of ACGME competencies, and what was held up as professionalism in the workplace.

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More often than not, students perceived inconsistencies and disconnects, and thus disjunctures between what was said in the classroom (the formal curriculum) and what is done in the clinic (the hidden curriculum) (Brainard & Brislen, 2007; Leo & Eagen, 2008; Reddy, 2007). These disconnects are by no means permanent, but can only be addressed if educators are able to align the values of the profession with the realities of the workplace. Early in this chapter, we took our primary thesis that workplace learning truly is extraordinary when it is marked by structural congruence and a positive synergy between the intended and formal preparation of professionals (the formal curriculum), the tacit learning that takes place within the hidden curriculum, and the subsequent demands, both formal and tacit, that are embedded in subsequent workplace settings. Second, although Freidson insisted that much of individual behavior is situationally determined, and the current work setting is more important than prior socialization, we found a stunning degree of variability in the types of practice and practice values encountered by learners as they navigate their way through a very rocky and storm-riddled series of learning environments. In short, and until we do a better job of reducing the chaos of workplace learning, we are not convinced that recency of experience is the trump. Third, related, and with medicine functioning as our “bad role model,” we find it hard to imagine how a stable and underlying professional identity can emerge within the caldron of role models and the multitude of training settings that make up the learning environments of new physicians. If physician and nurse autobiographies are of help here, it may well be that what students ultimately share is the experience itself, an experience marked by stress, indeterminacy, and chaos, rather than any fundamental and underlying set of knowledge, skills, and interests. In short, we may need to revisit how we think about professional training as a process of socialization. In the end, one solution may be to train teachers to teach within the constraints of the workplace. Thus, might we be able to establish extraordinary workplace learning by challenging ourselves to more effectively teach in the workplace. This would include addressing learning in both the formal and the hidden curriculum and accept the current organization of medical care settings as ideal environments in which our future professionals learn.

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Part II

Learning and Instruction

Chapter 3

Conceptions and Theories of Learning for Workplace Education Ilene B. Harris

Overview This chapter on conceptions and theories of learning is intended to inform the work of educators about those components of professional education that occur in the practice settings of the workplace. Education for any profession typically includes learning in these settings. Shulman, in the work on the Carnegie Foundation study of education for the professions (Shulman, 2005), conceptualizes professional development in terms of professional socialization, development of professional or clinical skills, and development of specialized knowledge through what are referred to as signature pedagogies – the pedagogies that are special, often unique, in a domain of education. In education for the professions, learning in the practice settings of the workplace is perhaps the signature pedagogy. It is in these milieus that novices experience professional socialization as they enter into a community of practice; develop clinical and professional skills through observation, coaching, mentoring, and supervision; and develop specialized knowledge as the situations of practice provide meaning and motivation for abstract learning. For example, medical students participate in what are called preceptorships and clerkships, in hospitals and community clinic settings, supervised by physicians in practice. These clinical experiences are an integral part of their medical education, typically beginning in their first year of training. Following graduation from medical school and as medical residents, students will have at least three or more years of supervised experience in medical practice settings, prior to being licensed to practice independently. Student nurses, typically beginning in their first year of training, participate in what are called clinical rotations and preceptorships – in hospitals, private practices, and school clinics. They are supervised both by nurses practicing in those settings and by a faculty member from their university. Student teachers, preparing to teach I.B. Harris (B) College of Medicine, University of Illinois, Chicago, IL, USA e-mail: [email protected]

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in K-12 settings (kindergarten through 12th grade), engage in practice teaching in classrooms, in what are called internships, practicums, or field placements. They are supervised both by “cooperating teachers,” responsible for the classrooms in which they practice teaching, and by university faculty members. Divinity students have internship placements throughout their 4-year curriculum, guided by a “ministry supervisor,” in practice settings such as hospitals, community organizations, prisons, schools, and church environments. It is common, indeed prototypical across the professions, to include placement in workplace settings as an integral part of preservice education. Why is this done? It is done, in part, because it is a tradition. It has always been done, akin to apprenticeships. But in addition, evolving conceptions of the nature of professional practice provide a firm grounding for this vaunted tradition. Moreover, an evolving array of learning theories provides validation for this common practice and suggests approaches to make these placements more effective for teaching and learning in workplace settings. The larger purpose of this chapter, its role within this book as a whole, is to characterize conceptions and theories of learning that are particularly applicable to learning in the workplace. This chapter provides a context for the synthesis in Chapter 4 of research on pedagogy and best teaching practices in workplace settings including the preparation of students and setting expectations, observation and feedback, role modeling and coaching, supervision, reflective practice, and the use of technology resources. It provides a context for the syntheses in Chapters 5 and 6 of research and recommendations for assessment. It also provides a context for Chapter 7 on faculty development. Conceptions of learning have implications for the process of faculty development in suggesting approaches for educating faculty to be effective teachers in workplace settings and for the content of faculty development programs in suggesting effective instructional practices in workplace settings. First, we will discuss the nature of professional practice and the knowledge, competencies, and qualities required for effective professional practice. Then, we will characterize conceptions and theories of learning pertinent for “best practices” of instruction, assessment, and faculty development for “clinical education” in the practice settings of the workplace. The focus of this chapter is on learning in the context of practice situations, in the early stages of professional education. It is clear that throughout a lifetime of professional practice, professionals must continue to learn in the context of their practice through methods of self-directed and practice-based learning. While our discussion clearly applies to this ongoing professional development, it is not the focus of this chapter.

Part I: The Nature of Professional Practice – Essential Knowledge, Competencies, and Qualities What is the nature of professional practice: the knowledge, competencies, and qualities required for skilled professional practice? The response to this question has

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implications for selection of conceptions and theories of learning for the professions and for related conceptions and best practices of instruction, assessment, and faculty development (Harris, 1993). Definitions of professional practice have focused on the specialized bodies of theoretical and applied knowledge needed for professional practice. For example, Starr (1982) states, “A profession is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technological, specialized knowledge; and that has a service, rather than a profit, orientation enshrined in its code of conduct” (p. 15). Schön (1983, 1987, 1991) has formulated a persuasive and influential epistemology of professional practice, encapsulated in the term “reflective practice.” His work is grounded in important philosophical traditions, most notably Dewey’s conceptions of the role in learning of reflection on experience (Dewey, 1938). It is based on empirical analyses of case studies, across the professions, of professional practice and education for professional practice. Moreover, it is supported by studies in cognitive psychology and the development of expertise. Schön acknowledges that effective professional practice, competent and wise action, typically involves the use of specialized knowledge – the theories and technologies developed in the basic and applied sciences, but equally important for wise and competent action is demonstration of “practical knowledge” or “know-how,” which Schön refers to as “knowing-in-action,” and also reflective competencies that he refers to as “reflection-in-action” and “reflection-about-action.” These competencies are essential, due to the nature of professional practice. Professional practice is context specific and requires competent action adapted to specific situations. Moreover, some of the most important problems in professional practice require wise action to address situations characterized by complexity, uniqueness, uncertainty, and conflicting value and ethics orientations. Schön suggests that these three competencies – knowing-in-action, reflection-in-action, and reflectionabout-action – account for the skill, and sometimes the artistry, that professionals demonstrate in situations of complexity, uniqueness, and value conflict. The concept of “knowing-in-action” has a rich lineage in the discussion of philosophers. Following Ryle (1949), Schön characterizes “knowing-in-action” as the “tacit” knowing, the “knowing more than we can say,” implicit in the spontaneous patterns of action demonstrated in everyday life and by skilled professionals. It is demonstration of knowledge that does not necessarily stem from a conscious prior intellectual operation, such as our ability to speak in conformity with the rules of phonology and syntax, without thinking about these rules before speaking or even being able to readily describe them (Schön, 1983, p. 51). Similarly, Oakeshott (1962), a philosopher, distinguishes among types of knowledge, which have implications for professional practice. He argues that every activity involves two types of knowledge, “technical” knowledge that may be “formulated into rules which may be deliberately learned, remembered, and put into practice” (pp. 7–13) and “practical” knowledge, expressed only in practice in customary or traditional ways of doing things and acquired only by continuous contact, in apprenticeship to a master who is consistently practicing it (p. 13). More

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specifically, professionals develop “know-how,” or what Buchler (1961) refers to as “tactics,” for adapting precepts to variable circumstances, “know-how” that is learned through observation, personal experimentation, and reflection. How do professionals develop this “practical knowledge,” “know-how,” or “tactics”? Based on case studies across the professions, Schön argues that professionals develop this “practical knowledge” in practicing their practice. Schön’s work is consistent with studies in cognitive psychology and in development of expertise. In cognitive science, schema theory describes how acquired knowledge is organized in the mind and how cognitive structures facilitate use of knowledge (Sternberg & Wagner, 1986). Schemata are prototypes in memory of frequently encountered situations. Ryle (1949) first introduced a distinction between two types of schemata: “declarative” knowledge – “knowing that” something is the case, whether facts, generalizations, theories, etc., and procedural knowledge – “knowing how” to do something. Research in cognitive psychology has demonstrated that “procedural” knowledge structures are learned principally in practice, when activated by the problems or situations of practice, and involve not only recall of knowledge but also transformation of knowledge for use in practice (Gagne, 1985; Lesgold et al., 1988; Shuell, 1986). Studies of professional expertise, done by conducting systematic analysis of expert practice, address questions such as: What is the nature of professional expertise? How do experts develop their expertise? Studies of expertise in a variety of professions, such as medicine (Dowie & Elstein, 1988; Elstein & Schwartz, 2002), nursing (Benner, 1984), and teaching (Clark & Peterson, 1986; Feiman-Nemser & Floden, 1986), support the importance in professional practice, of “practical” knowledge, “tacit” knowledge, and “know-how” – knowledge that is learned through experience with professional practice. Based on case studies across the professions, Schön argues, that in addition to “practical knowledge,” “reflection-in-action” and “reflection-about-action” are central to the “art” by which professionals deal well with situations of uncertainty, instability, and uniqueness – problems in the “indeterminate zones” of practice that do not yield to technical or familiar solutions, problems that elude the ordinary categories and boundaries of the professional’s knowledge. Reflection-in-action occurs in the midst of action, and if done well, provides for flexibility in response to the problems of professional practice. Reflection-about-action occurs in the postmortem, subsequent to action. In reflection-about-action, the knowledge implicit in action is delineated, criticized, restructured, and embodied in further action through what Schön labels “on-the-spot experiments” (Schön, 1983, p. 63). Schön argues that reflection-about-action is essential for professionals in the development, renewal, and self-correction of their practice. Moreover, combined with demonstration and supervision, it is a fundamental process for initiating novices, that is, for teaching. Schön’s perspectives, based on case studies across the professions (Schön, 1983, 1987, 1991, 1995), are consistent with Ericsson’s findings showing the role of deliberate practice with feedback in the development of expertise (Ericsson, Charness, Hoffman, & Feltovich, 2006).

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How do professionals develop the “practical knowledge” essential for professional practice and the related competencies of “reflection-in-action” and “reflection-about-action”? Essentially, professionals, both novices and masters, learn through experience with the problems of their practice. Schön (1983, p. 60) observes that “as a practitioner experiences many variations of a small number of types of cases, he is able to ‘practice’ his practice. He develops a repertoire of expectations, images and techniques. He learns what to look for and how to respond. His knowing in practice tends to become increasingly tacit, spontaneous, and automatic.” Schön elaborates, more specifically, “A practitioner’s repertoire includes the whole of his experience insofar as it is accessible to him for understanding and action. When a practitioner makes sense of a situation he perceives to be unique, he sees it as something already present in his repertoire . . . as both similar to and different from the familiar one, without at first being able to say . . . with respect to what. The familiar situation functions as a precedent, or a metaphor, or – in Thomas Kuhn’s phrase – an exemplar for the unfamiliar one” (p. 138). This discussion of the nature of professional practice, and the knowledge, competencies, and qualities required for skilled professional practice, has clear implications for the venues in which professional practice needs to be learned. Specifically, some of the most important knowledge, competencies, and qualities needed for competent and wise professional practice are expressed only in practice by experts in their practice and learned through experience with professional practice – observation of experts, practice with feedback, and reflection about practice. The apprenticeship experience, the traditional initiation of the novice to professional practice, is therefore justified and validated, by our increasing knowledge of the nature of professional practice and how it is best learned. Moreover, as stated previously, Shulman, in the work on the Carnegie Foundation study of education for the professions (Shulman, 2005), provides the penultimate rationale for the early integration of workplace learning in the preservice education of professionals. They conceptualize professional development in terms of intertwined processes of professional socialization, development of professional or clinical skills, and development of specialized knowledge through what they refer to as signature pedagogies. In education for the professions, learning in the practice settings of the workplace is the signature pedagogy. It is in these milieus that novices experience professional socialization as they enter into a community of practice; develop professional skills through observation, coaching, mentoring, and supervision; and develop specialized professional knowledge as the situations of practice provide meaning and motivation for abstract learning. In this chapter, we have discussed the nature of professional practice, that is, an epistemology of professional practice, and the knowledge, competencies, and qualities required for skilled professional practice – the “what” that is to be learned and demonstrated in practice. From this discussion, we have provided a justification and validation of the integral role of workplace learning in preservice professional education. In the section that follows, we will characterize conceptions and

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theories of learning particularly pertinent for understanding and optimizing learning in the workplace, through more effective instruction, assessment, and faculty development.

Part II: Conceptions and Theories of Learning In Part I, we characterized the nature of professional practice and the generic knowledge, competencies, and qualities essential for skilled professional practice. In Part II, we provide an overview of conceptual frameworks and theories of learning and explore in more detail several that have special value for understanding and optimizing learning in the practice settings of the workplace, considering the fundamental interactions and components in these settings: the student, the master practitioner(s), the client(s), and the context or environment. We use the term theory, as do Kaufman and Mann (2007), in a general sense, namely “a set of assumptions and ideas that help to explain some phenomenon” (p. 1), or according to the dictionary definition: “a set of facts, propositions, or principles analyzed in their relation to one another and used, especially in science, to explain phenomena.” Trends in learning theories that have influenced faculty development have been summarized by Irby and Wilkerson in their review paper, Strategies for improving teaching practices: A comprehensive approach to faculty development (1998, pp. 388–390). They observe that during each of the three final decades of the twentieth century, a predominant learning theory significantly influenced instructional and, in turn, faculty development practices – behavioral learning theories during the 1970s; cognitive and constructivist learning theories during the 1980s; and social learning theories during the 1990s. Behavioral learning theories focus on behavior and behavior change as evidence of learning, knowledge, and competence and the strategies that influence behavioral change. Cognitive and constructivist learning theories focus on the mental processes, conceptual constructs, understandings, and practical knowledge of learners that influence their decision-making and action and on the strategies that influence development of their cognitive processes. Social learning theories focus on learning in social settings and, more broadly, on socialization into communities of practice through observation and increasingly central participation in these communities, as well as the influence of this engagement on learners’ knowledge, competence, and personal and professional development. It is clear that the learning theories that influenced teaching and faculty development during those decades also influenced curriculum design and assessment of learner performance. Now, during the first decade of the twenty-first century, it is clear that each of these groups of learning theories, combined, can contribute to our understanding and improvement of curriculum development, instruction, assessment, and faculty development. In this section, we will describe these groups of learning theories, focusing on their major constructs, and implications for learning in the practice setting of the workplace – first behavioral learning theories; then what

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have been referred to as “adult learning theories,” both of which serve as a prelude to our discussion of constructivist and then social learning theories.

Behavioral Learning Theories The common denominator of behavioral learning theories is a focus on behavior, and behavior change as evidence of learning, knowledge, and competence (Shuell, 1986) and the strategies, practices, or experiences that influence behavioral change. Beginning with the work of Edward Thorndike (1911), psychologists working in a behavioral tradition, referred to as Stimulus–Response (S–R) psychology, have studied learning in terms of connections between stimuli (external events) and responses (visible and/or measurable behavior). Among behavioral psychologists, B.F. Skinner (1954) has had the greatest influence on development of a theory of learning. As noted, behavioral learning theory was the predominant learning theory influencing education through the decade of the 1970s, with some significant influence that continues until the present time. Fundamentally, Skinner formulated and investigated the concept of reinforcement – the concept that behavior could be influenced by controlling the consequences,that is, the reinforcement, associated with that behavior. Based on a series of studies, Skinner determined that the variables influencing the effects of reinforcement were frequency (frequent, but not always), contiguity (immediate), and contingency (depending on appropriate response). Reinforcement has been associated with the concept of external rewards (and punishment). So, for classroom learning, teachers were enjoined to provide reinforcement for, or reward, desired behavior and ignore undesirable behavior. For higher and professional education, and increasingly for K-12 education, a fundamental implication drawn from behavioral learning theory has been the importance of feedback – information provided about behavior in relation to specific behavioral objectives, set at a level appropriate to learners’ level of knowledge and skill. It is not sufficient to simply reward desired or ignore undesirable behavior; it is important to provide information about a given behavior that provides guidance to shape learning as well as a reward and motivation for continued learning (Mosel, 1964). Behavioral learning theories had immediate applications in systems of instruction during the decades of the 1960s and 1970s, notably in programmed instruction. A well-known and sophisticated example of programmed instruction is Keller’s Personalized System of Instruction (PSI) (Keller, 1968), which has been shown to be effective for learning (Kulik, Kulik, & Cohen, 1979). The PSI is a self-paced set of sequenced instructional units, each with behavioral objectives, criterion-based tests, and passing scores. In addition, behavioral learning theories have had a pervasive influence on teaching generally, beginning in the 1970s and continuing, to some extent, to the present time. Wilkerson and Irby (1998) observe, “Learning was defined as

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a change in behavior and was believed to be facilitated by providing instruction in small linear steps through drill, practice, and feedback, and by reinforcing correct responses” (p. 388). They add, “To facilitate learning, essential teaching skills included writing measurable behavioral objectives, delivering well-organized and sequenced educational materials designed to accomplish the objectives, providing practice opportunities, coupled with immediate feedback, and evaluating the learner’s behavior based upon the objectives” (p. 388). Also, behavioral learning theories have had an ongoing and pervasive influence on curriculum design. For example, the canonical and enduring approach to curriculum design, at all levels of education, has been the systems approach, best known by its formulation in Tyler’s classic book, Basic Principles of Curriculum and Instruction (1950), and its companion texts, the taxonomy of objectives in the cognitive domain (Bloom, 1984) and in the affective domain (Krathwohl, Bloom, & Masia, 1964). The work of Tyler, which is a curriculum theory, and of Bloom, which is fundamentally an expansion of Tyler’s work in classifying types of objectives, have of course had far more influence on education than the behavioral learning theorists. The systems approach to curriculum design which they formulated focuses on the systematic analysis of purposes and objectives, selection and organization of learning experiences, evaluation of students’ performance and of curricula, and alignment among the objectives, teaching, and learning experiences and assessment of learner performance. It has been translated into a quasi-technology of curriculum design, firmly grounded in a focus on specific behavioral objectives (Gronlund, 1991; Mager, 1984). In medical education, a widely used text on curriculum design, Curriculum Development for Medical Education: A Six-Step Approach (Kern, Thomas, Howard, & Bass, 1998), is grounded in this systems approach. It is noteworthy that the work of Tyler had precedents in the curriculum theories of Bobbitt (1918, 1924), who also focused on educational objectives, who was in turn influenced by Taylor’s ideas about scientific management (1911). Behavioral learning theories have had, and continue to have, a significant influence on assessment, even of complex competencies learned in the workplace. As Custers and Boshuizen (2002) observe, “whether learning indeed has occurred can ultimately only be assessed by a change in behaviour. . . knowledge cannot be observed directly. . . statements about knowledge always require some form of inference from overt behavior” (p. 164). Behavioral learning theories have also influenced faculty development practices, with feedback in relation to clearly defined criteria for effective teaching, as the essential strategy in an array of faculty development approaches. These approaches include the pervasive use of student evaluations to provide feedback (Eble & McKeachie, 1985), as well as consultation by experts and peers – both to interpret students’ evaluations and to provide feedback in relation to “best teaching practices” (Centra, 1973; Erickson & Erickson, 1979; Skeff, 1983; Wilkerson & Irby, 1998). The tenets derived from behavioral learning theories apply to students of the professions learning in formal classroom settings, as well as to their learning in the

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practice settings of the workplace. Overall, learners develop professional knowledge and skills in their placements in the workplace – medical students in clerkships and residency training; nursing students in clinical rotations and preceptorships; student teachers in internships, practicums, or field placements; and divinity students in the practice settings of church environments, schools, prisons, community organizations, and hospitals. They develop professional knowledge and skills through observation, role modeling, practice, and reflection on practice and feedback, with coaching and supervision by their workplace supervisors – who are master practitioners of the profession in these settings. The behavioral learning tenets that apply with particular force to learning in the practice settings of the workplace are the importance of setting expectations for learning objectives – the knowledge and competencies and qualities learners should seek to develop; opportunities to practice with supervision; and specific and timely feedback in relation to observations of the learners’ performance in practice.

Transition to Conceptions of “Adult Learning” and Self-Directed Learning Beginning in the 1970s, a persuasive set of assumptions about teaching and learning, referred to as “adult” learning, became influential in education program design (Knowles, 1975, 1980, 1981, 1990); its central tenets are the importance of active learning by self-directed learners. At about the same time, constructivist theories of learning vied with behavioral learning theories as the predominant theories for influencing education program design. These constructivist theories of learning emphasized learning as an active process of constructing meaning. Among constructivist theories of learning, cognitive theories emphasized the role of cognitive structures or schemata, developed through experience, in facilitating the use of knowledge in practice (Gagne, 1985; Shuell, 1986; Sternberg & Wagner, 1986). Other learning theories in the constructivist paradigm include experiential learning theory (Kolb, 1984), reflective practice (Schön, 1983), and transformative learning theory (Mezirow, 1981, 1990, 1991). These conceptual frameworks – “adult learning” and constructivist theories of learning – are different in their lineage and their methodological groundings. It is also noteworthy that “adult learning” refers to the “what” (i.e., the learning of adults) and “constructivism” refers to the “how” (i.e., learning by active construction of meaning). Conceptions of “adult learning” are essentially sets of assumption and suggested implications, such as those formulated by Knowles (1975), rather than an empirically based theory. The constructivist theories of learning, to a greater extent, are based on empirical studies. We present them in tandem, because the conceptions of “adult learning” and the constructivist theories of learning have in common an emphasis on students as self-directed learners who are actively seeking to construct meaning, for understanding and/or practice, with teachers more in the role of facilitators. As Custers and Boshuizen (2002) observe, “The major shift from older

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approaches of learning to contemporary views has been from theories of teaching and instruction to theories of active student learning and the role of context. Today, the primary role of the teacher is viewed as engaging students in learning activities that are likely to result in their achieving target learning outcomes; what the student does is actually more important than what the teacher does” (p. 177). It should be observed overall that, despite their influence in education generally, and in higher and professional education, well-founded concerns have been expressed about the lack of an empirical grounding for conceptions of “adult learning” (Norman, 1999). Moreover, investigators have suggested that the assumptions of “adult learning,” fundamentally the importance of active, self-directed learning in relation to authentic problems, apply to all learners not solely adult learners (Norman, 999; Colliver, 2002). It is noteworthy that these ideas were formulated as far back as in the work of Rousseau in Emile (translation 1979), his text on the education of children. In this section, we will review the assumptions, and implications for learning in the workplace, of conceptions of “adult learning,” because they are well known and continue to be influential in the lexicon of educators. In the next section, we will review the tenets of several influential constructivist theories of learning – cognitive theories of learning (Shuell, 1986), experiential learning (Kolb, 1984), reflective practice (Schön, 1983, 1987, 1991, 1995), and transformative learning (Mezirow, 1981, 1990, 1991, 1994). Merriam and Caffarella (1991) survey well-known themes and principles of adult learning. Of the conceptions of adult learning, the work of Knowles (Knowles, 1975, 1980, 1981, 1990) is perhaps the best known. Knowles introduced the term “andragogy” to refer to the “art and science of helping adults learn” (1975). He formulated four influential assumptions related to adult learning, based on the premise that adults have different life situations than children. The first assumption relates to self-directed learning. Knowles suggests that as individuals mature into adulthood, their conceptions of themselves move from dependency on others to self, with an increasing ability to identify their own learning needs and methods to address those needs. The second assumption relates to the role of experience in learning. Knowles observes that adults develop a repertoire of experience, which provides a rich resource for developing knowledge and competence. The third and fourth assumptions relate to the role of motivation in learning. Knowles argues that adults are motivated to learn by envisioning the immediate application of situationspecific skills to solve authentic problems, problems that seem real to them. He also argues that adults are motivated to learn by internal factors, such as personal goals, professional goals, or the satisfaction of learning. As indicated, it has been argued that these assumptions, and the implications for teaching and learning that follow from them, apply to all learners, not just adults (Colliver, 2002; Norman, 1999). The central and best-known tenet of “adult learning” is the importance of selfdirected learning and in turn the importance of learning to learn and lifelong learning skills. Self-directed learning has been viewed as important in three respects. First, it is a goal related to self-actualization (Maslow, 1970). Second, it is also a goal for

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professionals to have skills for lifelong learning to keep up to date in their professions. Third, it is an instructional method in which learners take responsibility for regulating and monitoring their own learning. A number of approaches to learning and instruction flow from recommendations for self-directed learning, as both a goal and an instructional method, which are particularly relevant to learning in the workplace (Knowles, 1981). First, it is desirable to have a supportive learning environment where students feel safe to express themselves, ask questions, and admit to gaps in their understanding. Second, students need guidance in their learning from a master practitioner of the profession. Third, students need opportunities for collaboration with their workplace supervisors in the essential processes of self-directed learning – diagnosing their own learning needs; formulating their learning goals and objectives; selecting approaches to achieve their learning goals, including learning resources; and assessing their progress. Fourth, students need guidance in enriching their existing knowledge structures with opportunities for deep learning (Entwistle & Ramsden, 1983), that is, formulating principles related to multiple cases, experiences, and opportunities for elaboration, thereby adding to their existing knowledge structures by analysis of multiple perspectives (Bransford, Stein, Shelton, & Owings, 1981). Fifth, self-directed learning requires critical reflection on one’s goals, learning experiences, and progress, to determine learning needs and set new goals, namely reflective practice (Miflin, Campbell, & Price, 1999; Schön, 1983), for which students need guidance. Finally, self-directed learning requires skills in self-assessment, to identify gaps in knowledge and skills, and to formulate new objectives. Yet a review of the literature on self-assessment suggests that we have limited ability to assess our own performance (Eva & Regehr, 2005). Accurate self-assessment requires knowledge of performance criteria and other sources of information and feedback from others. Here too, students need guidance in this process of self-assessment. There are important issues in self-assessment and self-directed learning related to what should be learned first. Cognitive mapping, a tool for making the hierarchical structure of conceptual knowledge explicit, can be helpful in guiding self-directed learning (Edmondson, 1993). These recommendations for optimizing self-directed learning in the workplace suggest that workplace supervisors should help to create a supportive environment for learning. They should collaborate with learners in diagnosing their learning needs, in formulating learning goals and objectives, in selecting approaches to achieve their learning goals, and in assessing their progress. They should provide guidance in enriching students’ existing knowledge structures, through recommended reading and experiences, and provide guidance in processes of self-reflection. It is noteworthy that the central tenet of “adult learning,” the importance of selfdirected learning, is an integral component of other empirically grounded theories of learning that will be discussed in the following sections – constructivist, cognitive, experiential, reflective practice, transformational, and social-cognitive theories of learning.

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Constructivist and Cognitive Theories of Learning During the 1970s and the 1980s, constructivist theories of learning vied with behavioral learning theories, discussed earlier, as the predominant theories for influencing educational program design. These constructivist theories of learning emphasized learning as an active process of constructing meaning, by self-directed learners, for better understanding and/or for practice (Bransford, Brown, & Cooking, 2000). Among constructivist theories of learning, four influential theories will be reviewed – cognitive theories of learning (Shuell, 1986), experiential learning (Dewey, 1938; Kolb, 1984), reflective practice (Schön, 1983, 1987, 1991, 1995), and transformative learning (Mezirow, 1981, 1990, 1991, 1994).

Cognitive Theories of Learning By the early 1960s, it became apparent that stimulus–response behavioral theories of learning were inadequate to account for advanced knowledge and skills development, and that meaning, which is a function of the learner’s background and prior knowledge, is perhaps the most important factor in learning. Among learning theorists who first took meaning into account, Ausubel is perhaps the best known and his subsumption theory of meaningful verbal learning can be viewed as an important precursor of cognitive theories of learning (Ausubel, 1960, 1962, 1963, 1968; Custers & Boshuizen, 2002). According to Ausubel, learners construct meaningful knowledge by connecting new concepts to concepts already known in existing organized cognitive structures. These structures facilitate retrieval of the new concepts. He demonstrated that meaningful learning is facilitated by the use of advance organizers and by structured overviews of material, which facilitate making a match between the learner’s cognitive structures and the new material. Cognitive theorists emphasize that learning is an active, constructive process of meaning-making, in which prior knowledge and experience provide the context for development of new knowledge (Gagne, 1985; Shuell, 1986; Sternberg & Wagner, 1986). Overall, these theories conceptualize the organization of knowledge in terms of knowledge structures referred to as schemata, structures that encompass common aspects of a category of concepts, structured in such a way that new concepts can be understood in terms of existing concepts (Bobrow & Norman, 1975; Custers & Boshuizen, 2002). These evolving schemata facilitate the transfer of knowledge for use in various practice situations. Learning is viewed as largely under the control of the learners, who use knowledge of how they learn to plan and monitor their learning, a concept and process referred to as “metacognition”; a process that is clearly consistent with conceptions and processes of self-directed learning. Rumelhart and Norman (1978) describe three distinct, but related, types of cognitive learning: accretion, tuning, and restructuring. Accretion refers to the process of learning by adding new knowledge to existing schemata. Tuning refers to the refinement of existing schemata, particularly by applying knowledge in

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practical situations resulting in discrimination (a schema becoming more specific). Custers & Boshuizen (2002) comment that the effect of tuning is that “inferences that required deliberate reasoning in earlier stages are now made automatically” (p. 173). Restructuring refers to creation of new schemata through extensive experience, resulting in the subjective feeling of having gained expertise. The schemata are developed, tuned, and restructured through the fundamental process of elaboration – of enriching schemata through embedding the concepts to be learned in them through such methods as teaching and solving new problems (Bransford et al., 1981). Finally, cognitive learning theories address the fundamental problem in learning – how to use or transfer knowledge into practice settings that require problemsolving or decision-making. Salomon & Perkins (1989) identify two routes to transfer, which they label “low road” transfer (sometimes called near transfer) and “high road” transfer (also called far transfer). Low road transfer refers to the automatic transfer of practiced skills, with little need for reflective thinking. Methods to foster low road transfer include providing students with multiple examples and opportunities for practice in different contexts (Anderson, Reder, & Simon, 1996). High road transfer refers to the conscious application of knowledge learned in one situation to a different situation and requires more abstract and higher order thinking. Methods to foster high road transfer include mindful reflection and analysis, such as deliberately identifying a principle or concept that is not tied to one specific problem or encouraging learners to reflect on the potential for transfer (Anderson et al., 1996). Custers and Boshuizen (2002) argue that both routes to transfer are important for optimal transfer. Low road transfer is achieved through practicing skills, such as problem-solving, until they become automatic. High road transfer is achieved through conscious and reflective application of skills, such as problem-solving, learned in one situation to different situations. The implications of these cognitive theories of learning for learning in the workplace are that workplace supervisors should provide opportunities for practice in multiple situations and should guide students, through focused discussion of principles and concepts, in linking what they’re learning to their existing knowledge base.

Experiential Learning Theories Experiential learning theories, which focus on the role of experience in learning, are clearly pertinent to learning in the work place. Kolb’s experiential learning theory (1984) is perhaps the best known and most frequently cited of experiential learning theories. His work is grounded in the philosophical investigations of Dewey (1938), who argued for the essential role of experience in learning. It is also grounded in the social psychology investigations of Lewin (1951) in group dynamics. Kolb formulated what has been referred to as the learning cycle, comprised of four interactive and iterative activities: concrete experience; reflective observation; abstract conceptualization; and active experimentation (Kolb, 1984). He

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recommended that learners should have opportunities for engaging in concrete experiences as if they were practitioners. They should have guidance in reflecting on these experiences from different perspectives, in developing conceptual frameworks based on their reflections, and in evaluating their new conceptual models through active experimentation, engaging in a new set of concrete experiences. Experiential learning theories have important implications for education program planning. Just as for the other constructivist theories of learning, in experiential learning, students take greater responsibility for their own learning. Some of the most important learning is based on reflection and conceptualization related to concrete experience, prototypically learning in the practice settings of the workplace. In these settings, workplace supervisors should provide learners with opportunities for concrete experiences, i.e., for practice at appropriate levels, with guidance in reflection about these experiences, with help in developing conceptual frameworks related to these experiences, and with guidance in applying their new knowledge in further practice.

Reflective Practice and Transformative Learning Theory Among the constructivist theories of learning, the work referred to as reflective practice is perhaps the most important, since mastery of skills for reflection about practice is both an attribute of “true professionals” and an approach to developing mastery that is integral to other constructivist theories of learning. Reflection about experience is integral in discussions of “adult” and self-directed learning, cognitive theories of learning, and experiential theories of learning. In our discussion of the nature of professional practice in Part I, we focused on an influential epistemology of professional practice formulated by Schön (1983, 1987, 1991), who conceptualized reflective competencies as essential goals for effective professional practice. To reiterate – based on case studies across the professions, Schön argues that effective professional practice – competent and wise action – typically involves the application of specialized knowledge, namely the theories and technologies developed in the basic and applied sciences. It also involves the application of “practical knowledge” or “know-how,” which Schön refers to as “knowing-in-action,” and reflective competencies, which he refers to as “reflection-in-action” and “reflection-about-action.” These competencies are essential for effective professional practice because professional practice is contextspecific and requires wise action to address situations characterized by complexity, uniqueness, instability, uncertainty, and conflicting values and ethics orientations. Schön describes “knowing-in-action” as akin to “practical knowledge,” “knowhow,” or “tactics,” the seemingly spontaneous patterns of action demonstrated by skilled professionals. His description of “knowing-in-action,” based on empirical analysis of case studies across the professions, is consistent with studies in cognitive psychology, particularly schema theory (Sternberg & Wagner, 1986), which focuses on development of rich schemata through experience. It is also consistent with studies of the development of professional expertise, through experience with

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professional practice (Benner, 1984; Clark & Peterson, 1986; Clark & Peterson, 1986; Dowie & Elstein, 1988; Elstein & Schwartz, 2002). Schön describes “reflection-in-action” and “reflection-about-action” as central to the “art” by which professionals deal wisely with situations in the “indeterminate zones” of practice that do not yield to technical or familiar solutions, problems that elude the ordinary categories and boundaries of the professional’s knowledge. “Reflection-in-action” occurs in the midst of action, and if done well, provides for flexibility in response to the problems of professional practice. “Reflection-aboutaction” occurs in the postmortem, subsequent to action. In reflection-about-action, the knowledge implicit in action is delineated, criticized, restructured, and embodied in further action through what Schön labels as “on-the-spot experiments” (Schön, 1983, p. 63). It is noteworthy that this description of the goals and processes of “reflection-in-action” and “reflection-about-action” bear a striking similarity to the “experiential learning cycle” described by Kolb (1984). While reflective competencies are one set of goals for professional practice, the processes of reflection are also integral to effective instruction and learning for professionals, as demonstrated by their centrality to conceptions of “adult learning,” cognitive learning theories, and experiential learning theories. The importance of reflective competencies, both as goals for professional practice and as processes for learning, has several implications for teaching, which apply with particular force to teachers in the practice settings of the workplace. In the workplace, aspiring professionals should – and typically do – have opportunities to observe skilled practice, sometimes referred to as “shadowing,” as well as to reflect about this practice with their workplace supervisors. In addition, they should have opportunities to engage in practice appropriate to their levels of knowledge and skill, with opportunities for self-assessment, observation, and feedback. The first implication for workplace supervisors in the context of their own practice is that they should model, demonstrate, and share their reflections about their practice with aspiring professionals and help learners to frame and reframe problems discussed and to consider alternative approaches. Second, in the process of observation and feedback to learners, they should assist learners to reflect upon the actions they chose, upon the knowledge and values that influenced their choices, and upon what they learned that they could integrate into their existing knowledge structures. Kaufman and Mann (2007) observe that these processes of reflection are increasingly becoming a collective activity in communities of practice (p. 13) – an observation that relates to social-cognitive learning theories, discussed below. A related learning theory in the constructivist tradition is transformative learning theory (Mezirow, 1981, 1990, 1991), for which reflection is an essential process. Transformative learning fundamentally involves a paradigm shift in learners’ interpretations of the meaning of their experiences, based on reflective analysis of values and beliefs (Mezirow, 1990). For example, such a shift would be akin to a transformation in thinking and action from using behavioral learning theories as a guide to instruction and faculty development to using cognitive learning theories as a guide.

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The implications for workplace teachers and supervisors are that, when appropriate, they should engage with learners in several processes: of challenging current perspectives; of critically reflecting about the content, methods, and premises or assumptions of professional practice; of exploring their beliefs by giving and defending reasons, exploring alternative points of view, testing new assumptions through practice and critical reflection, and exploring options for new professional roles and relationships (Mezirow, 1981, 1990, 1991). Such reflection can be stimulated by such things as major life events, disorienting dilemmas, provocative incidents, or controversial statements. Transformative learning theory is perhaps an extension of reflective practice, in that it focuses particularly on the use of reflection for exploring premises and assumptions to achieve a transformation, a paradigm shift in thought and action. In the practice of medicine, for example, the increasing emphasis on interprofessional practice and on patient safety through error disclosure are examples of paradigm shifts in professional practice. It is noteworthy that reflection for transformative learning typically occurs in the social context of a community of practice, discussed in the section below on social-cognitive learning theories.

Social Theories of Learning During the 1990s and to the present time, social theories of learning vied with, and perhaps superseded, constructivist learning theories as the predominant theories for influencing educational program design. Social learning theories focus on learning in social or practice settings and the actual situations of practice (i.e., situated learning) and socialization into communities of practice through observation and increasingly central authentic participation in these communities. These theories address the influence of learners’ engagement in the situations of practice and in practice communities on their knowledge, competence, and personal and professional development. Wilkerson and Irby comment, “In the social constructivist view, learning is defined as socialization into a new knowledge community through the student’s active participation in the community and the internalization of socially constructed meanings” (p. 389). They add, “Major sources of learning include socializing experiences, role models that new members seek to emulate, collaborative learning with peers, and direct engagement with the beliefs, roles, power, and culture of the learning environment” (p. 389). It is important to note that aspiring professionals are typically involved with and learn in a variety of professional contexts and communities of practice. Kaufman and Mann (2007, p. 7) observe that social cognitive learning theories, most clearly the social cognitive theory formulated by Bandura (1977, 1986), blend two approaches to understanding learning – the behavioral approach, which focuses on the impact of the environment on learning, and the cognitive approach, which focuses on the importance of cognition in learning, but with a clear emphasis on the socially embedded aspects of learning. In turn, it is clear that social learning theories are complementary to constructivist learning theories, with their common emphasis

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on the importance of the learner’s construction of meaning, learner self-direction, the role of prior knowledge and experience in learning, and the role of reflection, but with a clear focus on the context of learning in professional situations and learning communities. In the social learning theory tradition, two influential approaches are social cognitive learning theories (Bandura, 1977, 1986; Vygotsky, 1978), which focus on learning through observation of others, and social cultural learning theories (Brown, Collins, Duguid, 1989; Collins, Brown, & Newman, 1989; Lave & Wenger, 1991), which focus on learning in communities of practice, as well as on the meanings constructed in communities of practice. These will each be described and their implications for teaching and learning in the workplace explored.

Social Cognitive Theories of Learning In the 1980s, Bandura transformed the then current paradigm for conceptualizing learning through his formulation of the social-cognitive theory of learning. A central tenet in Bandura’s formulation (1986), and that of Vygotsky (1978) as well, was that learners actively construct meaning through observation of others in a social context (Salomon & Perkins, 1998). In addition, Bandura emphasized the role of cognitive, vicarious, self-regulatory, and reflective processes in learning, but with special emphasis on the importance of social modeling, social learning, and observational learning. He formulated, in this context, the influential concept of learner self-efficacy, namely the learner’s perspectives on their task-specific competence, which is central in affecting what learners choose to do, how much effort they invest in activities, and how long they persist (Bandura, 1986). Most fundamentally, Bandura (1986) argues that learning occurs in an ongoing interaction among: students – with their goals, knowledge, skills, values, prior experiences, and perceptions of self-efficacy; the learning environment – which includes the formal curriculum, the hidden curriculum, the practice setting, the faculty, other professionals, other students, and learning resources; and the learner’s activities – which include classroom activities, workplace activities, interactions with others, and so on. As they engage in learning, individuals have certain basic capabilities: symbolizing – using symbols to preserve the lessons of experience as a guide to future action; forethought – formulating learning goals; vicarious – learning from observations of others; self-regulatory – self-assessment in relation to internal standards; and self-reflection – analyzing their experiences. Individuals also have perceptions of self-efficacy, which, as noted earlier, affect what learners choose to do, how much effort they invest in activities, and how long they persist. Bandura observed that four sources of information contribute to learners’ perceptions of self-efficacy: their vicarious experience of observing others, who they perceive to be like themselves, perform effectively; performance achievement – task-specific experiences of mastery; authentic feedback; and their physiological state, namely their level of tension.

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Considering the combination of these learning processes and capabilities, Kaufman and Mann (2007, pp. 10–11) recommend five teaching and learning processes, which are clearly pertinent to learning in the workplace. These processes include: developing clear objectives describing desired outcomes; providing opportunities for modeling and demonstration of applied knowledge and skills, namely opportunities for vicarious experience; providing opportunities to develop taskrelevant knowledge; providing opportunities for guided practice with feedback; and providing opportunities to reflect on learning, as well as new strategies and approaches to problem-solving. It is important to observe that students learn from the entire setting, directly through reflection and feedback about their own experience and performance and indirectly through observing others’ actions and the consequences. They not only develop applied knowledge and skills, but in addition they also learn about the rewards and sanctions in these settings of practice; the relative value placed on various skills; and the expertise implicit in behavior, among many elements of knowledge, skills, values, and beliefs. It is noteworthy that the strategy of providing opportunities for guided practice with feedback is central to Ericsson’s theories of the development of expertise (Ericsson, 2004). Vygotsky (1978) describes a zone of proximal development, a space where aspiring professionals learn through observation and interaction with more experienced practitioners, reflection about the practices they have observed, and practice with feedback and further reflection. They learn through social and task interaction in the contexts of relationships with role models and exemplars. Through this process of learning, they develop knowledge and skills; applied knowledge of the context, processes, and values of professional practice; and learn what there is to learn from the context of the entire learning environment. In these settings, knowledge, skills, and the values associated with the professional practice are learned in their social and cultural context through observation, coaching, practice, and feedback.

Social Cultural Theories of Learning Social cultural learning theories (Brown et al., 1989; Collins et al., 1989) focus on the importance of “situated learning” in learning for professional practice in the authentic context of practice settings (Brown et al., 1989; Collins et al., 1989). Later, other social learning theorists focused on learning in communities of practice, as well as the meanings constructed in those communities of practice. The concept of the importance for professional practice, of learning in and initiation into communities of practice, was proposed by Lave and Wenger (1991) and elaborated by both (Lave & Wenger, 2002; Wenger, 1998). Lave and Wenger (1991) describe a trajectory of professionals’ learning and development, beginning with their legitimate peripheral participation in communities of practice during which they perform less essential tasks and moving on to their increasingly full participation in the central work of the community, in turn serving as mentors to more junior members. Lave

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and Wenger (1991) posit that learning around relationships with masters and other apprentices creates a curriculum in the broadest sense, with learners experiencing a transformation in understandings, roles, and responsibilities. Some have argued that a major challenge in educating professionals is to strike an appropriate balance between learning in applied contexts and helping students derive abstractions and generalizations that apply across contexts (Custers & Boshuizen, 2002; Patel & Kaufman, 1995). The implications of social cultural theories of learning for workplace supervisors are that learners should be provided with opportunities for increasingly full participation in the central work of the community of practice, whether of medicine, nursing, teaching, or divinity. Increasingly, central participation should follow after peripheral participation, with opportunities for observation of role models, reflection on the practice of these role models, and opportunities for practice with reflection and feedback.

Discussion and Conclusions In this chapter, we first discussed the nature of professional practice – the knowledge, competencies, and qualities required for effective professional practice – the “what” that must be learned and demonstrated in professional practice. Then, conceptions and theories of learning were characterized in terms of implications for best practices for instruction, assessment, and faculty development for education in the practice settings of the workplace. Discussion of the nature of professional practice was based on philosophical investigations, case study research, and studies in the traditions of cognitive sciences and development of expertise. We concluded that professional practice requires specialized knowledge from various disciplines. But further, given its characteristic conditions of complexity, uniqueness, uncertainty, and conflicting value and ethics orientations, professional practice requires “practical knowledge,” “knowhow,” or “tactics” for adapting knowledge to various specific situations. It also requires reflective competencies, which Schön refers to as “reflection-in-action,” in the midst of practice, and “reflection-about-action,” in the postmortem, for selfcorrection, development, and renewal of professional practice. Practical knowledge and reflective competencies are learned principally in practice, through experience with the actual problems of practice. Therefore, the characteristic apprenticeship experience of learning in the workplace, even in the preservice stages of learning, for professions such as medicine, nursing, teaching, and divinity, is justified and validated. It is through learning in the workplace that novice professionals experience what Shulman (2005) has referred to as professional socialization, development of professional or clinical skills, and development of specialized knowledge. In turn, learning in the context of the workplace is the signature pedagogy for the professions. Three predominant conceptions and theories of learning were described in terms of implications for best practices for instruction, assessment, and faculty

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development for education in the practice settings of the workplace. Following Wilkerson and Irby (1998), we observed that during each of three decades, a predominant genre of learning theory significantly influenced efforts in education – behavioral learning theories during the 1970s, cognitive and constructivist learning theories during the 1980s, and social learning theories during the 1990s. Behavioral learning theories focus on behavior and behavior change as evidence of learning, knowledge, and competence. Cognitive and constructivist learning theories focus on the mental processes, conceptual constructs, understandings, and practical knowledge of learners that influence their decision-making and action. Social learning theories focus on learning as socialization into communities of practice, through observation and increasingly central participation in these communities. From our analysis, it is clear that each of these groups of learning theories can contribute to our understanding and improvement of curriculum development, instruction, assessment, and faculty development – and in turn to optimizing the benefits of learning in the workplace. Indeed, they are complementary to one another. For example, three of the behavioral learning tenets most relevant for learning in the workplace are: (1) the importance of setting expectations, in behavioral terms, for learning goals and objectives – the knowledge, competencies, and qualities that learners should seek to develop; (2) providing opportunities for practice with supervision; and (3) providing specific and timely feedback in relation to observations of learners’ performance in practice. Conceptions of “adult learning” and constructivist theories of learning emphasize active learning by self-directed learners in relation to authentic problems. Given this central thrust, it is important that workplace supervisors: (1) maintain a supportive and safe environment where students feel comfortable asking questions and admitting to gaps in knowledge and skills; (2) collaborate with learners in diagnosis of their learning needs, in formulating learning goals and objectives, in selecting approaches to achieve their learning goals, in assessing their progress, and in engaging in reflective practice; and (3) provide learners with opportunities to practice and to gain experience in multiple situations, to reflect upon their experience, to formulate principles for practice based on their reflections, and to apply these principles to practice in new situations. Social learning theories focus on learning in the authentic contexts of practice and communities of practice. In addition to the importance of active learning by selfdirected learners, social learning theories emphasize the importance of constructing meaning through observation and collaboration with others in a social context. The implications for workplace supervisors are that they should provide learners with opportunities for increasingly full participation in the central work of the community of practice, initially with opportunities for observation of role models and reflection on the practice of these role models, followed by opportunities for practice with reflection and feedback – all in the context of a community of practice. The various conceptions and theories of learning have different emphases – for behavioral learning theories, the importance of shaping observable behavior through feedback; for constructivist learning theories, the importance of meanings constructed by learners; and for social learning theories, the importance of the social

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context of learning. Though different in what they stress, the contributions the different conceptions and theories make to optimizing teaching and learning in the workplace are complementary, and in fact, converge on a straightforward set of recommendations for workplace teaching and learning. Specifically, it is important for workplace faculty to: (1) engage collaboratively with learners in identifying their learning needs, formulating appropriate goals and objectives, selecting appropriate learning experiences and resources, assessing their performance in relation to these goals and objectives, and reflecting on their experiences; (2) provide opportunities for observation of role models and reflection on these observations; and (3) provide learners with opportunities to practice, with problems appropriate to their level, to reflect on their rationales and strategies for practice, and to develop principles for practice that they then test in practice – all with timely feedback. This chapter provides a context for the synthesis in Chapter 4 of research on pedagogy and best teaching practices in workplace settings, including broadly the preparation of students and setting expectations, observation and feedback, role modeling and coaching, supervision, reflective practice, and use of technology resources. It provides a context for the syntheses in Chapters 5 and 6 of research and recommendations for assessment, in suggesting opportunities and strategies for assessment in the workplace. It also provides a context for Chapter 7 on faculty development. Conceptions of learning have implications for the process of faculty development, in suggesting approaches for educating faculty to be effective teachers in workplace settings; and for the content of faculty development programs, in suggesting effective instructional practices in workplace settings.

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Chapter 4

Coaching, Mentoring, and Supervision for Workplace Learning Beverly W. Henry and Kathleen F. Malu

Overview Have you ever heard someone talk about teaching in the workplace in a way that makes it sound easy? For example, the phrase “see one, do one, teach one” highlights the reliance on learning through observation in medical education. Another, “as long as you know it, you can teach it,” implies that you only need content knowledge to teach in any arena. However, a multitude of factors suggest that teaching and learning situations vary considerably. These factors include the professional curriculum, the goals of the workplace, and expectations among all parties (Billett, 2006). Furthermore, instructors in workplace settings are constantly challenged to identify and apply appropriate teaching methods that will help preprofessional students reach their learning goals. Education theory and research show that teaching and learning processes in the workplace setting are complex. Hence, the essential objective of this chapter is to present research related to teaching methods that best supports learning in the workplace for students pursuing careers in the four professions featured in this volume: medicine, education, nursing, and clergy. The learning theories literature presented in the earlier chapter provides the backdrop for this review of teaching methods and instructional design considerations. In this chapter, we first identify the contextual factors that are important to consider in workplace teaching. Then we review the literature on three methods, which exemplify effective teaching in the workplace: coaching, mentoring, and supervision. In coaching, teachers provide learners with individualized and task-oriented instruction through one-on-one interactions, such as demonstrating, observing, and critiquing. Mentoring occurs as teachers develop rapport with students, providing advice to support them through learning experiences and professional development. With supervision, teachers transition from demonstrating the knowledge and skills of their craft as students to observe to providing expert guidance for students’

B.W. Henry (B) Northern Illinois University, DeKalb, IL, USA e-mail: [email protected]

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practice as they progress in their abilities. Based on a review of research focused on implementation of these methods, we identify insights about setting expectations, questioning, feedback, and reflective practice; we highlight each of these areas. Technology resources relating to workplace learning are referenced as they supplement other teaching strategies with a brief discussion of the research in this area. To conclude this chapter, commonplace challenges to workplace instruction are discussed and suggestions provided.

Contextual Factors in Workplace Learning The coach, mentor, and supervisor should be aware of the complexities and competing interests that emerge when work, teaching, and professional preparation activities overlap. Contextual factors merit consideration when selecting and implementing a teaching method. These contextual issues take into account the following: teaching methods to ensure that accreditation standards are met, organization of work so that students can learn from their experiences, responsibilities associated with student work assignments, interactions between students and professionals within workplace communities, shared responsibilities for students’ learning among team members, and cultural influences on teaching. Billett (2006) describes the impact of the workplace on how work is organized and structured and refers to “a curriculum for the workplace” (p. 31). This curriculum is seen through the lens of multiple learning theories and explores how workplace preceptors need to decide both what to teach and how to guide student learning. Of special interest are three primary purposes to be served: the division of labor and how learners will increase their participation in real work; what will constitute learning about the work onsite; and what influences the experienced curriculum, such as the ordering of experiences, engagement of learners, and goals that are shared between individuals and organizations. Billett (2002) described intentional workplace teaching that relates to the methods discussed in this chapter, such as guided workplace learning with modeling, coaching, and questioning. The review of learning theories suggests that workplace instructors organize teaching methods so that learners are encouraged to construct meaning from the experiences they encounter. Through a concrete set of experiences with attention paid to observation and reflection, learners can attain the desired goals and generalize to new experiences. An example that illustrates Billett’s conceptions of division of labor and how students progress in real work settings is found in a study of clinical teaching methods in medicine (Ottenheijm, Zwietering, Scherpbier, & Metsemakers, 2008). In this study, a strategy for early contact with patients was designed to support early learning through shared work responsibilities (Ottenheijm et al., 2008). Results from early student–patient contact showed that student exposure to the work site, wherein students take an active role, increased their awareness of the consequences of their actions (Ottenheijm et al., 2008). Instructional design considerations for the clinical setting included methods faculty

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used to supervise students in clinical practice and to provide feedback to students about patient contacts. In this manner, faculty promoted the transformation of experience into knowledge. How instructors facilitate skill development in workplace learning relates to different constructs in social learning theory. These constructs include demonstrating desired behaviors for students to observe and replicate, providing guidance to students for their skills development, giving feedback on practice attempts, and supporting students’ motivation and confidence in the learning situation. In addition, structured interactions between teachers and students have been shown to lead to students’ increased competence in various learning goals in medicine and nursing (Cox, 1996; Leach, 2002; Neher, Gordon, Meyer, & Stevens, 1992; Burns, Beauchesne, Ryan-Krause, & Sawin, 2006). While the whole medical team may accept responsibility for student learning, in the education profession the student teacher’s practice is viewed as a more individual event (Booth, Hargreaves, Bradley, & Southworth, 1995). Compared to social learning in the medical field where clinical practice focuses on learning discreet skills with a gradual decrease of teacher support for the student clinician, the field of teacher preparation does not yet espouse one particular theory-based model of training (Sockett, 2008). Furthermore, culture, socioeconomic status, language, practices, and relationships influence learning (Gee, 1996; Marton & Booth, 1997; McMillan & Forsyth, 1991; Vygotsky, 1987). Faculty members, instructors, and learners bring their own personal “small c” cultures to the workplace setting (Gee, 1996). Those cultures influence and are influenced by socioeconomic status and language(s) spoken and can be drawn from individual families and neighborhoods, schools, and religious communities (Gee, 1996). There is the additional influence of culture, the big “C,” that is traditionally labeled as the “American” culture (Gee, 1996) or the “Professional” culture that learners seek to enter. Similarly, language(s) may influence and impact workplace learning. Following a parallel to culture, the “small d” discourse of individuals and the “big D” discourse at the national and professional levels may impact the teaching and learning environments of the workplace (Gee, 1996).

Coaching, Mentoring, and Supervising to Support Extraordinary Learning in the Workplace Answers to the question “How do professionals teach?” also factor in to answers for the question “How does teaching promote learning in the workplace?” (Cook, 2006; Harden & Crosby, 2000; McKeachie, 1999; Theall, 1999). A review of the literature on workplace teaching and learning across the professions provides evidence of effective teaching methods that, at times, span more than one profession. In reviewing the literature in education for medicine, education, nursing, and the clergy, notably fewer studies exist in the education and clergy literature than in medicine and nursing. Key research that supports specific teaching methods as important

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for exemplary teaching in the workplace include Dornan, Boshuizen, King, and Scherpbier (2007), Byrne, Pugsley, and Hashem (2008), McAllister, Tower and Walker (2007), Graffam, Bowers, and Keene (2008), Cox (1996), Day (2005), Smith (2003), Mogan and Warbinek (1994), Dolmans, Wolfhagen, Gerver, De Grave, and Scherpbier (2004), Booth et al. (1995), Porte, Xeroulis, Reznick, and Dubrowski (2007), White (2007), Gillespie and McFetridge (2006). Further research is included with the descriptions of each teaching method. In the sections that follow, we explore teaching methods encompassing coaching, mentoring, and supervision. We also discuss strategies that teachers use to implement these methods, along with the research in each area. These strategies include setting expectations, active questioning and feedback, and reflective practice. Additionally, comparisons are made as to how these strategies are applied across the professions. It is important to note that the instructional methods cited are not isolated and discreet within the four professions examined in this volume. Rather, teachers weave them together fluidly and dynamically as they teach in the workplace setting. Also, these teaching strategies may be supplemented with computer-assisted learning and interactions. As Smith (2003) describes, advancement in technology, with flexible delivery of information and opportunities for collaboration, increase the power of these instructional methods for workplace learning. On the other hand, as noted in the medical education literature, an empirical basis for web-based learning and instructional methods is needed instead of a simple description of the topics to be presented with technology (Cook, 2006; Hege et al., 2007). For our purposes, research reports that incorporate technology as related to the teaching methods are included.

Coaching In their description of workplace teaching methods, Booth et al. (1995) described coaching as essential for training in medicine and education. They comment, “Coaching here is defined as the ways in which apprenticeship can be opened up into its component parts: for example, the skills of demonstrating, questioning, assisting. Each of these has a subset of skills, knowledge, and understanding” (p. 165). In the workplace, both faculty and students may recognize that to achieve learning objectives, the application of coaching as a teaching method could be of benefit. Through coaching, teachers provide students with personal and individualized task-oriented support. Besides modeling professional behaviors and demonstrating tasks, coaches provide specific feedback and support student progress. Students, in response to coaching, practice workplace tasks with the expectation that their teachers will observe and critique their practice, helping them to improve. Along with coaching methods, teachers may still be expected to complete typical instructor responsibilities, but fulfilling the role of coach is distinguished by interactions with students that are less prescribed and more individual. As a result, coaching interactions may have special meaning and impact, such as Billett describes, on the enacted curriculum

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(Billett, 2006). A discussion of the research on coaching in medicine and teacher education follows below. Sepdham, Julka, Hofmann and Dobbie (2007), Muething, Kotagal, Schoettker, del Rey and DeWitt (2007), Booth et al. (1995) describe coaching methods in the workplace and the impact of coaching on student learning. Coaches can use the Reporter, Manager, Interpreter, and Evaluator (RIME) model originally developed by Pangaro (1999) to facilitate learner progress. In one study, the RIME model was applied with faculty interactions to facilitate learners’ development of competence in clinical tasks (Sepdham et al., 2007). In this chapter, the authors highlighted preceptors’ use of the coaching method with responses to learners’ demonstration of levels of clinical practice. For example, in an effort to help students progress, preceptors could say “Excellent differential diagnosis. Now, how will we proceed to manage the workup?” (p. 162). The authors indicated that nonjudgmental responses by coaches helped learners improve. In research on family-centered bedside teaching, medical faculty applied coaching methods by modeling appropriate patient interactions for students (Muething et al., 2007). In this coaching method, a concerted effort was made to demonstrate shared roles and responsibilities so that students could observe and then practice desired behaviors with positive results. The impact of expert review and feedback was highlighted in the results of research by Porte et al. (2007) when they studied clinical teaching of surgical skills. Expert guidance with goal-setting and feedback on progress were more effective as a motivation technique than self-determined goals. Coaching methods with students have been identified as an area that faculty in multiple professions rely on for shared work responsibilities, informal learning, and clinical learning (Booth et al., 1995; Grealish, 2000). Booth et al. (1995) compared coaching in education to that applied in medical teaching and found some patterns. For example, teachers using coaching methods typically modeled what the student needed to say or do. Coaching methods commonly occurred after the supervising teacher found that students needed additional help, including, for example, developing “how-to-knowledge” from the experience (Booth et al., 1995). Hallett (1997) compared coaching in nursing education with learning through reflection as described by Schon’s work. Grealish (2000) emphasized that coaching was a common method that expert clinicians used to help students progress. In summary, coaching is an effective teaching method to enhance workplace learning.

Mentoring Ogur, Hirsh and Bor (2007) presented mentoring as a method to establish longerterm relationships between teacher and student to “provide a richer learning experience and to guide the student’s professional development” (p. 401). Examples of teaching through mentoring have been identified as helpful for students’ progression through clinical experiences, beyond the exposure to professionals as role models, across the professions (Billett, 2006; Carini, 2000; Harden & Crosby, 2000;

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Infante, Forbes, Houldin, & Naylor, 1989). The dialog between the teacher and the student, either as a formal or as an informal situation that aids in the development of a relationship between mentor and protégé, appears to be a key element in mentoring. Mentoring includes active listening, questioning, and feedback, sharing of personal stories, and suggesting. Those actions are comparable to the techniques that coaches may use. However, mentoring differs from coaching because the mentoring relationship is less task-oriented, more in-depth, of longer duration, and mutually beneficial (Gillespie & McFetridge, 2006; Harden & Crosby, 2000; Ogur et al., 2007; Parse, 2008). Billett and Rose (1996) described verbal interactions between mentors and students in which students formulate the responses, questioning dialogs, analogies, and diagrams. Other strategies for mentors have included use of verbal interactions that match the pace of the learner, balancing positive and corrective feedback, and using questions to prompt student reasoning. Close guidance and active participation of mentors in student learning processes have helped learners understand the characteristics of the workplace, uncovering what is hidden and finding meaning in that knowledge. Examples of teaching methods that feature mentoring relationships for the four professions are presented here to demonstrate a range of ways in which mentorship has been integrated into workplace education. An illustration of mentors in the primary role of teacher is found with the Harvard Medical School Integrated Clerkship (Ogur et al., 2007). In this clerkship, a year-long mentoring program for third-year medical students was created where students were assigned to a faculty preceptor for the year. The students attended the preceptor’s clinic each week and the mentoring relationship provided by the preceptors included consistency of contact while students learned fundamental skills. The authors report that students developed supportive relationships with faculty preceptors as role models and mentors. In addition, student learning was enhanced as faculty saw students regularly and were able to facilitate progress and provide effective remediation. Mentorship may also consist of a non-assessment teaching role, as Harden and Crosby (2000) described clinical teachers’ roles in medicine. From this perspective, mentorship reflects having a student-centered view of learning relating to a wide range of student issues. In a clinical teaching model for nursing, balancing clinical supervision with theoretical linkages is emphasized and related to the mentoring of students (Infante et al., 1989). In this model, the teaching methods of university faculty are contrasted with those of clinical preceptors. The latter provide guidance to students and serve as role models and mentors, while university supervisors are responsible for curriculum and assessment. One effective instructional approach in the workplace context is that clinical preceptors role-modeled patient care and offered students a view of real-world skills and demands. As a result of clinical preceptors’ mentoring students in their skill development, a realistic perspective of what is needed in practice became better understood. Gillespie and McFetridge (2006) also describe the role of a nursing teacher as one who has clinical credibility – is able to apply scholarship in the field and integrate theory into practice in the practice setting. The practice of mentoring is described as one in which preceptors help nursing students achieve learning outcomes, extending beyond the role of teacher.

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In the preparation of clergy, the role of mentor is typically assumed by the workplace instructor because the instructor is responsible for the activities that occur in the practice setting. For example, seminary students may be assigned to direct a particular program within a congregation such as a Sunday School Program, a food pantry, or new worship services for young adults. In such practice settings, instructors mentor students by guiding and supporting them. Instructors do not direct student actions, share in their work responsibilities, or demonstrate skills or techniques. Students in divinity schools and seminaries enter into learning communities where they discuss their field experiences, particularly in the supervised ministry fieldwork during their second year. Although such discussions are promoted throughout their divinity education, during the student’s second-year mentors primarily use strategies such as active listening, questioning and offering of feedback, clarifying, and probing. Typically, clergy students must participate in an academically focused course that addresses principles of supervised ministry based on their fieldwork. It is in such a course where seminary faculty members engage in the further mentoring of seminary students. Students are assigned mentors and receive feedback from their onsite workplace supervisor. Within the field of teacher preparation, experiments (Carini, 2000; Dyson, et al., 1997) have expanded the notion of mentoring to include more than just one individual as mentor. Some schools (Carini, 2000; Fine, 1996) are trying to create new discourse communities that include not only student teachers but also practicing teachers, teacher educators, and administrators (Carini, 2000; Fine, 1996; Hutchings and Shulman, 1999). These new discourse communities are often called study groups and can complement learning in workplace settings. Carini (2000) reported on one study group that used descriptive reviews of student work to encourage active questioning and reflection where any member of the study group could lead the review. The member began by describing the student in question and sharing examples of the student’s work. New insights were gained and used to modify or adapt teaching practices in the classroom. The purpose of this process was for the group member to see the student without labels, judgments, or assumptions. The central goal of another effective study group was to explore a central teaching question (Dyson, et al., 1997). This study group met periodically throughout the school year to discuss and share a central teaching question and to explore ways in which the conversation was relevant to the group members’ teaching and learning practices. Mentoring, as a teaching method used in education, was included as an example of participatory evaluation research, wherein researchers join school communities and serve as mentors for school members, including student teachers, and thus help to bring about changes in school communities. In one participatory evaluation research group (Fine, 1996), members either self-selected research questions that they explored in their school community and/or studied questions that the study group selected. In addition to practicing teachers, student teachers, administrators, and the lead researcher, this study group included selected students at the school and their parents (Fine, 1996). Teacher educators have served as mentors to their student teachers when they are placed in the schools (Fine, 1994). Mentoring practices faculty exhibited

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included listening, actively questioning, making suggestions, and encouraging student teachers to clarify and search for solutions to the problems they encounter in the classroom. While interactions between mentors and protégés occur at different points during workplace learning in these professions, the main tenets of developing a relationship between faculty and students that supports students are noteworthy.

Supervision Whitman and Schwenk (1997) describe the role of the workplace supervisors as those that “supervise the learner, who is now given the opportunity to practice the skill under your watchful eyes. The learner is more actively engaged but still dependent” (p. 99). For many professionals, workplace instruction draws upon the apprenticeship model (Billett, 2006; Booth et al., 1995; Day, 2005; Foster, Dahill, Goleman, & Tolentino, 2006; Smith, 2003; Whitman & Schwenk, 1997). As novices observe experienced practitioners and in turn practice under expert guidance, students learn the knowledge and skills of their craft in a variety of settings. An example from medical education demonstrated how supervision exemplifies the best of workplace teaching methods outlined in this chapter (Ottenheijm et al., 2008). Instructor supervision included observing, reporting, and evaluating student practice. Supervisors prepared for and ensured implementation of workplace learning, monitored student experiences and progress toward predetermined objectives, and provided appropriate feedback and guidance to students. The supervisor’s primary and unique action that has set this practice apart from the practices of coaching or mentoring is the responsibility to evaluate student performance in the workplace. Students in the workplace must demonstrate for the supervisor the knowledge and competencies related to expectations set at the beginning and throughout the workplace learning experience. In a medical curriculum, Boehler et al. (2007) described the method of giving the students explicit directions and found that this enhanced learning in the workplace. In addition, how students made sense of what they observed and experienced through the medical instructor’s arrangement of experiences served to enhance clinical learning (Cox, 1996). Also, helping students understand what was expected and how that connected to prior learning offered clinical instructors a key starting point for learning in the workplace. Equally important, during teaching through supervision, instructors should ensure that workplace conditions and instructor supervision match the level of learners – from the perspectives of personal, professional, and educational development. Workplace learning depends on supervision of students that allows students to actively participate in developing practical skills and provision of the appropriate level of support to challenge without overwhelming or ignoring (Dornan et al., 2007). Additionally, professional values and attributes are learned during supervised practice, for example, how to behave in the workplace setting (Day, 2005). This point is consistent with the study by Wright, Kern, Kolodner, Howard and Brancati (1998), in which attributes of physician teachers as excellent

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role models extended beyond the time spent teaching to include an emphasis on the doctor–patient relationship and teaching the psychosocial aspects of medicine. Ultimately, supervising instructors supported learner development so that reliance on instructor oversight and shared participation in the task gradually diminished (Dolmans et al., 2004). A well-recognized model of medical teaching that provides a framework for oral interactions or dialog between supervising teacher and student is the Five-Step Microskills model by Neher et al. (1992). First, teachers engage students in the patient care process by asking for the students’ opinions on the patient diagnosis. Described as an important part of the process, teachers should get a commitment from the students on the patient’s issues. Second, teachers probe for supporting evidence, encouraging students to think through how they came to a conclusion. Third, teachers formulate general rules and supplement student knowledge with their ‘more expert’ understanding of the situation and explore broader contexts than the given case. This step can be compared to the shared analogies described by Billett and Rose (1996). The remaining two steps directly address feedback to reinforce what was done right (step four) and correct mistakes (step five). The authors commented that both content areas for feedback were important and purposefully placed the corrective feedback after positive reinforcement. The Five-Step model was described as an easy-to-learn and efficient teaching approach to diagnose problem-solving abilities of students and serve as an example of questioning and feedback techniques that may be helpful to enhance learning in other settings. Viewing the teaching method of supervision as directing student learning across a continuum highlights the shifting of responsibility for workplace functions from instructor-directed to student self-regulated. This transition in the roles of supervisors and learners relates to the Dreyfus model of different levels of learner – novice, advanced beginner, competent, proficient, expert, and master (Dreyfus & Dreyfus, 1986). Different teaching strategies support progression from knowing what should be done, as in the classroom, to context-based behaviors and the independent practice of skills in the workplace. For nursing preceptors, researchers have also described the developmental progression of students’ experience that can be applied to teaching through supervision. In a study of workplace teaching (Burns et al., 2006), the authors modified the levels of learner from the Dreyfus model to capture the nursing students’ learning in three phases: beginner, transitional learner, and competent proficient learner. With each level learner suggestions for teacher supervision were presented. For beginners, instructor support was needed for all facets of learning. Teaching methods for supervision of this level of learner included student observation of more experienced individuals providing care, student preparation time to review patient materials prior to providing care, and a mix of patient cases, with some routine and some complex, so that students began to actively participate in the clinical setting. For transitional learners, instructors played a less intrusive role in actual workplace situations. For example, instructors met with student nurses before and after daily clinical experiences. For the third stage, after students were deemed competent and proficient, students functioned increasingly independently. However,

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students recognized their own limitations, sought input from more knowledgeable clinicians as needed, and sought new challenges. Instructors fostered more collegial relationships with students. Throughout the process of supervision, instructors should be aware of learner progress, recognize student efforts that lead to positive accomplishments, and provide resources when learners encounter challenges that are too difficult to overcome without renewed support. The teaching method of supervision for both medical and nursing students focuses on the importance of maintaining the appropriate balance between the proximity of the teacher to the student, the learner’s needs, and the degree of difficulty in the experience (McAllister et al., 2007). Additionally, when supervising students, encouragement of reflective practice is suggested as a transformative approach. Mechanisms to support reflection include debriefing with peers or supervisors, seeking feedback, journaling, and at times using technology to support reflection. McAllister et al. (2007) suggested five questions for supervising teachers to prompt learners’ reflections about the day’s activities. In brief the questions to consider were: What skills did you see? Who practiced these skills? What were the positives and negatives? What messages were given to clients? And which skills do you intend to use? In this manner, students were prompted to be mindful in their reflection about workplace experiences and not routinely repeat what they observed. Ultimately, the nursing teacher provides supervision through planning and preparing, watching and observing, and reporting and evaluating the progress of the student for the duration on the clinical rotation (Malu, Figlear, & Figlear, 1994). In contrast, teacher preparation with supervised practice in schools is based more on a time orientation. Student teachers first typically observe their cooperating teacher for several weeks. Then, they are expected to “take over” the whole classroom for gradually increasing periods of time each week. By the end of 7–10 weeks, student teachers are fully responsible for all the activities of their cooperating teacher. Cooperating teachers conduct supervision of student teachers on a daily basis, but the final grade and official supervision reports are the responsibility of the university supervisor. There are a plethora of complex issues that determine whether the student teacher’s workplace experience will, in the end, be supportive and positive or frustrating and negative (see the section on barriers).

Setting Expectations, Questioning, Feedback, and Reflection Across the methods – coaching, mentoring, and supervision – discussed in this section, implementation often included setting expectations, questioning, feedback, and reflection. For example, teaching typically begins by ensuring that students understand what they can expect to learn and do. As instructors set expectations, they inform students about what is expected of them; how the experiences to achieve these expectations will be arranged; and, perhaps occasionally, by collaborating with students on setting expectations. Expectations can be presented in written format so

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that students can refer back to them throughout their workplace learning experience or they can be constructed or modified as the workplace environment changes. The literature on methods (Billett, 2006) for setting expectations to support workplace learning highlights this process as central to achieving student engagement and success with the learning experience. Student engagement in goal-directed activities is an important step for active participation in the learning process and sets the stage for deliberate practice as described by Ericsson (2004). In practice, a comprehensive review of clinical checklists can function as the starting point for instruction and help students to clearly understand what knowledge-based content and competencies are expected of them. Typically, applicants to divinity schools use catalog information to determine various schools’ field education components and then select the school they wish to attend. Once admitted, they receive information about the expectations for their field experience during orientation to the program and again immediately before beginning the second year of supervised ministry (Rev. Dr. Frederick W. Weidmann, personal communication). Technology has been used to facilitate workplace learning, including setting expectations and guiding completion of learning tasks – though the success of computer-assisted instruction has been mixed (Cook, 2006; Hege et al., 2007; Palmer & Devitt, 2008; Torre et al., 2007). For example, at the onset of a clinical clerkship, the instructor sets expectations for students to track their progress (Palmer & Devitt, 2008). Despite the availability of an online formative assessment tool to measure their progress with established expectations, some students’ lack of interest in using the self-assessment tool and supplementary materials was described. Cook (2006) highlighted the potential benefits of just-in-time learning to keep students engaged in medical settings. Uncertainty about the use of this instructional method suggests the need for further research. Further, a review of e-learning strategies for case-based learning in medicine identified a lack of student motivation to voluntarily complete modules as problematic – despite clear directions (Hege et al., 2007). When technology use was mandatory, the level of use improved. Still, benefits from the integration of technology varied among students in these studies. Beyond understanding the expectations and the procedures to access the e-learning materials, factors considered important for student participation were significant. Students needed to see the relevance of the content to the stated objectives for the learning experience and to be able to integrate the materials to the learning experiences. While technology offered students different routes to access information and be successful in the workplace, student perceptions of its relevance appeared critical to the level of engagement and student participation. How the instructor employed the method of establishing expectations with student learners appeared important for field-based as well as computer-assisted workplace learning. Byrne et al. (2008) compared the literature on teaching methods used in experiential learning for students of medicine, nursing, and emergency services. The results indicated that teaching methods most associated with positive learning outcomes included the following strategies: periodic feedback, activities based in the

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clinical setting, and supervising teachers with clinical background. Of note, comparing one instructional method to another, such as lab-based exercises, with or without a computer-based component, typically did not demonstrate improvement in learning outcomes. Teaching methods that placed learners in the hospital setting earlier rather than later and with clinical staff support resulted in students practicing skills more successfully. Across the professions, the practice of active questioning and feedback occurs as students engage in a learning situation in the workplace setting. Communications between teacher and student, such as social mediation, negotiation, and verbal interactions or joint problem-solving, have been suggested over preceptor actions of primarily observing and listening. Through the latter, more passive forms of guidance, core knowledge in the workplace may remain opaque or hidden from learners as they do not independently uncover it. Through verbal interactions between preceptor and learner, learners formulate the responses, such as with questioning dialogs, analogies, and diagrams (Billett & Rose, 1996). Also, it should be noted that this practice may not be a discreet set of actions but rather may often include and become interwoven with reflective practice. Verbal interactions with questioning and feedback strategies have been studied in clinical settings to determine effective instructional practices. Mogan and Warbinek (1994) designed an instrument to measure teaching behaviors by clinical nursing instructors with criteria drawn from the literature on student learning processes and observation of clinical teaching. Effective teaching interactions incorporated a problem-solving style rather than directive comments. Feedback was corrective or constructive, rather than merely positive or negative. Also, during verbal interactions, teacher response categories varied between those considered too high or too low for optimal effect. Such responses included teachers’ responding to their own questions or completing the student responses rather than prompting the students for more information. Also, instead of a low-level response such as merely asking students to recall factual information, asking questions for the students to identify clinical decision-making was preferred. Graffam et al. (2008) conducted direct observations of clinic medical instructors and compared those results with interviews of medical students and faculty. Positive teaching behaviors in conversing with students were exemplified by intentional questions from the instructor and pertinent follow-up questions to specific students. In addition, engaging students through “think aloud” processes of problem-solving helped to model for students’ desired decision-making and verbal interactions with the student to uncover pertinent facts about the patient. For feedback to be effective, clinical teachers need to find the balance between information that is potentially helpful rather than harmful for student learning. Examples are timely interjection of more expert understanding or prompting students for clarification, rather than being too directive or dominating. Blatt, Confessore, Kallenberg, and Greenberg (2008) reported the results of verbal interaction analysis from medical students as teachers of more junior students in clinical settings. A review of videotaped verbal interactions (14 episodes randomly selected from a sample of 155 sessions) yielded 417 utterances (65% from teachers and 35%

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from students). Patterns in the balance of feedback from the instructor (neutral, positive, and corrective) were analyzed with the learners’ responses. Three dimensions of interaction were identified: (1) verbal dominance, (2) positive-corrective feedback balance, and (3) cognitive level or what thoughts resulted from the interaction. The authors related their findings to the premise that the degree to which learners talked reflected how engaged they were in the learning process. Through questioning and feedback, the faculty determined how well what learners said reflected their understanding of the situation. Another point about feedback for instructors to consider relates to timing – when feedback should be expressed. Earlier work in medical education addressed the importance of timely and expected feedback (Ende, 1983). From a review of teaching methods of clinical skills for medical, nursing, and allied health students, how often feedback occurred was an important component (Byrne et al., 2008). As a teaching process, repeated episodes of training with periodic feedback conducted over time were associated with better learning outcomes. On a related note, in a study of feedback as a formative assessment tool during bedside teaching sessions, educators practiced structured feedback to enhance learning outcomes as compared to routine teaching sessions (Burch, Seggie, & Gary, 2006). From the medical student perspective, 95 of 135 students (70%) responded positively that structured feedback played an informative, advisory, and motivational role in their learning. Overall, the clinical instructors (n=13) perceived that structured feedback was a feasible though challenging process with educational value for bedside teaching. Of note, all the teachers in this study reported the perception that students appreciated structured feedback. Students in divinity schools and seminaries enter into learning communities where they discuss experiences they encounter during their field experiences, particularly in the 12- to 15-h supervised ministry fieldwork during their second year. Although such discussions are promoted throughout the years of study, active questioning and feedback experiences are particularly intense during this second year. Typically, clergy students in the field must participate in an academically focused course that addresses principles of supervised ministry, and in this course students and seminary faculty engage in active questioning and feedback. Students receive additional feedback from their professional supervisors and individuals at the field site, such as lay teams and committee advisory board members who are directly concerned with the program the student is working in. Within the field of teacher preparation in education, several experiments aimed to create new discourse communities that included not only teacher candidates but also practicing teachers, teacher educators, and administrators. These new discourse communities are often called study groups and can complement learning in workplace settings. Carini (2000) reported on one study group that used descriptive reviews of student work to encourage active questioning and reflection, and any member of the study group could lead a descriptive review. To begin, the member describes the student in question and shares examples of the student’s work. Care is given to ensure that the student is not portrayed as deficient. By focusing the group on describing the student and the student’s work and behaviors, the study group

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gained new insights into the student and the member’s relationship with the student. Issues of teaching and learning for the student and member are explored by the group. The purpose of this process is for the group member to see the student without labels, judgments, or assumptions. The central goal of another effective study group was to explore a central teaching question (Dyson, et al., 1997). In this report, the study group met periodically throughout the school year to discuss and share a central teaching question and explore ways in which the conversation was relevant to the group members’ teaching and learning practices. The goal of participatory evaluation research groups is to bring about changes in school communities. In one reported participatory evaluation research group (Fine, 1996), members either self-selected research questions that they explored in their school community and/or studied questions that the study group selected. In addition to practicing teachers, teacher candidates, administrators, and lead researcher, this study group included selected students at the school and their parents. This entire study group, including students, reported their research findings at a formal, professional conference (Fine, 1994). In addition to the use of study groups, teacher educators use active questioning and feedback with their teacher candidates in the workplace setting. Questioning and feedback typically occur during pre- and post-observation conferences. In these conferences, the goal of university supervisors is to raise the student’s understanding of the next learning task to a conscious level – whatever the university supervisor identifies as the next skill and/or disposition the teacher candidate needs to develop.

Reflective Practice As defined by Boud, Keough and Walker (1985), reflection is “a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations” (p. 19). Reflective practice, as a teaching strategy, is included in this section to highlight its role in facilitating learning in the workplace for all four professions in this volume. Reflective practice is encouraged at the start of student preprofessional learning and can be done independently or collaboratively by students and faculty. Also, in these professions, reflective practice is considered an ideal (Dunn & Shriner, 1999) – it is hoped that students will continue to reflect on their practice throughout their professional career. Students are asked to not only reflect on experiences but the process also calls upon students and faculty to analyze, connect, and ponder experiences in light of the assignment goals and outcomes within coach-, mentor-, or supervisor-established parameters. Reflection as a form of self-evaluation has been described in terms of deliberate practice to progress in competency to expert levels for various fields, including education, clergy, and medicine (Dunn & Shriner, 1999; Ericsson, 2004; Kaufman, 2003). Activities to support reflective practice can occur during all stages

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of learning and relates to the level of performance, with reflection continuing for ongoing improvement at expert levels (Dunn & Shriner, 1999). An important consideration for teachers in all the professions is the amount of time students may need to reflect on their experiences, the feedback they have received, and ultimately on their own learning. The most basic form of reflective practice is that of students consistently and systematically recording events and reactions in a professional journal or diary (Progoff, 1975; Schön, 1991). Most often recording activities involve writing for one’s self or one’s university faculty. In a typical example from the field of teacher preparation, at the end of each day, student teachers are expected to record their thoughts, feelings, experiences, and reactions to the events of the day in a journal. Student teachers may refer to these entries during pre- and post-observation conferences with their university faculty. Cooperating teachers and university faculty may review these reflections and use them to design supportive and helpful experiences for student teachers when teaching. For both parties this again raises the issue of how much time is spent on the reflection itself and the faculty review. University faculty may also use dialog journals to promote reflective practice. Student teacher entries may be similar to those found in a reflective journal or student teachers may be asked to record their reflections in a variety of formats. In the double entry format, student teachers fold over each page, creating two columns. They record their reflections in one column. The university faculty reads the reflections and responds back to the student in the second column, using comments and questions that prompt a dialog in writing with the student teacher about the reflections. This practice is more interactive than the strictly reflective journal and provides for more supervisor and student teacher “conversation.” In addition, this practice is easily modified for online communications. Email exchanges between supervisors and student teachers can also be used to prompt reflection. In email exchanges, supervisors ask open-ended questions and/or information about a student teaching experience. Using the student teachers’ responses, supervisors can ask for further details or clarification that will help the student teachers to further reflect and challenge an initial observation, experience, or action. Writing autobiographies, biographies, and personal stories provide additional reflective activities that teacher educators use to promote student reflection. These activities are frequently used during the middle semesters of practicum field experience and methods courses. Students write autobiographies about their childhood experiences in learning to read and write. Teacher educators use these writings to help students reflect on their school experiences and compare them to their field experience observations. By having student teachers tell their own literacy development stories, university faculty expect that student teachers will gain a more conscious understanding of their own perceptions and expectations. The greater goal is that student teachers will be able to identify their own strengths and weaknesses and gain a greater understanding of the teaching and learning setting from the children’s point of view. In addition to the email exchanges noted above, other forms of technology have been used to support reflective practice. Videotaping, which is reported above in

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the use of skill development, is used to promote reflection. Student teachers are asked to videotape a lesson and then view the tape privately or with the university faculty and/or a peer. The re-viewing can encourage student teachers to reflect and reconsider alternate ways of approaching a teaching dilemma. Because videotaping captures teaching moments, such moments can be viewed numerous times. Guided by faculty questioning, student teachers can be encouraged to consider a wide variety of interpretations for even just one classroom event. Within the field of clergy preparation, the level of reflective practice is extraordinary. Students engage in reflection throughout their coursework and in the workplace with their supervisors and classmates on a regular basis. Reflection is used in the preparation of mock sermons and through preaching to connect religious and spiritual writings with life experiences. Short reflective papers are frequently assigned during the supervised ministry and accompanying coursework. Sermons are also videotaped and played back so that students can reflect on a variety of aspects of their presentation. Reflective practice, to sum up, provides an opportunity for students to continually assess their learning and abilities during their workplace experience for the purpose of self-improvement. Factors such as timing and specificity of the reflections may impact the value of this process. Also, reflection on feelings, thoughts, and actions following a learning experience relates to one of three phases in self-regulated learning described by White (2007). The reflection process may offer learners a chance to examine surface learning for extrinsic purposes or to satisfy intrinsic motivation with a deeper understanding and self-recognition of developing skills.

Summary The teaching methods presented in this chapter include coaching, mentoring, and supervision. These are implemented in a wide variety of ways across the professions and strategies presented here, including setting expectations, questioning and feedback, and reflective practice. Lessons may be learned from how these teaching practices are applied in one profession to enhance workplace learning in another profession. One example is the different approaches to supervision in medicine versus education. The process of transferring clinical responsibilities from instructor to student fades over time. The supervising physician withdraws support based on the student’s level of ability rather than a more time-sensitive abrupt switch from observer role to teacher role as is seen with student teachers. In addition, reflective practice to enhance the formation of professional attributes and values as practiced by the clergy or teachers may have implications for other professions. However, as highlighted by the work of Teunissen et al. (2007), to develop a theoretical framework in medical resident learning processes, further research is needed to guide us in our understanding of workplace teaching methods. How faculty can best teach to influence the learning of preprofessional students in the workplace needs investigation across the professions. Challenges exist in each profession to

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maximize preprofessional education, though teaching practices in one area may assist another. A brief discussion of challenges to consider with workplace learning and suggestions to improve student experiences concludes this chapter.

Challenges Multiple challenges may impact the effectiveness of workplace teaching and learning. They include time limitations, the level of institutional support, and conflicts and mismatches among institutional, professional, and student learning goals and expectations. A brief discussion of the challenges teachers and students face in situations related to workplace learning offers an understanding of the opportunities to improve learning and areas in need of further research. Reports on the negative impact of time limitations on teaching and learning in multiple settings can be found in the fields of medicine, nursing, and education (Booth et al., 1995; Ludmerer, 2004; Murphy, 2008; Porte et al., 2007). Time constraints can reduce student exposure to the service site and impinge on workplace instructor responsibilities. An example from education emphasizes the effects of time limitations on workplace experiences for student teachers. Reports from faculty with decades of teaching experience suggest that effective teachers always have something new to learn (Paley, 1998). The one-semester time restriction placed on student teachers during which they are expected to learn how to teach may, in part, set these individuals up for eventual failure. In fact, within the first 5 years more than half of new teachers drop out (Grissmer & Kirby, 1997). Across the professions, the preservice field experiences serve only to introduce students to the workplace and all they will need to eventually learn. The level of institutional support and conflicts varies across the professions. In teacher education, as an example, the university typically offers minimal financial support to cooperating teachers for the hours they give to help prepare the student teachers. If a student teacher needs extensive supervision, mentoring, and coaching, the university supervisor or the cooperating teacher may not be in a position to provide as much support as the student teacher may want or need. Another factor directly related to instructional practices in the workplace is finding agreement between institutions – the university and the workplace – on recommended teaching practices. Both parties may question how effective teaching is demonstrated and what outcomes are desired that can be measured – both of which are difficult to assess in the first place (Hutchings & Shulman, 1999; Ericsson, 2004). Mismatches that arise between the institutional, professional, and student goals are a third source of barriers that influence workplace teaching. In clergy preparation, by way of example, the seminary placements typically have students interact with committees and advisory boards but students are not allowed to interact with church boards, much to the dismay of the seminary or divinity school. Without this church board interaction, graduating students are placed at a disadvantage when they assume leadership of a congregation if only because they have not had training

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in working with a church board. Teacher preparation can also show occasional mismatches between a student teacher and the cooperating teacher due to personality conflicts, teaching philosophy variances, or a perceived lack of student preparation. In such a situation, the school may refuse to accept additional student teachers or the university may decide to stop placing student teachers at the school. Another type of challenge relates to contrasting purposes between the workplace organization and the university. For example, increased emphasis on patient satisfaction and the delivery of patient care in healthcare settings has limited support for student education experiences (Leach, 2002). For nursing education, the shift to universities for the academic portion of preprofessional education has created a distance between content and practice, affecting the relationships between teachers in both settings (Gillespie & McFetridge, 2006). Now, establishing the workplace curriculum requires that teachers in the clinical settings and academic institutions must reach an agreement on instructional programs and goals. In a study of how nursing clinical teachers perceived their role, two main themes were the sense of not belonging to the education process between the university and workplace and a lack of preparation (Ferguson, 1996). Others have noted the tension between the theoretical perspectives of the academic site and nursing clinical practice as a limiting influence on workplace learning (McAllister et al., 2007). Also, a mismatch between student goals for workplace learning and clinical experiences can occur for several reasons. For example, if teacher educators or field supervisors are not sensitive to the unique background knowledge, skills, and commitment to social justice issues that student teachers – particularly those who are students of color or differing ethnicity – may bring to their field placements, conflicts and misunderstandings may occur. In clergy preparation, it is often the case that students who enter the seminary do not want to be prepared to work in traditional congregational settings. Yet, by the time they finish their preparation, they find that they want to work in a traditional site. Such institutions face the dilemma of preparing students for what they want when they enter the seminary or what they will want upon graduation.

Suggestions While challenges to effective preprofessional workplace experiences arise from different sources, the research reviewed for this chapter offers guidance for those involved in workplace instruction. To conclude this chapter, applications of the teaching methods and strategies discussed earlier are briefly reviewed with suggestions for effective workplace teaching in the complex environments that students and teachers face. Workplace teachers provide students with expert information and feedback to support their learning. While technology does not appear to be the solution to time limits or a substitute for teacher attention, it may serve as a complement to teacher interactions with students (Palmer & Devitt, 2008; Porte et al., 2007).

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Challenges with institutional needs and student expectations may be served by integrating student experiences earlier rather than later. For example, when early patient contact was initiated and students participated in family-centered care, educational experiences appeared to have more impact (Howe, Dagley, Hopayian, & Lillicrap, 2007; Muething et al., 2007). When students have effective workplace teachers, the complexities of skill development and professional attributes can be addressed. Workplace teachers can help to transform experiences into knowledge in collaboration with other teachers, service providers and students for the preparation of future professionals (Kirkpatrick, Byrne, Martin, & Roth, 1991; McAllister et al., 2007; Ottenheijm et al., 2008). The learner-centered workplace needs teachers who can apply the teaching methods of coaching, mentoring, and supervision (Harden & Crosby, 2000). Clear expectations and reflective practice can support effective transitions between teaching and learning and improve the benefits and support that workplace instructors perceive (Hyrkas & Shoemaker, 2007; White, 2007). In each profession, perhaps through setting expectations and reflective practice strategies, students may successfully progress through the varied stages of preprofessional experiences. Accreditation standards can provide the stimulus to apply some effective teaching strategies. For example, with teacher education program accreditation, the practice of setting expectations for student teachers in their practicum and student teaching field experiences has become more explicit. Additionally, role modeling may be an important area to address in faculty development programs as expressed by Guyton for teacher education programs (Guyton, Saxton, & Wesche, 1996). The Smolkin and Suina (1999) study suggests that the pairing of student teachers from different ethnic backgrounds might promote peer coaching experiences that student teachers do not currently have opportunities to experience, as well as deeper insights into cultural awareness and sensitivity. Clearly, more research that examines specific workplace learning activities and contextual factors that influence learning and growth for site-based and university faculty is needed. The instructional methods identified in this chapter offer a start toward determining best practices to support learning in the workplace. Continued research examining the impact of workplace teaching practices, not only on the preparation of high-quality teachers, doctors, nurses, and clergy but also on work that results from the efforts of student professionals, is required. Acknowledgments The authors gratefully acknowledge contributions from Rev. Dr. Frederick W. Weidmann, Kirsten Johnson, and Jeannette Rossetti, EdD, RN.

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Part III

Assessment

Chapter 5

Conceptual Perspectives: Emerging Changes in the Assessment Paradigm Robert Galbraith, Stephen G. Clyman, and Donald E. Melnick

Overview Over the past half century, there have been major advances in scientific knowledge, and the effects of this on medicine and healthcare delivery have been profound. We believe that professional educators can learn from the assessment literature in medicine, and so, in this chapter we will discuss the current paradigm of assessment through the lens of the literature in medicine and health care. We do this intentionally because very little literature exists in the other professional fields addressed in this book. Educators have labored mightily to represent current realities of the healthcare system and changing patient populations in their programs and have introduced substantial changes in curricula and pedagogical approaches (Ludmerer, 1999). On the assessment side, standardized testing using multiple choice questions (MCQs), introduced in the 1950s, has undergone progressive development and refinement (Hubbard & Levitt, 1985). MCQs are now the de facto gold standard for high stakes assessment in the United States and are used to assure the mastery of a body of knowledge appropriate to the individual physician and consistent with the precepts of medicine as a profession (Greenwood, 1957). In parallel, there has been a growing realization that the focus of education and assessment has rested more on factual knowledge and problem solving and less on the real-world application of these and other skills and behaviors in the daily run of settings (e.g., hospitals, ambulatory clinics, virtual interactions) that constitute the workplace1 (Epstein & Hundert, 2002). There are likely parallels here

R. Galbraith (B) National Board of Medical Examiners, Philadelphia, PA, USA e-mail: [email protected] 1 The definition of workplace assessment varies widely. Two common definitions are “assessment using data obtained in the workplace” and “assessment of physician proficiency necessary for effective function e.g., knowledge appropriate to the workplace.” We will use a broader, more holistic definition that incorporates both these constructs, namely “assessment of all necessary physician proficiencies for effective workplace function, including where appropriate data obtained in the workplace.”

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with other professions. The reality is that didactic instruction and standardized testing both live very comfortably with the “hard science” and “facts” of knowledge and serve as a foundation for performance in the real world. Furthermore, the emergence of a robust science of testing measurement – psychometrics – has emphasized the value of MCQ for standardization and for high reliability of the results obtained (Cronbach, 1951; Hambleton & Swaminathan, 1985), whereas standardization and high reliability are inherently more difficult to achieve with workplace assessment. However, standardized testing in simulated settings tends typically to measure potential to perform – or “competence,” rather than actual “performance” in real settings (Rethans, Sturmans, Drop, Van der Vleuten, & Hobus, 1991; Rethans et al., 2002). While competence testing can predict aspects of performance and should undoubtedly continue, explicitly designed performance assessment holds considerable promise for contributing to improvements in healthcare delivery. Measurement of other “softer” but nonetheless essential domains such as communication skills, professionalism, team work, leadership, and cultural sensitivity has lagged behind, although recently researchers and practitioners have begun to explore assessment of these areas more systematically. This reflects the rising levels of concern with actual physician performance (Campbell et al., 2007; Lefevre, Waters, & Budetti, 2000), together with the introduction of new technologies and the application of lessons learned from standardized testing. Retaining a strong focus on knowledge and reasoning while broadening the base of education and assessment to other important domains could do much to ensure that relevant professional attributes are being acquired and maintained (Greenwood, 1957). Moreover, George Miller famously observed that “assessment drives learning” (McGuire, 1999), and it is probably fair to assume that learners pay attention to what is being measured and may ignore that which is not (McGuire, 1999; Galbraith, Holtman, & Clyman, 2006). When the stakes are high, as for example in licensing examinations, failure not only precludes obtaining a license to practice but may also substantially affect the ability to enter residency programs in certain high-demand specialties. The other point not to be lost is that introduction of comprehensive measurement of both competence and performance across the full spectrum of knowledge, skills, and behaviors sends a powerful signal that physicians take professional self-regulation seriously. Another emerging change involves the tighter coordination of the processes of education and assessment. The benefits of doing this seem intuitively obvious in that learning clearly involves both. However, this has not always been the case; education and high stakes assessment have often been conceptualized and delivered separately. A more integrated approach to learning is consistent with the cultural view that high stakes testing often has an independent, external audit function rather than being an integral component of the ongoing learning process, as is pointed out by Harris in analyzing and presenting the application of learning theories to the workplace (see Part I, Chapter 3). Integration may also have become an easier task as new technologies have become available and as developers recognize the importance of lower stakes feedback in workplace education (Norcini & Burch, 2007).

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This chapter attempts to characterize the changing assessment landscape. Although there are parallels across the various professions, the primary focus here will be on medicine as practiced by physicians.

Historical Changes in Assessment It is possible to define three more or less distinct assessment approaches, corresponding to and supporting three main educational models.

Mentor’s Judgment of Performance Until the latter part of the nineteenth century, the educational model was usually based on that of apprenticeship (Norwood, 1957; Ludmerer, 1999). In essence, learning involved observation and doing, under the tutelage of a “master” clinician. There was little scientific knowledge, few procedures, and even fewer useful medications. Assessment, largely oral and written, revolved around the judgment of the mentor and was highly idiosyncratic since the master clinician was not trained to teach or assess, and the context for testing was local and correspondingly variable. There was little or no way to standardize the “curriculum.” This approach saw the flowering of superb clinical skills, giving of comfort rather than cure, laying on of hands rather than of technology, and strong communications skills and professionalism. In instances where the mentor was less proficient, it also saw less salutary training outcomes. Elements of this apprenticeship culture persist in our system today.

Standardized Testing of Competence The emergence of Johns Hopkins University School of Medicine ushered in a new “scientific” approach to education in which medical schools in the United States increasingly emulated the research university model (Ludmerer, 1999). This process was accelerated by the now fabled report of Abraham Flexner (1910), which castigated medical education in the United States and Canada and put in play reforms that changed the face of medical education and training. The ensuing scientific approach, with dedicated faculty in both basic and clinical sciences, ran throughout the remainder of the twentieth century. It involved the development of cadres of professional researchers and educators, and a culture in which scientific principles were progressively applied to almost every aspect of medical education. Oral and essay exams, which suffered from uneven grading by different examiners, were progressively replaced by MCQ testing starting in the 1950s (Hubbard & Leavitt, 1985); MCQ allowed testing of knowledge and its application to be separated from the bedside and to be standardized in many important respects. Furthermore, everyone

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could take the same MCQ exam and their scores could be accurately compared with those of their peers, both locally and nationally (Hubbard & Leavitt, 1985). In parallel, clinical “bedside” exams that resulted in uneven experiences with the patients pressed into service, and also rested on the judgment of individual examiners, became increasingly viewed as unfair and ultimately indefensible (Hubbard & Leavitt, 1985; Klass, 2000). More recently, standardized exams have been enhanced to test application of patient management and clinical skills in higher fidelity simR computer-based case simulations in the United States Medical ulations. Primum R ) test the ability of a physician using free-text Licensing Examination (USMLE entry to manage a patient over the course of minutes to months of simulated time (Dillon, Clyman, Clauser, & Margolis, 2002). Assessment of clinical skills (communication and interpersonal skills, history taking, physical examination, recording patient notes, and spoken language proficiency) with actors portraying patients have been introduced as part of the Medical Council of Canada Qualifying Examination Part II (Reznick et al., 1992); the United States Medical Licensing Examination (USMLE – Klass, 2000; Tamblyn, Klass, Schnabl, & Kopelow, 1991), and more recently as part of the Comprehensive Osteopathic Medical Licensing Examination (COMLEX – Gimpel, Weidner, Boulet, Wilson, & Errichetti, 2007). Another observational approach developed principally for assessment of residents utilizes real rather than simulated patients and clinical faculty as observers and has a particular focus on testing clinical skills in residents. This is termed the mini-Clinical Evaluation Exercise or mini-CEX (Norcini, Blank, Arnold, & Kimball, 1995; Norcini, Blank, Duffy, & Fortna, 2003). It would be hard to overstate the importance of such standardized testing. Generations of health professionals have undertaken a rigorous process of scientific training and been required to demonstrate minimal competence in national exams to a level judged by the profession to promote protection of the public. This approach has high face validity and serves as a necessary underpinning of real-life performance, but as noted may have limitations in reflecting the quality of all aspects of “physicianship.” As noted above, domains other than knowledge, problem solving, and clinical skills are not well covered (Rethans et al., 1991; 2002). In addition, performance in real settings is not directly measured, a point of some importance given the increasing evidence that patient care is far from safe (Kohn, Corrigan, & Donaldson, 2000).

Workplace Assessment of Competencies and Performance Most recently, the focus of both education and of assessment – or learning – have been redefined through the recognition of distinct professional roles and competencies identified by the Royal College of Physicians and Surgeons of Canada (The CanMEDS physician competency framework, 2009) and of closely related domains or “competencies” by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) (Evolution of the competency movement, 2007). The CanMEDS physician

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competency framework moved the literature in the field forward and may help the professions addressed in this book in understanding appropriate assessment strategies. The interest in competencies emerging in the 1990s was in part a reaction to the behaviorist movement of the 1950s, heralded by Bloom’s taxonomy of educational objectives (Bloom, Englehart, Furst, Hill, & Krahwohl, 1956). Two of the “newly defined” competencies, Medical Knowledge and Clinical Care, are anchored in the earlier scientific approach. However, the bases of education and of assessment have been deliberately broadened to emphasize other important areas (interpersonal and communications skills, and professionalism) that hearken back to the preceding apprenticeship period (Ludmerer, 1999; Norwood, 1957). In addition, two newer areas have been named. The first of these, practice-based learning and improvement, recognizes a new culture of improvement that has recently emerged as a complement to the original educational notion of minimal competence (Batalden, Nelson, & Roberts, 1994; Moore & Pennington, 2003). The second, systems-based practice, recognizes the importance of interrelated factors in healthcare delivery and the need for health professionals to understand and work effectively within these realities (Berwick, 1996; Dyne, Strauss, & Rinnert, 2002). In terms of the methodologies used, it seems clear for Medical Knowledge and Clinical Care that MCQs, computer simulations, and clinical skills exams will remain the bedrock for assessment (Swing, Clyman, Holmboe, & Williams, 2009; Hubbard & Leavitt, 1985; Klass, 2000; Tamblyn et al., 1991). However, some notable refinements are likely. First, examinations will need continued active development to respond to changes in medical knowledge and healthcare delivery, to adopt a general competencies schema (General Competencies, 2007) and to develop measures of ability to access and to apply information to solving clinical problems. This is being undertaken in the case of USMLE through a deliberate restructuring process that includes a wide variety of stakeholders while recognizing the ongoing importance of the scientific foundations of medicine in all components of the assessment process (Comprehensive review of USMLE, 2009). Second, other forms of standardized testing enhancement (e.g., use of sounds, and video clips) are already being put in place. Third, to the extent possible, such testing should be increasingly tailored to the individual and their particular practice environment (see the section “Assembling Performance Data Sets”). The assessment landscape in relation to the other competencies is still very much under development (Epstein & Hundert, 2002; Irby & Wilkerson, 2003; Schuwirth & van der Vleuten, 2006; Swing et al., 2009; Van der Vleuten, 1996), but will require an additional focus on actual performance in real settings. Thus, the application of Multi-Source Feedback (MSF) seems appropriate for behaviors observed relevant to communications and professionalism (Lockyer, 2003; Sargeant, 2006; Embedding professionalism in medical education, 2002, NBME). Assessment of practice-based learning and improvement, and of systems-based practice, will logically include measurement of such things as processes of care and outcomes (Batalden, Nelson, & Roberts, 1994; Berwick, 1996; Dyne et al., 2002; Moore & Pennington, 1995). It also appears likely that technology will increasingly be used to gather and display composite data sets for competency-based education with the use of extant

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portfolio technology (Davis & Ponnamperuma, 2005; Driessen, van Tartwijk, van der Vleuten, & Wass, 2007; NBME eFolio, 2007; ACGME, 2009). In addition, the increasing availability and fidelity of simulation technologies argue that these might provide a useful adjunct for assessment of several competencies, and particularly for practice and mastery of skills requiring painful, invasive, and potentially dangerous clinical procedures before their application to real patients (Issenberg & Scalese, 2008; Kneebone & Baillie, 2008). The newer measures mentioned previously are in no sense replacements for standardized tests measuring knowledge and its application, but rather a means of enriching and broadening the base of assessment toward a more holistic view of proficiency across all necessary skill sets (NBME eFolio, 2007). We will now consider in more detail the major features of traditional assessment developed for the “scientific” approach where assessment is explicitly separated from education, and the more blended learning approaches beginning to emerge from the “competency” movement.

Traditional Assessment The major features of traditional assessment include the following: • • • • • • • • • • • •

standardized to group; can equate across location/time; high reliability; can be separated in time and place from education; focuses on factual knowledge and problem solving; standardized testing of clinical and communication skills; high stakes, summative data; little formative feedback; point-in-time testing primarily during training; a focus on competence (in simulated settings); regulators and educators as the main locus of accountability; and the definition of a floor of minimal competence with high face validity.

Certain of these features bear elucidation. As noted above, the progressive standardization possible in the simulated setting brought with it conspicuous advantages (Hubbard & Leavitt, 1985). All examinees could now take either the same or an essentially comparable form of the test, under identical conditions of timing, physical conditions, frequency, breaks, and so on. Tests could be built from defined content blueprints, to a predefined level of difficulty determined empirically and could be readily delivered by computer-based testing methodologies. MCQ testing offers high reliability. Scores on national tests can be used to directly compare individual students across schools, and residents across programs. When aggregated appropriately across examinees, scores can be used to evaluate educational programs. Overall scores can be further enriched with subscores for each of the major

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content areas defined. On the other hand, the examinee receives little or no feedback beyond these standardized scores and the summative high stakes nature of many tests is often viewed as punitive. Historically, testing has occurred primarily during medical school and residency. Although most Specialty Boards have now introduced MCQ as part of recertification and more recently as the third of four components of MOC (Maintenance of Certification, 2006–2008, ABMS), such testing has not been widely used to support Continuing Medical Education (CME) and lifelong learning in clinicians once in practice. Separation of assessment from the bedside, identified previously as an important feature of standardization, means diverting the measurement focus away from performance in real settings (Murphy, Bruce, & Eva, 2008). Taking assessment “back to the bedside” will require close tailoring to the individual and what they are actually doing on a day-to-day basis (Rethans et al., 1991; 2002). However, directly comparing one individual’s performance with that of another who may have a very different clientele of patients or practice focus is obviously problematic. Many educators have therefore been content to use scores on standardized tests as a proxy for performance in real settings. This is conceptually reasonable if performance in real settings is known to covary closely with competence in simulated settings. In fact, studies of the correlation between standardized test scores and subsequent clinical performance in real settings as judged by supervisors have provided variable results (Black, Abzug, & Chinchilli, 2006; Metro, Talarico, Patel, & Wetmore, 2003; Tamblyn et al., 2002).

Emerging Assessment of Performance The major features of the assessment of performance (see list below) appear at first glance to be somewhat antithetical to those of traditional assessment, and yet for all that are nicely complementary. To the extent that newer assessment involves measurement of performance in an authentic context, it is often termed “assessment at work” or “workplace assessment” (Murphy et al., 2008; Norcini, 2003; 2005). Assessment of performance has the following main features: • • • • • • • • • •

assessments tailored to the individual; low reliability, inability to equate across location/time; embedded in learning process; broadened base to include skills (e.g., psychomotor) and behaviors (professional, communications, teamwork, cultural sensitivity); include measures of process and outcomes; add application in real-world settings (e.g., clinical reasoning, and management of information and uncertainty); lower stakes, more formative; abundant feedback, preferably with mentoring; more frequent and smaller samplings; longitudinal testing across the training: practice continuum;

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• individual an increasingly important locus of accountability; • designed to promote continuing improvement; and • potentially very high cost. The base of learning and assessment is demonstrably broader. Rather than focusing primarily on knowledge and problem solving, measurement attempts to span the full formal educational construct of knowledge, skills, and attitudes, or observable behaviors2 (Epstein & Hundert, 2002; Murphy et al., 2008), taking into account the informal or “hidden curriculum” operative in the workplace where learning actually occurs (Hafferty & Franks, 1994). The behaviors observed can be gathered by MSF, usually from multiple workplace observers, and then given as feedback to the relevant individual, together with the behaviors observed in peers as a comparator. This provides a triangulated calibration of the individual’s behaviors and of important changes over time. In addition, this feedback is both an opportunity and a stimulus for further discussion and dialog. Since this type of assessment is more formative, lower stakes, and more embedded in day-to-day learning rather than separated off, the net effect is that assessment is less obtrusive (Lockyer, 2003; Sargeant, 2006). A second major change is that learning is explicitly grounded in what the health professional does as individual or in a team, during training and later in practice. This mandates the availability of relevant practice performance data, preferably in near real time, and greater attention to measures of clinical processes and outcomes (see the section “Assembling Performance Data Sets”). Furthermore, since most health professionals have little or no experience of interpreting this kind of data or delineating formal improvement plans, some thought needs to be given as to how to build requisite self-assessment skills as a core component of professional development. It will also be key to develop mechanisms for ongoing mentorship, coaching, and remediation for those that may desire or need it (see the section “Improvement Planning” ). Health professionals, and particularly those in practice, will now have both the opportunity and the responsibility to participate more actively in defining their lifelong learning needs and ensuring that they are met. This effectively shares the accountability, moving from a predominantly external, regulatory locus toward an approach that engages both external authorities and the individual and their functional health team (Epstein & Hundert, 2002).

Assembling Performance Data Sets Assessment of performance necessarily starts with assembling appropriate data sets, but what data should be included? Traditionally, state licensure gives health

2 A focus on observing behaviors as the outward, observable manifestations of attitudes may be somewhat easier than a focus on attitudes that represent a more complex mix of values and beliefs that are internally held and may not be completely or truthfully revealed. This is also pragmatic in that at least some behaviors may be amenable to modification (Sargeant, 2006).

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professionals the right to engage in practice that is relatively unrestricted as to scope, although in the modern era this generic right has increasingly been restricted by local mechanisms such as payor credentialing or institutional privileging. In contrast, the profession’s view has long been dominated by the concept of practice by specialty/subspecialty or discipline, a construct focusing on “scope of practice” or what the practitioner ought to be able (or permitted) to do. As individual practices have become more restricted in scope, interest has grown in further restricting the base of measurement to those patients actually seen – in essence a practice profile (Melnick, Asch, Blackmore, Klass, & Norcini, 2002; Kerr, McGlynn, Adams, Keesey, & Asch, 2004; Klass, 2007). Ultimately, this would seem to provide lifelong learners with the best base from which to appreciate the proficiencies they need, their actual level of performance, the improvements required, and how best to tailor CME and Continuing Professional Development (CPD) activities to their individual needs. This argues for aggregation of appropriate data about the clinical activities of the individual to provide accurate and timely answers to “what am I doing, and how does it change over time?” This is a daunting prospect for several reasons. For example, there is generally poor understanding of which data from the individual practice should ideally be compiled and included in a “My Practice” report of this type. Is it fair to assume that what is useful for primary care clinicians is also relevant for those in more interventional specialties (e.g., surgery, cardiology) or service specialties (e.g., pathology, radiology)? Are there important geographical or local differences? Moreover, how can the requisite data be captured in a fashion that avoids the problems and hassle of “paper-and-pencil” and physician self-reporting and that generalizes across local settings with widely divergent practice and system characteristics? Is this actually feasible in the absence of interoperable Electronic Health Records (EHR)? Another unknown is to what extent healthcare professionals will view these kinds of reports as sufficiently accurate and potentially helpful to justify becoming engaged and actually using them, as opposed to pushing back or ignoring them. Given that remarkably few health professionals have ever seen a report of this type, how can we assure that reports will be appropriately interpreted and acted upon? In addition, much of the relevant data does not lend itself to straightforward interpretation. One example is that of outcomes, which require careful adjustment for bias due to such factors as attribution, number effects, and severity (Norcini, 2003). In addition, the ideal mix of data to drive effective improvement (viz. processes of care, outcomes, behaviors, psychomotor skills, results of knowledge testing with practice-based exams) is still unclear.

Analyzing Data Sets Assuming that a “My Practice” report that is accurate and timely can be compiled, the next logical question is “how I am doing,” with what I am doing. This raises the issue of the appropriate comparators to use (Norcini, 2003; 2005). Since each individual has a practice that at some level is unique, this complicates

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direct cross-individual comparisons, even within the same specialty or subspecialty. However, individuals or teams could certainly monitor its own performance over time, using themselves as their own control. In addition, relevant benchmarks could be derived from other practitioners with comparable practices. Another source of comparative data is the large number of national performance measures that have now been created (publications, NQF, 2008; performance measurement workgroup, AQA, 2009), against which the performance of the individual can be measured. Feedback on behaviors observed constitute a valuable additional focus for performance measurement, and comparative data from peers could again provide an important reality check. In addition, those whose practices involve substantial numbers of procedures could receive feedback from appropriate simulations. The progressive introduction of performance measures should not in any way be regarded as a replacement for standardized testing using simulations. Rather, selfassessment of knowledge that is more explicitly focused on patients actually seen by the individual rather than being defined exclusively by the relevant specialty or subspecialty group is a vital component of the new culture of improvement. Furthermore, the results of such practice-based self-assessment should also identify areas that could benefit from further learning and thereby identify appropriate targets for CME interventions. It can be anticipated that this type of global self-assessment based on patients actually seen may be greeted with further skepticism by healthcare professionals, particularly if there are seen to be professional consequences, either good or bad. Even if the data are accurate, it appears possible that the feedback provided will simply be misinterpreted. The ability of individuals to self-assess is notoriously unreliable. At the high end of proficiency, individuals often underestimate their performance, while at the low end, performance is overestimated, resulting in regression to the mean (Eva & Regehr, 2005; Davis et al., 2006). Furthermore, this phenomenon is likely to be exaggerated in those who have not previously received this kind of feedback. This argues that the results of self-assessment by the individual should be submitted to independent validation, preferably performed by credible external peers (e.g., professional and medical societies), as a reality check (Galbraith, Hawkins, & Holmboe, 2008). The introduction of MOC (Maintenance of Certification, 2006–2008) by Specialty Boards and the possible development of Maintenance of Licensure (MOL) by State Licensing Boards (Federation of State Medical Boards, 2009) may effectively provide another mechanism for external validation. Another important consequence of receiving appropriate feedback and obtaining external validation is the potential for further stimulation of reflection and mindfulness (Dobkin, 2009; Epstein, 2008; Epstein & Hundert, 2002; Schön, 1983).

Improvement Planning Providing individuals, or interdisciplinary teams, with feedback documenting what and how they are doing, and the resulting self-assessment and reflection on

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relevant strengths and weaknesses, should lead logically to the formulation of an improvement plan. This would ideally include explicit goals and timelines, and would then be followed by further cycles of measurement, and documentation of improvement that would constitute a reportable event for the purposes of regulatory initiatives such as MOC, or possibly MOL. Active engagement in such cycles of improvement and demonstration of real progress also demonstrate appropriate professional values (Lipner et al., 2006). As with self-assessment, it is important to note that individuals may need guidance and external validation. It would be sensible to offer the opportunity for mentorship and, if necessary, remediation or retraining. Currently, in the absence of measurement and feedback, deterioration in performance (Choudhry, Fletcher, & Soumerai, 2005) may go unrecognized for sufficiently long that remediation becomes infeasible or frank failures occur that lead to disciplinary actions or malpractice actions. The sequence of gathering workplace data, analyzing such data and improvement planning that is considered here could provide longitudinal monitoring and could perhaps better highlight incipient problems and offer mentoring and remediation before real problems occur. This should not only indicate a renewed commitment to professional self-regulation but also enhance healthcare quality and patient safety. Finally, although the literature is derived from sources primarily in relation to medicine, it is likely that many of these approaches for workplace learning are transferable to other professions.

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Davis, M. H., & Ponnamperuma, G. G. (2005). Portfolio assessment. Journal of Veterinary Medical Education, 32, 279–284. Dillon, G. F., Clyman, S. G., Clauser, B. E., & Margolis, M. J. (2002). The introduction of computer-based case simulations into the united states medical licensing examination. Academic Medicine, 77, S94–S96. Dobkin, P. L. (2009). Fostering healing through mindfulness in the context of medical practice. Current Oncology, 16, 4–6. Driessen, E., van Tartwijk, J., van der Vleuten, C., & Wass, V. (2007). Portfolios in medical education: Why do they meet with mixed success? A systematic review. Medical Education, 41, 1224–1233. Dyne, P. L., Strauss, R. W., & Rinnert, S. (2002). Systems-based practice: The sixth core competency. Academic Emergency Medicine, 9, 1270–1277. eFolio. (2007). A secure personal data manager serving physicians: Proceedings of an Invitational Conference sponsored by the Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, Federation of State Medical Boards, and National Board of Medical Examiners. Retrieved April 30, 2009, from NBME http://www.nbme.org/PDF/eFolioOct2007-conf.pdf Embedding professionalism in medical education. (2002). Report from an Invitational Conference Cosponsored by the Association of American Medical Colleges and the National Board of Medical Examiners. Retrieved April 30, 2009, from NBME http://www.nbme.org/PDF/NBME_AAMC_ProfessReport.pdf Epstein, R. M. (2008). Reflection, perception and the acquisition of wisdom. Medical Education, 42, 1048–1050. Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. Journal of the American Medical Association, 287, 226–235. Eva, K. W., & Regehr, G. (2005). Self-assessment in the health professions: A reformulation and research agenda. Academic Medicine, 80, S46–S54. Evolution of the competency movement. (2007). Retrieved April 30, 2009, from ABMS http://www.abms.org/About_ABMS/ABMS_History/Extended_History/Competency_ Movement.aspx Federation of State Medical Boards. (2009). An analysis of the impact of implementation of maintenance of licensure requirements. Retrieved May 6th, 2009, from FSMB at http://www.fsmb.org/pdf/mol_impact_analysis_report.pdf Flexner, A. (1910). Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching. Galbraith, R. M., Hawkins, R. E., & Holmboe, E. S. (2008). Making self-assessment more effective. Journal of Continuing Education in the Health Professions, 28, 20–24. Galbraith, R. M., Holtman, M. C., & Clyman, S. G. (2006). Use of assessment to reinforce patient safety as a habit. Quality and Safety in Health Care, 15, i30–i33. General Competencies. (2007). Retrieved April 30, 2009, from ACGME Error! Hyperlink reference not valid Gimpel, J. R., Weidner, A. C., Boulet, J. R., Wilson, C., & Errichetti, A. M. (2007). Standardized patients and mechanical simulators in teaching and assessment at colleges of osteopathic medicine. Journal of the American Osteopathic Association, 107, 557–561. Greenwood, E. (1957). Social work research: A decade of reappraisal. The Social Service Review, 31, 311–320. Hafferty, F. W., & Franks, R. (1994). The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 69, 861–871. Hambleton, R. K., & Swaminathan, H. (1985). Item response theory: Principles and applications. Boston: Kluwer-Nijchoff. Hubbard, J. P., & Leavitt, E. J. (1985). The national board of medical examiners: The first seventy years. Philadelphia: National Board of Medical Examiners.

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Irby, D. M., & Wilkerson, L. (2003). Educational innovations in academic medicine and environmental trends. Journal of General Internal Medicine, 5, 370–376. Issenberg, S. B., & Scalese, R. J. (2008). Simulation in health care education. Perspectives in Biology and Medicine, 51, 31–46. Kerr, E. A., McGlynn, E. A., Adams, J., Keesey, J., & Asch, K. M. (2004). Profiling the quality of care in twelve communities: Results from the CQI study. Health Affairs, 23, 247–256. Klass, D. (2007). Assessing doctors at work: Progress and challenges. New England Journal of Medicine, 356, 414–415. Klass, D. (2000). Reevaluation of clinical competency. American Journal of Physical Medicine and Rehabilitation, 79, 481–486. Kneebone, R., & Baillie, S. (2008). Contextualized simulation and procedural skills: A view from medical education. Journal of Veterinary Medical Education, 35, 595–598. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Lefevre, F. V., Waters, T. M., & Budetti, P. P. (2000). A survey of physician training programs in risk management and communication skills for malpractice prevention. Journal of Law Medicine and Ethics, 28, 258–266. Lipner, R. S., Bylsma, W. H., Arnold, G. K., Fortna, G. S., Tooker, J., & Cassel, C. K. (2006). Who is maintaining certification in internal medicine – and why? A national survey 10 years after initial certification. Annals of Internal Medicine, 144, 29–36. Lockyer, J. (2003). Multisource feedback in the assessment of physician competencies. Journal of Continuing Education in the Health Professions, 23, 4–12. Ludmerer, K. M. (1999). Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press. McGuire, C. (1999). George E. Miller, MD, 1918–1998. Medical Education, 33, 312–314. Melnick, D. E., Asch, D. A., Blackmore, D. E., Klass, D. J., & Norcini, J. J. (2002). Conceptual challenges in tailoring physician performance assessment to individual practice. Medical Education, 36, 931–935. Metro, D. G., Talarico, J. F., Patel, R. M., & Wetmore, A. L. (2003). The resident application process and its correlation to future performance as a resident. Anesthesia and Analgesia, 100, 502–505. Moore, D. E., & Pennington, F. C. (2003). Practice-based learning and improvement. Journal of Continuing Education in the Health Professions, 23, S73–S80. Murphy, D. J., Bruce, D., & Eva, K. W. (2008). Workplace-based assessment for general practitioners: Using stakeholder perception to aid blueprinting of an assessment battery. Medical Education, 42, 96–103. Norcini, J., Blank, L. L., Duffy, F. D., & Fortna, G. S. (2003). The Mini-CEX: A method for assessing clinical skills. Annals of Internal Medicine, 138, 476–481. Norcini, J. J. (2003). Work based assessment. British Medical Journal, 326, 753–755. Norcini, J. J. (2005). Current perspectives in assessment: The assessment of performance at work. Medical Education, 39, 880–889. Norcini, J. J., Blank, B. A., Arnold, G. K., & Kimball, M. D. (1995). The mini-CEX (Clinical Evaluation Exercise): A preliminary investigation. Annals of Internal Medicine, 123, 795–799. Norcini, J. J., & Burch, V. (2007). Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical Teacher, 29, 855–871. Norwood, W.F. (1957). American medical education from the Revolutionary war to the civil war. Journal of Medical Education, 32, 433–448. Performance measurement workgroup (2009). Retrieved May 5, from http://www.aqaalliance.org/ performancewg.htm Publications. (2008). Retrieved May 5, 2009, from http://www.qualityforum.org/publications/ reports

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Rethans, J. J., Norcini, J. J., Baron-Maldonado, M., Blackmore, D., Jolly, B. C., LaDuca, T., et al. (2002). The relationship between competence and performance: Implications for assessing practice performance. Medical Education, 36, 901–909. Rethans, J. -J., Sturmans, F., Drop, R., van der Vleuten, C., & Hobus, P. (1991). Does competence of general practitioners predict their performance? Comparison between examination setting and actual practice. British Medical Journal, 303, 1377–1380. Reznick, R., Smee, S., Rothman, A., Chalmers, A., Swanson, D., Dufresne, L., et al. (1992). An objective structured clinical examination for the licentiate: Report of the pilot project of the Medical Council of Canada. Academic Medicine, 67, 487–494. Sargeant, J. (2006). Multi-source feedback for physician learning and change. Halifax, NS: Halcraft. Schön, D. (1983). The reflective practitioner: How professionals think in action. London: Temple Smith. Schuwirth, L. W., & van der Vleuten, C. P. (2006). Challenges for educationalists. British Medical Journal, 333, 544–546. Swing, S. R., Clyman, S. G., Holmboe, E. S., & Williams, R. G. (2009). Advancing resident assessment in graduate medical education. Journal of Graduate Medical Education, 2, 278–286. Tamblyn, R., Abrahamowicz, M., Dauphinee, D., Hanley, J. A., Norcini, J., Girard, N., et al. (2002). Association between licensure examination scores and practice in primary care. Journal of the American Medical Association, 288, 3019–3026. Tamblyn, R. M., Klass, D. J., Schnabl, G. K., & Kopelow, M. L. (1991). The accuracy of standardized patient presentation. Medical Education, 25, 100–109. The ACGME learning portfolio. (2009). Retrieved April 30, 2009, from ACGME http://www.acgme.org/acWebsite/portfolio/learn_cbpac.asp The CanMEDS physician competency framework. (2009). Retrieved May 6th, from RCPSC at http://rcpsc.medical.org/canmeds/index.php Van der Vleuten, C. P. M. (1996). The assessment of professional competence: Developments, research and practical implications. Advances in Health Science Education, 1, 41–67.

Chapter 6

Assessment: Practical Strategies Applied to the Professions Maurice Clifton and Elza Mylona

Overview Assessment, a cornerstone of higher education, emerges as an essential element of successful professional workplace training programs. Types of assessment vary across workplace training, from direct observation of tasks performed inside the workplace to simulation of tasks performed outside the workplace. Other assessments do not occur in a workplace context, but are directly related to professional workplace settings. This section reviews research into the methods of assessment during workplace training for each of the four professions (medicine, nursing, theology, and education) utilizing knowledge, skills, and attitudes as an organizational structure while acknowledging that many assessment methods integrate more than one of these domains. Where one method may be used to assess attitudes in one profession, that same method may be used to assess knowledge in another (Mercer, 2002; Tyrone, 2003). Not all assessments discussed here are conducted in the “physical workplace.” In some cases, learners are observed and assessed in simulated, offsite situations under the assumption that they are a close approximation to conditions in the workplace. Another context, for example, would have medical students sent to observe an Alcoholics Anonymous (AA) meeting and then write an essay about the experience. That paper could be used to assess the students’ knowledge of the AA philosophy or their attitudes toward patients with substance abuse disorders. Though such an example does not represent a direct measure of a student’s ability to translate new knowledge or attitudes into the workplace in the future, it is illustrative of the work encountered and used to assess attitudes related to the workplace context. Irby and Wilkerson (2003) argue that “the scope of innovation has been accelerated, although not always caused, by five environmental trends that are changing the face of medical education making new ways for teaching and learning both M. Clifton (B) Mercer University School of Medicine, Macon, GA, USA e-mail: [email protected]

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necessary and possible” (p. 370) and included among those innovations is the creation of appropriate assessment methods. For example, medical and nursing students are required to demonstrate competence in areas such as critical thinking, technical skills, communication, and assessment. In addition, graduates are expected to be patient advocates and to have the ability to assist patients and their families in the decision-making process (Lowry, Timms, & Underwood, 2000). Such requirements have necessitated the development of innovative ways of teaching from problem-based learning (PBL) methods and learning that will support self-directed learning and peer evaluation. Curricula that make content relevant to real-life situations allow the socialization of the learners as professionals and colleagues (Alexander, McDaniel, Baldwin, & Money, 2002). The assessment methods within the four professions to be discussed were chosen according to their relevance to overall assessment in and related to workplace contexts. Highlighted are the methods that have been studied and have published data on the validity and reliability of methods. The aim has been to derive a framework based on those methods as to how knowledge of assessment in one profession is transferable to another profession.

Part 1: Assessment of Attitudes This section concentrates on assessment of attitudes within professional workplace learning environments. “Attitude” is defined as “a complex mental state involving beliefs and feelings and values and dispositions to act in certain ways” (Webster’s Online Dictionary, 2009). Within the professions, there is a considerable set of attitudes that one can assess. For example, one could assess the attitudes of medical students toward the elderly patient population, of student teachers about challenging students, of theology students about the homeless, or of nursing students toward healthcare reform. Observational methods can be used to assess attitudes and subjectivity, controlled through training of the observer.

Medicine In medicine, we have chosen to focus on the assessment of attitudes within the context of the development of professionalism in the workplace because this aspect of professionalism has been the object of intense focus over the past decade. There is widespread agreement in medicine on the importance of assessment of professionalism as well as interest in developing new assessment techniques (Arnold, 2002; Shrank, Reed, & Jernstedt, 2004). This focus on professional attitudes gained momentum when it was demonstrated that problems in professional behaviors while in medical school were shown to be associated with long-term lapses in professionalism and disciplinary actions by state boards (Papadakis, Osborn, Cooke, & Healy, 1999; Papadakis, Loeser, & Healy, 2001; Papadakis et al., 2005). In addition,

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several studies have demonstrated a decline in values consistent with professional behavior in medical students over time (Feudtner & Christakis, 1994; Satterwhite, Satterwhite, & Enarcon, 1998; Christakis, 1993). At the national level, the Association of American Medical Colleges (AAMC) published the Medical School Objectives Project in 1998. One aspect of the report set forth a consensus statement that medical students should possess four key attributes of professionalism by graduation: altruism, knowledge, skill, and duty (Medical School Objectives Writing Group, 1998). That was followed by the Accreditation Council on Graduate Medical Education’s endorsement of six general competencies for residents, one of which is professionalism (ACGME, 2009). Medical schools have been emphasizing such qualities in their curricula, with surveys showing that nearly all US medical schools include formal instruction in professionalism (Swick, Szenas, & Danoff, 1999) and that it is integrated into the curriculum in a variety of manners (Kao, Lim, Spevick, & Barzansky, 2003; Goldstein et al., 2006). The American Board of Internal Medicine (ABIM) has been at the forefront of assessing professionalism within the medical field and for decades has advocated for faculty to conduct observations of students while they are caring for patients (American Board of Internal Medicine, 1985). As defined by the ABIM, the elements of professionalism are altruism, accountability, excellence, duty, respect for others, honor, and integrity. Despite the importance of professionalism in medicine and, by 2002, the accumulation of over 170 published articles describing numerous tools, there is still much work to be done in developing adequate assessment methods (Arnold, 2002). Further literature analysis demonstrated that only a relatively small number of assessment methods have been studied that document validity, reliability, and practicality to the degree necessary for routine use (Veloski, Fields, Boex, & Blank, 2005; Shrank, Reed, & Jernstedt, 2004). Rogers and Coutts (2000) demonstrated that Standardized Patients (SPs) could assess humanism in students in a Clinical Performance Exam (CPX) and this study addressed the validity and the reliability of the tool. Another study by Hauck, Zyanski, Alemagno, and Medalie (1990) used a subset of a 24-item scale designed to assess whether a physician has a “sensitive, non-humiliating, and empathetic way of helping (a patient) deal with some problem or need.” The subset was an eight-item scale used by the SPs that included items such as, “This doctor seems to take a personal interest in me” and “Even when my problem is small, this doctor is concerned.” The results of this scale correlated well with a battery of validated attitude questionnaires. A study by Kovach, Resch, and Verhulst (2009) used peer evaluations as a component of the final grade in an internal medicine clerkship. Students served as peer evaluators and filled out the same form that the faculty used to measure professional characteristics during the rotation. The items included self-directed learning, interpersonal relationship, and motivation/dependability/responsibility. Though there was a weak correlation between the student and faculty ratings (r = 0.29, p < 0.001), that result may demonstrate that peer evaluation is a reliable measure for a domain that faculty are unable to assess.

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Theology In the theology literature, a wide variety of attitudes are assessed using the essay as the measurement tool. As an example, the authors of a study (Mercer, 2002) of attitudes of seminary students in the Philippines were concerned about students who were close-minded about issues. Students in the cultural context of the Philippines had expressed an interest in learning about theology and the ministry with respect to prostitutes and other social outcasts. Many held passionately articulated positions about prostitution prior to the experience, blaming one particular group of people for the problem. Through a method called “exposure learning,” students went to the red light district of Manila to observe. After a session in which they were debriefed on the experience, they were given an assignment to write reflection papers. The majority of the class wrote about empathic attitudes toward the women, had a more complex understanding of the issues involved in the sex trade, and discussed personal commitments that demonstrated an expanded understanding and broadening of attitudes about the problem. Still, others became more entrenched in their beliefs and, in those cases, the shock of new and contradictory experience actually became an impediment to learning. Using this methodology, the authors were able to qualitatively measure the effects of an exposure learning experience in a subject that was emotionally charged as well as an area where students had strong preexisting attitudes about a topic. While the method was not as quantitative as some methods, the authors felt that it was effective in differentiating the groups (Mercer, 2002). It is possible that this ability to discriminate between changes in attitudes is more suited to experiences of a similar intensity.

Nursing Nursing, like medicine, has begun to assess attitudes in the context of the development of professional behaviors in the workplace. The nursing profession recognizes (Day, 2005) that there is sometimes an overemphasis on analytic, procedural, and technical aspects of nursing practice. As a result, there have been calls for increased emphasis on values and ethics. The assessment of nursing professionalism relates closely to the development of values that guide attitudes, behaviors, and beliefs within the profession itself – values that provide a framework to evaluate the relationships with the broader community, including the patients. Unless values are clearly defined, the development of a reliable measure becomes a complex task. As Curtin (1988) highlights, “the ethical code of a profession embodies a set of ideals, the interpretation and application of which is central to practice.” As noted by Curtin (1988) the Code for Nurses, adopted in 1950, is considered “a hallmark of professionalism.” In 1998, the American Association of Colleges of Nursing published “The Essentials of Baccalaureate Education for Professional Nursing Practice,” in which it is recommended that training programs provide learning opportunities related to professional values. The Nurse Professional Values

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Scale (NPVS) is a validated screening instrument for the assessment of professional nursing values over time and was developed on the basis of the American Nursing Association’s (ANA) Code for Nurses. An example of the research done in this area is a study (Weis & Schank, 2000) that addressed assessing attitudes in nursing education. In this multisite analysis, the items of the NPVS were found using factor analysis to map to eight factors that accounted for 58% of the total variance. There was also a high level of test–retest reliability in this group of nearly 600 nursing students and practicing nurses. The authors found the NPVS to be a useful instrument for measuring professional values and enhancing professional socialization. Such tools can be utilized in a variety of settings and ways, including a post-intervention evaluation for programs designed to develop professional values, a measure of the change in values over time, and a screening tool for the profession.

Education In the literature for training educators, the assessment of attitudes in workplace training is similar to that of theology. A common intervention to promote the desired attitudes is the use of reflection, which has been used in the training of the future teachers since the early 1970s (Collier, 1999; Van Manen, 1977). Using various models (reflective journals or interviews, peer observation, and group seminars), novice teachers learn to self-monitor their beliefs and thoughts and critique their actions as learners and then as teachers. That training helps them to better understand the process of teaching and become active, critical, and progressive thinkers. Collier also developed a method to analyze and assess teacher attitudes using different reflective exercises: a reflective journal, in which the author and each student teacher had a conversation about the teaching experience; a reflective interview, in which the author observed, evaluated, and discussed the student teacher’s teaching activities; a peer observation conference, where student teachers completed three visits to a peer intern’s classroom and wrote narrative comments for discussion with the student; and, lastly, a small group discussion, where students met weekly to discuss a theme related to their workplace experience. The author analyzed the data through unitization and categorization of all written products of reflection. The first category was technical rationality, which concerns effective application of educational knowledge and skills, or a description of the event. The second category was practical action, in which the learner described an experience so that a subjective perception or commitment to a certain theory or system was indicated. The third category was critical reflection, which is indicated by ethical, moral, and social considerations. The result was a very rich composite of each student’s reflective ability. Another study (Hatton & Smith, 1995) of reflection in the education literature was conducted by analyzing essays of student teachers at Sydney University. This study used a similar definition of reflection: “deliberate thinking about action with a view to its improvement” (similar to lifelong learning in medicine). The

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essays demonstrated evidence of reflection and discrimination among three types of reflection: descriptive reflection reports events or literature and attempts to provide reasons based on personal judgment or the literature, dialogic reflection demonstrates a discourse with oneself that leads to an exploration of possible reasons, and critical reflection gives reasons for decisions or events that take into account the broader historical, social, and/or recent political contexts. Analysis of the essays demonstrated that in the education setting, reflection can be assessed using the essay method. And so our research found that there were many approaches taken to assess attitudes, ranging from quantitative approaches, such as checklists or multiple-choice questions, to qualitative methods, such as reflection or observation. The importance of selecting the methods is based on matching the goals to the intended.

Part 2: Assessment Skills This section focuses on research into the assessment of the essential skills that learners will be practicing in the future in the workplace setting. Authentic performance-based assessment has the ability to evaluate deeper levels of understanding that relate to skills carried out in the real world (e.g., in the four professions of our discussion: counseling a student, preaching a sermon in a community church, developing a treatment plan, or implementing a discharge plan). This assessment task itself is not always feasible in an actual workplace setting, but it can be replicated using a project, simulation, or portfolios. According to Wiggins and McTighe (2005, pp. 153–154), a form is authentic if it: • • • •

is in a realistic context; requires active involvement from the student; assesses the student’s ability to negotiate a complex and multistage situation; and allows opportunities to practice, consult others, and get feedback.

The aim in moving toward competency-based education in the 1990s was to teach, observe performance, and then assess outcomes based on competencies and to incorporate performance behaviors in many domains in order to provide effective patient care. Still, as early as in 1994, Hafferty and Franks (1994) noted that the approach missed the learning that took place in what he called the “hidden curriculum,” about which he has provided details in this volume. Research on the assessment of competencies in medicine and nursing has shown strong correlation among different aspects of competence, suggesting that the content rather than the assessment method should determine what is being assessed (van der Vleuten et al., 2000). Argyris and Schön (1974) suggest that an individual’s theory-in-use cannot be understood by asking questions, but rather by observing the individual’s behavior. Taken further, assessment of skills in the actual environment in which they

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are learned and practiced has a higher face validity when compared to assessment methods where the learner is removed from that setting. A review of the literature on the variety of methods used to measure performance in health care revealed that there are a variety of preferred methods used in different countries and by different organizations within the same country. Among them are reflection, portfolio, peer evaluation, self-assessment, observation, supervision, 360degree feedback, and critical incident techniques. Most are formative in nature and apply to individuals, rather than to groups. In many instances that were reviewed, assessment methods were combined (Hamilton et al., 2007). Hamilton concluded that defining performance in health care is a complex task and that there is no single method that is appropriate for assessing clinical performance. All institutions and organizations struggle with the same issues, since every method of assessment has its own set of advantages and disadvantages. Hamilton supported previous recommendations for a multi-method strategy that would allow the assessment of knowledge skills and attitudes. One example of a method encountered in the medical literature that seemed to be reported on less often in the literature of the other professions was peer assessment, which has been used frequently in health care to measure professional competence. Peers are frequently asked to make judgments about the quality of the performance they review or observe. Norcini (1995) reported on a five-step process involved in implementing peer assessment that could improve the method; this included the following: (1) the purpose of the assessment and the performance expectations need to be clearly stated to all participants; (2) assessment criteria, methods, and ways of capturing data should be communicated; (3) training, which could range from simple written instructions to intense videotaped standards with feedback, should be available; (4) results of the assessments should be monitored during the implementation while confirming their reliability and validity; and (5) feedback should be available to participants along with comparison data on their performance to improve the process.

Medicine There is a large amount of published material on the assessment of skills in the medical setting. This section will address the use of procedure logs to document the number of times a given skill is completed; of direct observations of students performing skills in the workplace, along with some weaknesses of direct observation and modifications of the technique to combat those weaknesses; and of writing skills and simulation as measures of skills in the medical profession. The importance of skill assessment is emphasized in a study of more advanced clinical procedures among Internal Medicine residents. The authors looked at the procedure logs generated by residents across 10 years and compared the number of procedures completed against complications reported during that time. Overall, 2,212 monthly procedure logs revealed a “complication rate” of 2.3 instances per 1,000 procedures. The authors compared the complication rates to the monthly

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rating of the residents’ procedural skills as scored on a monthly evaluation form and found no correlation. They also were not able to find a correlation between the total number of procedures completed and the complication rate, or the residents’ scores on a knowledge-based in-training exam. They did, however, find a decreased complication rate for procedures that were performed after the resident was certified as being competent to conduct the procedure without supervision. This certification process involved direct observation of the resident’s skills and was not merely based on the number of procedures completed, but required faculty to document that the resident had verbalized appropriate knowledge about the procedure, displayed the necessary technical skills, and displayed the confidence required for the procedure. In addition, there was no increased complication rates in residents who needed to perform more procedures in order to be certified once they did indeed become certified (Durning, Cation, & Jackson, 2007). In the healthcare environment, practice observations can be gathered from multiple sources (faculty, peers, other healthcare providers involved in the delivery of care and patients). Regardless of the source, the ever-changing nature of the clinical encounter complicates the assessment process. As well, studies have shown that not only do faculty observations of clinical skills happen infrequently, they also fail to discriminate between different levels of clinical competence (Noel et al., 1992). Faculty perceived multiple obstacles to completing the observations, including the time needed (Barrows, 1993) and inadequate skills to remediate problem behaviors should they be encountered (Burack, Irby, Carline, Root, & Larson, 1999). In addition, the characteristics of standardized clinical evaluation forms were shown to have poor reliability with less than three or more raters, even if the number of items on the forms was increased (Kreiter, Ferguson, Lee, Brennan, & Densen, 1998). Teaching the practice of medicine includes taking care of patients in a variety of settings using a wide range of faculty preceptors. Medical students commonly rotate through core clinical experiences in internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and family medicine. In addition, they have several months of elective time during which they obtain increasingly specialized experience in different areas of medicine, such as orthopedic surgery and cardiology. At this level of training, unsupervised invasive procedures are very rare, if they happen at all. In the case of an appendectomy, for example, there is typically a senior faculty member who has ultimate responsibility not only for the teaching but most importantly for the patient. Often a resident performs the more advanced parts of the procedure. The medical student is often charged with holding retractors to make sure that the object of the operation is in clear view. While the student is playing a relatively small part in the overall process, he or she is able to observe the more advanced tasks. The students are also commonly taught how to perform small parts of the procedure, such as cutting the suture material after a more senior physician ties a knot. In this context, the surgeon’s assessment is immediate and the feedback is often direct. Many students have the experience of being told, “too short, too long, too short” as they try to cut the suture material to the exact length requested by the surgeon. Another study focused on the ability of medical students to communicate their findings in writing. Kogan and Shea (2005) developed a 14-item form for grading

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write-ups with each item carrying a 4-point rating scale ranging from 1 (strongly disagree) to 4 (strongly agree). The items were derived from a variety of sources and covered sections of the write-ups – for example, “chief complaint was clearly stated,” “history of present illness was organized chronologically,” “symptoms fully characterized.” They also assigned a global score of either “fail,” “pass,” “high pass,” or “honors.” Using a total of 493 write-ups by 165 students, the authors compared the scores on this form to the global ratings, clinical grades, and a nationally administered knowledge-based exam. Analysis of the form results yielded a reproducibility coefficient of 0.67 and final global write-up grades were correlated with exam scores (r = 0.35, p < 0.05) and with clinical grades (r = 0.28, p < 0.05 for inpatient grades; r = 0.16, p < 0.05 for outpatient grade). Observing students complete the tasks that they will eventually perform as a practicing professional is the assessment method with the highest face validity (Kassebaum & Eaglen, 2000). Again using medicine as an example, some of the first formal assessments of clinical skills involved a faculty member observing a learner undertake a complete history and physical examination utilizing a procedure called a Clinical Evaluation Exercise (CEX). An early survey of 5,693 medicine residents who completed their training between 1987 and 1988 showed that 82% of residents completed at least one CEX as part of their training, with only 32% of those receiving more than one (Day et al., 1990). The three main issues seen in this type of assessment include inter-rater reliability, case specificity, and the large time requirement. In a randomized, controlled trial in 12 university and community teaching hospitals, faculty watched a videotape of one of two residents performing new patient workups and afterward completed an assessment of the resident’s clinical skills. When they did not have a structured form faculty reported an average of 30% of strengths and weaknesses identified by the authors watching videotapes of the same encounters. A structured form increased the accuracy, but to only 60% (Noel et al., 1992). Another problem with this type of assessment is that the student is observing only one patient where much variability is found among patients – some have much more difficult diseases to diagnose, others are less cooperative, and others still are unable to give an accurate history. It has long been recognized that a student’s performance with one patient is not predictive of the performance on another patient (Elstein, Shulman, & Sprafka, 1978). In addition, a trial of 27 residents by 16 faculty physicians compared the results of a monthly evaluation by the attending physician and resident, a committee evaluation, and the CEX. The study was effective in detecting a variety of errors, including items in both the history and physical exams. While the majority of errors were considered relatively inconsequential, there was also a very narrow range of scores, probably reflecting a positive skew on the part of the faculty (Kroboth, Kapoor, Brown, Karpf, & Levey, 1985). More recently, it was shown that such poor reliability is in conflict with the higher validity of the whole encounter and that increasing the number of cases is more important than standardization of the patients for increasing the precision of the assessment (Wass & van der Vleuten, 2004). While direct observation may still be the most commonly used method (Norcini, 1995), studies with residents have shown its usefulness to be limited. It requires

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a large amount of time (up to 2 h), has limited reliability for a given learner, because each has only a few assessments, and, most notably, it is not consistent with how physicians practice in the real world – i.e., with multiple focused encounters (Norcini, Blank, Arnold, & Kimball, 1995). In response to those findings, the American Board of Internal Medicine developed the mini-clinical evaluation exercise, in which a focused encounter and multiple observations with different patients are used, thereby more closely replicating a physician’s practice. The mini-clinical evaluation exercise (mCEX) has been shown to be feasible in a busy clinical education setting and reliable for residents (Durning, Cation, Market, & Pangaro, 2002). Those same findings were observed in the internal medicine clerkship for medical students (Kogan, Bellini, & Shea, 2003). In a study (Norcini et al., 1995) of internal medicine residents in five training programs in Pennsylvania, 88 residents completed 388 mini-clinical evaluation exercise (mCEX) encounters and were assessed by 97 different evaluators. The encounters were short (averaging 20 min) and consisted of a focused history and physical exam in a variety of settings. Some encounters were with new patients and others were with patients that the resident had already seen. Each medical evaluator assessed two residents, from a minimum of 1 time to a maximum of 14 times. The reproducibility of the assessment was related to the number of encounters, reaching 0.71 after 8 encounters and 0.81 after 14 encounters. Simulation provides another approach to assessment of skills in medicine and nursing. Here the term “simulation” is used to describe the devices that attempt to recreate characteristics of a real work setting via such tools as case studies or role plays, as examples. A “fishbowl” simulation could be used in the workplace to assess skills related to care management such as leadership, conflict resolution, or group communication skills. In this method, trainees replicate a clinical situation or a team meeting while they are observed by assessors, who are sitting around the “fishbowl” (Frohna et al., 2004). The term “high-fidelity” simulation is used to describe the technological advantages that replicate “the look and feel” of the actual work environment (Beaubien & Baker, 2004). The use of technology has created a plethora of opportunities in the area of information management and skills training. Simulation (or high-fidelity simulation) allows trainees to experience life-like scenarios that require action and decision-making, while providing feedback in a standardized environment appropriate to the trainees’ level of competence. Procedures that require repeated practice to master specific skills lend themselves to simulator use in formative, summative, and self-assessment venues. Research shows that the use of simulation for the examination of skills is always associated with significantly improved performance (Issenberg et al., 1999). The development of simulation games, along the lines of Sim-City and virtual reality, is suggested to assess residents in practice situations (Frohna et al., 2004). Simulation has been encountered as a means of measuring a student’s clinical skills, such as the use of Standardized Patients (SPs) who are professionals trained to simulate patients with medical conditions. SPs are also trained to recall objective behaviors that the student successfully completes and record them on a checklist.

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When performing a clinical assessment with an SP, the student must complete a history, physical examination, or counseling – much as he/she would with a real patient. Each student can encounter the same clinical scenario, thereby allowing a more valid comparison of performances. In addition, multiple encounters can be done in succession in an Objective Structured Clinical Examination (OSCE), which, if done correctly, can ensure that the scores are consistent and accurate (Boulet, McKinley, Whelan, & Hambleton, 2003). Each student must pass a national simulation test as part of the United States Medical Licensing Examination in order to obtain a medical license (USMLE, 2009). There have been extensive studies of the OSCE’s reliability since the exam’s inception in the 1970s (Harden, Stevenson Downie, & Wilson, 1975). The concern over reliability centers mainly on two areas: the size of the performance sample and the number of assessors. Using a large performance sample, as in an OSCE assessment that has multiple clinical scenarios, decreases the negative effects of “content-specific” problems and, therefore, increases the reliability of the method. A further improvement in reliability occurs when using a large number of assessors for different parts of the test, as well as specific assessment guidelines and checklists (Van der Vleuten et al., 2000). Lastly, unannounced SPs have been used successfully with residents to assess communication skills in a real practice environment and to evaluate the ability to balance ethical issues while maintaining responsibility for the patient and society at large (Frohna et al., 2004; Schnabl, Hassard, & Kopelow, 1991). Concerns (Van der Vleurten et al., 2000) have been raised about the validity and reliability of using unannounced SPs as a formative assessment tool to teach residents about managing care. Overall, literature reveals that competency assessment is situation-specific and varies considerably across content areas, regardless of the chosen assessment method.

Theology Assessment of skills in the pastoral workplace largely uses portfolio-based methods. The goal of the assessment is the trainee’s “self-understanding and clarity regarding vocation and faithfulness” (Union Theological Seminary in the City of New York, 2009). This technique “recognizes the individuality of knowing” by allowing the students the freedom to present their educational experiences in their own unique ways that reflect their learning style, passions, and interests. In courses such as the New Testament or Introduction to the Bible, portfolios have been used as a repository of all the work the individual student produces during the semester and assessments here allow individual learning styles to be acknowledged. For example, students have the ability to revise and resend their work based on the instructor’s feedback without having the revisions affect their grades. The experience has been satisfactory for students since “different ways of learning, different passions and interests, different wisdoms and different skills are equally valid under this form of assessment” (Aspan & Hawkins, 2000).

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Ippolito, Latcovich, and Smith (2005) state that the assessment of theological training is complex for two reasons: (1) the existing guidelines and program requirements are not specific enough to allow the use of objective assessment methods and (2) the belief among some faculty that the outcomes of such training should be seen as a process of professional judgment and personal growth. As a result, faculty members are resistant to using assessment methods other than the traditional ones, even if they have been effectively used in other professions. A pilot project funded by the Wabash Center for Teaching and Learning in Theology and Religion focused on the use of subjective measures (Ippolito et al., 2005). Academic faculty with common content knowledge came together to decide on the best practices regarding the professional development of trainees in theology. The development of a common language that would be used to describe the knowledge and skills expected of trainees and a clear view of the full range of responsibilities of the ordained priests in contemporary society were seen as important for the successful completion of the project. Nine areas of service were identified: (1) celebrates Liturgy and Sacraments, (2) provides Pastoral Care and Spiritual Guidance, (3) teaches Faith, (4) leads Parish Administration, (5) practices a Ministry of Presence with Parish Groups, (6) participates in the Life of the Diocesan church, (7) engages with Diverse Publics, (8) engages in Professional Development, and (9) engages in Personal Development. The decision was made to use rubrics as an assessment tool to integrate the human, spiritual, and pastoral domains. Focus group reports indicated that rubrics help to benchmark faculty reflection on a student’s development and this can serve as a framework for individual priests to self-assess. A national validation of the priest profile, as defined by this project, is in progress (Ippolito, 2005). Students who study divinity often have the opportunity to develop their own program in one of the selected sites. After selecting the site, the trainee and the advisor develop a learning agreement that defines goals, objectives, task, resources, and the supervision process; enhances the clarity and expectations of the educational program and sets limitations; and becomes the point of discussion during the midterm assessment, where it gets revised to reflect the expectations for the rest of the studies. The final examination is based on the learning agreement and looks especially at the trainee’s observable behaviors and competence.

Learning Agreement Intentions and Plan for Learning LEARNING GOAL: Indicate in a few sentences or a short paragraph your overall expectations for this learning experience in light of your vocational/professional goals. For example: What has led you to choose this setting as your field educational project?

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MINISTRY ARTS: For each of the Arts of Ministry which you have indicated you intend to develop in this placement please describe, using as precise objectives as possible, the issues you wish to explore, the competencies you wish to cultivate, the theological areas you wish to reflect on, and the areas of personal and spiritual growth you would like to address. TASKS: Considering the Arts of Ministry and the issues and areas you intend to address, describe each task you have agreed to do in this placement. Indicate the Arts of Ministry to which each task relates. Describe each task as specifically as possible. For example, if you are preaching, indicate how many times in the year, and even the dates if they are known. If you are planning to do pastoral visiting, indicate which days and hours and whom you will be visiting. RESOURCES: For each task, outline the resources available to support and educate you. Resources may be people in the placement, courses you have taken or will take, reading assigned in the placement, or your professional or personal experience. SUPERVISION: Specify the ways in which your work will be presented and reflected upon in supervision. The supervision to which this section refers is different from planning or staff meetings. This is the time to reflect theologically and in other ways about your work, your interactions, your identity, and your theology as they come up in your ministry. There are many useful tools to help the supervisory process. Among them are theological reflection reports, critical incident reports, verbatim reports, sermon feedback forms, or journals. Harvard Divinity School, 2009

Reflective supervision is another method used to assess theology students. The students spend time weekly with the assigned advisor in addition to the regular or project meetings. The trainees discuss their developing role in the ministry, the tasks of the ministry, or any critical incidents, assumptions, and theories. In addition, trainees are expected to discuss issues of inclusiveness and social justice.

Nursing In contrast to the literature in medicine, but consistent with findings in theology, our review of the nursing literature as it pertains to the assessment of skills in the workplace identified the use of portfolios as the most commonly reported method. Portfolios have been used in nursing education to document and assess trainees’ skill level during training in the workplace; however, their use in assessing residents’ competency in care management needs to be examined (Frohna et al., 2004). However, in an attempt to utilize an indirect measure of clinical competence for

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nontraditional nursing students Lettus, Moessner, and Dooley (2001) developed a portfolio project. Students received explicit guidelines on portfolio preparation and were able to work independently and at their own pace. That method of documenting clinical competence was well received by both faculty and students. Faculty issues included accuracy and legitimacy of the documentation as well as the inter-rater reliability of the examiners. A random verification program was instituted to satisfy the first concern. A 2-day training session and practice in rating portfolios addressed the second, as did the use of three raters who reached consensus via discussions to resolve any discrepancies. The outcomes resulted in a methodology that was acceptable to the faculty. Students also had concerns. The first was the need for ongoing feedback during the portfolio development process. By means of small group sessions led by faculty, students received needed feedback as well as valuable peer input that aided the reflective process. One difficulty that continued throughout the program was that some employers would not release performance reviews, thereby severely limiting the documentation of learning at the associated institutions. Still, in the end and overall, the process was seen as a positive assessment experience. The International Society of Nurses in Genetics has created and validated the use of portfolios for credentialing nurses in genetics. A team of trained raters is selected for a 3-year term. In the first year, the rating is done by the student in conjunction with a senior scorer; in the second year, the student rating is performed independently; and in the third year, each student serves as a senior scorer and trains a new student member. Using a scoring rubric from 4 to 10 and a neural net computer program that accommodates inter-rater variations and allows for valid differences of professional opinion, judgment differences were accommodated with a reported accuracy and validity of 97% (Cook, Kase, Middelton, & Monsen, 2003). Like many assessment methods in general, the usefulness of the test is dependent on how the test is used. As was demonstrated by the nursing example, the usefulness of portfolios can be increased by formalizing the process by which they are used and conducting assessments in a rigorous fashion.

Education This section explores common methods reported in the education literature for the assessment of teaching skills in the workplace. First addressed is some background material on the teaching competencies that should be assessed as well as the literature concerning the value of teaching the teachers; next, the use of portfolios as a performance-based measure along with a look at some critiques of the methodology; and finally the use of critical reflection as an adjunct method of assessment. To address the issue of skills assessment of student teachers in the workplace, Stiggins (1999) has recommended a set of program evaluation competencies that could be used by teachers’ training institutions as a quality control mechanism to evaluate their own programs. In addition, each competency has an associated selfstudy question that institutions which train teachers can complete to evaluate the

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quality of their training programs in the area of student assessment (Stiggins, 2005). The competencies include the following: 1. Connecting Assessment to Clear Purposes (Self-Study Question: Do we help teachers understand how to respond to differences in information needs among different assessment methods?); 2. Clarifying Achievement Expectations (Self-Study Question: Do we prepare teachers to be confident, competent masters of achievement targets that their students are to master?); 3. Applying Proper Assessment Methods (Self-Study Questions: Do we teach teachers to align a variety of assessment methods properly with the particular achievement targets that they teach? Do they understand what kinds of achievement targets align well with . . . different methods?); 4. Developing Quality Assessment Exercises and Scoring Criteria and Sampling Appropriately (Self-Study Question: Do we teach graduates how to design and develop sound assessment exercises and scoring criteria and to understand how many exercises to include in an assessment in an efficient, yet representative, manner?); 5. Avoiding Bias in Assessment (Self-Study Question: Do we prepare our graduates to understand and avoid the various sources of bias that can lead to inaccurate assessment, including biases that can arise from the assessment itself, the evaluator, the students, and the environment?); 6. Communicating Effectively About Student Achievement (Self-Study Question: Do we teach graduates to understand and adhere to the principles of effective communication about student achievement as they apply to report card grades, detailed written progress reports, various types of portfolios, interpretation of test scores and various conference formats?); 7. Using Assessment as an Instructional Intervention (Self-Study Question: Do we prepare our graduates to understand the relationship between assessment and student motivation, including how to use that relationship to maximize student confidence and success?). Studies have demonstrated for over 30 years that education of teachers in teaching and assessment techniques leads to higher-rated teachers with better educational outcomes (Darling-Hammond, 2000). In one analysis, students in Texas districts with greater proportions of fully licensed teachers were significantly more likely to pass the state achievement exam, even after controlling for factors such as socioeconomic status, school wealth, and teacher experience (Fuller, 1999). In contrast, the emphasis on standardized content area tests as a requirement for certification has not demonstrated the same effect. Angrist and Guryan (2008) used the Schools and Staffing Survey to estimate the effect of state teacher testing requirements on teacher wages and teacher quality, as measured by educational background. While educational background is not a direct measure, it is commonly used in the education literature. They found that state testing requirements were associated with increased teacher salaries, but there was no evidence of increased teacher quality.

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During the last decade, the use of performance-based assessment in US teacher education programs has dramatically increased, as has the use of portfolios for formative or summative assessments. Portfolios can provide authentic sources of information to determine teaching excellence. Johnson and Jones (1998) described two models developed to evaluate the performance of beginning teachers. Both frameworks share a common vision of the characteristics of an accomplished beginning teacher and have defined the qualities of good teaching in a way that helps beginning teachers to understand, reflect upon, and improve their practices. Although the Teach for America (TFA) and California Standards for the Teaching Profession (CSTP) were developed separately, both derive from a very similar philosophical basis that developed five domains to represent the knowledge, skills, and abilities that characterize effective teaching, which are (1) classroom management, (2) curriculum/content, (3) instruction, (4) assessment, (5) professionalism. The authors commented on the significance of developing similar frameworks and the fact that teaching is a complex task that is best assessed by methods that include multiple sources of data. Portfolios assist teachers in becoming more reflective thinkers who are accountable for their own learning of teaching skills as well as conscious and self-confident about their development and future practices. Portfolios also support the improvement of the teaching profession as a whole: training programs around the United States have used them in all varieties and phases of observation and teaching experiences in preservice teacher education programs, from field experiences that precede education course work, early field experiences that are tied to professional courses, student teaching and internship experiences, single courses, practicums, and student teaching (Zeichner, 1999). The literature (Zeichner & Wray, 2001) suggests several different kinds of teaching portfolios, depending upon the purpose for which they are constructed. The most common addresses learning, which allows teachers in training to document their development; the next most often found addresses credentials, which assesses students’ competence according to a set of teaching standards; and the last cited is the showcase portfolio, which allows teachers to include samples of their best work. In America, different standards in each state describe the requirements for demonstrating an acceptable proficiency in teaching skills to obtain an initial teaching license. In some states, preservice teachers are required to include samples of their best work that define their vision of good teaching; in other situations, teachers are required to include evidence of growth over time or show evidence of student learning. The most commonly used set of standards is supported by the Interstate New Teacher Assessment and Support Consortium (INTASC, 1992). Programs require students to include many different items in their portfolios: statements of teaching goals and philosophy of teaching; photographs, videotaped teaching samples, lesson plans, and samples of learners’ work; notes for the supervisor/observer; samples of assessment methods used; communications with parents; and action research projects, among others. Those examples are frequently accompanied by a heading that emphasizes the substance of the work, as opposed to the scrapbook that emphasizes the presentation of the information.

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There are variations in the amount of time and in the nature of the interactions between students and teachers during portfolio development. Multiple opportunities for interaction enhance the perceived value of the methodology among students. The sense of ownership and the quality of the product are amplified when students are allowed to make decisions about their entry selections, while still having a set of required entries that satisfy the teacher’s needs for assessment and professional development. The ways in which completed portfolios are used also differ. In some cases, students are asked to publicly present their work to university faculty and peers and often the presentations are followed by an in-depth discussion. The evaluation of the portfolios is usually done on a pass/fail basis, but can also follow a set of rubrics in which the evaluation criteria are predetermined by the institution. The literature is ambiguous about the consequences of using paper or electronic portfolios, or a combination of the two methods. There has been a lack of research on the construction process of the portfolios (Zeichner & Wray, 2001). In a study by Anderson and Demeulle (1998) in which teaching portfolios were assessed, faculty reported being more flexible in their interactions with their students, allowing them to challenge curriculum and assessment methods; more willing to allow students to take control over the development and evaluation of their work; more responsive to the need for professional standards; and more reflective on their own teaching. Comments included: “Portfolios as a process have caused me to see the value of having the student take responsibility for evaluation and to negotiate that in reciprocal dialogue with me.” “I’m compiling my own portfolio, and struggle just as they do” (p. 27). However, teaching portfolios have their shortcomings for both students and teachers. Students have expressed frustration and confusion about using the teaching portfolios, mainly due to lack of experience in constructing them and an unwillingness to expend the required energy. Also, portfolios represent learning and growth over time, which is not how students view their course work (Wade & Yarbrough, 1996). Barriers to the widespread use of portfolios in the workplace include limits on time; buy-in from faculty; insufficient institutional resources; issues with reliability and validity; and unfamiliarity with the method, with the grading, and with how they capture the individuality of the learner and can still be used as a “high-stake” assessment (Anderson & Demeulle, 1998; Frohna et al., 2004). Teachers come in contact with students whose ethnic and cultural backgrounds differ from theirs and so teacher educators have the responsibility of providing their students with the knowledge and skills that are required for educating the diverse student population. Critical reflection has been used as a way to train and evaluate student teachers to integrate culturally relevant teaching practices. The term “critical” is used to indicate the type of reflection that takes into account the political, moral, and ethical contexts of teaching. In a case study of a mandatory course titled “Identity and Teaching,” critical reflection was used to assist preservice teachers in monitoring their own identities, beliefs, and classroom ethos as they become active professionals (Tyrone, 2003).

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As with assessment of attitudes in workplace training, there are many ways to evaluate learners’ skills in that same setting. Also similar to the assessment of attitudes, the methods used range from the very concrete and quantitative to the very subjective and qualitative. Some similarities exist among the different methods in the different professions: the performance of professionals is a complex task, as is the assessment of skills within that profession. In medicine, it was shown that measuring the number of times that someone completes a task does not ensure that they will be more competent at the task. If the task is observed by an expert within a system that is optimized for assessment – such as in the mCEX or through the use of simulation in medicine – or is evaluated through the use of rubrics in theology or portfolios in nursing and education, accurate measures of student performance in the workplace can be achieved and a rigorous assessment methodology can be attained.

Part 3: Assessments of Knowledge This section explores the literature of assessments used in the cognitive domain as it applies to learning in the workplace. After an examination of studies in the use of true-false, multiple choice, and open-ended questions in medicine, oral examinations in medicine will be discussed and then compared to the use of oral examinations in theology. The use of multiple choice questions will be revisited and then oral examinations from the perspective of nursing and education will be presented. There is an astounding amount of work that has been produced in the medical field as it pertains to assessment of knowledge in the workplace. Because of the large volume and high quality of this work, most of the assessment methods presented will come from medicine. Student knowledge is assessed at the national level at three distinct points in medical education. Each licensed physician completes three sections of the United States Medical Licensing Examination (USMLE) whose purpose is to “assesses a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care.” (USMLE, 2003). The first step of the examination concentrates on the basic sciences needed to practice medicine and is commonly taken before formal teaching in the workplace. The subsequent steps are taken after formal training has commenced, with the second step commonly occurring after 1 year and the third, more than 2 years into the formal training in the workplace. In contrast to medicine, the other professions seem to focus more on the assessment of skills and attitudes once the students move into the training in the workplace. The literature is rich with assessment of knowledge in the classroom in the other professions, for example, understanding the bible in theology, anatomy in nursing, and science content in education. There is surprisingly little outside of the methods of assessment used in medicine, however, once the student progresses to the workplace.

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Medicine The most common approach to assessment of knowledge in medicine is through written methods and a recent review concludes that using a complementary mixture of methods is more useful than trying to find or develop one method that is best in every aspect (Schuwirth & van der Vleuten, 2004; Fallows &Chandramohan, 2001; Frohna et al., 2004). According to Schuwirth and van der Vleuten (2004), the category of written assessment can be divided into two groups: response and stimulus formats. The first includes assessment methods based either on open-ended question types (short answer or essays) or on multiple choices (true-false or single best option). McCoubrie (2004) reported that true-false questions are not used frequently in the United States due to guessing and cueing effects. They are considered ambiguous and difficult to write. While short-answer questions can assess broad curriculum areas, they are difficult to correct and have low reliability. Fowell and Bligh (1998) argued that this type of assessment could encourage trainees to practice question spotting, which may lead to less effective patterns of learning. The second group (stimulus format) could be subdivided into context-rich and contextfree types of questions. Context-rich questions typically consist of a case scenario accompanied by open-ended or multiple-choice questions. Context-free questions are, as they imply, standalone and appear to be the most appropriate for determining factual knowledge; Multiple-choice questions (MCQs) are the most widely used format for assessing core knowledge in any discipline. They are efficient to administer, relatively easy to construct, and can have high reliability, although McCoubrie (2004) reported that the assumption about MCQs being more reliable than other methods of assessment is not well documented in the literature. Their reliability, he states, probably results from the ability to test a broad area of a topic in a time-efficient manner and from the fact that MCQs predict and correlate well with the overall competence and performance of examinees. He also argued that mixing the MCQs with other methods of assessment would increase the validity and fairness of the test. Though MCQs are extensively used because of their perceived objectivity, Walvood and Anderson (1998, p. 11) noted that they can be far from neutral: “The selection of items, the phrasing of questions, the level of difficulty, all these judgments are made by the teacher according to the circumstances.” Frohna et al. (2004) supported the use of MCQs and written assignments in general and argued for the need to develop “innovative MCQs” appropriate for assessing practice management, patient communications, or teamwork and collaboration. McCoubrie (2004) suggested that well-constructed MCQs could assess high-order cognitive functions such as synthesis, analysis, or interpretation. He offered some practice points that should be met if the questions are to be considered “up to standard.” Those include “be closely aligned with the syllabus; be combined with practical competence testing; sample broadly from important content; be free from construction errors; use a criterion-referenced pass/fail level; be careful about reuse of questions; use the extended-matching question format” (p. 712). There are national question banks that are used in many schools, which allow an individual school or clerkship to compare student performance on an exam

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to a national mean of students at the same educational level. There are also local/specialty question banks, but one consequent issue is that the quality of questions varies. Conventional thinking was that MCQs primarily focus on factual knowledge. In spite of this, carefully constructed questions have been shown to measure clinical judgment and knowledge synthesis reliably and with adequate validity (Norcini, Blank, Arnold, & Kimball, 1984). Among the biggest criticisms of MCQs is the fact that the small number of alternatives presented may prompt students to the correct answer. The structure, it is said, reduces the validity of the method to accurately assess the diagnostic and treatment abilities of the trainees. Specifically, one process by which that happens and is itself an issue associated with MCQs is called the cueing effect. When there are four or five options available, the student can be cued toward a correct answer or away from a negative one (Schuwirth, van der Vleuten, & Donkers, 1996). In a comparison between MCQ and open-ended questions, medical students scored 11% higher overall and 22% higher on a subset of difficult questions when the same information was tested using MCQs as compared to open-ended questions (Veloski, Rabinowitz, & Robeson, 1993). Pickering (1979), in his publication entitled “Against Multiple Choice Questions,” criticized MCQs as artificial and “a hazard to the future of medical culture. . . Our present culture in medicine has been based on curiosity, the scientific method, and precision in thought and expression. The present generation of students is not encouraged to develop any of these habits of mind” (p. 85) – all of which, he states, are important habits in medicine. He emphasized the need for the establishment of continuous assessments that would allow the trainees to monitor their own progress and improve their performance. Open-ended questions (OEQs) avoid that cueing effect and, in one study of medical students taking a pathology course, have been shown to have slightly higher discrimination ability and equivalent reliability (Damjanov, Fenderson, Veloski, & Rubin, 1995). OEQs are considered to be a reliable and valid method of assessment of higher levels of knowledge (Fowell & Bligh, 1998). Others have shown that extended matching and uncued tests have higher reliabilities and better discrimination than MCQ tests (Fenderson, Damjanov, Robeson, & Veloski, 1997). Further, long-menu questions (LMQs) may reduce cueing, using a stem that is similar to MCQs, but including a long alphabetical list of possible answers rather than four or five possibilities. A comparison of LMQs, OEQs, and MCQs showed that LMQs and OEQs have similar psychometric properties and that while both avoid the cueing effect, the response time is greater and more time is needed for examinations (Rotthoff et al., 2006; Farmer and Page, 2005; Page and Bordage, 1995). Similar results were also found in a large study of resident and practicing physicians (Veloski, Rabinowitz, Robeson, & Young, 1999). Next, a look at the use of oral presentations, which have been used extensively to assess the knowledge and understanding of trainees in many postgraduate medical programs, higher education, and disciplines such as law and architecture. While the use of oral assessments has significantly declined, they continue to play an important role in western countries, Europe, and Canada. The use of the oral examination in high-stakes assessment has been criticized in the medical literature. One characteristic cited is low reliability due, it is said, to the

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active participation of an examiner in the process whose presence could possibly introduce bias; to the fact that each examiner receives a different set of questions, sometimes from various content areas; and to the various levels of prompting that examinees receive – all creating difficulties in either norm-referenced or criterionreferenced systems (Muzzin & Hart, 1985; Weingarten, Polliack, Tabenkin, & Kahan, 2000). Other concerns found in the literature are related to the cost effectiveness of the technique in terms of faculty time and to the high levels of stress for the examinees, especially those with low scores. In their commentary, “The place of oral examination in today’s assessment systems,” Davis and Karunathilake (2005) reported the following advantages of oral assessment: direct personal contact, assessment of problem-solving and reasoning, recognition of safe and competent physicians, assessment of professionalism and ethics, opportunity to probe depth of knowledge, flexibility from moving from one area to another, feedback on curriculum, and the ability to tailor the questions asked to the needs of each individual candidate. Several suggestions were made about the best practices with regard to the use of oral assessment, which include the following: (1) structure the oral on clinical scenarios, (2) use a number of orals, (3) use a number of examiners, (4) ask the candidates the same questions; (5) use descriptors, rubrics, or criteria for answers, and (6) train the examiners. The American Board of Anesthesiology (ABA) has used Oral Practice Examinations (OPE) to assess clinical competence. OPEs offer the opportunity to interactively get trainees’ responses to a somewhat standardized real-life clinical scenario and consequently assess problem solving, communication skills, and clinical judgment. An institutional study (Schubert, Tetzlaff, Ryckman, & Mascha, 1999) in the department of anesthesiology used an OPE modeled after the ABA to assess its residents from 1989 to 1993. The study evaluated 441 OPEs and were given to 190 residents. Each test consisted of 21 standardized guided-questions scenarios. Also involved were 17 faculty examiners who had met the internal criteria for participation. Each trainee reviewed a similar scenario prior to the oral assessment. A standardized grading sheet was used to guide the examination scoring. Results of the study demonstrated significant internal consistency (0.82) and inter-rater reliability (0.65–0.72) of the OPEs in the program. The OPE scores were positively correlated with other in-training assessment scores and were related to anesthesia training duration, exposure to prior OPEs, and trainee-assessed preparation. Finally, the OPE results correlated with other faculty assessments (Schubert et al., 1999).

Theology Again in contrast with the highly quantitative nature of the literature in the medical field, the theological literature about assessment of knowledge in the workplace is much more qualitative. Jouglin’s (2007) research on student conceptions of

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oral presentations builds on his and others’ work on oral assessment and student approaches to learning by providing an understanding of oral presentations as a type of assessment from the point of view of the student in a certificate-level theology course. The course was designed for teachers who taught religious education in Australia. It included an orientation work and series of self study sessions, in which students used self-instructional printed materials and then met in small groups to discuss them. The groups had access to a tutor and a group mentor. The course required the completion of six items of assessment in two semesters, and alternated between written papers and oral presentations. The presentations were short (5-min presentation followed by 5 min of questions and answers and 1 min of personal reflection). At the end of the presentation, trainees received feedback from the group and completed a feedback sheet, which was sent to the tutor with student notes. Both types of assessments had the same required tasks, which allowed for a comparison of the two methods. Students overall described the oral assessment as more demanding, stating that it required deeper understanding and led to better learning. In another article in the theological literature, Glennon (2008) discusses the learning Covenant in which he brings together diverse teaching theories in order to adapt to diverse learning styles. In an extension of this idea, he discusses using a group final exam in which the students write an essay in a cooperative manner. True to the goals of the profession, the purpose of the exam is not to identify gaps in knowledge or judge the individual learning of the students but to have a “thorough, intellectually stimulating, and useful discussion of course materials” (p. 38). From this essay, the author looks for mastery and deeper understanding of the ideas and concepts presented. In addition, the students evaluate the participation of each member of the group (including themselves) according to predetermined criteria.

Nursing The measurement of knowledge in workplace learning in the nursing literature also is heavily focused on the use of written items. The nursing profession has question banks for efficient use of MCQs, but there have been criticisms of the quality of some of those banks. Two analyses of several question banks for nursing MCQs showed a large number of violations of item-writing guidelines. In addition, almost half were written at the knowledge level of Bloom’s taxonomy (Masters et al., 2001; Tarrant, Knierim, Hayes, & Ware, 2006; Considine, Botti, & Thomas, 2006). In evaluating knowledge of medical/surgical nursing trainees, another study compared the effectiveness of oral examinations against traditional objective written examinations, consisting of multiple choice, matching, and true-false items. The study also looked at the effects of the assessment method on trainees’ learning by comparing scores and comments on course evaluations. Although oral assessment was stressful and time consuming for the faculty, it helped nursing students to develop more effective study habits by either studying individually or forming study groups that increased collegial exchange of real-life clinical scenarios. Oral examination scores were significantly higher and demonstrated improved learning,

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increased knowledge base, increased clinical thinking, and the ability to apply knowledge in clinical scenarios (Rushton & Eggett, 2003).

Education Similar to the theological literature, the education literature as it pertains to the assessment of knowledge while students are training in the workplace is relatively sparse. Much of the education literature focuses more on knowledge acquisition rather than assessment. One interesting article that adds to the discussion here concerns the fact that students have different preferences in their approach to studies. Some students prefer a deep method that focuses on meaning and understanding of a topic, while others prefer a surface approach that stresses recall and reproduction (Marton & Saljo, 1976; Biggs, 1979). Interestingly, a study conducted within an education course looked at the effect of the type of written assessment method on the approach students used to study for the test. The authors demonstrated that students were much more likely to use surface approach when they were studying for an MCQ exam and more likely to use deep approaches when they were studying for an essay test (Scouller, 1998). As with attitudes and skills, there are many ways to evaluate knowledge and many of the same methods used in the other sections are seen here. The assessment of knowledge in the workplace is heavily concentrated in the use of written methods. It is interesting that while considerable effort has been placed on improving the precision of the assessments, especially in medicine, the use of written assessments in the workplace is perhaps the farthest removed from the actual workplace. In the professions of theology and education, much of the emphasis of assessment of students in the workplace has been placed on skills and attitudes.

Conclusion Part 3 on Assessment reviewed research into the methods of assessment during workplace training for each of the four professions: medicine, nursing, theology, and education. While an analysis through the commonly used organizational structure of knowledge, skills, and attitudes revealed a considerable overlap among those dimensions across the professions, the literatures revealed respective differences. Still, there are more similarities than not in the assessment methods used in the different professions. Each seems to emphasize different methods currently, but there are examples of authors in each profession using the assessments of the others. There are examples of simulation in theology and education and of reflection in medicine and nursing. From the assessment perspective, the field of medicine is precision driven, with an emphasis on quantifying differences between students. The fields of theology and education are more focused on qualitative assessments, with more emphasis on helping the students develop as professionals in their own way. Also of note are

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the differences across professions in the level of precision needed for a method to be considered adequate. There is little in the literatures of theology and education devoting attention as to the validity and reliability of different assessment methods within their specialties. Another interesting perspective gained from this work was that the literature in theology and education emphasized the acquisition of skills and attitudes within the workplace, whereas medicine continued to focus substantial emphasis on continued knowledge acquisition even after the students had moved from the classroom to the workplace. The overarching awareness from this section is that each profession can probably learn from the other. Medicine may have more research into quantitative assessment methods, but there are areas within medicine where the assessments in the workplace could be improved by more qualitative methods, for example, in the use of essay questions or oral examinations to assess attitudes and deeper understanding of complex issues. Likewise, educators in the other professions may be able to gain more precision in their assessments of students in the workplace through rigorous use of simulation and other more quantitative assessment methods that have been used by medicine.

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Part IV

Implementation

Chapter 7

Faculty Development for Workplace Instructors Marilla D. Svinicki and LuAnn Wilkerson

MEMO To: Karen Jones, NICU From: Jeanne Smith, Nursing Clinical Manager, NICU Re: Preceptor for student nurse As you’ll recall, the unit agreed to have a student nurse assigned for the next month. Karen, thank you for agreeing to serve as her preceptor. Good luck and thanks for taking on this important duty. Karen thinks to herself, “That’s great. . ..I think, but now I’ll have the added responsibility of seeing to it that the student nurse has a good learning experience, along with keeping up with my own duties to the patients. How am I supposed to do both?! What am I expected to do?” Therein is the conundrum for the workplace instructor – how to get the job done and at the same time see to it that the student learns the key skills, understandings, and attitudes he/she needs to function as a professional in that particular setting. Perhaps the more amazing thing is that most workplace instructors are expected to succeed at this without very much training in what to do or how to do it.

The Target of This Chapter The foregoing chapters of this volume have dealt with the curriculum, learners, and instructors interacting in a workplace setting and attempted to tie them all together to give a solid description of who is doing what to whom and why. The purpose of this chapter is to step back one level of organization and discuss the preparation of instructors like Ms. Johnson to teach in those workplace settings. Figure 7.1 illustrates the relationships among the levels of teaching and learning that we are M.D. Svinicki (B) The University of Texas, Austin, TX, USA e-mail: [email protected] J.P. Hafler (ed.), Extraordinary Learning in the Workplace, Innovation and Change in Professional Education 6, DOI 10.1007/978-94-007-0271-4_7,  C Springer Science+Business Media B.V. 2011

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M.D. Svinicki and L. Wilkerson Level 3: Students who have been placed in the workplace as learners (Chapter 3)

Instructional strategies to help students learn workplace skills, the topic of Chapter 5.

Level 2: Instructors who have been assigned the task of developing workplace skills in students

Faculty development strategies to help faculty learn new teaching skills, the topic of Chapter 6.

Level 1: Faculty developers who have been assigned the task of developing the teaching strategies and skills of the instructors who are teaching in the workplace

Fig. 7.1 A visual depiction of faculty development for workplace teachers

dealing with as we attempt to improve workplace learning. The ultimate goal of workplace learning is to be successful at level 3 with the students who have been placed in the workplace setting to learn. Theories about learning that inform us about what is happening at the level were discussed in Chapter 3 by Harris, this volume. Strategies that will help the instructors at level 2 support the students as they learn were discussed in Chapter 4 by Henry and Malu, this volume. Strategies that will help those instructors learn how to support those students are the focus of faculty development (also called staff development or educational development in different countries and disciplines) and its practitioners, who are slotted at level 1. To use the more familiar workplace learning denotation, the faculty developers are the trainers who train the trainers. The focus of that training and this chapter is the workplace instructor,1 and the goal of that training is to make the workplace instructors more effective at helping students. The goal of this chapter is to identify evidence-based practices that can help that happen. We focus on this because the instructor is the key to successful implementation of a curriculum regardless of the level of instruction. From a cooperating teacher who is mentoring new student teachers at the K-12 level to clinical nursing instructors or preceptors like Ms. Johnson to the attending physician or residency director at

1 To clarify the workplace settings that we have researched for this chapter, we are studying clinical settings for the medical and nursing professions, student teaching in real schools and classrooms for the teaching profession, and placements in congregations and other social service settings for the pastoral profession. This means that we are targeting attending physicians or preceptors, clinical nursing supervisors or preceptors, cooperating teachers, and clinical pastoral education supervisors.

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a medical school who works alongside the students to treat the patients under their care, the success of learning in the workplace depends heavily on the skill of the workplace instructor to 1. 2. 3. 4.

recognize key skills and opportunities to teach them; set goals and evaluate their attainment by the student; observe the student and give supportive yet diagnostic feedback; and orchestrate all the pieces of the workplace learning environment so that the student gets the broad picture of what is required as well as the day-to-day skills to function in that environment.

And all the above must be done while maintaining the integrity of the workplace activities as well. There are still patients to treat, students to teach, clients to counsel, and administrative paperwork to maintain. Hawkins and Shohet (1989) lay out a process of supervision that highlights three key aspects of supervision: 1. an educational aspect (such as encouraging students to reflect on what they’ve learned, helping them develop understanding and skills, giving them both content and process feedback); 2. a supportive aspect (such as giving the students support as they develop a view of themselves as new members of the profession, being there so they won’t feel isolated as they learn, helping them explore their new responsibilities and the ethics of the field); and 3. a managerial aspect (such as helping them plan and monitor their time and effort, alerting them to resources that are available to help them, and ensuring the quality of their work). We have depicted the tension between these aspects as a contrast between roles in Table 7.1. It is often the case that workplace managers may not have had to be aware of these conflicts when they were supervising workers in a real work setting; perhaps the managerial rather than the educational and supportive aspects of their role have dominated their attention with employees. Of course, good managers would perform all these tasks already without realizing it, but it is their designation as workplace instructors that brings the two roles of the work to the forefront. An important aspect of being a workplace instructor is striking a balance between these two, sometimes conflicting roles. To complicate things, a third player may be inserted between the learner and the workplace instructor, representing the primary academic institution from which this learner comes. Such a representative is differentially referred to as the residency or clerkship director in medical education, clinical supervisor in nursing education, director of field education in the ministry, and supervising faculty in teacher education. As a supervising faculty member with responsibilities for multiple students working in multiple workplaces, this individual has obligations to both the educational institution in which the student is enrolled and the workplace setting at which they are training.

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M.D. Svinicki and L. Wilkerson Table 7.1 Competing roles for a workplace instructor Workplace instructor acting as teacher

Workplace instructor acting as supervisor

Who is the client? What is the dominant goal?

The student Student learning

What is the nature of the relationship? What is the focus of the feedback? What is the stance of the individual? What are the legal and ethical issues?

Coaching for learning

The workplace Reliable and competent completion of tasks Coaching for performance

More formative

More summative

More academically oriented persona Mostly ethical; possibly some legal

Practicing professional

How is the activity structured?

Mostly around the learning needs

Legal as well as ethical responsibilities for student performance Mostly around the workplace needs

The literature on mentoring/supervising in the workplace makes clear the necessity for there to be cooperation between the two individuals playing the teaching role, as conflicts between them only harm the students they co-teach (Beck & Kosnik, 2002; Borko & Mayfield, 1995; Bullough et al., 2002; Campbell & Brummett, 2007; Darling-Hammond, 2006; Melser, 2004; Smith, 2003; Valiga & Kear, 2008). Despite the importance of the workplace instructors to the success of workplace learning, they usually receive very little special training for the job. As Wilkerson and Irby (1998) observed: During the first half of this century, teaching expertise was assumed to be part of content expertise. If a faculty member acquired the knowledge of the discipline, she or he could teach (p. 387).

The assumption equating expertise in a skill with ability to teach that skill was seldom challenged. The belief was that only the most capable students were admitted into higher level programs and therefore there wasn’t much need to do more than apprentice them to a master of the craft. Under that assumption students would be very reluctant to criticize the clarity with which their professors taught, lest they be deemed not smart enough to learn. Thus the burden of progress in learning was placed squarely on the learners. Teachers taught the way they learned for the most part and were sometimes oblivious to the fact that learners might not all be like them or even like one another. Teachers were experts in the skills the students were learning, and that was sufficient. One exception to this situation is the field of teacher preparation. Here the workplace instructors are trained as teachers, albeit of a different type of student usually. “Cooperating teachers,” as they are called, are already teaching in the schools. They agree to mentor a student teacher, who joins them in the classroom to observe, assist,

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and eventually teach. Since cooperating teachers have been trained as teachers, one might think that the issue mentioned above wouldn’t apply. And yet and with other skills, even cooperating teachers in the schools have much to learn about being a mentor and supporting a new teacher. In many cases the preparation that these cooperating teachers need is not about teaching in general, but focused on the requirements of mentoring and the educational institution that is placing student teachers with them. For example, Giebelhaus and Bowman (2002) studied whether training cooperating teachers in either of two supervision models made a difference in the experiences that their student teachers had during the placement. They found that there was a significant difference in favor of training for some of the key skills, such as organization and creating a safe environment, when rated by the student teachers and trained observers. Similar findings of the impact of training were found in several other examinations of efforts to prepare cooperating teachers to supervise (Jin & Cox, 2000; Kent, 2001). Levine (1992) as cited in Schussler (2006) claimed that without preparation most cooperating teachers reverted to an “apprenticeship” model, without benefit of the analysis and reflection on the student teachers’ experiences that are the frequent focus of mentor training programs. An integrated approach to student teacher supervision and induction is seen most clearly in the Professional Development School (PDS) (Schussler, 2006; Stallings & Kowalski, 1990), a model for educating and supervising that was developed after the Holmes Group (a national partnership of K-12 schools and teacher preparation programs) suggested it as a way to improve teacher education. In PDS situations the student teachers have the bulk of their training directly in a K-12 setting with university faculty coming to those sites and teaching/supervising in the classes in collaboration with the cooperating teachers. This collaboration produces a much more coherent experience for the student teachers and is one model for workplace learning that allows formal learning and workplace learning to occur simultaneously. At the same time, the PDS model provides a vehicle for training of the cooperating teachers, since they are in constant contact with the teacher education faculty as well as the student teachers and have the opportunity to work closely with both. This kind of teamwork appears to result in much greater commitment to the program on the part of the cooperating teachers as well as providing professional development for them in their changed role (Schussler, 2006). Several researchers have studied the degree to which cooperating teachers were able to learn from their interactions with student teachers and found a definite professional development benefit, even for expert teachers (Arnold, 2002; Carroll, 2006; Colbert, 1997; Daane, 2000; Devlin-Scherer, Mitchel, & Mueller, 2007; Duquette, 1994; Kilbourn, Keating, Murray, & Ross, 2005; Kiraz, 2004; Landt, 2002; Lund, Gurvitch, & Metzler, 2008). In some pastoral education systems there is a certification process in place to prepare professionals who will be supervising student pastors (Certification Commission, 2005). In this faculty development process the focus is more on counseling skills, theoretical grounding, and personal depth and understanding of values and ethics consistent with “spiritual” caregiving (p. iii) than it is on teaching or

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supervision. The program is not necessarily one to prepare supervisors, but rather to lay out the key qualities of a pastoral student that need to be documented for certification and to approve the plan for achieving those goals submitted by the candidate and his/her own supervisor, such as a director of field placement within a seminary. Some seminaries that offer fieldwork programs organize workshops and programs for the supervisors to help them understand the goals and processes that the seminarians are to work through. In addition, at annual retreats cohorts of supervisors are created in a region to then serve as communities of practice for this role. A third group to provide some legitimacy to the need to train workplace instructors for their preceptorships is the nursing profession. In fact the current shortage of nursing faculty has prompted the National League for Nursing to call for increased training of staff nurses to supervise student nurses with an accompanying rise in status for those who become Certified Nurse Educators (Ortelli, 2008). The nursing profession in general has been very receptive to the idea of nurses going on to obtain degrees in nursing education. While quite a bit of the curriculum in most nursing educator programs is fairly academic in tone, there are some programs, such as the Colorado Center for Nursing Excellence, that are developing programming for clinical faculty (Kowalski et al., 2007). The curriculum of this programming is described more completely by Jarrett, Horner, Center, & Kane, 2008. The preceptorship in nursing (similar to mentoring) has helped to increase retention of nurses in the profession (Block, Claffey, Korow, & McCaffery, 2005). Most hospitals now include a department of nursing education to provide support for staff nurses both in new nursing techniques and in their supervision of student nurses. There has been movement in the medical profession for many years toward more attention to the enhancement of teaching skills of physicians and community preceptors, much of it stimulated by the birth of Family Medicine as a specialty in the 1970s (Holloway, Wilkerson, & Hejduk, 2007). Accreditation standards for medical schools require programs in faculty development focused on the improvement of teaching skills. One study (Searle, Hatem, Perkowski, Wilkerson, 2006) has identified 50 North American medical schools with a comprehensive educational program for physicians and other healthcare professionals interested in becoming more expert in medical education (Gruppen, Frohna, Anderson, & Lowe, 2003; Steinert & McLeod, 2006) in the form of “Medical Education Scholars” or “Teaching Scholars.” Many medical schools in the United States and Canada have created offices of medical education staffed by professional education specialists to provide the necessary educational support for curriculum and faculty development. The practice goes back to 1976 when medical schools approached colleges of education to work with them on quality teaching (Davis, Karunathilake, & Harden, 2005; Hitchcock, 2002; Hitchcock & Anderson, 2008). At that time individuals trained in educational theories and strategies were brought into medical schools, establishing the first offices of medical education and have contributed tremendously to what is known about the way medical students learn. It should be said, however, that some specialty groups, such as the Ambulatory Pediatric Association (APA), have developed programs such as the

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Faculty Development Scholars program to train faculty members to provide faculty development for their colleagues (Simpson, Bragg, Biernat, & Treat, 2004). One source of dissonance about teaching that workplace instructors experience is the change in the teaching situation from the way it was when many of those current teachers were students. With a much wider diversity of learners entering higher levels of education, simple exposure to content is no longer sufficient for student learning, as described in Chapter 3 by Harris, this book. The amount students have to learn has also expanded tremendously without a concurrent expansion of time to learn it. When the proliferation of new technologies and instructional methods that most workplace instructors have not themselves experienced as students (Smith, 2003) is added to that, the challenge of teaching in today’s workplace is expanded tremendously. Even workplace practitioners who are superb examples of their craft cannot be counted on to be excellent instructors for all students or in all situations. They need to develop as teachers, not just practitioners of their craft. It is the charge of faculty development to help them recognize and take that next step.

A Brief Overview of Faculty Development As noted above, most instructors who teach at the postsecondary level have not had any formal training in teaching, but are expected to pick it up on the job. In the 1970s this lack of support for instructors was highlighted by Gaff (1975) in a seminal book entitled Toward Faculty Renewal. Gaff made the argument that the largest investment that any institution has is its faculty. Over the years of an instructor’s 30 to 40 year career, Gaff noted that an institution makes well over a $1,000,000 investment in each faculty member. Investing in the well-being and high-quality practice of each instructor more than pays for itself. This argument was expanded by Svinicki (2002) to encourage those in charge of postsecondary institutions to provide support for faculty as a way of creating a self-sustaining resource of welltrained instructors capable of constant self-renewal. Since the mid-1970s, the field of faculty development has grown substantially until virtually every major postsecondary institution has a program that provides these opportunities for faculty. In 1998 Wilkerson and Irby provided a very comprehensive overview of the growth of the field with a particular interest in faculty development in medical education. Recognizing that ongoing research and theory building in the areas of learning and motivation have been the primary foundation of teaching improvement, Wilkerson and Irby tracked the changing focus of learning and teaching from behaviorist perspectives of the 1970s through the cognitivist perspectives of the 1980s and on to the socially based theories of the 1990s and the early 2000s (see Chapter 3). With those changing views of what learning is and how it is fostered, teaching practices changed from a focus on behavior change through one on cognitive change to one on the social nature of learning as joint meaning making and socialization into a knowledge community (Wilkerson & Irby, 1998, p. 398). Those changes were also mirrored in the strategies used to help instructors themselves learn. Early

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faculty development practices were primarily based on workshop/information delivery models along with classroom behavior observations and feedback. Skills such as writing behavioral objectives or providing clear goals with constant feedback to learners were often the focus of faculty development programs. Wilkerson and Irby (1998) tracked the shift of teaching behaviors that accompanied the shift toward a cognitive theory-based education system. What became important were the teachers’ thought processes as they carried out the design and implementation of instruction. Being able to recognize what learners brought to the situation and using that knowledge to tailor teaching to that prior knowledge was a key skill for teachers to develop. This “pedagogical content knowledge” as Shulman (1987) called it or “case-based teaching scripts” as Irby (1993) called it was recognized as a cross between the earlier content expertise that had been dominant in postsecondary education in earlier decades and pedagogical expertise that had been the mainstay of K-12 teacher training. An important skill that an instructor needed to develop in order to enhance that crossover type of knowledge was the ability to monitor and recognize his/her own thinking and how it affected teaching. Schön (1987) referred to this as reflective practice and held that it was a critical component of any profession. This emphasis on reflecting on one’s practice was seen in the growing popularity of faculty development practices that helped instructors to develop an understanding of why some instructional practices worked with some students and not with others. Recognizing that learners were complex thinkers helped instructors to move beyond a “one size fits all” type of instruction to more nuanced and varied methodologies, and the same was true for faculty development approaches. The third phase of learning theories highlighted by Wilkerson and Irby (1998) as the dominant model for education today is the recognition of the social nature of learning. This is an acknowledgement that learning is more often than not a social phenomenon. Interactions with others (or with the products of others, such as texts) result in reconsideration of one’s own interpretation of the world, which is eventually a reconciling of the perspectives of all who interact around a problem. This social constructivist view of learning asserts that learning is “socialization into a new knowledge community” (Wilkerson & Irby, 1998, p. 389). This perspective on learning is particularly pertinent to workplace learning, where students are learning to function as professionals in a field rather than simply as acquirers of information. Social constructivist-defined learning also depends heavily on learning from more experienced members of the community, another component of workplace learning. Smith (2003) highlights the social nature of workplace learning in the following passage: It appears, therefore, that reliable skill development beyond the level of procedural knowledge is likely to require more than training manuals or manufacturer’s handbooks. Guidance by a fellow human being and opportunities to explore through questions, discussions and action learning are also necessary (p. 61).

The shift to a socially based theory of learning was also reflected in faculty development practices. Rather than a single instructor learning from a direct presentation or a videotaped analysis of his/her teaching, socially based models of faculty

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development focus on peer learning and learning communities involving multiple instructors working together to understand and refine their teaching. Along with this emphasis on group support of instructor growth came a focus on research or evidence-based teaching. Begun as the Harvard Assessment Seminars (Light, Singer, & Willett, 1990) and paralleled by the Classroom Research movement (Cross & Steadman, 1996), interest in encouraging instructors to view their teaching with the same scholarly, questioning approach with which they view their disciplines was closely related to a landmark publication by Ernest Boyer entitled Scholarship Reconsidered: Priorities of the Profession (Boyer, 1990). Boyer suggested that the typical definition of scholarship promoted by the academy was too narrow and that postsecondary educators needed to recognize that there should exist a scholarship of teaching to go with the scholarship of discovery that most faculty thought of as worthy of the name. This push to study teaching and learning in the classroom by the instructor fit well with the idea of reflective practice championed by Schön (1987) described previously. As a result a large portion of faculty development now revolves around the Scholarship of Teaching and Learning in communities of inquiry (Huber & Hutchings, 2005) and the development of learning communities (Richlin & Essington, 2004), with instructors taking an active interest in understanding what is occurring at a deeper level in their students’ interaction with the class and content. In the next section we will describe the current status of faculty development practice, the evidence (or lack thereof) for its effectiveness, and examples from the four professions (medicine, nursing, teaching, and clergy) that we have chosen to highlight in this book.

Where Does Faculty Development in the Professions Stand Today? In a comprehensive survey of general faculty development programs, Sorcinelli, Austin, Eddy, and Beach (2008) found a consistent offering of the following activities: • • • • • • •

consultation for individual instructors; university-wide orientations; university-wide workshops; intensive programs (lasting from 1 week to year-long seminars); grants and awards for individuals and departments; resources and publications; and specialized services, such as technology support or measurement support.

In the Wilkerson and Irby (1998) work as well as in other publications (Barnes, 1999; Nursing Executive Center, 2008; Chism & Szabo, 1997; Clark et al., 2004; Gillespie, Hilsen, & Wadsworth, 2001; Skeff, Stratos, & Mount, 2007; Steinert, 2000; Steinert et al., 2006), the authors lay out very similar catalogs of faculty development practices that have risen to the top as the most commonly used strategies.

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Skeff et al. (2007) show how faculty development activities are increasing in acceptance, especially within the period since the late 1990s as evidenced by published articles. Despite this fairly consistent set of offerings, the various articles are often critical of the field because the studies they report did not provide hard evidence based on stringent research that these strategies had significant impact on the teaching practices of faculty. Chism and Szabo (1997) conducted a survey of professionals in the field of faculty development to determine how they evaluated the programs that they offered. Although almost all programs evaluated their activities regularly, the evaluations were done mostly for program improvement or to document their efforts rather than for publication or to advance the knowledge base of the field. This finding is reasonable given the fact that most faculty development programs began as, and remain, service-oriented programs rather than scholarly academic enterprises. For example, in open-ended responses at the end of the Chism and Szabo survey, a frequent observation by the respondents had to do with the amount of time such evaluation would take away from their ability to serve their clients for very little return on their investment. The types of evaluation strategies used were primarily of user satisfaction rather than deeper levels of impact, for example, on student learning. Wilkerson and Irby (1998) noted in their review of the medical education literature that “there is a paucity of experimental research on the effects of teaching-improvement interventions” (p. 390), a finding echoed by Steinert et al. (2006) in a report for the Best Evidence Medical Education (BEME) Collaboration. Wilkerson and Irby did, however, acknowledge that there were more quasi-experimental studies and qualitative studies being published than there had been in the past. In the 2006 BEME report Steinert et al. (2006) did a systematic review of the literature on faculty development efforts in medical education in order to answer the following question: What are the effects of faculty development interventions on the knowledge, attitudes and skills of teachers in medical education, and on the institutions in which they work? (p. 499)

In their review of the literature Steinert et al. included study designs that fit several different paradigms, including positivist, interpretivist, and participatory. However, they only retained studies that included measures beyond participant satisfaction and looked for evidence of learning and change. They sorted the articles on the basis of a focus on faculty development for basic science and clinical faculty members, adherence to the paradigms just listed and a publication date of 1980–2002. Steinert et al. ended up with only 53 out of an initial 2,900 articles that met their criteria. They conclude by calling for more rigorous designs as well as increased use of other paradigms, such as qualitative and mixed methods along with new areas in which research should be done. A similar critique of the literature on more general faculty development (as opposed to that restricted to medical faculty) by Aleamoni (1990) argued that one of the most pressing needs for good evaluation of faculty development programs was creation and validation of high-quality measurements of the phenomena

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to be studied. The changes that faculty development programs often seek are changes in attitudes or tendencies that take place over several semesters rather than immediately. Measuring such changes more often requires a different type of data collection than solely quantitative measures. If one looks closely at the type of situations in which faculty development work is done, the methods and assumptions of qualitative research are a better fit. The desire to have high-quality interventionist research of the type seen in the experimental literature may be more difficult to fulfill in a faculty development setting for these situational factors in addition to the measurement issue raised by Aleamoni. Since these phenomena also have to be demonstrated in real instructional situations, the realities of the timing and unpredictability of real classes can easily disrupt any given implementation, forcing a much longer timeline in which to demonstrate effects. In addition the number of participants in any single faculty development project is usually quite small, making it difficult to have sufficient power given small effect sizes to be able to draw statistically valid conclusions. Concern over the rigor and appropriateness of the research being done in education in general and faculty development research in particular has prompted several individuals to offer their own perspectives on how this might be done (Allen, Eby, O’Brien, & Lentz, 2008; Bligh & Brice, 2008; Colliver, Kucera, & Verhulst, 2008; Eva & Lingard, 2008; McLeod, Steinert, & Snell, 2008; Nolan, Hawkes, & Francis, 1993). Along with Chism and Banta (2007) and Skelton and Buckley (2008), we would suggest that a broader perspective of program evaluation be taken to respect the conditions under which most faculty development programs are operating. The nature of faculty development work lends itself more readily to qualitative methods, provided they are carried out with the appropriate safeguards to ensure the trustworthiness of the data gathered and conclusions reached.

Types of Learning Opportunities for Workplace Instructors In their 1998 article Wilkerson and Irby discussed three main types of learning opportunities for medical faculty:(1) workshops, (2) consultation about teaching, and (3)faculty development fellowship programs. In this chapter we will echo and build on those types of programs by adding some recent versions that seem to have promise in helping all faculty members improve their performance as teachers. The newer additions to the array of instructional options for faculty usually emanate from the socially based learning theories that Wilkerson and Irby identified as the trend in psychological understanding of learning.

Workshops – How to Structure Them In general we can characterize these as group-based instructional settings focused on a single topic and lasting from a few hours to those that continue for an entire academic year, although the latter would more likely be referred to as seminars

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or courses. In general, preference is given to longer term programming because of the complex nature of what is being taught, the need to integrate what is being learned into the workplace learning setting, and the generally full schedule of most instructors’ lives. For example, Barnes (1999) describes a typical workshop structure for theology supervisors, consisting of 2 weeks and 2 weekends during a year, and reports that this format is very common. In a larger study of faculty training Hall, Fisher, Musanti, and Halquist (2008) reported an analysis of grant reports documenting projects to help university faculty integrate technology into the teacher preparation curriculum across a wide range of institutional types and found that workshops were by far the most frequently used method for faculty development (14 out of 34 projects). Steinert et al. (2006) reported that 23 out of the 53 studies of faculty development in medical institutions on which they based their analysis were workshop format. Although these researchers reported generally favorable results for workshop-based studies, the data were mostly self-reports and very few had a control group comparison. Very few reported student results and the one that did found very little effect on student learning. In another research study on the value of workshops, Pichert, Stetson, Lorenz, Boswell, and Schlundt (1993) reported that the impact of even short workshops held up over time. An interesting discussion of what might impact the staying power of workshops was provided by Rubak, Mortensen, Ringsted, and Malling (2008). In their analysis of short- and long-term effects of a training workshop required for all faculty at their institution, these authors cite two possible explanations for why they found effects from their training sessions while others had not. First was the speculation that participation in the workshops gave the faculty members a common vocabulary with which to discuss their teaching, something that would be equivalent to a “discourse community” (Lave & Wenger, 1991). Having that common vocabulary facilitates communication and possibly even shapes the way its members think about their work. A second possible cause was the reaching of critical mass when it came to knowledge about and interest in teaching. Since all the participants in the intervention group were required to participate, a sufficiently large number of knowledgeable people then existed at that hospital to allow them to feed off of one another’s experiences and ideas. If indeed this latter possibility is the cause of their success, it might be a problem for workplace learning faculty development, since there would usually not be a large enough number of instructors at any one workplace to constitute a critical mass to sustain this type of discussion. Other ways to create that mass might have to be explored, such as online communities of practice for dispersed participants. This possibility is discussed later in this chapter as part of the discussion of learning communities. Although Hall et al. (2008) found several different models for training used across institutions when investigating the infusion of technology into faculty practice, they reported that the familiar barriers of time and support were the most frequently mentioned sources of difficulty in getting the faculty to participate in these programs. They found that no one model fits all the situations addressed in the grants, nor did there appear to be much of a difference across models in their ability to help faculty develop these skills. They report:

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The major insight from this document analysis is the importance of flexible, multi-pronged means of supporting faculty members’ skills development and visions of technology use in teaching and learning. Other insights include the importance of individualized, just-in-time learning; faculty understandings of the relevance of proposed changes; and the ability of incentives to create interest in grant participation but not to sustain long-term participation (p. 30).

This refrain is heard in other venues, such as Steinert (2000), who acknowledges that the current methods of workshops and seminars have the ability to produce some change in instructors’ beliefs and methods. She also exhort the field to diversify the methods used in faculty development in recognition of faculty needs: . . . we must design programs that are sensitive to the needs of different faculty members. We must also consider differing faculty roles and address the various developmental stages of faculty members. Adult preferences for learning vary significantly and we should try to offer a variety of methods and content areas, tailored to individual and organizational needs (p. 48).

Another study of the critical features of professional development in an education setting was done by Garret, Porter, Desimone, Birman, and Kwang (2001). These researchers surveyed a very large, but well-selected sample of teachers who had taken part in one of a number of federally funded teaching improvement programs as part of the Eisenhower Professional Development Program. In this project no single type of training format, focus, or content was being studied; rather institutions or organizations applied to receive funding to support a wide range of faculty development activities. The participants of those activities were asked to indicate the Eisenhower-supported program in which they participated and the impact that it had on their teaching behavior. Participants were asked to categorize the type of activity, the duration, the coherence with their work, and several other features that the literature had indicated might be influential for a program’s success. A subsequent regression analysis indicated that the key predictors of high-quality outcomes for this particular population were (1) sustained contact over a longer period of time, (2) a focus on the academic content, (3) hands-on work, and (4) integration into the daily life of the school. There was also support for collective activities that involved instructors from a common school setting. Although these researchers were focusing on teaching of mathematics and science in the K-12 system, the results resonate with other calls for improvements in faculty development models. Steinert (2000) also believes “. . . we should consider the development of ‘formal’ mentorships, integrated longitudinal programs, decentralized activities, self-directed learning initiatives, and computer-based faculty development” (p. 45). There is evidence in support of this belief. For example, Gozu et al. (2008) involved medical faculty in an extended 10 month, one half day a week program around the topic of curriculum development. Cohorts of participants and non-participants were compared pre–post after 6 to 13 years beyond the initial training and showed a statistically increased (self-reported) ability to work with curriculum development tasks and issues between participating and control instructors. Although there are many drawbacks to this report, it does indicate that the learning experience was related to faculty development and retention of the skills taught. More directly Notzer and

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Abramowitz (2008) conducted a pre–post with control group study of the impact on student perceptions of clinical medicine faculty members who participated in an 8-h workshop on instructional skills. Student surveys showed improved scores for those instructors who took part in the training. The authors were pleased to find this effect for what was in their perspective a fairly short amount of training. We would support Steinert’s (2000) call for diverse programming, especially with workplace instructors, who are generally dispersed across many locations, whose time slots for training and supervision vary greatly, and who frequently do not receive adequate compensation for the time they spend supervising workplace learners. Training for these individuals demands the 24/7 just-in-time approach to learning that is found more readily in staff development in business and industry. However, we would note that the interpersonal connections between workplace instructors and others responsible for student learning are an important component of any workplace learning format, both for the students and for the instructors. Smith (2003) has summarized the characteristics of workplace learning after reviewing a large body of literature and concludes that in workplace learning it is the interaction between the participants that allows for the deepest understanding of the skills and knowledge needed to develop. Barnes (1999) echoes that conclusion in her study of workshops for religious faculty. Community was the first and most important characteristic of a successful workshop cited by her study population. Although Smith is describing the experience of the learners in a workplace setting, one can easily extrapolate that to include the workplace instructors as learners in the workplace situation of teaching. They, too, benefit from an acknowledgement of the adult learning strategies that involve control by the learner, flexible schedules and guidelines, and participation in a community of practice. Smith cites Billett (1994) as making the connection between workplace learning and the concepts of socio-constructivism with regard to learning: that learning is a socially negotiated activity that takes place in authentic settings with authentic problems and involves a learner interacting with a more knowledgeable peer who supports the learner’s initial participation in the process, but gradually withdraws that support as the learner becomes more capable of completing skilled tasks on his own. That is an excellent description of learning in the workplace. Although these theorists were speaking about the students as learners of a skill, the principles hold for the instructors as learners of how to teach. However, as is the case with any instructional method, the method chosen should match the learning objectives in order to maximize effectiveness. So we would encourage faculty developers to use a range of strategies, including short presentations, active learning methods, long-term participation, self-guided instruction, and other methods yet to be studied. In recognition of the research on workshop qualities done by Garret et al. (2001); Loucks-Horsley, Love, Stiles, Mundry, and Hewson (2003); Parsad, Lewis, and Farris (2000); Sprinthall, Reiman, and Thies-Sprinthall (1996); Steinert et al. (2006) representing a wide range of audiences, settings, workshop strategies, and topics, the following qualities seem to stand out as important for workshop success: 1. a focus on development of deeper content understanding by the participants; 2. opportunities for active, experiential learning in applying concepts learned;

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3. collaborative learning, particularly between teachers working in a common setting; 4. sufficient duration (more than 8 h) to allow for the above; and 5. recognition of the nature and needs of adult learners. Adherence to the above suggestions seems, in general, to produce satisfaction and results at various levels of outcomes. Steinert et al.’s (2006) review of the literature on faculty development workshops in medical education drew the following conclusions about their ability to produce various levels of learning. Overall satisfaction with the programs was high and the content relevant and useful. In terms of changes in attitudes most participants reported a positive change in their attitudes toward teaching, including awareness of themselves as teachers and increased enthusiasm for teaching. Participants also reported increased knowledge and skills related to teaching. The foregoing was accompanied by self-reported changes in teaching behaviors as well and an increased participation in educational innovations and programs at their institutions. Steinert et al. (2006) also indicated a few issues that should be explored further. First was the context for these workshops and the impact of that context on the outcomes. Most important of these was a match between the needs of the participants and the design of the workshop. Where the program had been designed for a particular purpose and a particular group, the results were more positive. The results also varied with the nature of participation of those who took part. For example, Steinert et al. recommend that the kind of participation be factored into studies of workshop impact. Those who have a more active role in the program, or who participate as part of a group, or who are more experienced teachers might have different outcomes from workshops than individuals who are less vested in the program. Steinert et al. also believe that the duration and format of the program are important factors that merit further research. They note that more of the studies in their analysis involved traditional workshop structures of face-to-face teaching for a short period of time. They believe that recent developments in instructional methodologies including those using technology need to be investigated as alternatives.

Workshops – What to Teach the Workplace Instructors Perhaps a less-obvious consideration is what topics should be the focus of the workshop instruction for workplace instructors. Using a Delphi technique to tap the aggregate wisdom of the leaders in medical education, McLeod, Steinert, Meagher, and McLeod (2003) created a list of 30 concepts most important for clinical teachers. Clustering these into four major categories, the researchers concluded that the key areas for development of clinical instructors were (1) curriculum design, (2) adult learning, (3) how to help adults learn, and (4) assessment. The list they include in their paper could easily form an entire curriculum on teaching for clinical instructors.

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In another study of the qualities of preceptors Huggett, Warrier, and Maio (2007) differentiated between qualities needed by preceptors of new medical students as opposed to preceptors of more experienced students. One can see from reviewing the two lists that the latter preceptors needed to be able to emphasize self-determination in their learners such things as autonomy and self-reflection as opposed to more demonstration of expertise. This would indicate that preceptors could benefit from the kind of faculty development curricular structure possible in a longer program and not just single workshops. Although there is still the need for workshops on the standard topics that worry new teachers, such as learner management, direct instruction versus active learning, and balancing theory with praxis, there has been a sufficient amount of change in educational practices over the recent years that some topics might be unfamiliar even to more experienced teachers. What follows are some examples of topics that are coming to the fore as aspects of workplace learning and with which these instructors might not be familiar: • the How People Learn model, a National Academy of Sciences-commissioned synthesis of research on learning (Bransford, Brown, & Cocking, 1999); • learning through self-reflection (Forneris & Peden-McAlpine, 2007; Moon, 2004; Smedley & Penney, 2009); • assessment and feedback strategies (Booth, Hargreaves, Bradley, & Southworth, 1995; Kilbourn et al., 2005; Dudek, Marks, Wood, & Lee, 2008); • the cognitive apprenticeship model (Collins, Brown, & Newman, 1989); • coaching (Anderson & Radencich, 2001; Holmboe, Hawkins, & Huett, 2004); • socialization strategies (Ashforth, Sluss, & Saks, 2007; Saks, Uggerslev, & Fassina, 2006); • stages of development of expertise (Smith, 2003); and • situated learning (and transfer of skills) (Brown, Collins, & Duguid, 1989).

Online, On-Demand Training for Faculty As noted earlier, workplace instructors may be located in many different places rather than being concentrated at a single workplace. They also very likely work on different schedules, making group instruction difficult to provide. A logical alternative that has become much more feasible in recent years is online learning for training workplace instructors. If training in the skills, background knowledge, and attitudes and beliefs required of these instructors could be made available in the 24/7 online format that has begun to take hold for many forms of training, including business and industry, it would become much easier to provide development to match their needs. This would remove one of the barriers for recruiting workplace instructors: the time involved in preparing them to work with the students. Steinert (2000) advocates for medical educators to develop computer-based programs for faculty development.

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An example of just such a program was developed at the University of Nebraska, Lincoln, by Steckelberg et al. (2007) to prepare classroom teachers (the cooperating teachers) who were going to be responsible for supervising para-educators to work with special needs children. The Web-based program consisted of several modules on key issues in working with para-educators. The cooperating teachers worked through a series of typical situations they would be likely to encounter and constructed responses that they could use in such a situation. These responses were then graded by a university supervising instructor and feedback was made available to the cooperating teachers. Some material was presented in a way that could be tested using objective items on tests, which could be graded automatically. All posttest knowledge scores exceeded the pre-test scores significantly, but there were no control participants to determine whether the change was a function of the intervention, the pre-test, or some other cause. In addition the cooperating teachers created case studies in how they would integrate what had been learned into their practice. They also evaluated the utility and ease of use of the Web-based materials. The materials were rated as very relevant and appropriate by the participants. The authors conclude that online delivery of professional development was effective in this case. Taking a different approach, the physician Preceptor Development Program in Asheville, North Carolina, created an array of self-paced learning materials that were made available to community preceptors (Langlois & Thach, 2003) over a period from 1997 to 2000. The materials took several different forms, including written materials, web-based materials, and even videotaped lessons. These developers found it hard to monitor the actual use of these materials, but they felt that not as much use was being made of them as they had hoped. Although the use of Web-based or other online technology strategies for faculty development is probably going to increase over time, not all educators are convinced that it is the solution to the problems raised by the constraints of workplace instructors’ time and situation. Smith (2003) provides a very solid discussion of the need for “flexible delivery of training” (p. 71) for workplace situations, but he also cautions that computer-based instruction cannot be the answer for all workplace instruction. He begins by saying that “recent research has been designed to determine how computer-mediated communication (CMC) can be used to provide for human interaction in a context of flexibly delivered workplace learning” (p. 75). In this section of a very comprehensive article Smith goes on to argue that recent theories of learning that acknowledge the social nature of learning assert that it is the human interaction in teaching and learning that is its most powerful component. While technical information and procedural practice can be handled by the everadvancing technology of computer-assisted instruction, the need for face-to-face or at least person-to-person interaction cannot be denied. Therefore even if workplace faculty development makes a move to online 24/7 delivery, there needs to be a mechanism by which the workplace instructors still have an opportunity, possibly by CMC, to interact with others in a community of practice. Alford et al. (2008) also found that face-to-face instruction was important to build teaching confidence among preceptors and to teach some skills that could not be taught otherwise.

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Extended Seminars and Fellowship Programs In line with this latter observation about the need for building communities of practice, several faculty development programs have moved beyond the single-topic short workshop format. Although some community can be built in short (less than 8 h) workshops, learning over a longer period of time allows for a much deeper and richer exploration of a topic with accompanying application attempts and critiques interspersed between didactic sessions. This model might be even more appropriate for dispersed workplace instructors because they are often the only instructor at a participating site and are thus deprived of the spontaneous collegial discussions that can occur among instructors working in the same venue. In addition, having attention focused on teaching over a longer period of time gives it more weight in the eyes of the participants. Steinert (2000) cites several studies that support the idea for programs that are integrated and longitudinal. In particular she mentions the Teaching Scholars program at North Carolina (Stritter, Herbert, & Harward, 1994, as cited by Steinert, 2000). She emphasizes that these extended programs allow the teaching faculty to continue their clinical work while at the same time developing their teaching skills. These extended seminars also have the ability to combine several strategies that have been beneficial in promoting learning over the long term. For example, Pololi and Franken (2005) describe a year-long program for medical faculty that consisted of several parts, including day-long sessions every month along with “booster” luncheons, also monthly. Some sessions involved demonstrations of learner-centered teaching practices or discussions of relevant teaching concepts. Groups of participants practiced and discussed teaching strategies. In the long sessions, reflective discussions on a range of issues with which the participants were dealing gave them sufficient time to work through their feelings and concerns. Some of the groups identified projects of various kinds and volunteers worked in small groups on those projects. There were also individual activities, such as journals, that allowed individuals to reflect on their own practice throughout the period. The organizers also gathered evaluation data through individual written responses to prompts, individual self-assessments of progress, and paired interviewing. These data were analyzed qualitatively for evidence of impact on teaching, increased self-awareness, and the development of community feelings. All three themes were found in the responses from the participants. The researchers also felt that the opportunities to reflect on teaching, which were part of the design, had a great influence on the development of the participants’ leadership growth. A study on the extended training of cooperating teachers in the school system showed an even more important result: the impact on the student teachers. Giebelhaus and Bowman (2002) compared the performance of preservice teachers who were supervised by cooperating teachers receiving a 1-day orientation to their task or by cooperating teachers who had 10 sessions of training on very specific mentoring skills and models. Although there were differential effects depending on the specific student outcome being observed, the researchers concluded that the extended training made a difference in teachers’ ability to impact student

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teacher behaviors. The authors conclude that it is worth while to provide such extended training for mentors. However, in at least two examples of very extended (a full semester) training for cooperating teachers (Jin & Cox, 2000; Kent, 2001), researchers found that although the cooperating teachers reported learning a great deal about supervision from the course, only a small number actually implemented the strategies they had learned while supervising their student teachers. In both cases the cooperating teachers felt that the demands of the workplace kept them from using more of the sophisticated strategies to which they had been exposed.

Communities of Practice and Other Peer Learning Strategies It is possible that this last observation cautions us to be wary of asking too much of workplace instructors in terms of additional training. Whether this is because of the demands of their job or possibly because they feel that they already have all the skills that they need to teach cannot be discerned from these two studies. There is some evidence that an approach different from a training seminar might allow both clinical instructors and their advisees to prosper. In this type of approach, the goal is to build a community of practice consisting of all the clinical instructors, the supervising instructors that represent the institution, and even the student learners. As a constantly growing community of practitioners, every participant contributes and benefits from the interactions (Chism, Lees, & Evenbeck, 2002; Lave & Wenger, 1991). There is quite a bit that has been written about how cooperating teachers feel that they have learned and become better teachers from the experience of supervising student teachers, for example (Ganser, 1996; Kiraz, 2004; Landt, 2002; Lund et al., 2008; Tatel, 1996). In Arnold (2002) a cooperating teacher describes how she and four of her colleagues, also cooperating teachers, took the opportunity to form a study group during the time in which student teachers were assigned to their classrooms. Through journals, teacher study group transcripts, teacher questionnaires, and student surveys, she looked for changes in the way the cooperating teachers carried out their responsibilities and the impact it had on their student teachers. Analysis of the various data sources led her to the following conclusion: As a result (of their participation in the group) they (the cooperating teachers) appear to gain confidence, seem less anxious, and are able to reaffirm their values, principles, and sense of purpose as teachers (p. 130).

In a similar study Carroll (2006) reported an additional benefit of creating the cooperating teacher study group format: the cooperating teachers began to feel a greater sense of accountability for what was going on in their school. In effect, teachers’ identities were transformed from relatively passive cooperating teachers, following the direction of teacher education program guidelines and procedures, to active school-based teacher educators, consciously developing repertoires of mentoring practice, and taking initiative to remake the culture of their school as a context for learning to teach (p. 3).

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This expansion of the cooperating teachers’ perspectives on teaching, themselves as teachers, and their role with respect to the student teachers has been found in several studies with a variety of formats. For example Daane (2000) chose to create teams of cooperating teachers that would assume total responsibility for overseeing the learning of the student teachers. The teams met regularly to compare notes and collaborate on activities. These cooperating teachers said that they felt more professional under these circumstances and more aware of what was happening to the student teachers and to the students in their classes. Devlin-Scherer et al. (2007) used the new technique of “lesson study” with a group of cooperating teachers. In this model the cooperating teachers were offered an on-site course in which they planned lessons together, generated data collection strategies to determine whether the lessons were successful, observed one another teach the lessons to actual students, and then reconvened and critiqued the lesson as a group. The technique has been very successful in Japan as a way of helping even seasoned teachers become more aware of what is happening with students during a teaching episode. An example of clinical nursing teaching that is somewhat similar to the lesson plan used by teachers is described in a “best practices” volume compiled by The Advisory Board Company Nursing Executive Center (2008). The University of Portland School of Nursing developed a teaching simulation lab similar to clinical labs used in nursing education. Here, however, the simulations were of student nurse/clinical preceptor interactions that commonly occur and require instructor intervention. For example, the participants view a “student nurse,” working under the supervision of a preceptor, who “accidently” breaks sterile technique. The preceptor has to respond. Her response options are then discussed by the instructors in training, the “student,” and the master teacher. Alternative scenarios can then be played out. After viewing the modeled interaction, each preceptor is then paired with a student nurse who deliberately makes errors in the procedures, allowing the preceptor to practice her newly learned strategies. (This situation would be somewhat similar to the use of standardized patients taught to portray a patient with a particular condition. Medical, nursing, and other health science students get to practice with these patients before interacting with a real patient.) The preceptors receive feedback from the other participants on their responses to the situation. Another type of peer learning happens when multiple workplace instructors are working with a common group of students. This creates a need to coordinate the training of the students, which then requires the instructors to work together, either across workplace settings or between the academic institution and the workplace. In the student teaching setting, McIntyre, Byrd, and Foxx (1996) make a very good case for the value to students of having more than one mentor. They find that having multiple mentors reduces the learners’ tendency to just imitate what their mentor does. Instead they have an opportunity to compare practices, which causes deeper processing of what is going on with any given skill. In addition, coordinating across instructors makes learning more coherent because the requirements of the institution as well as the workplace must be in sync for the system to work best (Beck & Kosnik, 2002; Darling-Hammond, 2006; Smith, 2003).

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This building of a community of practice among teachers and students was part of the logic that undergirds the movement toward the creation of Professional Development Schools (PDS) in the K-12 educational system described earlier. The structure of the PDS put the university instructors directly into the workplace settings, the schools, rather than attempting to teach from afar. University faculty and cooperating teachers were then interacting on a daily basis and beginning to see themselves as partners in the development of the student teachers. University classes involving the student teachers were even taught on site. The participants became a community of practice in the best sense of the term with all partners being treated with respect and attention and giving the students a sense of the profession as a community as well. In a thorough review of the PDS development, Stallings and Kowalski (1990) give a very clear picture of the role of the cooperating teachers in this arrangement and the degree to which their own perspective on teaching and on themselves as professionals changes as a function of being a part of this organizational structure. This phenomenon of teachers becoming collaborative researchers into their own practice has been mirrored in the postsecondary arena with the rise of the Scholarship of Teaching and Learning (SOTL) movement (Cross & Steadman, 1996; Huber & Hutchings, 2005; Lieberman, 1996) and other peer learning structures such as learning communities (Richlin & Essington, 2004). The Carnegie Foundation for the Advancement of Teaching has been sponsoring a program, the Carnegie Academy for the Scholarship of Teaching and Learning (CASTL), in which faculty from a wide range of disciplines and institutions are brought together to conduct research on teaching at the postsecondary level (there is also a branch for K-12 teachers) to create a foundation of evidence-based practice in teaching at that level. Carnegie Scholars also are expected to involve their own institution’s faculty in an effort to spread the benefits of CASTL (Huber & Hutchings, 2005). These programs are somewhat similar to Teaching Academies that have been formed by medical schools, such as by Harvard and the University of California, San Francisco (Rider, Cooke, & Lowenstein, 2002), and the University of Texas Academy of Health Science Education, made up of the best and most innovative instructors across all medical and health science campuses of the System. The concepts behind such collaborative activities are very much in line with the socio-constructivist approach to learning as described in Chapter 4. As workplace instructors work together or with institutional instructors to solve learning problems of student interns, the shared understanding that develops enhances everyone’s ability to practice. In some cases the community might be a temporary one such as that in the Wabash Center for Teaching and Learning in Theology and Religion (Marshall, 2005). Here instructors are brought together away from their home setting for an extended period to reflect critically on their teaching and design individual as well as group studies that address the questions that their reflections and discussions raise. Since the participants come from many different settings, they create a much broader community of practice in the teaching of theology by returning to their home base and passing along what they learned. This development of cohorts of individuals who support one another seems to be a very consistent practice in the training of

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clinical pastoral educators (Certification Commission, 2005). These cohorts continue on for many years in some cases. This particular model of bringing dispersed instructors together for some period of reflection and discussion might be especially applicable to workplace instructors in settings where they are isolated from other instructors due to distance or timing, as are the pastoral supervisors. Another way to deal with the single instructor placement issue would be through the use of technology and online learning communities (Lock, 2006; Sprague, 2006; Sherer, Shea, & Kristensen, 2003; Steinert, 2000; Steinert et al., 2006) although this avenue for faculty development has not reached its full potential yet. The technology can even be used for supervision as in online coaching, that has been explored in student or first-year teacher supervision (Frey, 2008; Steckelberg et al., 2007). Providing workplace instructors with virtual communities of colleagues should both reduce their feelings of isolation and increase their resources to deal with instructional and student intern issues while not requiring the time involved to travel to a central location for training.

Consultation with Feedback The final faculty development practice discussed by Wilkerson and Irby (1998) is the practice of consulting with individual faculty members who wish to learn more about their teaching in an effort to make it better. Early researchers (Brinko, 1997; Hicks, 1999; Piccinin, 1999) reported that instructors who received feedback with support from a consultant were able to do more in improving their instructional practices than those who received only feedback. This has become standard practice in faculty development, although it is a very time-consuming and expensive process. As a result faculty development programs are always experimenting with alternative strategies that might be equally effective as face-to-face individual consultation, but require fewer resources or make better use of the limited resources that most programs have. Providing such individual consultation to workplace instructors has the possible confounding difficulty of having worksites spread out from the main campus, thus requiring consultants to have to travel from site to site, another possible addition to the expense of the program. One strategy that has long been used in faculty consultation is the use of peers as consultants. Cox (1999) reports on the effort to combine faculty consultation with faculty learning communities such that a faculty member could receive several perspectives on his/her teaching, each of the perspectives responding to a different aspect of the faculty member’s questions. The individual might receive contentrelated feedback from a colleague in a similar discipline, clarity of presentation from a colleague in a different discipline who approaches the content as a novice, organizational strategies from an expert educational consultant, and ways to vary his/her approach from a learning community of faculty teaching similar courses. In another instantiation of consulting Koehler, Mishra, Hershey, and Peruski (2004) involve graduate students in working with faculty on instructional design

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issues around the use of technology in teaching. The faculty members provide the content expertise and course direction while the graduate students, many of whom are more advanced in their understanding of technology applications, provide the technology expertise and the bulk of the work required to design technology-based instruction. The design team is rounded out with technology specialists who can make it all work. Koehler et al. describe this process as the “learning by design” approach and asserts that this integrated approach to consulting gives the faculty member much more control over the whole process of instructional improvement. This was noted by Smith (2003) in his description of flexible delivery of instruction for workplace learning. Along with several other sources, Smith asserts that a key to flexible delivery is control by the client (in our vocabulary, the workplace instructor). One resource that Smith (2003) cites as making flexible delivery of instruction possible is technology, specifically computer-mediated communication (CMC). This would also be possible as a way of providing consultation to workplace instructors who might be dispersed at several sites. Smith cites several examples of CMC used to provide the kind of individual and group communication for learners in the workplace that could be adapted for use by the instructors as well. For example, as noted earlier, creating online communities of practice for workplace instructors would be an easy extension of the use of the technologies that were developed for students. Similarly there have been programs for K-12 teachers (Sanchez & Harris, 1996) and in work settings (Ensher, Heun, & Blanchard, 2003) that provide online mentoring of learners or workers. Workplace instructors could just as readily receive mentoring, coaching and/or feedback from a supervising instructor who is monitoring the field placement of students. Whatever the vehicle of consultation and feedback, a widely agreed upon goal of this process is to stimulate self-reflection on the part of the instructor. Earlier in this chapter we discussed the idea that one goal of workplace learning was to encourage the learners to be reflective about their practice in order to improve. This is especially the case of the supervision of student ministers (Hunter, 2004; Certification Commission, 2005; McKinney & Drovdahl, 2007) where a large part of the student experience is coming to understand that “ministry is primarily about who one is and not about what one does” (McKinney & Drovdahl, 2007, p. 57). The same is true for instructors. A goal of faculty development for all faculty members, including workplace instructors, is to develop the ability to be reflective practitioners (Brookfield, 1995) so that they can become ever more effective as teachers. In their longitudinal study of the effects of a faculty development program, Pololi and Franken (2005) reported that participants cited self-awareness as one of the key long-term outcomes of their program, which had an emphasis on activities that encouraged reflection on the part of faculty. Moon (1999) provides a very thorough and thoughtful analysis of how difficult it can be either to be a reflective practitioner or to help someone else to be one. This is very relevant in the practice settings that constitute the workplace learning setting. Not only is it difficult for workplace instructors to have the time and inclination to pause and reflect while still trying to get the job done, it is made

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more difficult by the fact that as experts in their field, they likely are operating on a very high level of automatic behavior, which they sometimes have difficulty even recognizing. However, if they can develop the habit of reflecting on their teaching, questioning what they do and why they do it, they put themselves in a place where new insights are possible. How do we encourage instructors to become critically reflective? It can be a private reflection in the form of journaling or teaching notes completed after every teaching session. It can be a collaborative reflection as in a community of practice working together to create a course or a teaching dyad involving peers who observe each other teach and then dialog about what the observer saw and the teacher intended. The goal should be to stimulate questioning about the reasoning behind teaching choices. Moon (1999), citing Reid (1994), lists 6 questions that constitute the Gibbs’ reflection cycle (Gibbs, 1988). They are as follows: • • • • • •

description – “What happened?”; feelings – “What were you thinking and feeling?”; evaluation – “What was good and bad?”; analysis – “What sense can you make of the situation?”; conclusion – “What else could you have done?”; and action plan – “If it happens again, what would you do?” (Moon, 1999, p. 73).

Although these questions were originally designed for a mentor to use to help a learner work through a problem, they are just as appropriate as questions for a reflective practitioner of teaching to ask of himself/herself. Perhaps something as simple as helping workplace instructors see the value of addressing such issues would be the most powerful and least expensive of all the faculty development practices we could suggest.

Barriers and Supports for Faculty Developers of Workplace Instructors Caffarella and Zinn (1999) wrote an article about the barriers and supports for professional development of higher education faculty that was based on an earlier framework suggested by Zinn (1997) for teacher leadership. In the article, they lay out four “domains” (Caffarella & Zinn, 1999, p. 243) in which individuals will experience barriers or supports for professional development. They maintain that by being aware of these domains, a faculty member might be able to maximize the impact of the supports and minimize the impact of the barriers. Although they did not take the next step and suggest that faculty development programs might use these domains to organize the activities that they offer instructors, we see them as a possible framework for just that approach to supporting workplace instructor development. The four domains are described as: “(1) people and interpersonal relationships, (2) institutional structures, (3) personal considerations and commitments,

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and (4) intellectual and psychosocial characteristics” (p. 243). In the following sections, we connect them to the workplace instructor’s situation.

People and Interpersonal Relationships This domain focuses on the relationships that the workplace instructor has both at the worksite and beyond, including the reactions of other workers, managers, supervisors, and workplace administrators toward the idea of having learners present at the worksite and the instructor’s responsibilities being changed. Being tapped to train students could be seen by those others as either a benefit (increased respect and recognition for one’s professional skills) or a curse (annoyance at time taken away from the actual work, which often means more work for them). Coworkers and supervisors can support a workplace instructor’s efforts at development by word and deed, or they can refuse to make accommodations for the instructor’s increased responsibilities and expect the work to continue without any adjustment. The caution for the faculty developer in this case is to recognize that the audience for his/her efforts to improve workplace instructor skills is not only the instructor, but also those with whom the instructor must interact. Helping to emphasize the positives and de-emphasize the negatives of having learners present by involving the others in the process, if only in terms of making them aware of the whole program, could make the faculty developer into the ally of the workplace instructor, thus smoothing the path for development activities.

Institutional Structures This domain focuses on the kinds of supports that the institution provides to support an instructor’s development. For example, will the workplace instructor be given resources that are needed to facilitate his/her instructional role? This might include instructional materials, administrative supports such as clerical assistance for documenting learner progress to the home institution, time and travel support for attending faculty development activities, or computer access for participating in online professional development or a community of practice of other workplace instructors. Would the worksite provide educational monies for the instructor to improve his/her professional skills along with the instructional skill development? Will the workplace trade release time from such time-consuming activities as committee work or paperwork in exchange for agreeing to supervise a learner? Here the faculty developer could ease the workplace instructor’s way to receiving such support by suggesting it to the instructor’s supervisors. Many times such accommodations have not even occurred to the management of the site or they are unaware of what it means for someone to be a workplace instructor. Helping all parties understand the kinds of institutional support that would help the instructor be maximally effective at both the job and the supervision would be another way of helping the instructor see the faculty developer as an ally.

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Personal Considerations and Commitments Although Zinn (1997) described this domain in terms of the personal side of life, meaning the circumstances of the instructor’s life beyond the workplace, including family commitments, health and well-being, and cultural values, we feel that the most a faculty developer can do in this area is to help the individual recognize when his/her interactions with students are being affected by these forces. Instructors should realize that teaching is strongly affected by the affective side of one’s life, no matter how much he/she thinks the two are separate. A recognition of the impact of emotional well-being on the interactions with students is the first step in learning to manage that impact.

Intellectual and Personal Characteristics This domain focuses on our internal motivations and perceptions of ourselves as scholars and teachers. On the support side are factors such as strong beliefs and values that demand excellence in our work, perceptions that we can make a difference in the lives of students and other educators, and self-confidence in our faculty roles (Caffarella & Zinn, 1999, p. 247).

Of course, Caffarella and Zinn were describing university faculty in that quote and workplace instructors might not aspire to be that kind of scholar or see themselves yet as faculty. However, if we substitute the word “professional” for “scholar” or “faculty,” we can see that this domain is quite relevant for the professional development of the workplace instructor. A particular area of intellectual characteristics that would be very important in positioning a workplace instructor as an “instructor” would be his/her beliefs about how learning takes place and whether or not his/her “students” are capable of learning what he/she has to offer. These beliefs about learning are often reflected in the idea that “you can only learn from the school of hard knocks” or “you have to get your hands dirty to really understand the job.” Beliefs such as these or their opposites have a tremendous influence on the openness of instructors to alternative instructional strategies. In this area the faculty developer may serve as a mirror into these insights about personal beliefs and characteristics. Asking questions and offering alternatives, engaging the instructor in a dialog about teaching and learning, introducing the instructor to the community of practice of educators could be the best way to help the instructors find their own place in the educational landscape.

Acceptance into the Community of Practice: “Those Who Can, Do; Those Who Can’t, Teach” That old adage highlights a second area of challenge to faculty development for workplace instructors: the acceptance of faculty development and faculty developers as supports for workplace teaching. Each profession constitutes a community of practice (Lave & Wenger, 1991; Barab, Barnett, & Squire, 2002) and each worksite

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is its own community of practice. Participation in the community of practice both allows new members to learn from the wisdom of practice of the more senior members and legitimizes the presence and practices of the individual as they interact with the community. As Barab et al. (2002) describe a community of practice, it has the following characteristics: 1. 2. 3. 4. 5. 6. 7. 8.

a significant history with which the members can identify; shared beliefs about goals and practices; the notion that the community is more than the individual; the constant induction of new members to replace the old; a common goal toward which they are working; interaction and participation by the members; meaningful relationships among the members; and respect for different perspectives of the members.

One can see from this list that faculty developers who are not members of the community of practice to which the workplace instructors belong can be at a significant disadvantage. Not only does this list help us see how much goes into being a member of a community, it also contains many components that are normally tacit knowledge of the members and often used as a way of excluding nonmembers or welcoming new members. Even with the best of intentions on the part of both developer and worksite, one’s ability to work with the instructor is hindered by the following conditions, which grow out of not being a practicing member of the community. For example: 1. Lack of firsthand, personal knowledge of the content/skill being taught probably means that the developer also lacks pedagogical content knowledge, the understanding of how the discipline and its skills are learned, where the learners are likely to have difficulty, and what are the best ways of overcoming those difficulties. To complicate matters, the workplace instructor might have this knowledge at a tacit level and have difficulty articulating it for the developer. 2. The developer may also not be part of the discourse community of the profession yet, meaning that there will be terms and allusions that are commonly used in discussing the work that will have to be explained repeatedly until the terms become a part of the developer’s own vocabulary. Sometimes the developer and the instructor will use the same term but interpret it differently without even knowing it or use different terms for the same concept without realizing it. 3. The developer may also suffer from a lack of familiarity with procedures or resources specific to the workplace setting. Learning is often situated in the context of the work and fields often have very specific problem-solving approaches and strategies that fit the way they think about why difficulties arise and how to deal with them. Most faculty developers come from an educational, psychology, or social science background, each of which has its own strategies. Working across disciplines often calls for more general problem-solving approaches, which tend to be rather weak and to sound “soft” to the naive ear.

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What can an outsider like a faculty developer do to mitigate the effects of this phenomenon? There don’t seem to be many formal studies of this issue, but in the field of medicine, recognition of this problem caused leaders in the field to document the development of Medical Education as a specialty within the field in medicine and Certified Nurse Educators as a track within nursing. Davis et al. (2005) provided a very complete analysis of the rise of Departments of Medical Education beginning in the late 1950s but expanding until at the turn of the twenty-first century 61 medical schools in the United States had such departments. Staff in the departments included both medical and educational specialists. The early pioneers in the field came in at different times and for different reasons, but in 2008 Hitchcock and Anderson compiled recommendations for outsiders entering the field of medical education to work with medical professionals. Their recommendations echo some that have been given to faculty developers as the field has grown. We offer them excerpted here as hard-won strategies for gaining credibility with medical faculty. 1. Focus on the faculty’s problem – collaborate. 2. Be prepared to answer the question “What have you done for me lately?” (be able to justify your value to the medical educators, who are no longer being mandated to engage in faculty development). 3. Get smart about something specific (become a local or national expert on an area in order to command respect). 4. Use research-based approaches and publish results in reputable journals. 5. Be self-aware and interpersonally wise. 6. Keep up with your own discipline. 7. Have fun and use humor as an effective teaching strategy. 8. Bring in independent funding (to establish local credibility). 9. Develop a network of colleagues in medical education to understand the unique culture of medical education. 10. Recruit and develop the next generation of educationists. (adapted from Hitchcock & Anderson, 2008, pp. 566–568) These recommendations are very helpful to someone on the periphery of a discipline who needs to work with those at the core. Below we offer a set of important words that should characterize the interactions between a faculty developer and a workplace instructor: 1. “Collaboration.” Recognize the workplace instructor for the expertise that he or she brings to the situation, but also assert one’s own expertise in teaching and learning. Both areas must be represented for the best learning to take place. 2. “Respect.” It must be both given and earned. Be able to back up comments and observations with data, both from personal observations and from the literature, but conduct all discussions with respect and expect it in return. 3. “Communication.” Listen carefully and speak in ways that cause the instructor to do so as well.

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4. “Facilitation.” It is best to help the instructor come to a conclusion with which he/she is comfortable rather than trying to impose a solution on the situation. The latter types of solutions have a short shelf life. The best thing to learn is that you have lots to learn and you are willing to learn it.

Conclusion The purpose of this chapter has been to examine the possibilities and practices that could be used to help workplace instructors learn about their new roles as teachers and continue to become more and more skillful at the myriad acts those roles involve. As we said at the beginning of the chapter, we believe that the old adage that all you needed to know to teach was your content has been summarily dismissed as we have come to understand all the intricacies of teaching and learning. If we can make no other change in workplace instructors than to have them acknowledge that there is more to teaching than just telling, we will have come a long way toward improving their capacities to help their own students experience extraordinary learning in the workplace.

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Chapter 8

Envisioning the Future Bridget O’Brien

Overview Each chapter of this book has examined “extraordinary learning in the workplace” from a major area of educational theory and research, namely curriculum, instructional design, learning, assessment, and faculty development. The purpose of this chapter is to present a framework for workplace learning, to synthesize the findings of the preceding chapters as they relate to this framework, and to discuss opportunities to advance research on workplace learning and improve student learning in professional workplaces. Recall that, for students, workplace learning involves engagement in professional activities and tasks as they occur in authentic settings of practice. For example, student teachers learn strategies for managing a classroom while teaching a group of second graders and nursing students learn to prioritize competing demands and patient care needs while working on a hospital ward. Workplace learning is a social process, meaning that the learning is influenced by relationships and interactions with other professionals, many of whom tend to have more advanced knowledge, skills, attitudes, and moral perspectives than the student. Medical students join teams with residents and a supervising physician and often must interact with other experienced health professionals involved in caring for their patients. And workplace learning occurs through immersion in a culture, which means becoming accustomed to the rules and norms that guide work practices. Students must learn their way around the hospital ward, the clinic, the school, or the church – figuring out how to get the supplies they need, what time to arrive in order to prepare for the day, or who is the best person to answer questions about billing or scheduling or attendance policies. Ideally, the learning process can be likened to that of joining any community; the student, as a newcomer, requires substantial guidance and assistance learning the rules, norms, tasks, and supportive relationships within the

B. O’Brien (B) San Francisco School of Medicine, University of California, San Francisco, CA, USA e-mail: [email protected] J.P. Hafler (ed.), Extraordinary Learning in the Workplace, Innovation and Change in Professional Education 6, DOI 10.1007/978-94-007-0271-4_8,  C Springer Science+Business Media B.V. 2011

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practice community. However, over time the student takes on greater responsibilities and becomes an established part of the community with significant roles and reduced need for guidance and support (through ongoing need for feedback). Presumably, extraordinary learning in the workplace is achieved when conditions for learning are optimized – meaning there are supportive relationships with professionals and staff who are both excellent instructors and model practitioners, settings in which high standards of practice and core values and commitments of the profession are upheld, and ample opportunities for learners to participate in ways that foster growth and development in multiple domains. These conditions are challenging to establish but they provide a vision to strive toward. This chapter is organized around a framework for workplace learning that contains three themes: relationships within the practice community, selection of tasks and activities, and the nature of work practices [Fig. 8.1]. This framework draws on behavioral, cognitive, constructivist, and social learning theories as they apply to learning through real work practices. Curriculum, instruction, assessment, and faculty development are discussed within this framework when they pertain to one of the themes, thus providing an opportunity to incorporate much of what the authors presented in previous chapters of this book. The first theme, relationships among participants in the work environment, addresses the social dimension of learning including relationships with instructors, mentors, peers, staff, and recipients of services (patients, students, members of the congregation) and ways in which these relationships can support and/or hinder learning in the workplace. The second

Fig. 8.1 A conceptual framework. Adaptation and expansion of Billett (2001)

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theme, activities and tasks of the practice, explores the meaning of curriculum in the workplace and the important role of assessment processes in this curriculum. Issues such as alignment of tasks and activities with the learner’s ability, facilitating connections between current and prior experiences, and access to work-based assessments can promote or impede workplace learning. The third theme, work practices, covers the rules, norms, and culture of a work environment that shape the ways in which people interact with one another and guide the ways in which tasks and activities are performed. These work practices often constitute a large part of what is commonly referred to as the informal and hidden curriculum. Of note, these themes are interdependent in their influence on learning. Tasks and activities usually occur in the context of relationships and are guided by general work practices in the environment. Furthermore, topics such as assessment are discussed in both the relationship theme and the task and activity theme because there are important dimensions of assessment to consider under both themes.

Theme 1: Establishing Relationships to Support Workplace Learning How Do Relationships in the Workplace Facilitate Learning? “Supported participation,” a construct developed by Dornan and colleagues through grounded theory research in medical education, suggests that effective workplace teachers “simultaneously support students and challenge them in a way that builds practical competence and a positive state of mind” (Dornan, Boshuizen, King, & Scherpbier, 2007, pp. 88–89). In Dornan’s model, students learn through participation in actual patient care activities. Relationships in the workplace often play a key role in determining the level and extent of student participation in activities; this includes not only relationships with designated workplace teachers, but also with other professionals, staff, and learners with whom a student interacts in a workplace. However, since most of the literature reviewed in this book focuses on teacher–student relationships, we will begin our discussion with this relationship.

Chapters 3 and 4 on learning theories and instructional practices discuss three types of relationships between instructors and students – coaching, mentoring, and supervising. How can these three types of relationships create “supported participation” for students in the workplace? Based on behavioral, cognitive, and social learning theories, these relationships are likely to promote learning when the instructor models and demonstrates desired skills and attitudes, sets clear expectations for the student’s performance of these skills and attitudes, periodically assesses the extent to which the student meets these expectations, and then provides constructive feedback to guide the student toward improvement. What may be underrepresented in these models of instructional relationships, though highlighted in Dornan’s work, is the way in which students are introduced and incorporated into practice communities, given legitimacy, and encouraged to build relationships with other members of the community who may or may not be members of the student’s profession. Billett

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refers to these important aspects of social learning as the “invitational quality” of the workplace (Billett, Barker, & Hernon-Tinning, 2004, p. 233). The strategies used to welcome, invite, and encourage the student’s involvement in practice are a key part of workplace instruction because they can influence the “state of mind” of the learner – namely the sense of identity, motivation, and confidence – as well as the access the learner has to dialog and participation in activities. Workplace instructors can also provide tips and insights that help sequence experiences and guide students along a pathway of learning (Billett, 2001), as will be discussed in more detail in the second theme on the selection of tasks and activities To what extent does the evidence support these assertions? In all four of the professions the evidence for actual learning outcomes is surprisingly sparse because so few studies have attempted to make rigorous, outcomes-oriented comparisons between students who are and are not coached, mentored, or even oriented to the workplace or who receive different forms of supervision. Thus far, research is largely either descriptive or attitudinal (Grossman, 2005). The descriptive research helps define different models of coaching, mentoring, and supervision and thus lays the foundation for comparisons. For example, the nursing literature provides descriptions of different models of practice-based education, including preceptorships, faculty-supervised practicum, collaborative learning units, and cooperatives, and has examined student perceptions of the quality of learning and preparation for practice provided by different models (Budgen & Gamroth, 2008; Callaghan et al., 2009). Other professions may find such typologies and comparisons beneficial, particularly when selecting and defining optimal coaching strategies. In medical, nursing, and teacher education, coaching strategies have been defined for specific skills such as clinical reasoning, critical thinking, and classroom practice. Examples include the Five-Step Microskills Model of the One-Minute Preceptor (Aagaard, Teherani, & Irby, 2004; Furney et al., 2001; Irby, Aagaard, & Teherani, 2004; Irby & Bowen, 2004; Neher, Gordon, Meyer, & Stevens, 1992; Teherani, O’Sullivan, Aagaard, Morrison, & Irby, 2007), the SNAPPS model for clinical teaching (Wolpaw, Wolpaw, & Papp, 2003), the RIME scheme for evaluating learners’ progression in clinical skills (DeWitt, Carline, Paauw, & Pangaro, 2008; Pangaro, 2000), contextual learning interventions for critical thinking (Forneris & Peden-McAlpine, 2009), and peer coaching for classroom practices (Britton & Anderson, 2010). The studies describing these models often report high levels of student and faculty satisfaction and/or improvements in student performance, but since most of these studies, with the exception of Teherani et al., 2007, lack comparison groups we cannot conclude with certainty that a particular model or practice works better than others. We can, however, see that medical education offers strategies for efficient, focused coaching in time-pressured environments, nursing offers coaching strategies to fit a wide array of teacher–student relationships in a variety of settings and often focuses on coaching for reflection and critical thinking, and teacher education (along with medicine and nursing) is finding ways of incorporating peer coaching to compliment coaching from supervising teachers and to facilitate workplace learning.

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In the mentoring literature, there are many configurations varying by the length of relationships; whether the relationships are based in the workplace, outside of the workplace, or both; whether the mentor is assigned or selected; and the role or status of the mentor (near peer, very senior, etc.). Studies in medical, teacher, and nursing education have identified characteristics of outstanding mentors (Cho, Ramanan, Arean & Feldman, 2009; Ferrier-Kerr, 2009; Webb & Shakespeare, 2008). Across the four professions, some commonly recommended features of mentoring relationships include interactive dialog (active listening, questioning, and feedback by the mentor), opportunities to discuss professional development, and extended relationships (often a year or more). However, linking these features of mentoring relationships to professional development and learning outcomes is difficult. Research in nursing education has made some attempts to collect information from graduates about the mentoring they received during clinical placements and to use this information for program improvement (van Eps, Cooke, Creedy, & Walker, 2006). Similar efforts would likely be beneficial for the other professions as well. All four professions need to think carefully about appropriate outcomes beyond learner satisfaction with mentoring and identify ways of documenting connections between mentoring relationships, professional development, and learning. In the research relevant to supervision, Kennedy conducted an interdisciplinary review of the literature on one common model of supervision, progressive independence (Kennedy, Regehr, Baker, & Lingard, 2005). Although her focus was on the training of medical students and residents, the concept of providing learners with opportunities to perform professional work with decreasing amounts of direct supervision commensurate with demonstrated competence, while maintaining the well-being of the individuals under the learner’s care is a critical topic for all professions. After graduation and licensure, students of the profession will hold substantial responsibility with minimal supervision. Enacting models of supervision in professional training programs to ensure that students truly are ready for this level of responsibility is critical. So far there is a theoretical basis for progressive independence but little empirical evidence to suggest specific models that constitute effective progressive independence (Kennedy et al., 2005). Differences in the length of training and in workplace regulations among professions provide opportunities to consider how a learner-centered model of progressive independence would look under different circumstances and contexts. In reality, there is not just one best model for relationships in the workplace, but rather a menu of strategies that work better for certain types of relationships, contents, and settings than others. In the choice of instructional practices, it is necessary to keep in mind that students and faculty have certain preferences about approaches to teaching, learning, and feedback. Several studies have examined learner preferences for certain teaching approaches in the workplace and found that students prefer learning from actual patients as opposed to simulation or written cases (Dornan, Arno, Hadfield, Scherpbier, & Boshuizen, 2006), high levels of supervision (Dolmans, Wolfhagen, Essed, Scherpbier, & van der Vleuten, 2002), engagement in substantive discussions, use of video and hypermedia (Grossman, 2005), and delivery of spontaneous talks and presentations (Guarino et al., 2006).

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Relationships are an important part of another component of instructional practices – namely, feedback. The literature on instructional practices places much emphasis on the instructor’s provision of feedback to the learner, and this naturally relates to the length and quality of relationships, the establishment of trust, and the formative and summative assessment processes. Many recommend providing feedback to learners that is based on direct observation of performance (Holmboe, 2004), particularly on multiple occasions by the same observer (someone who has established trust and credibility with the learner). The norms around direct observation vary by profession and by setting. In teacher education, the student–teacher almost always functions under supervision while in medicine and nursing, students spend a large amount of time working on their own but with help readily available. Only certain particularly complex tasks or procedures are directly supervised. To improve the provision of feedback based on direct observation, medicine is beginning to implement sampling techniques so a faculty member might selectively and briefly observe a student for a brief period of time and complete a structured observation form with specific feedback points (Kuo, Irby, & Loeser, 2005). The assumption is that this focused observation provides more effective feedback for specific tasks or skills and more pointed suggestions for improvement as compared to global ratings provided at the middle or end of a rotation. Alternately, longer periods of more consistent observation, as opposed to brief observations, may be better for feedback in areas such as integrated performance, professionalism, classroom management, or interpersonal interaction where consistent patterns of behavior can be rated. The point is that, when thinking about the role of relationships in assessment of workplace performance and workplace learning, certain types of relationships may work more or less optimally depending on context and the performance goals. Moreover, how assessments are conducted, monitored over time, and shared with students, instructors, and other members of the workplace is a significant relational issue that has received relatively little attention. In medical education there are often multiple people assessing the learner, though a single faculty member in each specialty is usually responsible for compiling and then assigning a grade. Typically, subsequent teachers of the student are not informed about the student’s performance on prior rotations. While this may attenuate some biases (e.g., the “halo effect”), it also limits the opportunity for clinical educators to work with students on targeted areas in need of attention (Frellsen, Baker, Papp, & Durning, 2008). In teacher education, the university supervisor who typically does not work with the student in the workplace is responsible for the final-grade assignment and supervision report. It is not clear how these particular approaches to synthesizing and sharing summative information about student performance positively or negatively impact student learning and relationships in the workplace. What message is conveyed when those who have responsibility for coaching or supervising students in the workplace are disconnected from faculty who do not interaction with students in the workplace but are responsible for assigning student grades? The value of direct observation is potentially undermined by the ultimate authority given to university-based faculty. Thus far, the discussion of relationships has focused primarily on formal, one-onone relationships between the student and the workplace supervisor or instructor.

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However, the reality in many workplaces is that student relationships with other members of the community have a profound impact on learning. The tips, strategies, and perspectives that students encounter through informal interactions with peers, staff members, administrators, and others are often identified as formative influences in student reflections (Haidet et al., 2008; Lown, Davies, Cordingley, Bundy, & Braidman, 2008). All these relationships are possible sources of feedback and can potentially influence the student’s learning in the workplace (Branch & Paranjape, 2002).

How Can Relationships in the Workplace Interfere with Learning? Learners interact with many, many different individuals in the workplace. These interactions are one of the major factors that add both complexity and authenticity to workplace learning. The student is no longer able to focus on content alone (i.e., the chemical and biological mechanisms associated with different statins or the conceptual model for learning multiplication), but now must figure out who is responsible for doing what, who is a reliable source of information and guidance, who is accessible and willing to give feedback, and even who is an appropriate role model. As Hafferty and Hafler point out, students in medicine and nursing work with many different people and often see or are coached on multiple different examples of “best practices.” If unprepared for this variability, students can feel frustrated and overwhelmed by choice and uncertainty. Students often will not understand the context or rationale unless someone makes it explicit. For example, a nursing student learned in class that she should never, under any circumstances, give a patient with NPO status (nothing by mouth) any food or water, but she regularly sees nurses on the floor giving patients a cup of water with their pills. She is unsure what to do – follow the practice norms or go by the guideline she learned? Should she prioritize patient comfort over possible risk of complications? How serious is the risk? Without explicit discussion of these issues the student may adopt a behavior and miss the opportunity to learn concepts that underlie or motivate each behavior. Furthermore, if students are prepared to see variability as an opportunity for inquiry and development of personal practice, then exposure to four different approaches to diagnosis of a heart murmur or preparing a memorial sermon or increasing student participation in a discussion may be viewed with appreciation rather than with stress and anxiety. As suggested by experiential theories of learning and reflective practice, the way in which experiences are framed by learners can play an important part in the learning process. As workplace instructors and others in the work environment interact with learners, they have opportunities to provide or assist with this framing. In all four professions reviewed in this book, the professional student always has at least one assigned supervisor. However, the proximity of this supervisor on a moment-to-moment basis can vary considerably. In teacher education, the student teacher is likely to spend little time alone and unsupervised in the classroom. Similarly, in the operating room a medical student is unlikely to be left alone. But

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in “lower stakes” tasks such as checking in on patients throughout the day (as in nursing or medicine) or writing a lesson plan or grading student assignments, the novice professional may be left very much on his/her own to figure out. Some of the implications of supervision for feedback, primarily formative feedback, have been discussed in the previous section. On the flip side, when summative assessments are largely disconnected from formative feedback as described by Gailbraith, Clyman, and Melnick in Chapter 5, the formative feedback may be trivialized or even disregarded if not given appropriate legitimacy or, alternately, students may feel the summative grades are random, based on personality, and therefore unfair, biased, subjective, and invalid. Students should be able to make a clear connection between the feedback they receive in the workplace, the assessments they receive outside of the workplace, and their actual performance. Finally, one of the biggest factors interfering with learning in the workplace is a hostile and unwelcoming response to learners. Aggressive or contentious relationships among peers, more advanced learners, or even other staff members who feel students are encroaching on their “turf” can pose a major barrier to learning. Such relationships can sprout when workplace learning opportunities are limited and many learners of different levels work in the same space with a limited pool of learning material. In fieldwork for a national study of medical education (Cooke, Irby, & O’Brien, 2010 ), my colleagues and I frequently heard third-year students despair about the limited opportunity to get to do a delivery or participate in a procedure because interns and residents were ahead in the queue. What is the solution under such circumstances? Perhaps one solution might be to create partnerships or small pods of learners working together on a specific set of assigned responsibilities to ensure more even distribution of learning opportunities. Or, there may be ways simulation could be used to substitute for actual experience – trading off guaranteed opportunities for practice with less-available authentic experience.

Directions for Future Research on Relationships in Workplace Learning The benefits of coaching, mentoring, and supervision have been described, but important questions remain about who most appropriately fills these roles and how best to structure these roles, particularly for learners in the early stages of professional development. Several chapters in this book offer theoretical and, to a lesser extent, empirical grounds for longitudinal relationships between students and workplace instructors across the professions. Such relationships are hypothesized to be more supportive of knowledge, skill, and professional development because such relationships are more conducive to setting expectations, providing regular guidance, instruction, and feedback; monitoring progress; and creating a sense of accountability that can motivate students. Within any given profession, answering questions about the value of longitudinal relationships is challenging because structural or resource constraints and regulatory or accreditation requirements limit variation. In teacher education, the window of time for supervised practice is only

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one or two semesters and is often in just a single classroom with a single supervising teacher, while in medicine and nursing it lasts several years and includes rotations through many different specialties and settings with many different supervisors and instructors. By building a common program of research to examine questions across professions, using a shared framework, study design, and methodologies, we have more opportunity to make rigorous comparisons and to expand the horizon of possibility and understanding. Such comparisons may provide us with powerful new evidence about how to optimize relationships in professional workplaces for learning. Some questions to guide this research might include the following: 1. Do students have a clearer sense of expectations, receive more guidance and constructive feedback, have a better sense of their level of performance, and/or feel more motivated to improve their performance if they have a longitudinal relationship with a workplace instructor compared to students who do not? 2. What strengths and challenges do different professional models pose for supervision and identification of learners who need extra support? What strategies have been devised to address the challenges? 3. How do workplace instructors and supervisors conceptualize students’ learning trajectories? How do they monitor students’ progressive development of competence? Do they use evaluations of students’ competence to provide students with increasing amounts of independence? If so, how? 4. What is the relationship between workplace instructors and academic supervisors? How does this relationship impact students’ learning goals, priorities, and response to feedback? 5. What other relationships in the workplace can be capitalized on for learning, beyond instructor–student? What learning outcomes are best supported by these relationships? 6. How can faculty be educated to optimize the full range of resources available in the workplace, rather than feeling they must rely solely on themselves as the source of learning and instruction? There are also opportunities for the professions to learn from one another. As medical education makes efforts to provide more continuity of supervision, many important insights might be gained from teacher education. Similarly, teacher education may see value in giving student teachers exposure to more classrooms and more teachers. The nursing and medical education literature may offer ideas about how to maintain appropriate supervision and facilitate continuous learning as the training model shifts away from a pure apprenticeship model.

Summary In the workplace, it is important to see not just one person as the teacher – but rather to acknowledge the importance of many different relationships in the practice community. Students of the profession learn from interactions with the people they

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serve, their peers, and the staff members who are in the workplace day to day. The configurations that best support learning are understudied, although having designated coaches, mentors, and/or supervisors is widely accepted across the professions as essential for learning and assessment purposes. Important topics that each profession seems to grapple with and handle slightly differently include: (a) the appropriate length of relationships between students and workplace instructors (teacher education and pastoral education use extended, focused relationships between learners and cooperating classroom teacher or minister while medical and nursing education often expose students to many different instructors during rotations in a variety of different settings); (b) the relationship between the workplace instructors and the academic supervisors or mentors, particularly in terms of providing feedback, evaluating performance, and assigning grades (in teacher education the roles are most distinct, in medical and nursing education there is often some overlap, and in pastoral education the roles are often blended); (c) how to facilitate students’ development of relationships with staff and other professionals in the workplace (medical and nursing education has started devoting considerable attention to interprofessional education and teamwork, though learning outcomes associated with this efforts are limited).

Theme 2: Selecting Tasks/Activities to Support Learning in the Workplace How Do Tasks and Activities Constitute a Workplace Curriculum that Not Only Supports Learning, but May Make the Learning Extraordinary? To an educator, who is used to teaching in classrooms, and to a novice professional, the curriculum in the workplace can seem ad hoc or nonexistent. The workplace curriculum is not a syllabus or set of readings to be discussed, as in the classroom, but rather the tasks and experiences that engage the learner in the workplace. For clergy students part of the workplace curriculum might involve organizing and supervising a youth group or a food pantry, for teachers it might be the preparation and delivery of chemistry lesson or a Spanish lesson, and for medicine and nursing students it might be a visit with a patient and documentation of the key information gathered during the visit in a chart note. The content covered in the workplace curriculum is harder to predict on a dayto-day basis and often workplace instructors seize the teaching moment based on what seems important or interesting to them about a situation, case, or incident. For example, a diabetic patient coming in for a follow-up could present any number of teaching opportunities – from counseling techniques to opening up a discussion about lifestyle changes to epidemiology to the latest developments in pharmacology relevant to management/treatment of type 2 diabetes. Although some excellent

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teaching can occur in this way, instructors who approach these opportunities with a developmental framework in mind and an outcome orientation will be more likely to check in with the student’s needs, to focus on knowledge, skills, and/or attitudes that can best help the student progress in understanding and performance, and to highlight connections between current experiences and prior knowledge, skills, and attitudes, making the learning extraordinary. When thinking about the workplace curriculum, the key point to keep in mind is that everything the student does is a learning opportunity and experience. This point can be emphasized and reinforced to students, accompanied by a conscious effort to provide continuity by highlighting ways in which what they are currently doing relates to what they have done in the past and what they are preparing to do or will need to do in the future. A major challenge in much of workplace learning is the tendency to focus on the immediate content and context and to lose sight of the relevance to larger concepts, bodies of knowledge, and experiences. The student and teacher may focus more on specific details, subtle distinctions, and nuances than on general premises and principles. For example, rather than seeing Johnny’s refusal to participate in a math game and Sara’s withdrawal during readaloud time as two cases of the same phenomena of performance anxiety (fear of being embarrassed in front of their peers), the student teacher may focus instead on the personalities of the students and her frustrations by the disruption to the lesson as planned. Furthermore, the student teacher may have learned some strategies that might help her more effectively manage these situations in a way so that Sara and Johnny feel encouraged, supported, and safe, but be unable to tap into these strategies without guidance. These are the connections that help learners build practical knowledge (e.g., develop the ability to detect a murmur, identify a student who needs to be tested for dyslexia, or know just the right moment to begin a prayer) and connect experience to knowledge. Hafferty and Hafler also note the tendency for workplace experiences to become fragmented or siloed, particularly when students move through multiple workplaces over a short period of time in order to gain breadth of exposure. In workplaces, demonstrated ability to perform a task or activity skillfully, reliably, responsibly, knowledgeably, efficiently, independently, and/or cooperatively is the way a practitioner or student earns opportunities to do more, to take on more challenging tasks, and to gain the respect and trust of others. According to social learning theories (Lave & Wenger, 1991), this is how students gradually develop into competent professionals. When a medical student demonstrates the ability to follow and concisely present the status of a hospitalized patient, he might then be asked to take responsibility for doing the admission work up for another patient; or when a minister-in-training completes a home visit with a member of the congregation and writes an insightful reflection on the experience, he/she might then be asked to make a more complex visit, perhaps to a patient who is dying, and then write up a reflection. There is a progressive increase in the complexity of tasks and activities taken up by the student, presumably based on demonstrated competence. The challenge for the student (or any learner in the workplace) is how to

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connect the activities of work with relevant knowledge bases, more generalizable concepts or conceptual frameworks, or best practices. As described in Chapter 3 by Harris and in Chapter 4 by Henry and Malu, workplace instructors in all four professions often play an important role in facilitating these connections by making explicit the implicit, or “hidden,” knowledge and articulating or scaffolding the concepts that underlie the skilful and seemingly effortless execution of the task or activity.

How Can the Selection of Tasks and Activities Optimize or Inhibit Workplace Learning? Conceptualizing workplace experiences as a learning progression or curriculum can take a substantial shift in thinking and practice for educators and students. Achieving this shift requires attention to several issues such as familiarity with the learning trajectories of students, workplace instructors’ capacity to incorporate sequencing and continuity of experience into their teaching, access to tools and resources needed to support learning in a developmental model, and students’ capacity to direct their own learning. First, in many professional workplaces there may not be a clear understanding of what a learning pathway or progression is, which activities are more or less complex, or even what a learning sequence means in relation to basic tasks and activities. Necessary questions to consider include what is best learned within the first few days of a workplace experience, what are the baseline or foundational competencies in a given workplace, what activities build upon these baseline competencies to allow learners to take on additional responsibilities or ownership of professional work, and what levels of competence are expected of a graduate? Taking medical education as an example, the tendency has been to identify particular objectives to be achieved during workplace experiences, but with little guidance about the order or sequence in which these objectives might be best achieved or even specification of which objectives are achieved through engagement in high, medium, or low difficulty activities. Perhaps because the workplace seems more unpredictable than a classroom, workplace instructors are more inclined to think about learning opportunities in the moment or, at best, relevant to the objectives, but rarely in terms of longitudinal learning and progressive development. Evidence that this longitudinal focus is not happening appears most strikingly in the medical education literature as clerkship students describe the sense of starting all over again each time they begin a rotation in a new specialty or even in a new setting for the same specialty (e.g., an internal medicine clinic versus an internal medicine hospital ward). Presumably the student has developed knowledge and skills that are necessary in both settings, but often they have difficulty seeing the connection (O’Brien, Cooke, & Irby, 2007). In absence of an understanding of task difficulty and learning pathways, there is a risk that students will remain in a comfortable zone of competence for a

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prolonged period of time when they should be taking on new challenges and responsibilities that will enhance their learning. Although there is value to student engagement in basic, routine tasks initially, there is a point of diminishing returns for learning. Engagement in nonroutine activities often produces new knowledge and understanding. Yet, from the perspective of the other members of a workplace, having a student continue to do simple, routine tasks like scheduling and reserving rooms for all the Sunday activities at the church or running to the lab several times a day to check on orders or collect results increases the efficiency of the workplace by freeing others up to do other tasks and activities. Thus, the issue of responsibility for tasks and activities is where the learning agenda of the student and the work agenda of the staff and other professionals in the workplace come together and often into conflict. The student is in a weak position to defend his/her learning agenda and thus must rely on relationships with others, particularly his/her supervisor or workplace instructor, to advocate for and help set priorities for the student’s learning. All students will spend some of their time-performing activities that are more “serviceoriented” than “learning-oriented.” Although both types of activities are formative to some extent, achieving a balance between the two is important. Second, the skills required of workplace instructors cannot be underestimated. In Chapter 7, Svinicki and Wilkerson identified four critical skills for workplace instructors: recognizing key skills and opportunities to teach them, setting goals and evaluating their attainment by the student, observing the student and giving supportive yet diagnostic feedback, and orchestrating the various elements of the workplace learning environment to make it accessible to the student. Although these skills were not explicitly associated with a developmental model of learning, they can be aligned with it by adding a fifth skill of framing experiences in ways that encourage learners to make connections and find continuity among experiences. In addition, workplace instructors need to be skilful navigators and managers of their work environments. Often they are balancing responsibility for maintaining a standard of quality practice while allowing students to demonstrate their ability and the limits of their ability. When they are working directly with a student, the workplace instructor must quickly assess the risks and benefits of involving the student as an observer, assistant, or independent practitioner and quickly establish the role and expectations for the student. The workplace instructor must feel confident that if something goes wrong, he/she will be able to remedy the situation. Perhaps even more challenging, workplace instructors must be skilled at monitoring and guiding students’ performance from a distance. Students of professions must demonstrate readiness for independent practice, which includes trustworthiness, reliability, respect for others, sound judgment, and various other professional competencies. Thus, they must be given the opportunity to engage in professional practice on their own and the workplace instructor must have a way of monitoring the results so they can make decisions about the readiness of the student for independent practice. In clergy education and teacher education, this is achieved through reflective writing and discussion between students and workplace instructors. But the effectiveness of these methods for identifying and then actually remediating

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or holding back students who are not ready to enter independent practice was not found in the literature reviewed in any chapters of this book. In medicine, perhaps because students graduate from medical school and then enter 3–7 years of additional supervised training before beginning independent practice, the decisions about progression to a new level of responsibility are largely based on summative exams that typically occur outside of the workplace. Only recently, as a result of a shift to competency-based assessment, are medical schools developing benchmarks that encompass a broader range of student performance in a variety of settings on a more continuous basis. Third, related to the previous discussion of formative, work-based assessments, achieving a sequential learning progression requires resources and tools that may be more or less available among the different professions. For example, are there formative assessment processes that accurately assess performance in real time? Are workplace instructors trained to use these assessments properly, to interpret the results, and to deliver feedback to the student based on the results? Are there integrated assessments that capture multiple dimensions of performance rather than honing in on just a particular element (e.g., technical skill) to the exclusion of others (e.g., interpersonal skills)? In Chapter 6, Clifton and Mylona provide an extensive review of tools used to assess learners’ knowledge, skills, and attitudes in the workplaces of the four professions. Interestingly, all four professions (theology to a lesser extent) have taken a competency-based approach to assessment at some point in their history and have attempted to develop authentic assessments of student performance in practice. While medicine has tended to use quantitative tools such as multiple choice tests, checklists, and survey instruments to measure students’ knowledge, skills, and attitudes, pastoral education and teacher education have relied more heavily on qualitative assessments such as reflective essays, journals, portfolios, interviews, and small group discussions with peers. Nursing has drawn widely from both types of assessment. In many ways, the approach to assessment in each of these professions reflects core beliefs about the educational process and the learning outcomes that take priority. Medical education has long focused on knowledge and skills while pastoral education has focused heavily on professional formation (character and values). As each profession moves toward more comprehensive teaching and assessment in all three domains of professional practice (head, hand, and heart), the advantages of learning from the efforts and experiences of other professions is clear. For example, medical education is beginning to use portfolios to document students’ skills and professional development and to encourage reflection. Many of the other professions have used portfolios for decades and can offer guidance on topics such as implementation, review processes, mentoring, and use for formative and/or summative purposes. In addition to efforts to improve assessment in specific domains, workplaces also demand integrated assessment tools that reflect the multifaceted nature of professional practice. Integrated assessments will require a shift in thinking about assessment practices akin to what Galbraith, Clyman, and Melnick describe. It may mean giving up some features of the assessment that are held as the gold standard

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(high reliability and standardization) in exchange for features such as the ability to provide immediate feedback on performance that is closely aligned with actual work practices and that covers multiple, rather than a single, specific domain of practice. In pastoral education and teacher education, closer supervision and mentoring by one or two workplace instructors may make it easier for instructors to think in a developmental or longitudinal model and to have an implicit sense of benchmarks relevant to student progress. In medicine and nursing, where supervision is far more distributed and students rotate through many different workplace instructors, a developmental framework for learning and longitudinal benchmarks may be less intuitive. However, there is evidence to suggest that when the model of workplace learning shifts from block experiences to longitudinal experiences, clinical instructors do begin to develop a sense of a “normal” versus a “concerning” or “stalled” learning trajectory with observable cues and performance expectations (Hirsh, Ogur, Thibault, & Cox, 2007; Teherani et al., 2009). Finally, the role students play in their own learning is a particularly important consideration in workplace learning because students typically have more opportunity to participate in the selection of tasks and activities in the workplace than they do in classrooms. Although much of the discussion so far has focused on the role of instructors and, to a lesser extent, other members of the workplace, the student adds many variables to the learning equation. There is some debate among the learning theories about the extent to which these characteristics are stable traits of the individual versus more variable states that change with the social and physical environment. For the purposes of workplace learning, since each instructor typically will see the student in a given environment, the difference may not be particularly important. Each student brings a unique combination of interests, motivation, commitment, confidence, and experiences along with his/her knowledge and skills. These characteristics will, for example, influence the reading the student chooses to do outside of work, the types of activities the student volunteers for, or the way in which the student responds to feedback about an area in need of improvement. Consider a nursing student who spent the day caring for a homeless patient with a severe pneumonia. The nurse may choose to go home and search the web for resources available in the local community for homeless persons with severe illness or she may investigate the cost and side effects of different medications she has been administering to this patient. She may bring the information back into work the next day to share with the patient or with her colleagues so they will also benefit from the knowledge. Alternately, rather than looking this information up on her own, she may consult with her supervising nurse to get the information more quickly or to get suggestions about topics that would be best for her personal growth. The point is that there are many opportunities for learning and both the student and the workplace instructor play important parts in directing the learning. The partnership between the two is important so that the student does not spend substantial time doing activities that are interesting but not particularly beneficial from the perspective of professional growth. Similarly, the instructor must allow the student space for some curiosity and self-directed learning so that the student appreciates that these are valued and expected attributes of professionals. Workplace instructors can select

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tasks and activities as opportunities to develop students for lifelong learning much as they would select tasks and activities to develop students’ communication and interpersonal skills.

Directions for Future Research on Tasks/Activities in Workplace Learning Much of the research so far in this area provides a rationale for why learners must be given authentic responsibility for routine activities and how this can be achieved (e.g., Dornan, Lave, & Wenger). Far less research has examined workplace learning from a developmental perspective, with a focus on the steps or sequences that lead to competence in a given domain. In nursing, Benner’s application of the Dreyfus model of expertise development is one of the few attempts to provide an empirically grounded account of the processes by which nursing students develop clinical judgment, technical and procedural skills, and moral/ethical comportment (Benner, 1984; Benner, Tanner, & Chesla, 1996). Research to confirm, disconfirm, or develop this model by honing in on specific domains of learning and studying larger samples of students is much needed, but significantly lacking. On the outcomes side, most of the research examines learners’ perceptions of their contribution to patients, student learning, etc., but has not gone the next step to test whether students with this sense of responsibility do, in fact, perform more ethically, responsibly, and with greater integrity. Students from different professions enter the workplace with different levels of preparation and experience performing the tasks and activities demanded of professionals. For example, medical students and student teachers spend several years of primarily classroom and simulation-based training before full immersion in the workplaces of their profession, while nursing students have far less classroom preparation before entering clinical training. Documenting these differences and designing studies to compare student learning processes and outcomes both interprofessionally and intraprofessionally would contribute substantially to longstanding questions about the value of different types and amounts of preparation for workplace learning. Although observational research (including video) is challenging because it is time and resource intensive and can involve entry into sensitive situations, there is a significant need for this type of research in professional education in the workplace. Without documenting what students actually do in the workplace, it is difficult to formulate evidence-based conclusions about the sources of their learning. Some questions to guide this research might include: 1. Through what series of tasks and activities do learners achieve competence on a specific outcome? In what ways does this vary among learners and across professions? Do some series or sequences lead to competence faster? Are there certain steps or tasks that seem to be stumbling blocks or sticking points for some or most students?

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2. From the perspective of learners, what tasks and activities are most difficult to learn in a given work environment and why? From the perspective of workplace instructors, what tasks and activities are most difficult to learn in a given work environment and why? Are there discrepancies? How do these discrepancies compare across professions? 3. When comparing student achievement of desired outcomes, are there observable differences in student mindset, initial competence upon entry into the workplace, or amount of interaction with particular workplace instructors? Are such differences evident across professions? What strategies, if any, do different professions take to address these differences? 4. What types of assessments are most helpful to students for the purposes of directing their own learning? What types of assessments are most helpful to clinical instructors in guiding student learning? Are there certain assessment tools that some professions use effectively that could be adapted for use in other professions?

Summary The tasks and activities in which students of a profession engage are the key components of the workplace curriculum and the foundation for student learning in the workplace. Correspondingly, the selection and monitoring of what students are doing and how well they are doing it during their time in the workplace is crucial to the success of workplace learning. Novices in particular will need substantial guidance, support, real-time performance assessment, and feedback because they will find it challenging to distinguish between practices that are more or less desirable to emulate, to know what is a reasonable task or activity to expect of them and what is unreasonable (either because it is too difficult or because it is no longer contributing any value to the student’s learning), and know what the appropriate next steps are to move them along a learning trajectory. Workplace instructors and supervisors will need to be trained to fill these roles and, in many cases, to think about work activities as part of a curriculum that supports a developmental learning trajectory. Although the specific knowledge, skills, and values needed to perform core tasks and activities vary from profession to profession, some general issues cut across all professions such as defining competence, monitoring and facilitating students’ development over time, creating effective tools to assess learning both in specific domains (knowledge, skills, attitudes, and professional values) and holistically, and determining when extra support or remediation is necessary. Fortunately, the professions vary in the amount of focus and the ways in which they have approached many of these issues. By encouraging more comparative and collaborative reviews and research among the professions, there are exciting opportunities for the professions to borrow and learn from one another.

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Theme 3: Utilizing Work Practices and Culture to Support Student Learning in the Workplace How Do the Routine Practices in a Work Environment Facilitate Student Learning? In the preceding two sections we have discussed the interpersonal interactions and the specific tasks and activities that influence student learning. In this section, the focus is on the culture and environment of particular workplaces; essentially, this is the context in which these interpersonal interactions and activities occur or, more simply, “the way in which we do things around here.” In Billet’s discussion of workplace learning (2001), the physical and social environment provides indirect guidance to learners. The physical arrangement of a classroom (students seated in rows, a circle, or small clusters) and the tools available (white board or chalk board, overhead projector or LCD projector, computer, and internet access) will shape certain aspects of the student teacher’s learning about designing and delivering a lesson. Similarly, the number of rooms available for seeing patients, the number of patients scheduled during a half-day clinic, the use of an electronic medical record system or a paper system, and the resources available for taking vital signs and conducting a physical exam (e.g., automated blood pressure cuff and nursing staff available to take vitals) all influence the kinds of activities in which a medical student engages and the ways in which the student learns to perform those activities. Similarly, the social norms and interactions among members of the workplace can indirectly guide learners. The attitudes of the physicians and nurses toward their work and toward one another may result in very good communication processes, routine check-ins that ensure a shared understanding of the plan of care for a patient, and efficient completion of tasks. Although no one directly explained the importance of these interactions to the nursing or medical student, he/she will expect and attempt regular, efficient communication between doctors and nurses as part of routine practice. One frequently cited advantage of learning in the workplace is the tendency for the connection between content and relevance to practice to be clear. Students see how a minister uses his in-depth understanding of various scriptures and of members of his congregation to select just the right passage to inspire and uplift them during a time of hardship. In the classroom seminar, memorization, and analysis of scriptures seemed much more like intellectual exercises with little utility. The faculty member teaching in the classroom had to put much more effort into framing the exercise and providing context for the students in order to motivate them. Furthermore, in the classroom students must imagine the response among a hypothetical congregation, whereas during an actual meeting or sermon, the student can observe an actual response and judge the effectiveness of the minister’s behaviors. Another advantage of workplace learning is that students see how practices actually occur and how they relate to one another. Although it may be easier to ensure that students have a foundation of good technique and ethical conduct when their learning begins in the classroom, the transition to real workplaces and less controlled

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environments can be overwhelming and sufficiently disorienting to cause students to feel they need to relearn many things they thought they had mastered (Boshuizen, Bromme, & Gruber, 2004). In a classroom or simulation center, a medical student can practice auscultation of the abdomen over and over until he feels confident he can demonstrate the proper skills and detect bowel sounds. The opportunity to break down the skill into specific steps, to take unlimited time, and to be observed and receive feedback is a virtue of practicing outside the workplace. However, in the exam room with a pediatric patient or a geriatric patient diagnosed with a hernia, the student will have a whole new perspective on the abdominal exam. Now the student must consider how to get the patient positioned for the abdominal exam, how many attempts are acceptable if the student is having trouble hearing anything, what to do if the patient is ticklish, when to enter the findings in the electronic record, or even what to do if the student has been told by his preceptor not to bother with the abdominal exam unless there is a clear reason for it. There are time constraints and other portions of the physical exam are higher priority, but the student also knows he needs the practice. These are real circumstances and judgments that the student will need to make regularly as a physician in a primary care practice.

What Aspects of Work Practices and Culture Can Misguide Student Development? As Harris described in Chapter 1, the workplace curriculum consists of the formal or intended curriculum, the informal, hidden or unintended curriculum, and the experienced curriculum (typically a combination of the formal and informal/hidden). When substantial discrepancies occur between the experienced curriculum and the informal/hidden curriculum, Hafferty and Hafler suggest that the learning experience can be suboptimal. At the very least, it is inefficient to spend time teaching students knowledge, skills, and attitudes in one setting that are discredited or overwritten in another setting without a reasonable rationale or critical inquiry. Alternately, Billett (2001) suggests that the informal curriculum is the reality of the workplace. The challenge for workplace instructors and for students is to see the strengths and limitations of this environment, to acknowledge that this is the material available for the curriculum, and to work on optimizing the learning that can occur in this environment. Workplaces are learning environments with many unpredictable and uncontrollable variables. Even if students of the profession are fortunate enough to work with the most skilled workplace instructors, they will undoubtedly be exposed to a number of suboptimal experiences that can have a profound impact on their learning. In this section, I highlight four circumstances that are potentially suboptimal for student learning, particularly if not sufficiently managed by workplace instructors: (1) adapting and assimilating to new environments, (2) handling discrepancies between the formal/intended curriculum during preparation for workplace learning and the experienced curriculum in the workplace, (3) competing roles of the workplace instructor, and (4) keeping up with variations and changes in practice.

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First, to examine the challenges of adapting and assimilating to new environments, imagine a new teacher arriving for his/her first day of school. The number of rules, policies, and norms he/she must quickly absorb just to be able to carry out his/her role as a teacher is overwhelming. Basic functionalities that everyone else takes for granted, like logging into the computer system, making copies of materials, and requesting supplies, take time to learn. A student of a profession similarly encounters this onslaught of things to learn, but given the limited amount of time the student has for learning in any given workplace and the likelihood that he/she will soon move on to another workplace, is this really a productive use of students’ time and effort? In medical education, a few studies have explored ways of improving students’ transition from the classroom years to the clinical years of education (Chittenden, Henry, Saxena, Loeser, & O’Sullivan, 2009; Chumley, Olney, Usatine, & Dobbie, 2005) and nursing has developed courses to help students transition to their first job (Nash, Lemcke, & Sacre, 2009). As described by Henry and Malu in Chapter 4, teacher education typically addresses the transition through a very structured approach to easing the student teacher into the teaching role. The student teacher spends the first few weeks just observing his/her cooperating teacher and then gradually begins “taking over” the class for longer periods of time. In pastoral education, we found no literature describing the transition to clinical pastoral education, possibly because there is no need to explicitly address the transition or simply because nothing has be done so far to address it. These different models open up new possibilities for research around age-old but still unresolved questions about how best to support students through the transition from classroom to practice. Perhaps a more basic question is whether there should even be a need for such efforts or if, instead, there is a shortcoming in our approaches to assimilating newcomers into workplaces as learning environments. Hafferty and Hafler raise questions about the authenticity of workplace settings used for training, specifically whether the work practices that occur in these settings are the same when students are present as they would be if students were not present? This question may help explain the challenge of transition to a first job as a teacher, nurse, or member of the clergy. Perhaps a new way of conceptualizing the learning environment is needed. Rather than seeing false dichotomies between “classroom” and “workplace” or “training workplace” and “real workplace,” a more useful construct would be to think about a continuum from more controlled and simulated learning experiences to less controlled and simulated learning experiences. So far, none of the professions seem to have this sort of continuum in place. A related issue for transitions is what might be considered the downside of the relevance and authenticity that workplace learning affords. Situational specificity has the advantage of grounding learning in a specific context, but this also means some additional attention may be needed to connect to concepts and principles that apply more generally to a variety of situations. The power of workplace learning is the opportunity to engage in authentic practices. The challenge is that many times the context for practice in one setting is quite different from the context of another setting. For example, presenting a patient case on the internal medicine service of the hospital is quite different from presenting a patient case in an outpatient internal

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medicine clinic or on the postoperative service in surgery. Although the fundamental purpose of the presentation is the same, the structure or format of the presentation, the people listening to the presentation, the time pressure, and the patient needs and perspectives can make the presentation feel like a completely different set of skills are required. Second, in Chapter 2 Hafferty and Hafler highlight several consequences of discrepancies between the formal/intended curriculum conveyed during preparation for the workplace and the informal/experienced curriculum in the workplace. Both the medical and nursing literatures suggest that when students witness substantial variation in professional conduct across settings (value judgments, tolerable and intolerable behaviors especially in the moral/ethical realm, and standards of practice), many become skeptical about the espoused ideals of the profession (Ferguson & Jinks, 1994; Wear & Zarconi, 2008). Even more concerning, students’ development of internalized orientations toward good, just, and fair behaviors may suffer as students focus more on adapting their behaviors to “fit in” with the dominant professional and ethical norms of different environments. In positive learning environments, where the highest values of the profession are honored and modeled, the hidden (or at least the non-explicit) curriculum may have a desirable and beneficial influence on professional development. But in learning environments where the values of the profession are occasionally or even frequently disregarded or violated or in which multiple professionals with competing agendas and values are working alongside one another, the hidden curriculum can have a deleterious effect. Efforts to inculcate learners with a sense of righteousness, virtue, and moral clarity prior to entry into workplaces have limited effectiveness (Ginsburg, Regehr, & Lingard, 2003a, 2003b; Wear & Zarconi, 2008). The rationale for these efforts is that when learners encounter settings in which the espoused morals and values are not upheld, they can be aware, know what behaviors are wrong, and not emulate the behaviors. However, in many cases the pressure of the situation is overpowering. Research has documented the tension and anxiety learners experience when they encounter discrepancies between the formal, explicit curriculum around professionalism, and the actual attitudes and behaviors observed and communicated in some workplaces and has even shown that, when surrounded by persuasive and influential people, many learners succumb to their influence. This is the power of socialization (Feudtner, Christakis, & Christakis, 1994; Ginsburg et al., 2003b). Researchers suggest that acknowledging and engaging students in explicit discussions of observed “lapses” in professional behavior rather than ignoring or denying their existence will help students develop the skills to navigate, negotiate, and respond appropriately to difficult situations. Such practices seem to be more the norm in clergy education and teacher education where reflection and reflective dialogs between teachers and learners are more the norm. Although these practices make sense intuitively, research is still needed to demonstrate a positive impact on professionalism and identity development. This discussion of gaps between the formal/intended and the informal/experienced curriculum raises important questions about preparation for workplace learning. Among the four professions reviewed in this book, medicine devotes

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the most time, nearly 2 years, to classroom preparation. However, medicine also requires at least 5 years of clinical training in workplaces before physicians are allowed to practice independently – an amount of time that substantially exceeds any other profession. And, this longstanding tradition of separating classroom and clinical/experiential learning is increasingly being replaced by efforts to incorporate more clinical experiences with real patients into the first 2 years of medical school. While there is some evidence to support the value of earlier clinical experience for professional development and student satisfaction ratings are generally high, there is not yet a definitive set of studies showing that the learning outcomes are better (Littlewood et al., 2005). Similarly, in teacher education, though the training is much shorter, students are typically taught the core principles and concepts and then sent into classrooms to apply them. This approach may be more a reflection of the practical issues associated with scheduling student teaching experiences and the perceived benefit of immersion in a classroom as opposed to a distributed model in which a student teacher spends 2–3 days a week in a classroom and the remaining days in courses on curriculum, instruction, assessment, evaluation, and leadership/management. The third potentially challenging condition of workplace learning is multiple roles of the workplace instructor. Often workplace instructors are in a position of dual accountability both to provide quality service to their clients (patients, students, or congregants) and to facilitate the learning of the students of the profession. These two responsibilities can produce conflicting demands particularly when, as described in Chapter 2, there is significant pressure to maintain the same level of efficiency, productivity, quality, and safety of work whether or not learners are present. This pressure is at odds with a workplace curriculum that affords learners progressive engagement in and responsibility for complex tasks because as learners move to a higher level of complexity they will be slower and less efficient than an experienced professional. Furthermore, the capacity to observe and assess learner performance in real time is constrained by these pressures, particularly if the workplace instructor is unable to work in close proximity or collaboratively with the learner. This is particularly true in medical education and partially explains why the profession has relied so heavily on external assessments and summative assessment (see the “external audit function” described by Galbraith, Clyman, and Melnick in Chapter 5). However, these forms of assessment are at odds with an effective workplace learning curriculum that supports student learning based on demonstrated performance. In teacher education and pastoral education, there is more capacity for direct observation of learners who are taking over a portion of the work of the cooperating teacher or ministry supervisor because there is typically no additional workload that the supervisor is concurrently trying to manage. Both of these professions incorporate a number of formative assessments and expect students to engage in formal reflection on their practice through portfolios, journals, and/or discussions with their instructors. Many have advocated for better models for ambulatory medical education, such that preceptors have protected time to observe, teach, and provide feedback to students (Regan-Smith, Young, & Keller, 2002; Stewart, Preece, & Dent, 2005). In all four professions, practical faculty

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development, particularly for new instructors, related to time management, prioritization, and tips for efficiency may be helpful, but ideally, the work demands and expectations of workplace instructors must be reduced so that ample time can be devoted to observing, coaching, explaining, supporting, critiquing, encouraging, and many other functions needed to facilitate novice learning in the workplace. The fourth and final condition to consider about workplaces as learning environments is the frequency with which change occurs. Tasks, activities, routines, and relationships are subject to frequent change due to new technology, advances in research and development, policy or regulatory changes, new leadership, shifts in budgets and resource allocations, and a variety of other reasons. Consequently, the workplace curriculum is dynamic and the instructors who guide and consult with learners along the way must be prepared to examine the implications of these changes in relation to existing learning processes, pathways, and goals and adjust their coaching, mentoring, and supervision accordingly. Furthermore, the workplace instructor often must learn new practices himself/herself, sometimes alongside the student. For example, consider a seventh grade classroom in which all students are, for the first time, given access to laptop computers and are asked to complete a science lab presented in an online learning module. The student teacher may have some familiarity with online modules, but the use of these technologies may be completely new to her supervising teacher who has been teaching science to seventh graders for 10 years. The supervising teacher must consider several things to make this an effective learning experience for both the student teacher and the students in the class. First, is this a technology that is likely to last and even become more prevalent in the future? Presumably it is, so incorporating into the learning pathway is necessary. Second, how can the supervising teacher partner with the student teacher to maximize the experience for students in the classroom? Clearly, there are things the supervising teacher can learn from the student teacher and he/she must not be unwilling or embarrassed to admit this since the ultimate goal is to maximize the likelihood that the seventh graders will learn the key concepts of the lab and be able to write up a lab report with the assistance of the software. Similarly, there are many techniques and strategies the student teacher can learn from the supervising teacher such as how to explain the activity to the students, how to monitor progress and identify students who need assistance, and how to manage students’ excitement and/or anxiety about using computers and completing a lab in a new way. Finally, the supervising teacher must decide the appropriate level of responsibility to give the student teacher in this activity. She may over- or underestimate the difficulty of leading this activity, so how will she know if she needs to provide more or less support and guidance? And, having never done this activity before, what goals and expectations are appropriate for the student teacher, and how will the supervising teacher assess the student teacher’s performance and provide feedback? Although none of these four circumstances necessarily results in suboptimal learning in any of the four professions, each raises important questions about the selection of work environments for student placements and the selection and preparation of workplace instructors to coach, supervise, and generally guide learning in the workplaces of the profession. In many cases, the workplace instructors are

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selected by virtue of the place where they work. In other words, the setting and the types of experiences available (e.g., first-grade classroom, family medicine clinic) are prioritized over teaching capacity and culture of the setting. Correspondingly, preparation and ongoing training for workplace instructors must be a high priority, particularly given the unpredictability and ever-changing demands of work environments. Effective utilization of work practices for learning depends heavily on workplace instructors who are trained to identify or create good learning opportunities, particularly when the workplace poses challenges that are real, but not necessarily optimal for student learning (e.g., a disgruntled consultant on the radiology service, no-show patients in clinic, a rambunctious student in a class of 22 students, a sudden event that happens in a community and needs to be incorporated into a sermon last minute). Attention might also be given to preparation and ongoing development of workplaces as learning environments, not just for students but for all who work in them. For example, could performance monitoring systems, as suggested by Galbraith, Clyman, and Melnick in Chapter 5, be implemented? Are there ways of building feedback into the culture and making feedback an expectation of all members of the work community for the benefit of improving patient care or spiritual community or student learning? Strategies might include setting expectations to ensure that colleagues are respectful of one another and providing training on giving and receiving feedback. This improvement could yield positive outcomes on multiple levels, including decreased pressure for workplace instructors to provide constant feedback to learners and increased opportunity for students to provide feedback to other members of the work community.

Directions for Future Research on Work Practices in Workplace Learning One of the greatest virtues of workplace learning is the opportunity to experience the realities of professional practice without holding full responsibility for a patient’s care, a student’s learning, or a community’s spiritual growth and wellbeing. Students of the profession have the opportunity to learn both “tricks of the trade” and core knowledge, skills, and values from experienced practitioners. However, workplaces do not always provide ideal learning environments in terms of demonstrating best practices and model behaviors, assimilating learners into practice in efficient and supportive ways, encouraging inquiry and critical reflection on practice, and providing adequate feedback. Often times pressure and workload, limited space and resources, and inadequate staff or insufficiently trained instructors contribute to these challenges in the workplace. In medical, nursing, teacher, and pastoral education, there are required work experiences that all students must complete in order to graduate or obtain a license. As a result, placement options for work experiences can be limited and thus less optimal than desired. One solution might be to create dedicated teaching workplaces. Although to some extent this was the initial vision for the teaching hospital, in today’s environment the teaching mission

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is no longer the top priority of most teaching hospitals. The practicum model in teacher education may be the closest match to this concept. Such educationally oriented environments would potentially allow selection of a cadre of skilled workplace instructors, more careful monitoring of work practices to ensure alignment with best practices or recommended guidelines, a reduction of the competing roles and demands on the workplace instructor, and reduced or more controlled time pressures and workloads. For novice professionals, this proposal seems appealing. The closer professional students get to independent practice, the more they may need to shift toward real work environment. Some questions to guide research in this area include: 1. What strategies help students assimilate into a work environment most efficiently? Are there specific tasks and activities that afford students some responsibility while also helping them become acquainted with practices and the work environment? 2. To what extent does the nature of practice in a given work environment influence learning? Are there certain factors that are more influential than others (e.g., adherence to best practices taught in the classroom, communication processes, access to technology, workload of workplace instructors)? To what extent can workplace instructors attenuate the negative influence of certain factors? Is there a “quality threshold” below which learning inevitably suffers? 3. To what extent do disconnects between the formal/intended curriculum and the informal/hidden/experienced curriculum inhibit student learning in the workplace? Are there certain conditions or circumstances in which the disconnect is more or less problematic? 4. What are the advantages and disadvantages for learning process and learning outcomes when students spend brief periods of time in many different work environments compared to spending longer periods of time in a few work environments? Is one clearly better than the other? 5. Could students develop an equally solid foundation of good technique and ethical behavior if they started off learning predominantly in the workplace rather than in the classroom? What resources would be needed to achieve these outcomes? These questions are intentionally broad so that they can be investigated in any of the four professions and/or used for cross-profession comparative research.

Summary As mentioned in the introduction, the three themes of workplace learning are interdependent in each of the four professions examined in this book. Work practices and culture are present in relationships and in tasks and activities, but are useful as a separate theme for the purposes of understanding why relationships are so different across workplaces and why tasks and activities are sometimes performed so

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differently. Comparative studies of work practices both within and across professions provides new opportunities to identify elements of workplaces that do and do NOT make a good learning environment, regardless of the skills of the instructor in that environment and the types of activities occurring in that environment. Ideally, educators and administrators should be able to identify suboptimal workplace learning environments proactively rather than retrospectively through complaints or poor evaluations by students and take steps to improve them. Medicine, nursing, and teaching all have extensive bodies of literature on characteristics of the practice setting (the clinic, ward, or classroom) that positively impact patient care or student learning outcomes. Recently, medicine and nursing have initiated research to connect some of these workplace characteristics (e.g., patient-centeredness, use of best practices) with the quality of the learning environment (Haidet et al., 2006; Henderson et al., 2009). Teacher education has taken a slightly different approach, focusing on changes to the curriculum for teacher education that will better support teachers’ ability to create positive learning climates (Cohen, McCabe, Michelli, & Pickeral, 2009). These both suggest the beginnings of a promising program of research, though admittedly a challenging one, that will frame workplaces as learning environments and look for evidence of learning or educational outcomes as well as clinical or practice outcomes.

Discussion and Conclusions In the professions, workplace learning is gradually developing into an area of research, but in many respects it is still an amalgamation of research from many different traditions and perspectives that are situated in the workplace rather than an area with a distinct scholarly identity and a clear program of research. This is not a trivial distinction. For workplace learning to make a real contribution to professional education, I propose the following efforts. First, organize the research around a common framework. For multi-professional and comparative research to succeed in professional education, this is essential. There is a wealth of common goals, concepts, and challenges, but it can be difficult to see beyond the particular features and cultures of each profession without the help of a common framework. The three themes presented in this chapter, relationships, tasks and activities, and work practices and cultures, provide one possible framework, with the primary focus on documenting factors that influence participation and learning in the workplace for all professions. Existing research can be mapped onto this framework, as I have started to do in this chapter, and then examined for gaps to guide future research. Outcomes of particular interest can be specified along with appropriate research designs and methods to study these outcomes and then shared, interpreted, and applied in the context of each profession. One example of an outcome is a map of student changes in the level of participation and skill in domains such as classroom management, formulation of an assessment and plan for a patient, or delivering a eulogy. Although the specific outcomes are different, there

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may be common features in the learning process and the teaching strategies that provide insights across professions. Second, encourage practitioners and/or participatory researchers across professions to engage in (or continue to engage in) practice inquiry. This means identifying questions or challenges that occur in the context of practice and instruction, documenting them, experimenting with different strategies or approaches, and observing the results. For example, when supervising multiple students who have quite different strengths and weakness, what seems to account for these differences are the ways the instructor can encourage the students to help one another improve on their weaknesses rather than relying so heavily on the instructor for guidance. The instructor might keep a journal to track both the strategies he/she uses to achieve this goal as well as his/her observations of what the students do in response and how he/she decides when a strategy worked, did not work but might with some tweaking, or did not work at all. Workplace learning is in early stages of research, so field research of this sort is incredibly valuable and important. And workplace instructors, as practitioners, are best positioned to provide the nuanced understandings of workplace learning and make connections that enhance the conceptual framework of workplace learning. Providing opportunities for practitioners from one profession to share and discuss their inquiries and findings with practitioners from other professions can inspire a variety of new ideas, applications, and strategies as has been shown through years of interdisciplinary and cross-professional convenings for the scholarship of teaching and learning (Huber & Hutchings, 2005). Third, create scholarly communities to advance research within the framework of workplace learning by describing or testing general principles and approaches across settings and professions. This scholarship can be achieved in part by building collaborative research projects across the professions to answer common questions of interest. The scholarly community ideally would include researchers from multiple disciplinary traditions with a breadth of methodological capacities. Additionally, collaborative efforts to synthesize existing case studies and other research pertinent to workplace learning would offer confirming or disconfirming insights from an inductive angle to potentially develop the framework further. Finally, plan for translational research. In many areas of research, there is an unfortunate gap between research and practice. The needs of practitioners are not well communicated to researchers and the findings produced by researchers are not carried forward to practical steps that are feasible and possible to implement by practitioners. Workplace learning benefits from a solid foundation in theory and research from the learning sciences and a wealth of practical experiences and insights from a long tradition of apprenticeship and educational programs in the professions. In cross-professional research, there is an additional translational step needed, as discussed above, so that general principles and concepts tucked inside findings from one profession are brought to the forefront for interpretation, adaptation, and/or application in other professions. The framework proposed in this chapter may provide the basis for a shared language and conceptualization of workplace learning that can facilitate a dialog between researchers and practitioners within and across profession. In addition, building a strong strand of inquiry and research that involves

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observations of workplaces and interviews with instructors, staff, and students in these workplaces will encourage partnerships and dialogs that enhance the capacity to generate evidence to support excellent, implementable practices to support workplace learning. Acknowledgments The author thanks Dr. David Irby and Dr. Patricia O’Sullivan for their careful review and valuable suggestions for improving this chapter.

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Author Index

A Aagaard, E., 168 Abramowitz, R., 144 Abzug, J. M., 93 Adams, J., 95 Aleamoni, L., 140–141 Alemagno, S. A., 103 Alexander, J. G., 102 Alford, D., 147 Allen, T., 141 Allison, J. J., 25 Altschuld, J. W., 7 Anderson, J. R., 51 Anderson, N., 146, 168 Anderson, R., 161 Anderson, R. S., 117 Anderson, V. J., 119 Anderson, W. A., 158 Angell, M., 24, 27 Angrist, J. D., 115 Appleby, J., 25 Arean, P. A., 169 Argyris, C., 106 Armbruster, J., 29 Arnold, G. K., 90, 110, 120 Arnold, L., 102–103 Arnold, P., 135, 149 Arno, M., 169 Asch, D. A., 95 Asch, K. M., 95 Ashforth, B., 146 Aspan, P., 111 Austin, A., 139 Ausubel, D. P., 50 Avorn, J., 27 B Backer, E. L., 27 Baillie, S., 92

Baker, D. P., 110 Baker, E., 7 Baker, E. A., 170 Baker, G., 169 Baldwin, M. S., 102 Bandura, A., 6, 13 Banta, T. W., 141 Barab, S., 156–157 Barker, M., 168 Barnes, L., 139, 142, 144 Barnett, M., 157 Barrows, H. S., 108 Bartfield, J., 17 Barzansky, B., 103 Bass, E. B., 9, 46 Batalden, P. B., 91 Beach, A., 139 Beaubien, J. M., 110 Beauchesne, M., 65 Beck, C., 134, 150 Becker, H., 19 Bellini, L. M., 110 Bell, S. K., 23 Benner, P., 42, 53, 180 Berens, M. J., 25 Berwick, D. M., 91 Biernat, K., 137 Biggs, J. B., 123 Billett, S. R., 4, 11, 63–64, 66–67, 70–71, 73–74, 144, 167–168, 182–183 Birman, B., 143 Black, K. P., 93 Blackmore, D. E., 95 Blanchard, A., 153 Blank, B. A., 90 Blank, L. L., 90, 103, 110 Blatt, B., 74 Bligh, J. G., 119–120, 141 Block, L., 136

J.P. Hafler (ed.), Extraordinary Learning in the Workplace, Innovation and Change in Professional Education 6, DOI 10.1007/978-94-007-0271-4,  C Springer Science+Business Media B.V. 2011

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196 Bloom, B. S., vii, 7, 46, 91, 122 Bobbitt, F., 46 Bobrow, D. B., 50 Boehler, M. L., 70 Boex, J. R., 103 Bond, L., 17 Booth, M., 66–67, 70, 79, 146 Booth, S., 65 Bor, D., 67 Borko, H., 134 Boshuizen, H., 66, 169, 183 Boshuizen, H. P. A., 46–47, 50–51, 57 Bosk, C. L., 26 Boswell, E., 142 Boud, D., 76 Boulet, J. R., 90, 111 Bourke, R., 25 Bowen, J., 168 Bowers, L., 66 Bowman, C., 135, 148 Boyer, E., 139 Bradley, H., 65, 146 Bragg, D., 137 Brainard, A. H., 30 Brancati, F. L., 70 Branch, W., Jr., 171 Bransford, J., 146 Bransford, J. D., 5, 49–51 Brennan, R. L., 108 Brennan, T. A., 25–26 Brett, A. S., 27 Brice, J., 141 Brinko, K., 152 Brislen, H. C., 30 Britton, L. R., 168 Bromme, R., 183 Brookfield, S., 153 Brown, A., 146 Brown, A. L., 5 Brown, F. H., 109 Brown, J., 146 Brown, J. S., 6, 13, 55–56 Brown, R. R., 50 Bruce, D., 93 Brummett, V., 134 Buchler, J., 42 Buckley, S., 141 Budetti, P. P., 88 Bullough, R., 134 Bundy, C., 171 Burack, J. H., 108 Burch, V., 88 Burch, V. C., 75

Author Index Burns, C., 65 Burr, W., 27 Byrd, D., 150 Byrne, A. J., 66, 73, 75 Byrne, C., 81 C Caffarella, R. S., 48 Caldicott, C. V., 25 Callaghan, D., 168 Campbell, C. B., 49 Campbell, E. G., 27, 88 Campbell, M., 134 Cantrell, D., 25 Carey, L., 7 Carini, P. F., 67, 69, 75 Carline, J.168 Carline, J. D., 108 Carroll, D., 135, 149 Carroll, W. M., 3 Castellani, B., 10 Cation, L. J., 108, 110 Center, D., 136, 139 Centra, J. A., 46 Chandramohan, B., 119 Charness, N., 42 Chen, M., 27 Chesla, C., 180 Chimonas, S., 26–27 Chinchilli, V. M., 93 Chism, N., 139–140, 149 Chism, N. V. N., 141 Chittenden, E. H., 184 Cho, C. S., 169 Choudhry, N. K., 97 Christakis, D., 10, 103, 185 Christakis, D. A., 20, 103 Christakis, N., 185 Chumley, H., 184 Claffey, C., 136 Clark, C. M., 42, 53 Clark, J., 139 Clark, R. W., 4 Clauser, B. E., 90 Clifton, M., 101, 178 Clyman, S. G., 87–88, 90–91, 172, 178, 186, 188 Cocking, R., 146 Cocking, R. R., 5 Cohen, J., 190 Cohen, P. A., 45 Colbert, R., 135 Colby, A., 17

Author Index Cole, M., 6, 8 Collier, S., 105 Collins, A., 6, 13, 55–56, 146 Colliver, J., 141 Colliver, J. A., 48 Commission, C., 152–153 Confessore, S., 74 Cook, D. A., 65–66, 73 Cooke, M., 102, 151, 169, 172 Cooking, R. R., 50 Cook, S. S., 114 Cordingley, L., 171 Corrigan, J. M., 25, 90 Coutts, L., 103 Cox, J., 135, 149 Cox, K., 65–66, 70 Cox, M., 21, 152, 179 Crabtree, B. F., 27 Creedy, D. K., 169 Cronbach, L. J., 88 Crosby, J. R., 65, 67–68 Cross, K. P., 139, 151 Curry, L., 13 Curtin, L., 104 Custers, E. J. F. M., 46–47, 50–51, 57 D Daane, C., 135, 150 Dagley, V., 81 Dahill, L., 70 Dahill, L. E., 4 Damjanov, I., 120 Dana, J., 27 Danoff, D., 103 Darling-Hammond, L., 4, 115, 134, 150 Davies, I., 171 Davis, B., 25 Davis, D. A., 96 Davis, M., 121, 136, 158 Davis, M. H., 92 Day, L., 66 70, 104, 109 De Grave, W., 66 Densen, P., 108 Dent, J. A., 186 Desimone, L., 143 Devitt, P. G., 73, 80 Devlin-Scherer, R., 135, 150 Dewey, J., x, 41, 50–51 DeWitt, D., 168 DeWitt, T. G., 67 Dick, W., 7 Dillon, G. F., 90 Dilts, D. M., 21

197 Dittus, R. S., 25 Dobbie, A., 67, 184 Dobkin, P. L., 96 Doherty, S., 25 Dolmans, D. H., 66, 71 Dolmans, D. H. J. M., 169 Donald, A., 25 Donaldson, M. S., 25, 90 Donkers, H. H., 120 Dooley, L., 114 Dornan, T., 66, 70, 167, 169, 180 Dowie, J., 42, 53 Downie, W. W., 111 Dreyfus, H. L., 71 Dreyfus, S. E., 71 Driessen, E., 92 Drop, R., 88 Drovdahl, R., 153 Dubrowski, A., 66 Dudek, N., 146 Duffy, F. D., 90 Duguid, P., 6, 13, 55, 146 Dunn, T. G., 76–77 Duquette, C., 135 Durning, S. J., 108, 110 Dyne, P. L., 91 Dyson, A. H., 69, 76 E Eagen, K., 30 Eaglen, R. H., 109 Eby, L., 141 Eddy, P., 139 Eggett, D., 123 Ehringhaus, S. H., 27 Elstein, A., 42, 53 Elstein, A. S., 42, 53, 109 Enarcon, C., 103 Ende, J., 75 Englehart, M., 91 Ensher, E., 153 Entwistle, N., 49 Epstein, R. M., 87, 91, 94, 96 Erickson, B. L., 46 Erickson, G. R., 46 Ericsson, A., 42, 56 Ericsson, K. A., 73, 76, 79 Errichetti, A. M., 90 Essed, G. G. M., 169 Essington, A., 139, 151 Eva, K., 141 Eva, K. W., 49, 93, 96 Evenbeck, S., 149

198 F Fallows, S., 119 Farris, E., 144 Fazio, S. B., 23 Feiman-Nemser, S., 42 Fein, E. H., 27 Feldman, M. D., 169 Feltovich, P. J., 42 Fenderson, B. A., 120 Ferguson, D. S., 80 Ferguson, K., 108 Ferguson, K. E., 185 Ferrier-Kerr, J. L., 169 Feudtner, C., 20, 103, 185 Fields, S. K., 103 Figlear, E. A., 72 Figlear, M., 72 Fine, M., 69, 76 Fisher, C., 142 Fletcher, R. H., 97 Flexner, A., 89 Floden, R. E., 42 Forbes, E. J., 68 Forneris, S., 146 Forneris, S. G., 168 Fortna, G. S., 90 Foster, C., 70 Foster, C. R., 4 Fowell, S. L., 119–120 Foxx, S., 150 Francis, P., 141 Franken, R., 148, 153 Franks, R., 10, 17, 24, 94, 106 Frederic, W. H., 17 Freidson, E., 10, 18–22, 30 Frellsen, S. L., 170 Frey, T., 152 Frohna, A., 136 Frohna, J. G., 110–111, 117, 119 Fuller, E. J., 115 Furney, S., 168 Furst, E., 91 G Gaff, J., 137 Gagne, E. D., 5 Galbraith, R. M., 87–88, 96, 178, 186, 188 Ganser, T., 149 Garret, M., 143, 144 Gary, N. E., 75 Gawande, A., 19, 25–26 Gee, J. P., 65

Author Index Geer, B., 19 Gerver, W. J., 66 Gherardi, S., 17 Gibbs, G., 154 Giebelhaus, C., 135, 148 Gillespie, K., 139 Gillespie, M., 66, 68, 80 Gimpel, J. R., 90 Ginsburg, S., 26, 185 Glennon, F., 122 Gofton, W., 18 Goitein, L., 28 Goleman, L., 70 Goleman, L. A., 4 Goold, D. S., 10 Gordon, K., 168 Gordon, K. C., 65 Gozu, A., 143 Graffam, B., 66, 74 Grealish, L., 67 Greenberg, L., 74 Green, M. L., 25 Greenwood, E., 87–88 Grissmer, D., 79 Gronlund, N. E., 7, 46 Groopman, J., 26 Grossman, P., 168–169 Gruber, H., 183 Gruppen, L., 136 Grusec, J. E., 18 Guarino, C. M., 169 Gurvitch, R., 135 Guryan, J., 115 Guyton, E., 81 H Hadfield, J., 169 Hafferty, F. W., 3–4, 10–11, 17–18, 23–24, 94, 106, 171, 175, 183–185 Haidet, P., 18, 171, 190 Hallett, C. E., 67 Hall, L., 142 Halquist, D., 142 Hambleton, R. K., 88, 111 Hamilton, K. E., 107 Hamstra, S. J., 29 Harden, R., 111, 136 Harden, R. M., 65, 67–68 Hargreaves, D., 146 Hargreaves, D. H., 65 Harris, I. B., vii, ix, x, 3, 5–7, 10, 12–14, 39, 41, 88, 132, 137, 153, 176, 183 Harris, J., 153

Author Index Hart, L., 121 Hartley, R., 27 Harvill, L. M., 18 Hashem, M. A., 66 Hastings, P. D., 18 Hatton, N., 105 Hauck, F. R., 103 Hawkes, B., 141 Hawkins, D., vi Hawkins, F., 111 Hawkins, P., 133 Hawkins, R. E., 96 Hayes, S. K., 122 Healy, K., 102 Hegarty, E., 13 Hege, I., 66, 73 Hejduk, G., 136 Henderson, A., 190 Henry, B. W., 63, 132, 176 Henry, D., 184 Henry, S. G., 25 Hernon-Tinning, B., 168 Hershey, K., 152 Heun, C., 153 Hewson, P., 144 Hicks, O., 152 Hill, W., 91 Hilsen, L., 139 Hirsh, D., 67, 179 Hirsh, D. A., 21, 23 Hitchcock, M., 136, 158 Hobus, P., 88 Hodges, B., 29 Hoffman, R. R., 42 Hoff, T. J., 17 Hofmann, L., 67 Holloway, R. L., 136 Holmboe, E., 146, 170 Holmboe, E. S., 91, 96 Holtman, M. C., 88 Hopayian, K., 81 Horner, M., 136 Houldin, A. D., 68 Howard, D. M., 9, 46, 70 Howe, A., 81 Hubbard, J. P., 87, 89–92 Huber, M., 139, 151, 191 Huggett, K., 146 Hughes, E. C., 19 Hundert, E. M., 10, 87, 91, 94, 96 Hunter, C., 153 Hutchings, P., 69, 79, 139, 151, 191 Hyrkas, K., 81

199 I Infante, M. S., 68 Inkeles, A., 18 Ippolito, J., 112 Irby, D. M., 5, 44–46, 54, 58, 91, 101, 108, 134, 137–141, 152, 168, 172, 176 Irby, D. I., 170 Issenberg, B., 110 Issenberg, S. B., 92 J Jackson, J. L., 108 Janet, P. H., xv, 17 Jarrett, S., 136 Jinks, A. M., 185 Jin, L., 135, 149 Johnson, K., 116 Jones, E., 116 Jouglin, G., 121–122 Julka, M., 67 K Kahan, E., 121 Kallenberg, G., 74 Kane, L., 136 Kao, A., 103 Kapoor, W., 109 Karpf, M., 109 Karunathilake, I., 121, 136 Kase, R., 114 Kasper, D. L., 28 Kassebaum, D. G., 109 Katz, J. T., 20 Kaufman, D. M., 44, 53–54, 56, 76 Kaufman, D. R., 57 Keating, C., 135 Keene, K. N., 66 Keesey, J., 95 Keller, A. M., 186 Keller, F. S., 45 Kennedy, T., 169 Kent, S., 135, 149 Keough, R., 76 Kern, D. E., 9, 13, 46, 70 Kerr, E. A., 95 Kiefe, C. I., 25 Kilbourn, B., 135, 146 Kimball, H. R., 110, 120 Kimball, M. D., 90 King, N., 66 Kiraz, E., 135, 149 Kirby, S. N., 79 Kirkpatrick, H., 81 Klass, D. J., 90, 91, 95

200 Kneebone, R., 92 Knierim, A., 122 Knowles, M. S., 47–49 Koehler, M., 152 Kogan, J. R., 108, 110 Kohn, L. T., 25, 90 Kolb, D., 5, 47–48, 50–51, 53 Kolodner, K., 70 Kopelow, M. L., 90 Korow, M., 136 Kosnik, C., 134, 150 Kotagal, U. R., 67 Kovach, R. A., 103 Kowalski, K., 136 Kowalski, T., 135, 151 Krathwohl, D. R., 7, 46 Kreiter, C. D., 108 Kristensen, E., 152 Kroboth, F. J., 109 Krupat, E., 23 Kucera, K., 141 Kuczewski, M. G., 18 Kulik, C. C., 45 Kulik, J. A., 45 Kuo, A. K., 170 Kushner, T. K., 26 Kwang, S., 143 L Laird, N., 25 Lake, A. P., 25 Landt, S., 135 Langlois, J., 147 Larson, E. B., 108 Latcovich, M., 112 Lave, J., 4, 6, 8, 13, 21, 55–56, 142, 149, 156–157, 175, 180 Leach, D. C., 65, 80 Leape, L. L., 25 Leavitt, E. J., 89–92 Lebsack, J. A., 27 Lee, A. C., 146 Lee, K., 28 Lees, N. D., 149 Lee, W. C., 108 Lefevre, F. V., 88 Lemcke, P., 184 Lentz, E., 141 Leo, T., 30 Lesgold, A., 42 Lettus, M. K., 114 Levey, G. S., 109 Levine, R., 135

Author Index Levinson, D., 17, 24 Lewin, K., 51 Lewis, L., 144 Liang, L., 21 Lieberman, A., 151 Light, R., 139 Lillicrap, M., 81 Lim, M., 103 Lingard, L., 26, 141, 169, 185 Lipner, R. S., 97 Littlewood, S., 186 Lock, J., 152 Lockyer, J., 91, 94 Loeser, H., 102, 170, 184 Lopez, L., 20 Lorenz, R., 142 Loucks-Horsley, S., 144 Love, N., 144 Lowe, K., 136 Lowenstein, D., 151 Lowenstein, G., 27 Lown, N., 171 Lowry, J., 102 Ludmerer, K. M., 24, 79, 87, 89, 91 Lundberg, G. D., 24 Lund, J., 135 M McAllister, M., 66, 72, 80, 81 McCabe, E. M., 190 McCaffery, R., 136 McCoubrie, P., 119 McDaniel, G. S., 102 McFetridge, B., 66, 68, 80 McGlynn, E. A., 20, 25, 95 McGuire, C., 88 McIntyre, D., 150 McKeachie, W. H., 46, 65 McKinley, D. W., 111 McKinney, J., 153 McKinney, W. P., 27 McLeod, A., 145 McLeod, P., 136, 141, 145 McLoughlin, J., 25 McMurty, D. E., 21 McPhee, S. J., 27 McTighe, J., 106 Mager, R. F., 7 Mager, R. R., 46 Maio, A., 146 Malling, B., 142 Malu, K. F., 63, 72, 132, 176, 184 Mann, K. V., 44, 53–54, 56

Author Index Margolis, M. J., 90 Margolis, S. A., 90 Market, R. J., 110 Marks, M., 146 Marshall, J., 151 Martin, J. B., 28 Martin, M. L., 81 Marton, F., 65, 123 Mascha, E., 121 Masia, B. B., 46 Maslow, A. H., 48 Masters, J. C., 122 Mathews, S. C., 25 Mauck, A., 25 Mayfield, V., 134 Meagher, T., 145 Medalie, J. H., 103 Melnick, D. E., 87, 95, 172, 178, 186, 188 Melser, N., 134 Mercer, J. A., 101, 104 Merriam, S. B., 48 Merton, R. K., 19 Metro, D. G., 93 Metsemakers, J. F. M., 64 Metzler, M., 135 Meyer, B., 65, 168 Mezirow, J., 47–48, 50, 53–54 Michelli, N. M., 190 Middelton, L., 114 Miflin, B., 49 Mishra, P., 152 Mitchel, L., 135 Moessner, P. H., 114 Moloo, J., 27 Mommaerts, M., 29 Money, B. J., 102 Monsen, R. B., 114 Moon, J., 146, 153–154 Moore, D. E., 91 Morrison, E., 168 Mortensen, L., 142 Mosel, J. N., 45 Mount, J., 139 Moussa, I. D., 25 Moynihan, R., 27 Mueller, M., 135 Muething, S. E., 67, 81 Mundry, S., 144 Murphy, B. E., 79 Murphy, D. J., 93–94 Murray, K., 135 Musanti, S., 142

201 Muzzin, L. J., 121 Mylona, E., 101, 178 N Nash, R., 184 Naylor, M. D., 68 Neher, J., 168 Neher, J. O., 65, 71 Nelson, E. C., 91 Neville, A. J., 7 Newman, S., 146 Newman, S. E., 6, 55 Noel, G. L., 108–109 Nolan, J., 141 Nonu, M., 25 Norcini, J. J., 88, 90, 93, 95, 107, 109, 110, 120 Norman, D. A., 48 Norman, G. R., 7, 50 Nor wood, W. F., 89, 91 Notzer, N., 143 Nuthalapaty, F. S., 29 O Oakeshott, M., 41 O’Brien, B., 165, 172, 176 O’Brien, K., 141 Ogur, B., 21, 67–68, 179 Olney, C., 184 Ortelli, T., 136 Osborn, E. H., 102 O’Sullivan, P. S., 168, 184 Ottenheijm, R. P. G., 64, 70, 81 Owings, R. A., 49 P Paauw, D., 168 Paley, V., 79 Palmer, E. J., 73, 80 Pangaro, L., 67, 168 Pangaro, L. N., 110, 168 Papadakis, M., 10 Papadakis, M. A., 102 Papp, K. K., 168, 170 Paranjape, A., 171 Parker-Pope, T., 25, 29 Parsad, B., 144 Parse, R. R., 68 Patel, R. M., 93 Patel, V. L., 57 Peden-McAlpine, C., 146, 168 Penney, D., 146 Pennington, F. C., 91 Perkins, D. N., 6, 51, 55 Peruski, L., 152

202 Peterson, P. L., 42, 53 Piccinin, S., 152 Pichert, J., 142 Pickeral, T., 190 Pickering, G., 120 Pinar, W. F., 3–4, 9–10 Plante, T. G., 26 Pohl, H., 17 Polliack, M. R., 121 Pololi, L., 148, 153 Ponnamperuma, G. G., 92 Popham, J. H., 7 Porte, M. C., 66–67, 79–80 Porter, A., 143 Preece, P. E., 186 Price, D. A., 49 Progoff, I., 77 Pronovost, P. J., 25 Pugsley, L., 66 R Rabinowitz, H. K., 120 Radencich, M., 146 Ramanan, R. A., 169 Ramsden, R., 49 Reddy, S. T., 30 Reder, L. M., 51 Reeder, L. G., 19 Reed, V., 19 Regan-Smith, M., 186 Regehr, G., 18, 26, 49, 96, 169, 185, 193 Reid, B., 154 Reiman, A., 144 Reis, M., 25 Relman, A. S., 24 Resch, D. S., 103 Rethans, J. J., 88, 90, 93 Reynolds, W. M., 3 Reznick, R., 90 Reznick, R. K., 66 Richlin, L., 139, 151 Rider, E., 151 Ringsted, C., 142 Rinnert, S., 91 Roberts, D. H., 23 Roberts, J. S., 91 Robeson, M. R., 120 Rogers, J. C., 103 Root, R. K., 108 Rose, J., 68, 71, 74 Rosenberg, W., 25 Ross, I., 135 Rothman, D. J., 26

Author Index Roth, M. L., 81 Rotthoff, T., 120 Rousseau, J. J., 48 Rubak, S., 142 Rubin, E., 120 Rumelhart, D. E., 50 Rushton, P., 123 Ryan-Krause, P., 65 Ryckman, V., 121 Ryle, G., 41–42 S Sackett, D. L., 25 Sacre, S., 184 Safford, M. M., 25 Saks, A., 146 Saljo, R., 123 Salomon, G., 6, 51, 55 Sanchez, B., 153 Sargeant, J., 91, 94 Satterwhite, R. C., 103 Satterwhite, W. M., 103 Sawin, K., 65 Saxena, V., 184 Saxton, R., 81 Scalese, R. J., 92 Schaeffer, L. D., 21 Schank, M. J., 105 Scherpbier, A., 66, 169 Scherpbier, A. J., 66 Scherpbier, A. J. J. A., 64, 169 Schlundt, D., 142 Schnabl, G. K., 90 Schoettker, P. J., 67 Schön, D. A., 5, 9, 11, 13, 41–43, 47–50, 52–53, 57, 67, 77, 96, 106, 138–139 Schubert, A., 121 Schubert, W. H., 3, 9–10 Schulman, L. S., 17 Schussler, D., 135 Schuwirth, L. W., 91, 120 Schuwirth, L. W. T., 119 Schwab, J. J., ix, 12 Schwartzstein, R. M., 23 Schwenk, T. L., 70 Scouller, K., 123 Seggie, J. L., 75 Segouin, C., 29 Sepdham, D., 67 Shakespeare, P., 169 Shalof, T., 19 Shea, J. A., 108, 110 Shea, T. P., 152

Author Index Shelton, T. S., 49 Shem, S., 25 Sherer, P. D., 152 Shlipak, M. G., 27 Shoemaker, M., 81 Shohet, R., 133 Shriner, C., 76–77 Shubert, A. L., 3 Shuell, T. J., 5, 42, 45, 47–48, 50 Shulman, L., 138 Shulman, L. S., vi, x, 5, 39, 43, 57, 69, 79, 109 Sierles, F. S., 27 Simon, H. A., 27 Simpson, D., 137 Singer, J., 139 Skeff, K., 46 Skeff, K. M., 139 Skelton, J., 141 Skinner, B. F., 45 Slattery, P., 3 Sluss, D., 146 Smedley, A., 146 Smith, D., 105 Smith, J. M., 112 Smith, P., 134, 137–138, 144, 146–147, 150, 153 Smith, P. J., 66, 70 Smith, R., 25 Smolkin, L. B., 81 Snell, L., 141 Sockett, H., 65 Sorcinelli, M., 139 Soumerai, S. B., 97 Southworth, G., 65, 146 Spevick, J., 103 Sprafka, S. A., 109 Sprague, D., 152 Sprinthall, N., 144 Squire, K., 156 Stallings, J., 135, 151 Starr, P., 41 Steadman, M., 139, 151 Steckelberg, A., 147, 152 Stein, B. S., 49 Steinert, Y., 136, 139–146, 148, 152 Stein, H. F., 18 Steinman, M. A., 27 Sternberg, R. J., 5, 42, 47, 50, 52 Stern, D., 26 Stern, D. T., 10 Stetson, B., 142 Stevens, N., 65, 168

203 Stevenson, M., 111 Stewart, C. I. L., 186 Stiggins, R. J., 114–115 Stiles, K., 144 Stolberg, S. G., 27 Stossel, T. P., 28 Stratos, G., 139 Strauss, A. L., 19 Strauss, R. W., 91 Stritter, F. T., 148 Sturmans, F., 88 Suina, J. H., 81 Sullivan, W. M., 17 Svinicki, M., 137 Svinicki, M. D., 131, 177 Swaminathan, H., 88 Swick, H. M., 103 Swing, S. R., 91 Szabo, B., 139–140 Szenas, P., 103 T Tabenkin, H., 121 Talarico, J. F., 93 Tamblyn, R. M., 90–91 Tanner, C., 180 Tarrant, M., 122 Tatel, E., 149 Taubman, P. M., 3 Taylor, F., 62 Teherani, A., 168, 179 Tetzlaff, J. E., 121 Teunissen, P. W., 78 Thach, S., 147 Theall, M., 65 Thibault, G., 179 Thibault, G. E., 21 Thies-Sprinthall, L., 144 Thomasma, D. C., 26 Thomas, P., 3 Thomas, P. A., 9, 46 Thorndike, E. L., 45 Timmermans, S., 25 Timms, J., 102 Tolentino, B., 70 Tolentino, B. W., 4 Torre, D. M., 73 Tower, M., 72 Traynor, M., 25 Treat, R., 137 Tyler, R., vii, 7, 13 Tyler, R. W., 46 Tyrone, H. C., 101, 117

204 U Uggerslev, K., 146 Uijtdehaage, S. H. J., 27 Underwood, D. G., 102 Upshur, R. E., 25 Usatine, R., 184 V Valiga, T., 134 Van de Mortel, T., 25 Van der Vleuten, C. P. M., 88, 91–92, 106, 109, 111, 119, 120, 169 Van Eps, M. A., 169 Van Maanen, J., 18 Van Tartwijk, J., 92 Van Tonder, R. J., 27 Veloski, J. J., 103, 120 Verhulst, S., 141 Verhulst, S. J., 103 Vermillion, M. L., 27 Vygotsky, L. S., 6, 8, 55–56, 65 W Wade, R. C., 117 Wadsworth, E., 139 Wagner, R. K., 5, 42, 47 Walker, D., 76 Walker, R., 72, 169 Walvood, B., 119 Ware, J., 122 Warrier, R., 146 Wass, V., 92, 109 Waters, T. M., 88 Watson, R. T., 24 Wear, D., 185 Webb, C., 169 Wegner, J. W., 17 Weidman, J. C., 18 Weingarten, M. A., 121 Weis, D., 105

Author Index Wenger, E., 4, 6, 8, 13, 21, 55–57, 142, 149, 156–157, 175, 180 Wesche, M., 81 Wetmore, A. L., 93 Whelan, G. P., 111 Whitcomb, M. E., 24 White, C. B., 66, 78, 81 Whitman, N. A., 70 Wiggins, G. P., 106 Wilkerson, L. A., 5, 44–46, 54, 58, 91, 101, 131, 134, 136–141, 152, 177 Willett, J., 139 Williams, R. G., 91 Wilson, C., 90 Wilson, G. M., 111 Witkin, B. R., 7 Wolfhagen, H. A., 66 Wolfhagen, H. A. P., 169 Wolpaw, D., 168 Wolpaw, T., 168 Woodrow, S. I., 29 Wood, T., 146 Woolf, S., 25 Wright, S. M., 70 Wusthoff, C. J., 26 X Xeroulis, G., 66 Y Yarbrough, D. B., 117 Young, P. R., 120 Young, W. W., 186 Z Zaner, R. M., 25 Zarconi, J., 185 Zeichner, K., 116–117 Zinn, L. F., 154, 156 Zwietering, P. J., 64 Zyanski, S. J., 103

Subject Index

A Academic Pediatrics Association (APA), 136–137 Accreditation Council for Graduate Medical Education (ACGME), 11, 28, 90 Accretion, 50 Activities to support workplace learning, see Workplace learning Adult learning, 47 assumptions, 48 conceptions of, 8, 47–48, 58 and self-directed learning, transition to conceptions of, 47–49 theories, 45–47 Advisory Board Company Nursing Executive Center, 150 “Against Multiple Choice Questions,” 120 American Association of Colleges of Nursing, 104 American Board of Internal Medicine (ABIM), 103 American Nursing Association’s (ANA) Code for Nurses, 105 “Andragogy,” 48 Assembling performance data sets, 94–95 Assessment approaches, 89 of attitudes, 102 education, 105–106 medicine, 102–103 nursing, 104–105 theology, 104 defined, 101 feedback in, 94 historical changes in, 89 of competencies and performance, 90–91 mentor’s judgment of performance, 89

standardized testing of competence, 89–90 of knowledge, 118 education, 123 medicine, 119–121 nursing, 122–123 theology, 121–122 of performance, 93–94 analyzing data sets, 95–96 assembling performance data sets, 94–95 features, 93–94 improvement planning, 96–97 practical strategies applied to professions, 101–102 skills, 106–107 education, 114–118 medicine, 107–111 nursing, 113–114 theology, 111–113 traditional, 92–93 at work, 93 Assessment paradigm, emerging changes in, 87–89 emerging assessment of performance, 93–94 analyzing data sets, 95–96 assembling performance data sets, 94–95 improvement planning, 96–97 historical changes in assessment, 89 of competencies and performance, 90–91 mentor’s judgment of performance, 89 standardized testing of competence, 89–90 traditional assessment, 92–93 Association of American Medical Colleges (AAMC), 103

205

206 Attitudes, 102 assessment of, 102 education, 105–106 medicine, 102–103 nursing, 104–105 theology, 104 B Basic Principles of Curriculum and Instruction, 46 Behavioral approach, 54 Behavioral learning theories, 8, 45–47 faculty development practices, 46 focus, 44 frequency/contiguity/contingency, 45 reinforcement, 45 Best Evidence Medical Education (BEME), 140 “Best practices” absence of rule driven, 20 for clinical nursing teaching, 150 in medicine, movements, 11 observing, 7–8 pedagogical conundrum, 25–26 Boys in White, 19 C California Standards for the Teaching Profession (CSTP), 116 CanMEDS physician competency framework, 90–91 Carnegie Academy for the Scholarship of Teaching and Learning (CASTL), 151 Case-based teaching scripts, 138 Certified Nurse Educators, 136 Clerkships, 39 Clinical care, competencies, 91 Clinical Evaluation Exercise (CEX), 109 Clinical experience/classroom setting, trainees definition of, 10, 21 Clinical Performance Exam (CPX), 103 Coaching, 66–67 defined, 66 Coaching, mentoring, and supervision for workplace learning, 63–64 challenges, 79–80 contextual factors in workplace learning, 64–65 to support extraordinary learning in workplace, 65–66 coaching, 66–67 mentoring, 67–70 reflective practice, 76–78

Subject Index setting expectations, questioning, feedback, and reflection, 72–76 supervision, 70–72 Code for Nurses, 104 Cognitive mapping, 49 Cognitive psychology, 52 Cognitive theories of learning, 50–51 focus, 44 Collaboration, 158 Colorado Center for Nursing Excellence, 136 Communication, 158 skill, and its essentiality, 89–91 between teacher and student, 74 Communities of practice and other peer learning strategies, 149–152 social learning versus, 6 Competencies, 88 clinical care, 91 education assessment, skills, 115 medical knowledge, 91 professional practice, 40–44 standardized testing of, 89–90 workplace assessment of, 90–91 Computer-mediated communication (CMC), 153 Conceptions and theories of learning, 44–45 behavioral learning theories, 45–47 constructivist and cognitive theories of learning, 50 transition to conceptions of “adult learning” and self-directed learning, 47–49 Conflict of interest (COI) policies, 27–28 Constructivism, 47 Constructivist theories of learning, 8, 50 cognitive theories of learning, 50 focus, 44 Continuing Medical Education (CME), 93 Continuing Professional Development (CPD), 95 Cooperating teachers, 134 Courses, 141–142 “Critical,” 117 Critical reflection, 105, 117 Cueing effect, 120 “Culture of silence,” 11 Curriculum definition, 3 theory, 46 for the workplace, 64 Curriculum Development for Medical Education: A Six-Step Approach, 46

Subject Index Curriculum studies, traditions of scholarship and practice in, 6–7 deliberative curriculum inquiry, 12–14 reconceptualist approach, 9–12 systems approach, 7–9 D “Declarative” knowledge, 42 Deliberative curriculum inquiry, 12–14 defined, 11–12 fundamental process, 12–13 heuristics, 13 perspectives, 13 purposes, 12 Delphi technique, 145 Discourse community, 142 Diverse programming, 144 Divinity/teaching, 5 Dreyfus model of different levels of learner, 71 E Education assessment, attitudes, 105–106 reflective exercises for, 105 assessment, knowledge, 123 assessment, skills, 114–118 competencies, 115 portfolios for teachers, 116–117 theory and research, 63 Educational development, see Faculty development Eisenhower Professional Development Program, 143 Emile, 48 “Enacted curriculum,” 4 “The Essentials of Baccalaureate Education for Professional Nursing Practice,” 104 Evidence-based medicine (EBM), 25 movement, 11, 25 “Experienced curriculum,” 4 Experiential learning theories, 51–52 Exposure learning, 104 “Extraordinary,” v Extraordinary learning, v–vi practice and, vi in workplace, 22–23, 65–66 achieving, 166 coaching, 66–67 mentoring, 67–70 reflective practice, 76–78 relationship of role models and workplace settings, 23

207 role models, 22 setting expectations, questioning, feedback, and reflection, 72–76 supervision, 70–72 workplace setting, 22 F Facilitation, 159 Faculty development, 137–139 barriers/supports for professional development of workplace instructors acceptance into community of practice, 156–159 institutional structures, 155 intellectual and personal characteristics, 156 people/interpersonal relationships, 155 personal considerations and commitments, 156 professional development barriers/supports, 154–155 infusion of technology into faculty practice, models, 142–143 learning opportunities for workplace instructors, 141 communities of practice and other peer learning strategies, 149–152 consultation with feedback, 152–154 extended seminars and fellowship programs, 148–149 online on-demand training for faculty, 146–147 workshops, structuring, 141–145 workshops teaching workplace instructors, 145–146 literature on, 140 in professions, 139–141 programmatic offerings, 139 for workplace instructors, 131–137 for workplace teachers, 132 Far transfer, see High road transfer Feedback, 74–75 consultation with, 152–154 Fellowship programs, extended seminars and, 148–149 Field placements, 4 “Fishbowl” simulation, 110 Five-Step Microskills model, 71 Formal curriculum conceptual perspectives and, 3 learning in practice settings of workplace, 3–6

208 Formal curriculum (cont.) and learning in practice settings of workplace, 11 professional identity, hidden curriculum and, 21 traditions of scholarship and practice in curriculum studies, 6–7 deliberative curriculum inquiry, 12–14 reconceptualist approach, 9–12 systems approach, 7–9 Freidson’s challenge, 18–22 arguments about, training and work, 21 differentiation between prior training and workplace, 19 impact of training versus current work setting, 22 professional performance, variation, 18 “professional preparation” challenges, 18–19 socialization/professional inculcation, disconnects in training, 21 G Gibbs’ reflection cycle, 154 Global self-assessment, 96 H Hidden curriculum, 4, 17, 106, 167 professional identity, hidden curriculum and, 21 of professional preparation, 21 structural disconnects, and socialization, 17–18 extraordinary workplace learning, 22–23 Freidson’s challenge, 18–22 medical education and work, 24–25 pedagogical conundrum, 25–26 two modern-day arenas of pedagogical conflict, 26–29 through socialization theory, 10 “High-fidelity” simulation, 110 High road transfer, 51 I “Informal curriculum,” 4, 167 Innovations, scope for, 102 “Intended curriculum,” 4 International Society of Nurses in Genetics, 114 Internship placements, divinity students, 4 Internships, 4

Subject Index Interstate New Teacher Assessment and Support Consortium (INTASC), 116 “Invitational quality” of workplace, 168 K Keller’s Personalized System of Instruction (PSI), 45 “Knowing-in-action,” 41, 52 Knowledge, types of, 41 L Learning, 45–46 according to cognitive theorists, 50 cognitive theories of, 50–51 conceptions and theories of, 44–45 behavioral learning theories, 45–47 constructivist and cognitive theories of learning, 50 transition to conceptions of “adult learning” and self-directed learning, 47–49 cycle, 51 environment, 55 extraordinary workplace, 22–23 See also Extraordinary learning, in workplace factors influencing, 65 integrated approach to, 88 learning Covenant, 122 social cognitive theories of, 55–56 social constructivist-defined, 138 in social constructivist view, 54, 138 work, 52 social cultural theories of, 56–57 socially based theory of, 138 types of opportunities for medical faculty, 141 Learning for workplace education, conceptions and theories of, 39–40 cognitive theories of learning, 50–51 conceptions and theories of learning, 44–45 behavioral learning theories, 45–47 constructivist and cognitive theories of learning, 50 transition to conceptions of “adult learning” and self-directed learning, 47–49 experiential learning theories, 51–52 nature of professional practice – essential knowledge/competencies/qualities, 40–44 reflective practice and transformative learning theory, 52–54 social theories of learning, 54–55

Subject Index social cognitive theories of learning, 55–56 social cultural theories of learning, 56–57 Learning in practice settings of workplace, 3–6 formal curriculum and, 11 professions including, 4 systems approach to curriculum design, 7 Learning opportunities for workplace instructors, 141 communities of practice and other peer learning strategies, 149–152 consultation with feedback, 152–154 extended seminars and fellowship programs, 148–149 online on-demand training for faculty, 146–147 workshops, structuring, 141–145 workshops teaching workplace instructors, 145–146 Learning theories, 138 review of, 64 See also individual theories Learning tool, from object of work to, 20 Low road transfer, 51 M Maintenance of Certification (MOC), 93, 96 Maintenance of Licensure (MOL), 96 MCQs, see Multiple choice questions (MCQs) Medical education and work, 24–25 “conceit of professionalism,” 27 culture of silence, 26 “substandard”/“bad” practices, 26 “Medical Education Scholars,” 136 Medical faculty strategies for gaining credibility with, 158 types of learning opportunities for, 141 Medical knowledge, competencies, 91 Medical School Objectives Project, 103 Medicine assessment of attitudes, 102–103 assessment of knowledge, 119–121 assessment, skills, 107–111 complication rate, 107–108 elements of professionalism (ABIM), 103 Mentoring, 67–70 defined, 67 relationships, 169 Mentor’s judgment of performance, 89 “Messing about,” 6 Metacognition, 50 Mini-Clinical Evaluation Exercise (mini-CEX), 90, 110 Multiple choice questions (MCQs)

209 assessment with, 87 disadvantages in using, 120 innovative, 119 in knowledge assessment of medicine, 87 reliability of, 92 Multi-Source Feedback (MSF), 91, 94 “My Practice” report, 95 N National League for Nursing, 136 NBME eFolio, 92 Near transfer, see Low road transfer Nurse Professional Values Scale (NPVS), 104–105 Nursing, assessment attitudes, 104–105 knowledge, 122–123 skills, 113–114 O Objective Structured Clinical Examination (OSCE), 111 Online on-demand training for faculty, 146–147 Open-ended questions (OEQs), 120 Oral assessment, 120–121 Oral Practice Examinations (OPE), 121 P Pastoral education systems, certification process, 135 Patient safety movement, 11 Pedagogical conflict, two modern-day arenas of, 26–29 Pedagogical content knowledge, 138 Pedagogical conundrum, 25–26 Peer assessment, in health care, 107 Peer learning, 150 strategies, 149–152 Performance assessment of, 93–94 analyzing data sets, 95–96 assembling performance data sets, 94–95 improvement planning, 96–97 and competence, 88 in health care, 107 measurement of physician, 88 mentor’s judgment of, 89 Performance data sets, assembling, 94–95 Physicianship, 90 Practical action, 105 Practical knowledge, 5, 41 Practicums, 4

210 Preceptor Development Program, 147 Preceptorships, 39 R , 90 Primum Problem-based learning (PBL) methods, 102 Procedural knowledge, 42 Professional(s) trajectory of learning and development as, 6, 8 zone of proximal development, 6, 8 “Professional” culture, 65 Professional development, 6 critical features in education setting, 143 of workplace instructors, barriers/supports for acceptance into community of practice, 156–159 institutional structures, 155 intellectual and personal characteristics, 156 people/interpersonal relationships, 155 personal considerations and commitments, 156 professional development barriers/supports, 154–155 Professional development school (PDS), 4, 135 Professional identity, formal/hidden curriculum and, 21 Professionalism elements of, defined by ABIM, 11, 24–25 movement, 11, 24–25 Professional practice, 41 apprenticeship experience, 43 effective, qualities of, 41 nature of – essential knowledge/competencies/qualities, 40–44 Professional preparation, 10, 18–19, 21 Professional skills/professional socialization, goals in, 8 Professional socialization, 23, 57 Professions definition, 20, 41 education for the, 5 curricula for, 7 faculty development in, 139–141 Proximal development, zone of, 6, 8, 56 PSI, see Keller’s Personalized System of Instruction (PSI) R “Recommended curriculum,” 10 Reconceptualist approach, 6–7, 9–12 Reflection, 76, 105–106

Subject Index time needed for, of experiences, 77 unitization/categorization of, 105 “Reflection-in-action”/“reflection-aboutaction,” 5, 41, 52, 57 Reflective interview, 105 Reflective journal, 105 Reflective practice, 41, 50, 138 definition, 76 email exchanges, 77 promoting, 77 social theories of learning, 54–55 student teacher “conversation,” 77 and transformative learning theory, 52–54 videotaping, 77–78 writing to promote, 77 Reflective supervision, 113 Related learning theory, 53 Relationships in workplace learning facilitating learning, 167–171 future research on, 172–173 interfering learning, 171–172 models for, 169 Reporter, Manager, Interpreter, and Evaluator (RIME) model, 67 Respect, 158 S Schemata, 50–51 Schema theory, 52 Scholarship, 10, 139 and practice in curriculum studies, traditions of, 6–7 deliberative curriculum inquiry, 12–14 reconceptualist approach, 9–12 systems approach, 7–9 Scholarship of Teaching and Learning (SOTL) movement, 151 Scholarship Reconsidered: Priorities of the profession, 139 Scientific approach, 89 Self-assessment, 96–97 unreliable nature of, 96 Self-directed learning, 47–48 transition to conceptions of “adult learning” and, 47–49 Seminars, 141–142 extended seminars, 148 and fellowship programs, 148–149 Shadowing, 53 Signature pedagogies, 5, 39, 43 Simulation, 110–111 “Situated learning,” 56

Subject Index Skills, assessment, 106–107 authentic form, 106 education, 114–118 medicine, 107–111 nursing, 113–114 theology, 111–113 Social cognitive theories of learning, 55–56 Social cultural theories of learning, 56–57 implications of, 57 Social learning versus communities of practice, 6 theories, 8, 55, 58 Staff development, see Faculty development Standardized Patient (SP), 110 Standardized testing of competence, 89–90 with MCQs, 89 Stimulus–Response (S–R) psychology, 45 Strategies for improving teaching practices: A comprehensive approach to faculty development, 44 Student nurses, 39 The Student Physician, 19 Student teachers, 39–40 Study groups, 69, 75 “Substandard”/“bad” practices, 26 Sunday School Program, 69 Supervision, 70–72, 169 process, 133 Supported participation, 167 Systems approach, 6–9 limitations, 9 T “Tacit” knowing, 41 Tactics, 42 Tasks/activities to support learning in workplace, 174–176 future research, 180–181 optimizing/ inhibiting, 176–180 “Taught” curriculum of workplace, 10 Teach for America (TFA), 116 Teaching/divinity, 5 Teaching methods, examples of, 68–69 clergy, preparation, 69 clerkship, 68 clinical teaching model for nursing, 68 factors that characterize effective, 116 teacher, preparation, 69 “Teaching Scholars,” 136 “Technical” knowledge, 41 Technical rationality, 105 Theology areas of service, 112

211 assessment of attitudes, 104 assessment of knowledge, 121–122 assessment, skills, 111–113 complexity, reasons for, 112 Theory, definition, 44 Traditional apprenticeship model, 22 Traditional assessment, 92–93 Transformative learning, 50, 53 theory, 53–54 Tuning, 50–51 U “Unintended curriculum,” 4 United States Medical Licensing Examination R (USMLE ), 90–91, 111, 118 V Verbal interactions, 74 W Wabash Center for Teaching and Learning in Theology and Religion, pilot project, 112 learning agreement, 112–113 Work, medical education and, 24–25 “conceit of professionalism,” 27 culture of silence, 26 “substandard”/“bad” practices, 26 Workplace, v assessment, 87, 93 of competencies and performance, 90–91 See also Assessment curriculum, 64, 174–175 education theory and research, 63 faculty, 59 learning in, vi practice settings of, 3–6 See also Workplace learning versus prior training, 19 “taught” curriculum of, 10 teachers, faculty development for, 132 various occupation’s definition of, 19 Workplace education, v Workplace instructors community of practice acceptance into, 156–159 characteristics, 156 not being practicing member, 157 competing roles for, 134 development, domains, 154 faculty developer and, interactions, 158–159 faculty development for, 131–137

212 Workplace instructors (cont.) institutional structures, 155 intellectual and personal characteristics, 156 learning opportunities for, 141 communities of practice and other peer learning strategies, 149–152 consultation with feedback, 152–154 extended seminars and fellowship programs, 148–149 online on-demand training for faculty, 146–147 workshops, structuring, 141–145 workshops teaching workplace instructors, 145–146 people/interpersonal relationships, 155 personal considerations and commitments, 156 professional development barriers/supports, 154–155 skill of, 133 Workplace learning challenges, 79–80 coaching and, 66–67 conceptual framework, 166 contextual factors in, 64–65

Subject Index feedback, 74–75 impact of training experience on, 23 mentoring, 67–70 questioning, 74, 76 reflective practice, 76–78 relationships in facilitating learning, 167–171 future research on, 172–173 interfering learning, 171–172 setting expectations in, 73 as social process, 165 suggestions, 80–81 tasks/activities to support, 174–176 future research, 180–181 optimizing/inhibiting, 176–180 technology to facilitate, 73 resources relating to, 64 verbal interactions, 74 Workshops key areas for development of clinical instructors, 145 workplace learning aspects, 146 qualities essential for success of, 144 structuring, 141–145 teaching workplace instructors, 145–146