Linfadenectomía: ¿pélvica y/o paraaórtica?

The quote above from Eliza not only expresses her desire to demonstrate socially accepted, and possibly expected by the student, behaviour in her wanting to thank her educator for feedback – clearly something that she is unable to do if they are not present - but she also appears to be reflecting her interpreted norms of her professional community of practice (Wenger-Trayner & Wenger-Trayner, 2015; Wenger, 1998). Within the majority of healthcare professions, feedback in a practice-based learning environment is typically provided to learners on a day-to-day context, in the formative years by a patient-by-patient manner, and usually in verbal form. Notwithstanding the discrepancies highlighted earlier by Palermo et al. (2013) in terms of the consistency of feedback to pre-registration dietetic students, it remains commonplace within a healthcare community of practice to receive verbal feedback on performance of skill or knowledge, often more overtly related to demonstrable learning outcomes and/or competencies of practice (Health and Care Professions Council, 2013; Nursing and Midwifery Council, 2010). With the exception of mandated, formal and structured feedback meetings during a clinical placement – often termed tripartite meetings (Nursing and Midwifery Council, 2008) - that are often associated with formative or summative grading, regular written feedback within a practice-based setting is not conventional. Whilst there is a degree of dissonance in the literature about the usefulness of tripartite meetings to student learning (Passmore & Chenery-Morris, 2014; Rooke, 2014) their usefulness is accepted in terms of verification of learning.

It is interesting that the lifeworld “project” of the tripartite meeting is not perceived to be learning-focussed. A tripartite meeting typically involves the student, the practice-based educator, and a university-based educator (Passmore & Chenery-Morris, 2014). Given the argument in the previous chapter about the support offered to learning by those with whom the student is familiar, it might have been expected that the familiar university-based

educator was well-placed to transform this meeting from one that is assessment driven, into one with a learning focus. I hypothesise that this may, in part, be due to the university- based educator fulfilling more than one role (Reitz et al., 2013) within this “project”, and that of assessor appears to take priority over that of educator. This hypothesis draws on the earlier argument of educators enacting within more than one community of practice and the challenge to their role that this poses.

The behaviour of offering verbal feedback to a learner is a conventional strategy adopted in many practice or work-based learning settings, such as education and healthcare. Often described as mirroring an apprenticeship approach to learning (Woolley & Jarvis, 2007), this

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model of education is firmly situated within the context of social learning theory and this will now be explored further.

6.2.2.1 Generating authenticity

Situating learning within defined and, in part, unique boundaries offers the learner the opportunity to develop the knowledge and skill that is, in part, unique to the community within those boundaries. I have previously argued that whilst some of the skill and knowledge required of a nurse is equally required by, for example, an occupational

therapist, midwife and operating department practitioner to enable them to fulfil their own professional roles. However, in addition to this professionally overlapping skillset, there is equally a clearly-defined specific discipline of knowledge, understanding, competence and application that is unique to each of the professional disciplines. It is this unique discipline that sets apart the different professions and articulates their professionally-restricted community of practice. It is also this uniqueness upon which a feedback experience must draw in order that the novice members of that community develop an understanding about the application of feedback to their specific professional identity. This notion of authenticity of assessment and thus feedback, and potential false authenticity, is a fundamental

message from within the student data. The “Purpose of Feedback” chapter introduced an exploration about the authenticity of learning experiences; this section will now explore it in more detail in the light of a developing professional identity.

As discussed within the “Purpose of Feedback” chapter, the following quote from Gina highlighted a clear discrepancy between university and practice-based clinical practices, despite the assumed intention that the former is preparing the student for the latter:

[University] does say that they teach us the gold standard and everything, because we have the time to do that, and in 20 minutes [on placement] you’ve got to do what you can. Then you’ve got to be careful that you don’t do what you do here on placement, back in the [university environment] because they would be like “why are you doing that?” (Gina)

In the context of developing a professional identity from the learning experiences that students from specific disciplines are exposed to it is essential that the learning

opportunities that students engage with – including that which occurs from exposure to feedback – are genuinely authentic to the reality of the discipline, or community of practice, that they are intending to become a member of. There is evidence (Fenton-O'Creevy et al., 2015; Lave & Wenger, 1999; Wenger-Trayner & Wenger-Trayner, 2015; Wenger, 1998) to support the transition of new members of a community from the periphery to the centre of

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that community based on them becoming familiar with the culture of that community and subscribing to its practices, beliefs and values. With this in mind it seems increasingly challenging for a student healthcare professional to transit from the periphery to a more central position within a given community if they are being increasingly exposed to practices and beliefs that are at odds or in opposition to the authentic practices of that community. Gina’s example highlights the differences between the two learning environments – the university and “real” clinical practice - and the challenges faced by learners as a

consequence of such contesting practices but I pose that this quote reflects something even more fundamental to the ongoing development of identity of a given community of practice.

Work of Kilcullen (2007), Armstrong (2008) and Gordon (2013) around role modelling complements the evidence that expert clinicians and practice educators play a key role in influencing the practices of novices (Arreciado Maranon & Isla Pera, 2015; Dracup & Bryan- Brown, 2004; Hammond, Cross, & Moore, 2016). It is commonplace to recognise that the healthcare students of today are the professionals of tomorrow, and thus within the remit of the qualified healthcare professional, today’s healthcare students are also the practice- based educators of tomorrow. With this in mind, it is somewhat concerning that there is such a divide between practices taught and thus expected to be used within academic- based and practice-based settings. Gina does not suggest that the academic division of the community are unaware of the different and commonplace practices within the practice- based community, but she makes explicit that such practices would not be condoned within an academic setting. I suggest that this poses a significant challenge to the developing professional identity of the healthcare student. Much of the assessment feedback that is associated with verification of learning is university-based and yet the student knows that its authenticity to genuine clinical practice – because the practice-based community of practice operates differently – is limited. Superficially the feedback on such practice appears wholly authentic at a strategic level but in the operational reality of the profession it is less so.

This apparent dichotomy of norm within a given healthcare discipline is self-perpetuating if it remains unchallenged. Gina’s description of needing to be “careful” so as not to overtly demonstrate and expose the unsupported practice to the other party is interesting. There is a real sense from her description of accepting the fact that particular aspects of practice are hidden within discipline from those outside of that particular sub-division – academic or clinical – of a given community. She implies definite actions being taken by students to veil unaccepted practice within an academic environment and condone rather than challenge the differences in behaviour within the professional sub-communities of practice.

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6.2.2.2 Taxomony of belonging

The discourse used by Gina within this description is worthy of exploration regarding the concept of identity. Gina appears to superficially distance herself from the actions that she is describing by using “you” in her discourse rather that “I”. This suggests that the covert practices that she is exposing are engaged in by others rather than by her. Consciously or otherwise, she perceives herself as a passive observer of this activity, distancing herself from its core, though apparently condoning it by shielding those that do take part. As a passive observer, the extent to which one can fully engage with a community of practice and develop an identity synonymous with that community is limited (Lave & Wenger, 1991, 1999) and it seems that Gina is at odds with where she fits with this wider community.

Furthermore, Gina appears to distance herself from the academic clinical community - i.e. the university-based educators who support students in university-based clinical settings – by the way in which she refers to “they”. At the beginning of her quote Gina reflects the presence and inclusion of herself within the actions that she is describing, evidenced by her use of “we”. As her narrative develops, her language changes, her collegiality wanes and she appears to distance herself from the behaviour that she recognises as being disparate from genuine healthcare-situated clinical practice. I propose that this distancing adds weight to Gina’s sense of ill-fit with her wider professional communities [intentionally plural given my earlier arguments] and challenges her sense of identity, a sense of identity that one might expect to be more firmly developed now within this, her final undergraduate year. Whether it be in an academic or practice-based learning environment Gina will face feedback based on her demonstration of professional competence and disciplinary

expectations; she needs to develop strategies to reconcile the practices of the professionally accepted sub-communities she encounters if she is to truly recognise the value of feedback received. Educators from within and across the multiple communities of practice that Gina finds herself in may need to consider how they support her to accept diverse professional practice. This may be a signposting role for university-based educators.

A final consideration of the narrative from Gina is one that might arguably be expected of a final year pre-registration student. Within the quote, Gina’s sense of identity seems to be more akin to that of clinical colleagues in practice rather than to align with that of the academic (clinical) community. As a soon-to-be-qualified healthcare professional it is

unsurprising that she appears to favour the practices of the clinical community within which she can see herself belonging as a new graduate. It would be unusual, given the usual “second career” move into higher education for most healthcare academics, for Gina to

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preferentially align herself with the practices of the academic community. What is of particular interest though is that whilst Gina recognises the necessary austerity measures regarding patient time allocation in real (i.e. NHS) clinical practice, she fails to suggest any challenge, based on this, to the manner in which students are taught within a university setting in order to maximise authenticity and meaningful professional inclusion in a clinical community of practice.