Editorial

Abstract

This journal's relationship with practitioners in the wide-ranging field of health and social care was a recurring theme during our early discussions. In the Forum section of our first issue, Mark Doel considered barriers to practitioner authorship, while Sally Glen's plea for career pathways that combine academic and practitioner roles drew attention to the wider context of roles and relationships within the professions. Four types of role are usefully distinguished: the operational role of practitioners and middle managers; the strategic policy-making role of senior professionals in healthcare organizations, local and national government; the role of supporting learning by professionals of all ages and stages – the core business of a profession's ‘educators’ but also an important aspect of all professional jobs – and the role of researchers seeking to understand and improve the practices of their profession and their acquisition and development by practitioners of all the roles listed above. Although the relative proportions may vary, most professional jobs include some operational responsibility for either clients or students, and all of them include ongoing learning and contributions to the learning of others. From a client's perspective, what matters is the quality of the professional practices they encounter and the commitment of the professions to improving those practices. A profession's ability to meet this challenge depends on the extent to which it can deploy and interlink its jobs and roles to achieve its central purpose of providing the best possible services to its clients, and also, at an even greater level of complexity, on the extent to which it can work with members of other professional and occupational groups for the benefit of their common clients. Professional learning lies at the centre of this challenge. How could we learn more from our clients? How could we learn more from our colleagues? How could we learn more from our personal experience? How could we learn more from other professional and occupational groups? Without such learning, the challenge cannot be addressed seriously; and if it is not to be addressed seriously, why should society want to have professions? If we were to use a variable-focus ‘learning’ lens, we might see many professional relationships in a different light. For example, in healthcare settings there is an increasing use of guidelines where policy-makers think that clients would benefit from the widespread implementation of what their expert advisers consider to be best practice. Achieving this goal is usually conceptualized in terms of the dissemination of, and training in, practices perceived as defined by experts. But is it really that simple? Guidelines vary in their level of specificity, with some requiring more ‘local’ interpretation than others. In many cases, significant adjustments will be needed for variations in clients and their contexts, which can only be made by local practitioners. Moreover, activities associated with new practices will have to be accommodated alongside other activities within local work plans and arrangements. Thus, many facets of local implementation depend on local practitioners learning from experience during the early phases of implementation. What they learn will be a localized, possibly even personalized, variant of the new practice: they will be creating new knowledge through adapting and fine-tuning the innovation. This process has been well documented in the education sector, where most successful innovations have been shown to follow a process of ‘mutual adaptation’ between new practices and user contexts, rather than the ‘replication’ of innovation blueprints. The variations within any given type of practice are likely to be greater in social care than in some areas of medicine; however, even in such an apparently standard practice as drug administration, finding the optimal frequency and dosage for a particular patient can be a fine art. Another aspect of practice development, where the role of practitioners is much neglected, concerns the way in which new practices are introduced. How does a practitioner group change from one practice to another? In spite of relevant research in other sectors, change strategies in health and social care are often far from evidence-based, if not naive. Instead of studying what problems arise from attempts to change practices, even in the most propitious circumstances, and searching for the best ways to address those problems, there is a strong tendency to deny the problems and blame the practitioner. Yet practitioners’ goodwill and support are vital for a positive change process; changes preceded by an artillery barrage to soften people up, and accompanied by minimal or misdirected support for learning, just make practitioners more resistant the next time they are challenged. Learning to handle change better and provide more relevant forms of learning support is an important area for researcher–practitioner partnerships in which we might expect the practitioners’ voice to be particularly prominent. We should also note that the change process involves both learning and unlearning, and that the more the role of professional educators is expanded to include the support and facilitation of learning in the practice as well as the classroom context, the greater will be the likelihood that they also have a significant role to play in practice development. Also implicit in the above discussion is the need for policy-makers and senior professionals to learn a great deal more about change processes, their impact and effectiveness through studying existing research in this area and commissioning new research where necessary. If we now refocus our learning lens away from changes overtly linked to introducing new practices, we may find that professional learning occurs all around us in the workplace, though more noticeably in some environments than in others. The process of becoming a proficient practitioner is probably as rapid soon after qualification as before it; the evidence for ongoing, non-formal, mid-career learning is equally strong. Whenever one or more practitioners engage in problem-solving to find an appropriate response for a client, because no ‘ready-made’ response is available to them, they are learning and creating new knowledge. All problem-solving is learning and the learning that occurs during the development of new practices can be viewed as problem-solving, as well as knowledge creation to meet new contingencies. Indeed, a significant number of new practices are first developed by practitioners searching for new ways to serve their clients, sometimes taking advantage of new technology or basic research. Evaluating such practices requires research expertise as well; it is at this stage that careful discussion is needed as to whether randomized control trials or less experimentally elegant but more context-sensitive approaches are the more appropriate. Yet another view of learning emerges if we focus on how practitioners learn to use the theoretical resources provided by learning in formal contexts, both before and after qualification, or through reading and learning from colleagues. Learning just when a concept or theory is most relevant and precisely how to transform it for use in various practical situations is extremely challenging. Moreover, the lack of attention given to this issue by educational programmes discourages practitioners from taking up the challenge or even recognizing that it might enhance their practice. Such learning is largely personal or informal, and the resultant knowledge mainly tacit, so the disposition to engage in it is highly dependent on the local learning climate and/or access to skilful, trusted mediators. Thus, learning support is needed within the workplace itself, preferably from experienced practitioners and possibly in partnership with visiting educators. Another aspect of the problem is that theory is often embedded in practices acquired through working alongside colleagues, but without awareness of or reflection upon the underpinning rationales. This limits the ability to evaluate one's practice or to sensibly modify it to meet the needs of different clients. Is this not another area where partnerships between practitioners, educators and researchers need to be developed? The practices with which this journal is most concerned are the learning practices of all workers in health and social care, the learning support practices of those who facilitate such learning (preferably all such workers) and the policy-making practices that, by intention or inadvertently, affect this learning. In formal education settings, learning is seen as the core business, and roles in supporting that learning are explicit. Indeed, for most professional educators this role is linked to a distinct career path in which identity is conferred by what one teaches. There is also an opportunity for many to develop an additional role as a researcher, although this may not be as easy as is sometimes implied (see Hollis in the Forum for this issue). Support for learning the professional educator or researcher role is often very limited. In workplace settings, the situation is very different. Some practitioners are given explicit learning support roles with titles such as mentor or supervisor, but often little or no time in which to do any support work. Many others provide some support for learning as an integral, often indistinguishable, part of their normal working day. They learn from and share knowledge with colleagues, usually in the context of discussing a particular client; they participate in joint enterprises, during which mutual learning occurs; they answer questions and routinely work alongside less experienced colleagues, or invite them to participate in practices they need to learn. This informal learning is increasingly recognized as playing an important part in professional development, but is still conspicuously absent from policy-making. Learning support roles in the workplace are often regarded as extra burdens, because they entail an increase in a person's overall workload for no commensurate reward. Managers are not trained in how to create a learning climate or support the learning of those they manage. Continuing Professional Development (CPD) policies and events are often based on learning outside the workplace, with little joint planning for follow-up inside the workplace. The priorities for CPD appear to be visibility and verifiability rather than relevance and effectiveness. Once more, the need for greater collaboration between the various professional roles is painfully apparent. It would be naive to advocate closer links between different professional roles without acknowledging the tensions that frequently exist about their relative power and status. Issues of pay vary considerably between professions and across nations, but lie outside the scope of this journal. Issues of voice and knowledge, however, are both relevant to the journal and closely interconnected. If professional knowledge is defined in terms of what professional workers do, then the only ‘knowers’ are those practitioners who have the know-how. If professional knowledge is defined in terms of the ‘book knowledge’ underpinning or embedded in practice, then the professional educators are its guardians, though not the only knowers. If professional knowledge is defined in terms of researcher descriptions of practices or evidence about their impact and effectiveness, then researchers are its guardians, though not the only knowers. My argument is that it is only by recognizing the interdependence and equal status of these three aspects of professional knowledge that genuine partnerships, based on mutual respect for other roles, can be developed. Each needs to consult and take advice from the other, so they feel that all are serving the public interest in a mutually reinforcing way. The extent to which they trust and learn from others is critical to a profession's ability to provide the best possible service to its clients. This journal can contribute to this goal in several ways. As proposed in my last editorial, it wishes to adopt a very wide, inclusive position on knowledge and learning that does not privilege the academy. It includes the knowledge and learning of all workers in health and social care, and also that of our clients when it affects our ability to serve their interest. It seeks to encourage little-researched areas such as how and what professionals learn from other roles, other professionals and their clients, as well as what we learn from our immediate colleagues. However, we also recognize that a journal has a particular role to play in publishing the findings of research. Criteria for publication include: authenticity, originality, quality of evidence and argument, and benefit to our readers. Where possible, we hope that voices other than those of researchers will be heard, either through the evidence presented or through authorship. By our very nature, we rely on written contributions, but we also recognize that these can communicate only certain kinds of knowledge. That is a limitation we have to accept, but also one we do not intend to forget. Contributors who find ways of communicating about forms of knowledge and learning not normally found in journals will be especially welcome. Professor Michael Eraut Editor