Original article
Using concept mapping to locate the tacit
dimension of clinical expertise: towards a
theoretical framework to support critical
reflection on teaching
Blackwell Publishing Ltd
Ian M. Kinchin BSc MPhil PhD PGCE CBiol MIBiol,1*
Lyndon B. Cabot BDS MA(Ed.) MSc EdD AKC2 & David B. Hay BSc DPhil AKC1
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
Keywords
clinical teaching,
concept mapping,
expert knowledge
*Correspondence author.
Tel: 020 7848 3987;
fax: 020 7848 3481;
e-mail: [email protected]
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.
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd. Learning in Health and Social Care, 7, 2, 93–104
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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, facilitating 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 analysis and personal reconstruction of understanding
are essential (Kinchin, Lygo-Baker & Hay 2008).
However, although considerable attention is
afforded to the development of expertise in professional 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).
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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 orientation’ (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 undergraduates 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
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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.
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 necessarily 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 knowledge’, ‘competence’ and ‘expertise’ are made available for scrutiny. The relationships between these
components can be used to address current inadequacies 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 experiences 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. Identifying where a practitioner is on this model is therefore
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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I.M. Kinchin et al.
Fig. 2 The Dreyfus and Dreyfus skills acquisition model of expertise (indicating the significant attributes of each level).
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
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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 distinguish between ‘a vertical and a horizontal dimension’
of expertise. However, such a characterization suggests 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
Mapping expertise
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 identification 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 appropriate 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 structure experience is necessary to define expertise.
Benner (1984) avoids defining the expert clinical
practitioner; she does, however, provide a comprehensive 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 Dreyfus 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 positions described by Dreyfus & Dreyfus (1986) and
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Benner (1984) is the difficulty they present in visualizing 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 predictable and so reducing the learning effort required
(Halford 1993). The construction of concept maps
is an excellent way of helping to organize knowledge 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 concept 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.
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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I.M. Kinchin et al.
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).
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 constructed 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) observation 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 components to form a meaningful overview. Identifying
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
these fragments of understanding, termed ‘anchoring 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
Mapping expertise
studies with firmly established chains of understanding that have developed during their secondary 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 cognitive stress for the student (Hay, Wells & Kinchin
2008).
The chain of appropriate understanding is indicative 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 studying although others could interpret this as a blinkered 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 integrated nets of understanding may be seen as characteristic of the expert (Bradley et al. 2006), for whom
the demonstration of expertise is achieved by the
accommodation of competing chains of understanding 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 judgements. Each of these judgements is verified either
internally (through comparison with the clinician’s
underlying network of understanding), or externally, by consulting a colleague’s understanding.
Internal verification processes (often taking place so
99
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 networks of understanding 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
© 2008 The Authors
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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 development 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 appropriate 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 indication that tacit knowledge ‘lies beyond the reach of
science in some unscientific netherworld of intuitions 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 clinical expertise by adding transparency to the processes (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
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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
Mapping expertise
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 developing network of understanding, the patient is
typically given a discrete chain from which links that
may complicate or confuse are obscured, or intentionally neglected (Katz 1988).
The dual purpose of this professional discourse
may obscure the relationship between chains of
practice and underlying networks of understanding
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 function would be to explain diagnoses and treatment
options. Unless the student is aware of what is going
on, such latent functions may impede the understanding 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
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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 centres. 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?’. Student 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 educational 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 networks of understanding. For example,
interesting parallels can be drawn with the descriptions 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 structure 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 structures 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
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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 interpretation 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 literature 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 amendment to Dreyfus and Dreyfus offered by Dall’Alba &
Sandberg (2006), by showing how the dimensions
of expertise interact. Our model concentrates on the
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd.
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 knowledge 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 practitioner who has a commitment to continuing professional development.
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