|Year : 2014 | Volume
| Issue : 2 | Page : 49-53
Surgical education and the theoretical concept of communities of practice
Debra Nestel1, Annette Burgess2
1 School of Rural Health, Health Professions Education and Educational Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
2 Sydney Medical School - Central, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
|Date of Web Publication||30-Apr-2014|
Faculty of Medicine, Nursing and Health Sciences, Building 13C, Monash University, Victoria - 3800
Surgical practice is largely learned in the workplace. Changes in health services and education provision have seen a shift from traditional apprenticeship-type learning to competency-based curricula with the workplace remaining the principal site for learning. Sociocultural learning theories offer valuable lenses through which to observe, design for, and analyze workplace-based learning. In this paper, we consider the theoretical concept of communities of practice in surgery. We describe notions of legitimate peripheral participation and development of professional identity. We highlight the benefits that communities of practice bring to surgical training, as well as the limitations. By understanding community of practice theory as applied to the surgical workplace and the factors that both drive and impede its development, surgical trainers may improve the learning environment, enhancing the attainment of competencies by surgical trainees.
Keywords: Surgical training, workplace-based learning, situated learning
|How to cite this article:|
Nestel D, Burgess A. Surgical education and the theoretical concept of communities of practice. J Health Spec 2014;2:49-53
|How to cite this URL:|
Nestel D, Burgess A. Surgical education and the theoretical concept of communities of practice. J Health Spec [serial online] 2014 [cited 2020 Sep 29];2:49-53. Available from: http://www.thejhs.org/text.asp?2014/2/2/49/131746
| Introduction|| |
Surgical trainees acquire knowledge, skills, and attitudes requisite for surgical practice as they work. Further, through work they develop an identity essential for membership of their professional community. The changing landscape of health services and education provision has seen a shift from traditional apprenticeship-type learning to competency-based curricula with the workplace remaining the principal site for learning. Many recent factors influencing surgical training such as the introduction of restricted working hours, the emergence of surgical and educational technologies, and the raised profile of patient safety ensure a dynamic context for learning, but at the same time, create challenges within the learning environment. Key goals of professional education, however, remain the same - to steward knowledge, impart skills, and instill the values of the surgical profession.  This requires a balanced and integrated approach that orientates trainees to the cultural, social and humanistic aspects of surgery. ,
Theories that inform educational practice offer valuable lenses through which to observe, design for and analyze learning. Sociocultural learning theories are concerned with learning as a social activity. That is, where social interactions are central to learning, so they are particularly suited to making sense of learning that takes place in workplaces. In this paper, we consider the theoretical concept of communities of practice in the surgical workplace, highlighting benefits and limitations for learning surgical practice. Although we draw examples from surgical practice in Australia, they may have relevance in some other settings. We refer to surgical trainees as those in specialty training and surgical trainers, those charged with educational oversight.
Communities of practice
The concept of communities of practice as described by Lave and Wenger  and later by Wenger  is defined as "groups of people who share a concern or passion for something they do and learn how to do it better as they interact regularly." There are three structural elements of communities of practice - joint enterprise, mutual engagement, and shared repertoire. Lave and Wenger  also describe key-related concepts of legitimate peripheral participation and the development of identity. We outline each of these in the context of surgical practice and acknowledge their overlap [Table 1]. The stewarding of knowledge and practice is an important element of communities of practice and distinguishes it from other social structures.
|Table 1: Examples of the structural elements of communities of practice in a surgical training environment (surgical unit)|
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Joint enterprise refers essentially to the purpose of practice of the community, that is, the shared interest as understood and continually negotiated by its members.  In surgical practice, this is usually and at minimum the safe performance of surgical procedures on patients requiring such care. This also includes the development of new approaches to surgical practice. In a surgical training environment, this will acknowledge the responsibility for developing surgical trainees (and medical students). The concept acknowledges that all participants are learning - even those at the centre (e.g., trainers). Although there is significant expertise at the centre, communities of practice are continually evolving as all members contribute to and shape the future of surgical practice.
Mutual engagement describes the important role of interactivity of members of the community. These interactions need to be meaningful to participants and advance the practice.  For surgery, this occurs at many levels. The surgical team may meet daily to review patients, work in the same operating theatre, and the same outpatient department. It may also refer to interactions that occur at the level of the hospital (reviewing safety) or at the broader surgical community (surgical congresses). This includes formal and informal interactions. These features of the community of practice expand the dynamics of the learning and teaching process, allowing for distribution of cognition among junior and senior trainees and surgical trainers.  The surgical curriculum opens up with opportunities to engage with others with the same aims but different levels of skills and knowledge, offering guidance, which shapes the quality of learning.  Expert surgical trainers develop an in-depth understanding of the trainees' capabilities and are able to increase challenges balanced with appropriate supervision. 
Shared repertoire refers to the resources the community requires to function and have been developed in part by the community and continue to evolve. This is sometimes described as the routines, artifacts, and language of the community - the elements that characterize the community. In surgical practice, this incorporates a combination of surgical knowledge and judgment, techniques (e.g., cutting, cauterizing, minimally invasive surgery), theatre etiquette, dress, and language. There are also repositories of resources valuable to surgical practice (professional community websites). Fluency in the language of the surgical unit is an important indicator of belonging and identity as a member.  Not all are exclusive to surgeons but the combination characterizes the community of practice. Learning is an experience that involves not only the attainment of knowledge, but also 'doing' within the actual environment.  When trainers work alongside trainees, involving them in surgical activities, the trainees' learning process, acquisition of knowledge, and clinical skills are enhanced. 
Legitimate peripheral participation is a central notion in communities of practice. In order for newcomers to learn, they must be offered opportunities for meaningful participation in the community.  Initially, this takes place with newcomers undertaking tasks peripheral to the community. Only through participation, especially with old timers, will newcomers learn the practice of the community and progressively undertake tasks central to the community. This interaction enables sharing of the richness of the community including previous practice that may inform future practice. This opportunity for discourse is a powerful means of transmitting practice. It is also the means by which participants develop identity. For surgical practice, this means that surgical trainees are offered meaningful activities commensurate with their ability. Where possible, alignment of activities with learning needs is of greatest value to trainees  and that the level of challenges be progressively increased. It has been suggested that too much guidance or feedback to trainees may be educationally detrimental, so determining the optimum balance between supervision and autonomy within clinical tasks is valuable.  [Table 2] contains examples of legitimate peripheral activities that could be undertaken by a junior surgical trainee. The activities reflect the surgical competencies expected of novice trainees in Australia.  However, in order for meaningful tasks to be undertaken by the trainee that legitimates them as a peripheral participant, the following activities are requisite. Trainees need to receive an orientation to the workplace, including articulation of its unique elements, setting expectations of trainees, establishing baseline experience, clinical, and educational supervisory arrangements. Additionally, explicit conversations between trainers and trainees about learning objectives that align service and trainee needs will more likely lead to valuable learning than unstated assumptions. These conversations should continue across the clinical rotation highlighting trainee achievements and areas for development.
|Table 2: Examples of meaningful activities for a novice surgical trainee that offer legitimate peripheral participation in a surgical team|
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Language has already been cited as part of the shared repertoire, but it offers much more. That is, not only learning from the talk of the community but also learning to talk within the community as a fully participating member and hence, contributing to an important sense of identity. Professional identity is developed and established when the trainees' educational purpose is clear.  It is through participation in communities of practice that trainees gain an understanding of their various roles and responsibilities as future surgeons.  For surgical trainees, responsibilities may include not only patient care, but also less obvious responsibilities, such as the teaching of medical students. Role models, such as senior surgeons who are experts in the cognitive and psychosocial aspects of the surgical profession, play an important part in exemplifying professional identity, and where this fits within the multiple roles connected to these professionals. 
Benefits of communities of practice for facilitating surgical training
There are many benefits of cultivating communities of practice. The workplace is a valuable learning environment and often not optimized for educational activities. Awareness of the structures of communities of practice will not necessarily lead to learning but they may create a more suitable context in which learning can occur. These are sometimes referred to as affordances or the invitational qualities of the workplace. , Learning in the workplace fosters much more than the development of surgical knowledge and skills but the values important to the profession. These are enduring elements of practice that cannot be easily learned from books. Distinct from knowledge, phronesis (practical wisdom) is passed on and understood within meaningful and authentic learning environments. , It is this essence of surgical practice that may be best achieved in a community of practice. Individuals working alone are at a disadvantage compared with those working within a community of practice.  Within the community of practice, knowledge is constructed socially, drawing on the concept of distributed cognition, where participants in the community are dependent on others, and the resources and information within their community.
Wenger and Snyder  report benefits of communities of practice in a business context. However, when extrapolated to surgical practice, these could include the following:
• Decreasing the learning curve for surgical trainees through the sharing of experiences - formally and informally.
• Responding to patient needs through effective communication.
• Reducing 'rework' and preventing reinvention through sharing of practices across surgical communities.
• Developing new surgical techniques and approaches to care.
Creating structures for surgical trainees to have their own 'sub' community of practice in which they learn with other surgical trainees is beneficial. We have loosely called this a type of 'special interest group' [Table 1], but it may simply be a study group for trainees. The joint enterprise of this community of practice is successful navigation of surgical training. Of course, it overlaps with the community of practice in the surgical workplace but has a different principal aim [Table 1]. Identifying areas of overlap and difference between principal and secondary aims of the community of practice may be important in understanding trainees' perceived learning gaps in the workplace. The shared repertoire of surgical trainees is likely to emphasize resources and approaches to studying.
Limitations of communities of practice for facilitating surgical training
Although the concept is valuable there are also limitations. For example, the joint enterprise cannot always be assumed. Access to resources and transient personal goals can influence the emphasis on shared goals. Although hierarchical structures can result in effective teamwork, they can also be unhelpful if communication is restricted and trainees are not recognized and accepted as legitimate participants. For example, in the operating theatre, surgical, anesthetic, and nursing teams usually work with a framework of formality - rules, responsibilities, authority, and status. However, in workplaces, informal understandings can govern conduct and behavior, forming a complex group culture. Operating theatres are busy working environments, and for the trainee, they may need to self-promote as a legitimate participant (and learner). Achieving legitimacy in a trainer-centered environment can be challenging and may not happen despite the trainees' actions. Newcomers to a community of practice must be granted enough legitimacy to be regarded as potential members. 
Short-term team clinical attachments and high staff turnover can destabilize communities of practice. Surgical trainees may develop familiarity in one community of practice (a surgical unit) but the nature of surgical training is such that trainees undertake many rotations, each time entering a new community. This may create challenges for surgical trainees as they seek to negotiate their legitimacy in the new community. Surgical trainers usually have fewer changes and may forget the challenge this brings for trainees. Induction and explanation of local modus operandi is valuable.
Shorter patient stays, an increased awareness of patient safety, and the degree of autonomy afforded to surgical trainees have meant that there has been an emergence of a variety of communities of practice relevant to surgical education. There may be competition by surgical trainees for access to meaningful tasks in some communities of practice where there appear to be more trainees than opportunities for contributing to the workplace. Additionally, the boundaries for surgical communities of practice are diversifying. They may now include new clinical sites (e.g., outer metropolitan and rural hospitals) and simulated clinical environments (e.g., simulated operating theatre). Each of these surgical communities will likely have nuanced differences in the structures relevant to communities of practice. Although exposure to multiple communities may have benefits for trainees, it may also mean their learning is compromised if trainees' participation is limited.
| Conclusion|| |
Our aim has been to share a theoretical concept to make sense of learning in the surgical workplace. Wenger  acknowledges that the concept of communities of practice, legitimate peripheral participation, and development of identity offer a particular way of looking at learning in the workplace. Valuable lenses to learning in the workplace are also offered by theories from cognitive, behaviorist and constructivist perspectives. It is beyond the scope of this paper to consider these alternatives but all offer different ways of looking at surgical education. Although it is not possible to design learning per se, it is possible to design for learning by considering ways in which the structures of communities of practice and the concepts of legitimate peripheral participation and identity formation occur. We hope that this overview promotes reflection on existing workplace learning for surgical trainees by looking through a particular lens - the theoretical concept of communities of practice.
| Acknowledgment|| |
Students of the Masters of Surgical Education program (2010-2013) at the University of Melbourne and the Royal Australasian College of Surgeons for their robust discussion and sharing of ideas on communities of practice in surgery.
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[Table 1], [Table 2]