Using concept mapping to locate the tacit dimension of clinical

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

7

, 2, 93–104

Original article

Blackwell Publishing Ltd

Using concept mapping to locate the tacit dimension of clinical expertise: towards a theoretical framework to support critical reflection on teaching

Ian M.

Kinchin

BSc

MPhil

PhD

PGCE

CBiol

MIBiol

,

1

*

Lyndon B.

Cabot

BDS

MA(Ed

.

)

MSc

EdD

AKC

2

&

David B.

Hay

BSc

DPhil

AKC

1

1

Senior Lecturer, King’s Institute of Learning and Teaching, King’s College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK

2

Senior Lecturer, Department of Prosthodontics, King’s College London Dental Institute. Floor 25, Guy’s Tower, London Bridge, London SE1 9RT, UK

Abstract

The tacit dimension of expertise is given considerable prominence in the literature

on clinical education. However, the concept of

knowing more than you can tell

is

one that cannot be used explicitly to support student learning. In this paper, the

authors contend that much professional knowledge that has been described as tacit can

be surfaced for examination through application of concept mapping techniques.

This allows the articulation of expert practice in a way that can be modelled for

students. It also provides a new model of expertise that is based on connections

between

chains of practice

(characterized by sequences of observable actions) and

the underlying

network of understanding

from which they are extracted. These

connections, often overlooked and automated in daily practice, represent the location

of the tacit dimension.

Localizing the tacit dimension in this way allows the teacher and student to focus on

the connections of tacit knowledge with formal knowledge and with practice in such

a way that intuitive actions can be verified and connected to underlying knowledge

frameworks. The act of concept mapping also slows reflection on actions that are

normally automated and often overlooked. The resulting model includes an additional

dimension that is missing from the traditional stage models of expertise. As such,

it provides a conceptual framework upon which it would be possible to develop

protocols to support the continuing development of clinical teachers through peer

observation and/or guided self-reflection.

Keywords

clinical teaching,

concept mapping,

expert knowledge

*Correspondence author. Tel: 020 7848 3987; fax: 020 7848 3481; e-mail: [email protected]

94 I.M. Kinchin

et al.


Introduction

Eraut (2000) distinguishes between tacit knowledge

that is

not

communicated and that which

cannot

be

communicated because it is impossible to articulate.

In the context of clinical teaching, this paper is

confined to a discussion of Eraut’s first meaning of

tacit – that which is rarely communicated, but might

be through application of appropriate methods or

vocabularies. Eraut goes on to give reasons why we

should want to make tacit knowledge more explicit,

including improving the quality of performance,

facilitating the accountability of performance, facilit-

ating the communication of knowledge, maintaining

control of professional actions and to construct

artefacts to assist in decision-making (Eraut 2000,

p. 134). The benefits of making the tacit explicit are

also seen as a way of assisting novice academics in

their development as teachers (Sandretto, Kane &

Heath 2002). For these reasons, we argue that the

visualization of expertise and the identification of

the location of the tacit dimension within this would

be extremely useful to the student in the clinical

context.

Although Polanyi (1967, pp. 18–19) considers the

surfacing of tacit knowledge as a ‘destructive analysis’

leading to ‘unbridled lucidity’ that will change

the original meaning, he goes on to concede that

subsequent reconstruction may improve upon the

original understanding. Where university teaching

is modelled on the sharing of expertise through

scholarly dialogue, such processes of destructive ana-

lysis and personal reconstruction of understanding

are essential (Kinchin, Lygo-Baker & Hay 2008).

However, although considerable attention is

afforded to the development of expertise in profes-

sional learning (e.g. Eraut 2005), the literature is

unclear about the nature of expertise and the

attributes that may be justifiably taken as indicators

of its existence. Our contention in this paper is that

much of the literature on expertise has been implicitly

based on the assumption that expertise is based on

tacit knowledge and intuition that cannot be located,

and hence, cannot be described. However, in order

to defend intuitive judgements, the tacit dimension

must be articulated. Once this happens, it can be

subject to verification (Welsh & Lyons 2001).

Our response to this assumption is presented here

through application of a model of teaching in higher

education (Kinchin & Hay 2007; Kinchin

et al

.

2008), and supported by structured observations of

teaching in various higher education settings. These

observations and related interviews have allowed

detailed examination of a particular situational

context, striving to represent the participants’ world

view in the form of a narrative enquiry (Beattie

1995). This was complemented through the use of

concept mapping tools that act as

windows into the

mind

(Shavelson, Ruiz-Primo & Wiley 2005), and

enable the visualization of learning at university

(Hay, Kinchin & Lygo-Baker 2008). This approach is

compatible with the various curriculum models

adopted by healthcare professionals (including

guided discovery learning, collaborative learning

and interprofessional learning), or combinations of

these (e.g. O’Halloran

et al

. 2006).

Chains and networks

The ability to visualize the clinical reasoning process

is considered by Hill & Talluto (2006) to represent

one of the first steps in the formation of the cognitive

skills that are necessary for professional practice.

Visualization of knowledge structures through concept

mapping has enabled us to separate the

chains of

practice

that are manifest in teachers’ actions from

the underlying

networks of understanding

(see Fig. 1).

Chains are indicative of procedural sequences

that characterize observable clinical practice and

have been described as indicators of ‘goal orienta-

tion’ (Hay & Kinchin 2006). This seems entirely

appropriate in the clinical setting in that the goal of

clinical competence is the effective treatment of

patients. The chain illustrated in Fig. 1 shows the

typical sequence that is learned by dental under-

graduates when learning how to design a removable

partial denture. It concentrates on the

how

to the

exclusion of the

why

. However, such chains have to

be embedded in networks of understanding so there

may be appreciation of

why

the patient has (or has

not) been treated successfully and what alternative

treatments may be available. If there are no links

with an underlying understanding, the chain may be

seen as blindly following a recipe.

Mapping expertise 95


Networks are indicators of understanding which

may be integrated and holistic. The network in

Fig. 1 shows how the elements of removable partial

denture design are linked to each other and starts to

create the

why

that would complement the chain of

practice. However, understanding does not neces-

sarily equate to clinical decision-making ability.

Knowing there are several alternative treatments

with varying consequences is not the same as being

able to select the most appropriate one within a

clinical context. If this was the case, academic study

would not need to be backed by clinical training.

From this, the differences between ‘expert know-

ledge’, ‘competence’ and ‘expertise’ are made avail-

able for scrutiny. The relationships between these

components can be used to address current inade-

quacies in university teaching by adopting discipline

specific lexicons and practical examples that may be

adopted by academics (e.g. Kinchin, Cabot & Hay

2006; Cabot & Kinchin 2007).

Developing expertise

Among the many models of skills progression, that

put forward by Dreyfus & Dreyfus (1986) is well

known and has served as a template for subsequent

models within clinical teaching (e.g. Benner 1984).

Dreyfus and Dreyfus suggest that as a practitioner

develops a skill, s/he passes through five levels of

proficiency. These are novice, advanced beginner,

competent, proficient and expert. These sequential

levels reflect changes in three aspects of skilled

performance. The first is a movement from relying

on abstract principles to using past concrete ex-

periences as paradigms. The second is a changing

view in the practitioners’ perception of the situation,

which is seen less as a compilation of equally

relevant parts and more as a complete whole in

which only certain parts are relevant. The third is

the passage from ‘detached’ observer to ‘involved

performer.’ The performer is now engaged in the

situation (Manley & Garbett 2000).

The significant attributes of the Dreyfus model

are presented in Fig. 2. Their model has an emphasis

on learning from experience, but as Eraut (1994)

points out, Dreyfus and Dreyfus do not really

explain how this actually occurs. There are only

occasional references to theoretical learning or the

development of fluency on standard tasks. Identify-

ing where a practitioner is on this model is therefore

Fig. 1 Two concept maps of partial denture design giving emphasis to the gross morphology as either a chain (left) that relates to clinical practice, and a network (right) that relates to an integrated understanding of the subject.

96 I.M. Kinchin

et al.


difficult. In fact, in their recent critique, Dall’Alba

and Sandberg (2006) point out that a focus on the

defined stages of such a model veils or hides the

more fundamental aspects of skill development.

They argue that as such progression is taking

place, there is an ‘embodied understanding of

practice’ underpinning that progression. We suggest

that this criticism of, in particular the Dreyfus and

Dreyfus Stage model, supports the earlier work of

Cabot (2004). He highlighted the difficulty in

identifying the stages of observed professional

expertise, but suggested that the individual

attributes or strands were clearly identifiable and

very useful in signposting expert practice. Identifying

where a practitioner is on this model is therefore

difficult. Eraut argues that the strength of the

Dreyfus model lies in the case it makes for tacit

knowledge and intuition as critical features of

professional expertise. Critically, the progression

to expert requires that decision-making and

indeed an understanding of the particular situation

is intuitive.

A further criticism of the Dreyfus and Dreyfus

model (as depicted in Fig. 2) is that it represents only

one aspect of expertise (the linear chain of development

of observable practice), that must be complemented

by a personal context for each stage. This second aspect

is akin to the ‘embodied understanding of practice’

described by Dall’Alba & Sandberg (2006), who distin-

guish between ‘a vertical and a horizontal dimension’

of expertise. However, such a characterization sug-

gests an artificial separation of the two dimensions.

The key point is that in all staged models, the

expert practitioner has reached a completely different

level to his/her less expert colleagues. For Dreyfus

and Dreyfus, the performance of the expert is

viewed as largely automatic, and non-reflective

because of the speed at which it is undertaken:

An expert’s skill has become so much a part of him that

he need be no more aware of it than he is of his own

Fig. 2 The Dreyfus and Dreyfus skills acquisition model of expertise (indicating the significant attributes of each level).



body.... When things are proceeding normally, experts

don’t solve problems, and don’t make decisions; they do

what normally works. (p. 30)

The expert will only move out of this mode when

the task in hand is particularly difficult or critical, or

because they have critically reflected on their own

intuition and are reconsidering the initial action.

Manley & Garbett (2000) suggest that in selecting

expert practitioners, two assumptions seem to be

made: expertise can be recognized in others by

colleagues and significant practical experience is

required as a pre-requisite for expertise. Both these

assumptions can be challenged. These authors

reveal that in an analysis of studies in which expert

practitioners were selected, a range of criteria were

used to identify expertise. These included identifica-

tion by peers and/or senior colleagues, experience,

educational attainment, personal qualities and

status. They noted that there appeared to be little

consistency between studies in the criteria that were

employed and there were only a few examples of

attempts, Conway (1996) is one, to account for the

rationale behind the identification and/or selection

of participants. Curiously, the identification of experts

was not seen as being intrinsically problematic,

although the obvious effort taken to select appropri-

ate participants suggested that selection was an

important issue. Were they selecting for expertise or

experience? Bradley, Paul & Seeman (2006) are quite

clear that experience alone is not an acceptable

indicator of expertise and argue that other factors

must also be present to define expertise. Within this

framework, the cognitive ability to correctly struc-

ture experience is necessary to define expertise.

Benner (1984) avoids defining the expert clinical

practitioner; she does, however, provide a compre-

hensive account of the term in the context of a nurse

demonstrating her or his expertise in clinical practice.

She describes the expert nurse in terms of the Drey-

fus model. The expert nurse has an intuitive grasp of

situations and immediately focuses on a problem

without the wasteful consideration of a large range

of unfruitful diagnoses and solutions. In contrast,

a competent or proficient nurse faced with a novel

situation must rely on conscious deliberate analytical

problem solving. A common issue with the posi-

tions described by Dreyfus & Dreyfus (1986) and

Benner (1984) is the difficulty they present in visu-

alizing expertise. Visualization is often helpful to

students to understand complex ideas and provides

a language of common discourse, clarifying the

semantics of desired constructs, and focusing on

critical elements and excluding ‘noise’ (Copperman,

Beeri & Ben-Zvi 2007). The tool we have employed

to visualize such complex ideas is concept mapping.

Concept mapping

Concept mapping as developed by Novak (Novak

1998; Novak & Cañas 2006) is a graphical tool used

to represent links between ideas. Ideas are written in

boxes and linked with arrows carrying explanatory

legends. Concept mapping has been used effectively

in a variety of contexts as a classroom technique to

enhance learning (e.g. Horton

et al

. 1993; Lawless

et al

. 1998; Nesbit & Adesope 2006). The ability to

construct a concept map illustrates two essential

properties of understanding, the representation and

the organization of ideas. Halford (1993, p. 7) states

that ‘to understand a concept entails having an internal

representation or mental model that reflects the

structure of that concept’. A concept map is an

attempt to make explicit such a mental model so

that it can be reviewed with others (Chang 2007).

Organization of knowledge can facilitate learning

by making the material to be learned more predict-

able and so reducing the learning effort required

(Halford 1993). The construction of concept maps

is an excellent way of helping to organize know-

ledge and so help understanding. Concept maps are

increasingly used in teaching health professionals to

summarize learning, promote critical thinking skills

and meaningful learning or as an assessment strategy

(e.g. Irvine 1995; All & Havens 1997; Caeilli 1998;

Daley

et al

. 1999; Akinsanya & Williams 2004; Hsu

2004).

McAleese (1994) has explored the mental activities

in which students are engaged when producing con-

cept maps. His work suggests that concept mapping

may promote the development of thinking skills by

providing an explicit point of focus for reflection.

He describes this process as ‘auto-monitoring’. A key

aspect of this is considered to be the visualization of

the ‘learning arena’ as portrayed by the map.

98 I.M. Kinchin

et al.


The use of concept mapping is often linked to the

‘constructivist’ view of learning as a concept map

makes a good starting point for constructivist

teaching. This is a form of student-centred teaching

in which understanding is considered to be con-

structed by the learner rather than absorbed from

the teacher as a finished product. Concept maps

depict constructed and reconstructed knowledge

and teaching that helps this reconstruction process

that will lead to meaningful learning. The action of

mapping is also thought to help the process by

revealing to the student connections that had not

been recognized previously and by acting as a focus

for communication between student and teacher.

This is illustrated by Novak & Gowin’s (1984) obser-

vation that students and teachers often remark that

they recognize new relationships, and hence, new

meanings as a result of mapping activities.

An important function of the map is to help make

explicit the overall framework of concepts. This is

particularly important for complex topics where

students may display a fragmentary understanding

and are frequently unable to integrate all the com-

ponents to form a meaningful overview. Identifying

these fragments of understanding, termed ‘anchor-

ing conceptions’ by Clement, Zietsman & Brown

(1989), is vital as these form the foundations for

future meaningful learning.

The model

The model that has been used here (summarized

in Fig. 3) has been derived from the qualitative

examination of several thousand concept maps

produced by students and their teachers over the

past nine years (Kinchin & Hay 2007). These maps

have been classified according to their morphology

(as described by Kinchin, Hay & Adams 2000). This

focus resonates with the description of knowledge

structure as providing ‘the essence of knowledge’

Anderson (1984, p. 5), and shown to be a characteristic

of concept maps that is as influential on the learning

process as the content that is portrayed within them

(e.g. Hay, Kinchin & Lygo-Baker 2008).

The model in Fig. 3 may be read vertically or

horizontally. The vertical dimension explains the

characteristics and roles of each of the knowledge

structures. Many students start their undergraduate

Fig. 3 The relationship between chains of practice and networks of understanding. The active engagement in the links between these chains and nets are indicative of expertise (modified from Kinchin et al. 2008).



studies with firmly established chains of under-

standing that have developed during their second-

ary schooling (Martin 1994). Such chains may be

composed of lists of characteristics and definitions

that were required to pass a given examination.

However, such goal-orientated learning may miss

links which may enhance understanding if they are

not explicitly rewarded in the short term (e.g. by

examination grades). Previously acquired chains are

often incomplete or inappropriate for their new

context. Such chains are resistant to development

(Hay & Kinchin 2006) and so students are faced

with the dilemma of either trying to abandon their

existing beliefs and starting again, or rote learning

the new material as an adjunct to their existing prior

knowledge. This may be problematic when the two

chains may be in conflict and create too much cog-

nitive stress for the student (Hay, Wells & Kinchin

2008).

The chain of appropriate understanding is indic-

ative of strategically successful learners (students

and lecturers). Such goal orientation enables these

learners to select the essential information from that

which is available while selectively ignoring the rest.

This may be seen by some as an efficient way of study-

ing although others could interpret this as a blink-

ered view of higher education. There is certainly a

tension created within the university environment

by attitudes towards this kind of strategic approach

that may reflect disciplinary differences. For example,

in the clinical environment, the development of

chains of clinical reasoning is seen as one of the key

aims (e.g. de Cossart & Fish 2005).

The demonstration of highly developed and inte-

grated nets of understanding may be seen as charac-

teristic of the expert (Bradley

et al

. 2006), for whom

the demonstration of expertise is achieved by the

accommodation of competing chains of under-

standing and the selection of appropriate chains to

suit particular contexts. So for example, the clinician

can move from patient to patient, each time presented

with a problem to solve by making a series of judge-

ments. Each of these judgements is verified either

internally (through comparison with the clinician’s

underlying network of understanding), or exter-

nally, by consulting a colleague’s understanding.

Internal verification processes (often taking place so

quickly as to appear intuitive) require the clinician

to appreciate the links between the chain and the

network.

A horizontal reading of the model suggests a

progression in the development of knowledge

structures from chains to nets. Such a directional

development has been observed (Kinchin

et al

. 2000)

although the mechanisms of change are complex

and have been introduced elsewhere (Hay 2007). The

implication that the development of net structures

among students may be the goal of higher education

is one that may be contested, particularly where

chains of practice seemingly have more immediate

utility than networks of understanding.

Knowledge structure

Rather than attributing expertise to a certain level of

sophistication and integration within a knowledge

structure (e.g. Bradley

et al

. 2006), expertise may be

characterized by an individual’s ability to navigate

between underlying


and

chains of practice

that are appropriate to the context,

analogous to the ‘professional artistry’ described by

Manley

et al

. (2005). Application of Kinchin and

Hay’s model provides a transparent mechanism for

this artistry that goes beyond opaque assumptions

involving intuition or tacit knowledge as explanatory

factors. It is the link between these two components

of expertise (practice and understanding) that

indicates the location of the tacit dimension. The

expert will oscillate between chains of practice and

networks of understanding so quickly that it will

appear intuitive to the casual observer.

Modelling such transformations for the student

so they can develop their own expertise presents an

additional dimension to clinical practice. The difficulty

this presents is predicted by Novak & Symington

(1982) who made the key point when they stated:

The problem of moving from linear [text] structure to a

hierarchical [psychological] structure and back again is in

some ways the fundamental educational problem.

Although Novak and Symington were not

considering clinical education in particular when

they made this comment, the transformation they

describe appears most pronounced between the

100 I.M. Kinchin

et al.


clinical and non-clinical aspects of education for

healthcare professionals. That experienced clinical

practitioners cannot always articulate rational

explanations for their clinical practice (e.g. Benner

1984, p. 32) resonates with Polanyi’s view of tacit

knowledge as a description of ‘knowing more than

we can tell’ (Polanyi 1967, p. 4). Critics of Polanyi

have considered the label ‘tacit knowledge’ as a way

of avoiding addressing a whole class of mental

events (e.g. Fodor 1968), and so rendering the develop-

ment of expertise as a mystical event that defies

adequate description that would help those who are

trying to promote it. But the ‘black box’ of tacit

knowledge and intuition does little to support the

student or the teacher in the development of clinical

expertise. If colleagues are unable to verbalize their

actions, it may simply be that they lack the appro-

priate tools to uncover what it is that they are doing,

and/or the vocabulary to articulate it. Hoffman &

Lintern (2006, p. 216) argue that there is no indica-

tion that tacit knowledge ‘lies beyond the reach of

science in some unscientific netherworld of intui-

tions and unobservables’, and that tools such as

concept mapping can support colleagues in identifying

and describing their practice with unprecedented

clarity. That knowledge may be tacit is not in doubt.

Where we depart from accepted views is that not all

such knowledge need remain tacit and undescribed.

This paper contributes to the understanding of clin-

ical expertise by adding transparency to the pro-

cesses (often presumed to be tacit), that link invisible

expert knowledge to visible chains of practice. Such

transparency, mediated by concept mapping, may

help students and teachers appreciate the other’s

perspective and avoid the problem described by

Perkins:

Learners’ tacit presumptions can miss the target by miles,

and teachers’ more seasoned tacit presumptions can

operate like conceptual submarines that learners never

manage to detect or track. (Perkins 2006, p. 40)

To avoid such a mismatch, the links between

developing practice and expert knowledge need to

be made explicit. Figure 3 shows the relationships

between chains of practice and the network of

underlying understanding upon which they

depend. The links between the two elements are

rarely articulated by professionals who have not

conceptualized understanding in terms of knowledge

structures in this way and who therefore lack an

appropriate vocabulary for its description. This

model allows the difference between

expertise

and

expert knowledge

to be explained:

1

Expert knowledge describes an integrated/holistic

framework of understanding.

2

Expertise describes the application of expert

knowledge through selection of appropriate chains

of practice (i.e. repeated movements between chains

and networks that may occur so quickly as to appear

tacit).

This provides a mechanism to explain the loss of

expertise (know-how) experienced by teachers who

are no longer practising, but who clearly hold expert

knowledge structures (Dreyfus & Dreyfus 1986,

p. 17).

Variable structure (clinical–non-clinical)

Although we have observed our model of expertise

working across the spectrum of academic disciplines

through structured teaching observations, it is in

the context of clinical teaching that the separation

of chains of practice and underlying networks of

understanding is so pronounced and therefore easier

for the observer to identify in this setting. Although

expert knowledge structures are assumed to be

holistic (e.g. Bradley

et al

. 2006), clinical reasoning

skills have been shown to be linear in structure (de

Cossart & Fish 2005). Possession of highly competent

skills within a given chain of practice is not sufficient

within a clinical teaching environment that aims to

educate the next generation of professionals who are

able to make informed choices when innovative

clinical practice threatens established procedures.

Such isolated chains of practice are what Stronach

et al

. (2002) have called ‘broken stories’. These chains

of practice or broken stories will not have the

capacity to evolve with understanding unless they are

related to an underlying network of understanding.

The clinical teacher needs to be able to capture the

elements of his/her students’ broken stories and to

contextualize each of them within an underlying

network of understanding. This places a considerable



burden on the clinical teacher when, in addition to

the individualized learning needs of the students,

the clinical teacher also has to consider the needs of

the patient. Although the student is encouraged to

make links from his/her chain of practice to a devel-

oping network of understanding, the patient is

typically given a discrete chain from which links that

may complicate or confuse are obscured, or inten-

tionally neglected (Katz 1988).

The dual purpose of this professional discourse

may obscure the relationship between

chains of

practice

and underlying


for the observer/student. The clinician–patient

discourse may include latent functions (

sensu

Eraut

2000, p. 120) to keep patients happy while asserting

a professional role even though the manifest func-

tion would be to explain diagnoses and treatment

options. Unless the student is aware of what is going

on, such latent functions may impede the under-

standing of practice and inhibit the revealing of tacit

links between practice and understanding.

Assessing expertise

Expertise may be determined on a ‘closeness-of-fit’

model of assessment. Where an expert is designated,

using arbitrary criteria (e.g. Manley & Garbett 2000),

to assess junior peers, the implication is that the

expert holds the ‘right answer’. However, as experts

often fail to agree, the ‘right answer’ is a moving

target for the student to identify (Cabot & Kinchin

2007; Hay & Kinchin 2007). When there is

considered to be sufficient overlap between the

established expert view and the emerging expert

view, then the designation,

expert

, may be safely

applied to the junior partner. This model assumes

the established expert is able to stand back and

reflect upon his/her own practice and appreciate its

dynamic nature. Some may be able to do this, but

support from an observer with complementary

expertise may be helpful.

Appreciation of the skills by which the expert is

able to move from chain of practice to underlying

network can only really be appreciated by an

observer who holds at least one of those structures

within his/her own knowledge structure and is able

to appreciate the nature of the manipulations

required to successfully navigate the transition from

one knowledge structure to another. This would

have implications for the roles played by students

and by colleagues in educational development cen-

tres. The student (rather than exclusively the ‘fellow

expert’) is in a good position as assessor, giving a

real focus for student evaluations of teaching that

go beyond questions such as, ‘was the course well

organized?’, ‘were the lecturers’ slides clear?’. Stu-

dent evaluations of teaching would need to focus on

the lecturers’ success in demonstrating the link

between linear and hierarchical structures (Novak &

Symington 1982). Although colleagues within edu-

cational development units are placed in a position

to support the development of strategies to move

between structures, disciplinary colleagues may

help in the development of the underlying network.

This gives clear and complementary roles for the

development of higher education pedagogy, and a

clear purpose for those working in educational

development (e.g. Gosling 1996, 2001).

We can only speculate whether previous studies

of tacit knowledge in clinical education have really

exposed the tacit dimension or highlighted aspects

of the more easily viewed

chains of practice

and

underlying


. For example,

interesting parallels can be drawn with the descrip-

tions offered by Herbig, Büssing & Ewert (2001) of

the organization of tacit knowledge as either

sequential or holistic. If indeed these authors have

simply described the chains and networks that we

have shown to be linked by the tacit dimension, it

would explain why they found the sequential struc-

ture to be ‘less successful’ than the holistic structure

as it offers less scope for flexibility and development

(Hay & Kinchin 2006). We have elaborated upon

ideas put forward by Welsh & Lyons (2001) about

the link between tacit and formal knowledge, but

whether or not the links we propose between practice

and understanding as the location for the tacit

dimension can be characterized as exhibiting struc-

tures in their own right is an avenue that requires

further research.

The centrality of tacit knowledge in clinical

expertise as suggested by established models of

clinical expertise (e.g. Benner 1984) is supported by

the model given in Fig. 3. If we can go further and

102 I.M. Kinchin

et al.


confirm the location of the tacit dimension as that

which bridges the divide between practice and

understanding, then it becomes a tool for clinical

education rather than an amorphous barrier to

learning.

Conclusions

We have considered how the qualitative interpreta-

tion of knowledge structures through application

of concept mapping reveals how complementary

structuring as

chains of practice

and

networks of

understanding

provides a way of explaining some of

the anomalies that are described within the liter-

ature on expertise. We argue that it is the interaction

between these complementary structures and the

ease of transformation (from one to the other) that

may be the hallmark of expertise rather than the

existence of one or other structure in isolation.

That such transformations are rapid and appear

‘routinized’ has awarded them the label ‘tacit’. The

assumption that elements of such tacit expertise

cannot be made concrete is reinforced when clinicians

are unaccustomed to reflecting upon this practice,

and lack to vocabulary to explain their actions. The

time taken to verbalize their actions is an additional

barrier to making the details of their practice explicit.

The concept mapping method provides a tool that

facilitates this description, making it available for

public scrutiny.

We consider the assumption of the central role of

intuition (as described by Benner 1984 and Dreyfus

& Dreyfus 1986) in the consideration of expertise as

an opaque phenomenon that has provided a barrier

to the description of expertise. The labels ‘intuitive’

and ‘tacit’ have consequently served to cloud the

description of what actually takes place, and we

support Hoffman & Lintern (2006) in their view

that professionals have simply lacked the tools and

vocabulary to uncover and explain their practice.

We have observed our model (summarized in Fig. 3)

to function in various clinical teaching contexts and

provides a conceptual framework for the observer.

Our model is an improvement upon the amend-

ment to Dreyfus and Dreyfus offered by Dall’Alba &

Sandberg (2006), by showing how the dimensions

of expertise interact. Our model concentrates on the

links between the two elements (chains and networks

that correspond to practice and understanding), and

offers an explanation as to why linear progression is

insufficient to describe the development of expertise.

The underlying network of understanding (analogous

to Dall’Alba and Sandberg’s vertical dimension) will

develop as a personal construct that exhibits variation.

Such variation may persist throughout professional

education (Dall’Alba 2004), and will influence the

progression through the stages of skills acquisition

(Dall’Alba and Sandberg’s horizontal dimension).

The tensions we have observed in clinical settings

can be explained by our model. The chains of clinical

practice that are acquired by students are often taken

as indicators of competence. However, when the

utility of such chains are challenged, the clinician

needs to refer back to a wider understanding of the

field in order to select a revised chain of practice.

This resonates with the comment made by Schmidt,

Norman & Boshuizen (1990, p. 619):

‘The notion that expertise is associated with a qualitative

transition from a conceptually rich and rational know-

ledge base to one comprised of largely experiential and

non-analytical instances is a radical departure from

conventional views of clinical competence’.

It seems that a decade and a half later, this is still

a radical departure from orthodoxy. Such tensions

come to the fore when chains of practice are seen as

an end point by assessment regimes that promote

rote learning. Such goal orientation (characteristic

of linear learning sequences) is compatible with the

intentional neglect of uncertainty that has been

described within medical education (e.g. Katz 1988).

However, clinical students and health professionals

need to address the nature of uncertainty in their

practice. This surely is the goal of professional practice

and the key to the development of a clinical practi-

tioner who has a commitment to continuing profes-

sional development.

References

Akinsanya C. & Williams M. (2004) Concept mapping for

meaningful learning.

Nurse Education Today

24

, 41–46.

All A.C. & Havens R.L. (1997) Cognitive/concept

mapping: a teaching strategy for nursing.

Journal of

Advanced Nursing

25

, 1210–1219.



Anderson J.R. (1984) Some reflections on the acquisition

of knowledge.

Educational Researcher

13

, 5–10.

Beattie M. (1995)

Constructing Professional Knowledge

in Teaching: A Narrative of Change and Development

.

Teachers’ College Press, Columbia, New York.

Benner P. (1984)

From Novice to Expert: Excellence and

Power in Clinical Nursing Practice

. Addison-Wesley,

Menlo Park, California.

Bradley J.H., Paul R. & Seeman E. (2006) Analyzing the

structure of expert knowledge.

Information and

Management

43

, 77–91.

Cabot L.B. (2004)

The Dental Vocational Training

Experience: A Transition from Novice Dentist to Competent

Practitioner

. Unpublished Doctor of Education Thesis,

Open University, Milton Keynes, UK.

Cabot L.B. & Kinchin I.M. (2007)

Beyond Competence:

Visualising Expertise

. Paper presented at the British

Society for the Study of Prosthetic Dentistry (BSSPD)

Annual Conference, 3rd–5th March, Newcastle, UK.

Caeilli K. (1998) Shared understandings: negotiating the

meanings of health via concept mapping.

Nurse

Education Today

18

, 317–321.

Chang S.-N. (2007) Externalising students’ mental models

through concept maps.

Journal of Biological Education

41

, 107–112.

Clement J., Zietsman A. & Brown D.E. (1989) Not all

preconceptions are misconceptions: finding ‘anchoring

conceptions’ for grounding instruction on students’

intuitions.

International Journal of Science Education

11

,

554–565.

Conway J. (1996)

Nursing Expertise and Advanced Practice

.

Quay Books, Dinton. UK.

Copperman E., Beeri C. & Ben-Zvi N. (2007) Visual

modelling of learning processes.

Innovations in

Education and Teaching International

44

, 257–272.

de Cossart L. & Fish D. (2005)

Cultivating a Thinking

Surgeon: New Perspectives on Clinical Teaching, Learning

and Assessment

. tfm Publishing, Harley, UK.

Daley B.J., Shaw C.R., Balistrieri T., Glasenapp K. &

Placentine L. (1999) Concept maps: a strategy to teach

and evaluate critical thinking.

Journal of Nursing

Education

38

, 42–47.

Dall’Alba G. (2004) Understanding professional practice:

investigations before and after an educational

programme.

Studies in Higher Education

29, 679–692.

Dall’Alba G. & Sandberg J. (2006) Unveiling professional

development: a critical view of stage models. Review of

Educational Research 76, 383–412.

Dreyfus H.L. & Dreyfus S.E. (1986) Mind Over Machine:

The Power of Human Intuition and Expertise in the Era

of the Computer. The Free Press, New York.

Eraut M. (1994) Developing Professional Knowledge and

Competence. Falmer Press, London.

Eraut M. (2000) Non-formal learning and tacit knowledge

in professional work. British Journal of Educational

Psychology 70, 113–136.

Eraut M. (2005) Expert and expertise: meanings and

perspectives. Learning in Health and Social Care 4, 173–

179.

Fodor J. (1968) The appeal to tacit knowledge in

psychological explanation. Journal of Philosophy 65,

627–640.

Gosling D. (1996) What do UK educational development

units do? International Journal for Academic

Development 1, 75–83.

Gosling D. (2001) Educational development units in the

UK – what are they doing five years on? International

Journal for Academic Development 6, 74–90.

Halford G.S. (1993) Children’s Understanding: The

Development of Mental Models. Lawrence Erlbaum,

Hillsdale, New Jersey.

Hay D.B. (2007) Using concept mapping to measure deep,

surface and non-learning outcomes. Studies in Higher

Education 32, 39–57.

Hay D.B. & Kinchin I.M. (2006) Using concept maps to

reveal conceptual typologies. Education and Training

48, 127–142.

Hay D.B. & Kinchin I.M. (2007) Medical students’ response

to variation in expert knowledge structures: rote learning?

Paper Presented at the Annual Conference of the

European Learning Styles Information Network

(ELSIN), 12th–14th June. Trinity College, Dublin,

Ireland.

Hay D.B., Kinchin I.M. & Lygo-Baker S. (2008) Making

learning visible: the role of concept mapping in higher

education. Studies in Higher Education 33, in press

(accepted August 2007).

Hay D.B., Wells H. & Kinchin I.M. (2008) Quantitative

and qualitative measures of student learning at

University level. Higher Education, in press

(Accepted September 2007).

Herbig B., Büssing A. & Ewert T. (2001) The role of tacit

knowledge in the work context of nursing. Journal of

Advanced Nursing 34, 687–695.

Hill L.H. & Talluto B.A. (2006) Visualizing the clinical

thinking process to prepare students for effective

patient counselling. Journal of Pharmacy Teaching 12,

69–81.

Hoffman R.R. & Lintern G. (2006) Eliciting and

representing the knowledge of experts. In: The

Cambridge Handbook of Expertise and Performance

(eds K.A. Ericsson, N. Charness, P.J. Feltovich &

104 I.M. Kinchin et al.


R.R. Hoffman), pp. 203–222. Cambridge University

Press, Cambridge, UK.

Horton P.B., McConney A.A., Gallo M., Woods A.L.,

Senn G.J. & Hamelin D. (1993) An investigation of the

effectiveness of concept mapping as an instructional

tool. Science Education 77, 95–111.

Hsu L.L. (2004) Developing concept maps from

problem-based learning scenario discussions. Journal of

Advanced Nursing 45, 510–518.

Irvine L.M.C. (1995) Can concept mapping be used to

promote meaningful learning in nurse education?

Journal of Advanced Nursing 21, 1175–1179.

Katz J. (1988) Why doctors don’t disclose uncertainty.

In: Professional Judgment: A Reader in Clinical Decision

Making (eds J. Dowie, & A. Elstein), pp. 544–565.

Cambridge University Press, Cambridge, UK.

Kinchin I.M., Cabot L.B. & Hay D.B. (2006) The Variable

Structure of Expertise: Implications of Differences

Between Practitioners and Researchers for University

teaching. Paper presented at the Society for Research

into Higher Education (SRHE) Annual Conference,

12th–14th December, Brighton, UK.

Kinchin I.M. & Hay D.B. (2007) The myth of the

research-led teacher. Teachers and Teaching: Theory

and Practice 13, 43–61.

Kinchin I.M., Hay D.B. & Adams A. (2000) How a

qualitative approach to concept map analysis can be

used to aid learning by illustrating patterns of conceptual

development. Educational Research 42, 43–57.

Kinchin I.M., Lygo-Baker S. & Hay D.B. (2008)

Universities as centres of non-learning. Studies in

Higher Education 33, 89–103.

Lawless C., Smee P. & O’Shea T. (1998) Using concept

sorting and concept mapping in business and public

administration, and in education: an overview.


Manley K. & Garbett R. (2000) Paying Peter and Paul:

reconciling concepts of expertise with competency for a

clinical career structure. Journal of Clinical Nursing 9,

347–359.

Manley K., Hardy S., Titchen A., Garbett R. &

McCormack B. (2005) Changing Patients’ Worlds

Through Nursing Practice Expertise: Exploring Nursing

Practice Expertise Through Emancipatory Action

Research and Fourth Generation Evaluation. A Royal

College of Nursing Research Report, 1998–2004.

Royal College of Nursing, Cavendish Square,

London.

Martin D.J. (1994) Concept mapping as an aid to lesson

planning: a longitudinal study. Journal of Elementary

Science Education 6, 11–30.

McAleese R. (1994) A theoretical view on concept

mapping. Association for Learning Technology Journal 2,

38–48.

Nesbit J.C. & Adesope O.O. (2006) Learning with concept

and knowledge maps: a meta-analysis. Review of


Novak J.D. (1998) Learning, Creating, and Using

Knowledge: Concept Maps as Facilitative Tools in Schools

and Corporations. Lawrence Erlbaum Associates,

Mahwah, New Jersey.

Novak J.D. & Cañas A.J. (2006) The Theory Underlying

Concept Maps and How to Construct Them. Technical

Report IHMC Cmap Tools 2006-1, Florida Institute for

Human and Machine Cognition. Pensacola, Florida

http://cmap.ihmc.us/Publications/ResearchPapers/

TheoryUnderlyingConceptMaps.pdf.

Novak J.D. & Gowin D.B. (1984) Learning How to Learn.

Cambridge University Press, Cambridge, UK.

Novak J.D. & Symington D.J. (1982) Concept mapping for

curriculum development. Victoria Institute for

Educational Research Bulletin 48, 3–11.

O’Halloran C., Hean S., Humphris D. & Macleod-Clark J.

(2006) Developing common learning: the New

Generation Project undergraduate curriculum model.

Journal of Interprofessional Care 20, 12–28.

Perkins D. (2006) Constructivism and troublesome

knowledge. In: Overcoming Barriers to Student

Understanding: Threshold Concepts and Troublesome

Knowledge (eds J.H.F. Meyer & R. Land), pp. 33–47.

Routledge, London.

Polanyi M. (1967) The Tacit Dimension. Anchor Books,

New York.

Sandretto S., Kane R. & Heath C. (2002) Making the tacit

explicit: a teacher intervention programme for early

career academics. International Journal for Academic

Development 7, 135–145.

Schmidt H.G., Norman G.R. & Boshuizen H.P.A. (1990)

A cognitive perspective on medical expertise: theory

and applications. Academic Medicine 65, 611–621.

Shavelson R.J., Ruiz-Primo M.A. & Wiley E.W. (2005)

Windows into the mind. Higher Education 49, 413–430.

Stronach I., Corbin B., McNamara O., Stark S. & Warne T.

(2002) Towards an uncertain politics of

professionalism: teacher and nurse identities in flux.

Journal of Education Policy 17, 109–138.

Welsh I. & Lyons C.M. (2001) Evidence-based care and the

case for intuition and tacit knowledge in clinical

assessment and decision making in mental health

nursing practice: an empirical contribution to the

debate. Journal of Psychiatric and Mental Health Nursing

8, 299–305.

http://cmap.ihmc.us/Publications/ResearchPapers/TheoryUnderlyingConceptMaps.pdf

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Using concept mapping to locate the tacit dimension of clinical