The term ‘tacit’ means that something might be experienced, understood and enacted, but words cannot be readily found to explain it. Michael Polanyi, as the progenitor of the term ‘tacit knowledge’,1 stated it as ‘we can know more than we can tell’.2 Common words that attempt to describe this phenomenon include intuition, gist, gut feelings, gestalt, flow, second nature, instinct and art. There are two day-to-day examples that readily come to mind. The first is the rapid perception that is involved in intuitive pattern and facial recognition. The second involves embodied and enacted dimensions. The classic examples are riding a bicycle, playing a musical instrument and many skilful human undertakings that cannot be pinned down with explanations.
However, there is much more to this concept of tacit knowing than readily identifiable experiences.
Other interpretations include implicit, inherent, unconsciously competent and ‘taken for granted’ forms of tacit knowing that establish the meanings upon which, we as humans, manage our emotions, form our worldviews and guide our actions. Polanyi, through this deeper appreciation, posited that, tacit knowledge is better understood as a process of knowing that dwells and works within the knower, and not just a product of thought alone.2 This knowledgeability has a power that acts quietly to integrate perception, conception, action and learning in ways that are not fully explicable.
Within this broader understanding, the purpose of this study was to initiate research that can reveal the nature of the tacit knowing of general practice supervisors.
Although it might be said that tacit ways of knowing can be readily acknowledged as happening in actual practice, this is not reflected in the current literature. After repeated searches looking for research on tacit knowing involved in the work of general practice supervisors, none came to light. Such being the case, an open-minded starting point for the research was adopted. From this, our approach (hermeneutic phenomenology) demanded that our findings were sourced from supervisors’ real-life stories and not preconfigured theory.
Methods
Research questions
We sought to address two questions with our research. First, what is the nature of ‘tacit knowing’ experienced by general practice supervisors as they teach general practice registrars in clinical practice? For this question, we conceptualise knowing as embodied and enacted in human contexts and undertakings. In contrast, this research is not about explicit knowledge, which can be formulated into justifiable propositions and readily shared with language.
Second, what is the language of tacit knowing? In our research, this starts with a phenomenological question. Bynum and Varpio3 point out that both a real-life setting and the personal engagement of the researcher are prerequisites for a phenomenological study. The lead author (HvD) is an experienced general practice supervisor who initiated the interest in the research and provided the following phenomenological question:
I had several experiences in my clinic when I interacted with (general practice) registrars and I knew what was happening and needed to be done in a consultation but couldn’t fully explain this. Have you had experiences like this? Can you tell me about it?
It is from the first-hand accounts of supervisors that we describe and interpret their experiences of tacit knowing.
Methodology
We used hermeneutic phenomenology as our methodology and interpretive framework. Phenomenology explores, describes and interprets what is happening in a defined phenomenon occurring in real life. In our research, this is the tacit knowing of general practice supervisors. ‘Hermeneutic’ characterises an in-depth attentive and interpretive method. Ontology is the branch of philosophy that engages in understanding the nature of human existence arising from its realness. The sought-after meanings in our research are ontological (real-life) understandings about tacit knowing. These are revealed in authentic stories from nine supervisors. Contemporary phenomenological research in professional practice provides several approaches.3–12 From the various ways to proceed, we followed that of Giles,13,14 with the steps outlined in Table 1.
| Table 1. Steps undertaken in this research |
| Research development |
- Designing the research with an ontological question: knowing not knowledge
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- Settling on a phenomenological question that explores the lived experiences of supervisors’ tacit knowing
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- The lead researcher (HvD) undertook a supervised hermeneutic exploration of his own experience of tacit knowing while supervising registrars
- The reflexivity achieved through this enabled the development of skills to listen deeply to the participants’ responses and discover the potential meanings embedded in their stories
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- Further reflexivity was achieved by identifying and laying out extensive pre-assumptions
- This was undertaken to develop a broad range of ideas potentially relating to supervisors’ tacit knowing and to avoid premature closure with narrower perspectives
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| Data collection, analysis and documentation |
- Nine individual in-depth research interviews were undertaken, beginning with our phenomenological question
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- The full transcript of each interview was read and re-read
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- Crafted stories were formed from the interview transcripts (apart from some formatting, these are verbatim)
- Each story was titled with wording selected from the transcript
- The eventual number of crafted stories (47) was determined by how many aspects of tacit knowing appeared
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- Quality control to ensure the authenticity and credibility of the supervisors’ stories was established by having each participant review the original transcripts and the crafted stories and sign off on their accuracy
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- A description of and interpretation for each story were written, with the phenomenon of tacit knowing guiding the process
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- As the stories, descriptions and interpretations developed, they were shared across the research team, discussed and further interpreted; this involved two in-depth face-to-face meetings, several Zoom meetings and multiple email exchanges
- There was a sustained, collaborative, academic dialogue that analysed the vocabulary and forms of language in the supervisors’ stories. It is from closely attending to these accounts that explicit and implicit ideas and meanings in the stories were identified and interpreted. Reflexivity was also embedded in the analysis through these exchanges
- Subthemes were developed as specific aspects of the phenomenon of tacit knowing sourced from the stories
- It is the combination of the stories, their titles, descriptions, interpretations and subthemes that formed the data for this study. Researcher conversations also involved searching for different forms of language to conceptualise and express our findings
- The analysis required a prolonged engagement before the themes were credibly sourced from multiple stories (thus achieving an appropriate level of coherence and saturation). The themes were then developed further, justified and agreed upon as being both authentic and trustworthy by the whole team
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Context of the study, recruitment and data collection
Our study was set in Victoria, Australia. Nine individual supervisors (three female, six male) from three metropolitan, five rural and one semirural practice participated in research interviews between June and October 2019. The size of the interview sample and its composition were determined by the responses to a promotional flyer that was distributed within the two general practice training organisations in Victoria, inviting potential participants. Eight of the participants were late career supervisors and one had several years’ experience. Each research interview went for one hour. Four interviews took place face to face and the remaining five were conducted by Zoom videoconferencing. All interviews were audio recorded and professionally transcribed. From the nine transcripts obtained, 47 crafted stories were created.
This research was approved by Flinders University Ethics Committee (SBREC; Approval no. 8299).
Results
General practice supervisors’ tacit knowing is expressed as dispositions
Tacit knowing was experienced by our supervisors and expressed dialogically as an inseparable part of the reality of their lives, who they are and how they work as clinicians and clinical teachers. These are ontological (actual, real-life) characteristics and were revealed by our research to be in their skilful dispositions. We use the term ‘disposition’ because it describes essential human qualities such as the feelings, thoughts and actions that make up who we are and manifest the context-dependant ways in which we engage in the world. The dispositions of supervisors that interested us were how they open up ways to support and teach their registrars, but fall short in being able to explain them.
Finding a novel way with words
A challenge in phenomenological research is ensuring that the leading comes from the real-life stories, while uncovering and naming new insights. We found that the supervisors’ tacit knowing has many dynamic features and we needed to find a way with words to portray these features, without lessening their meanings in abstract classifications. To do this, we developed novel word couplets containing gerunds with hyphens. Gerunds are verbs that act as nouns and typically end with ‘-ing’. They can be regarded as being either a noun and/or verb. This means that they can function as ‘depicting’ or ‘doing’ words, or both. Hyphens are couplers and they can also uncouple words. The combined use of gerunds and hyphens is intentional. The aim is to express the range of meanings revealed in the stories.
Three ontological themes were created to show the links between the stories, the two words in the couplet and the supervisors’ dispositions, namely ‘re-presenting’, ‘with-holding’ and ‘path-marking’.
Note, complete stories and interpretations are not fully replicated in each of the examples given, but extracts relevant to the particular theme are quoted. In order to maintain the anonymity of both supervisors and registrars, and preserve uniformity, the female forms of the personal and possessive pronouns have been used in all the stories and interpretations. The supervisors’ narratives are in italics, with (our) abbreviated interpretation in parentheses.
Re-presenting
The first theme is ‘re-presenting’. This portrays a range of dispositions that supervisors draw upon to find ways to be ‘present’ with and guide their registrars. This was revealed and interpreted in the supervisors’ stories in relational, temporal and spatial ways (Box 1).
| Box 1. Dispositions expressing the theme, re-presenting |
- Recognising and reflecting upon issues appearing with registrars
- Reflecting on personal concerns and experiences
- Recollecting previous clinical experiences, times, places and people (patients, registrars and colleagues)
- Recollecting earlier educational experiences of their own or with other registrars
- Realising what it might be like to be in the patient’s shoes
- Realising what it might be like to be in the registrar’s shoes
- Balancing simultaneous demands of patients, registrars and the practice as a whole
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‘Re’ is a prefix expressing an action of returning or doing again. ‘Presenting’ is the verb of the word ‘present’, which can have temporal, spatial or relational meanings. Its temporal meaning is of something happening in the present, meaning now, in time. In addition, it can mean being physically present in different places. An additional notion is being present in a relational sense. The supervisors’ stories shared accounts of them reflecting upon different stories, places and people, while imagining the past, present and possible implications of these, in seeking to guide their registrars. This disposition shows how the supervisors learn to be ‘present’ with their registrars in order to guide them.
In-depth interpretation of four stories shared by general practice supervisors (GPS), GPS7, GPS6, GPS2 and GPS4 supports the credibility of this theme. An example of ‘re-presenting’ from GPS 7 follows. This is derived from the sub-theme ‘putting oneself in the shoes of the registrar’.
(Here we see her trying to bring forth some account, from the registrar, of why she was worried, and then for the registrar to be able to express it. In this story we see teaching as a disposition of seeking to understand and gain a fuller understanding of the registrar as a person.)
So, my Registrar was worried about this patient, but she couldn’t articulate why she was worried. I couldn’t work it out either until I had to drill it down a bit more and then reflect back on what she’d said …
But she still had something in the back of her mind that was just bothering her and she couldn’t put it into words and neither could I.
So, then I had to try and ask her, not questions like, what were the patient’s symptoms … And that kind of thing.
But more questions like, what is it that’s bothering you, what is it that you know you’re … what’s your … is it gestalt, what it is you’re … that’s making you feel uncomfortable about this patient? And she still couldn’t really articulate it and if she couldn’t, how was I to know?
In a follow-up story about the same patient and registrar, this supervisor shares the following:
I was trying to put myself in her shoes at that point and trying to formulate everything that I knew about this man with the addition of the information that she’d given from the consults … Just so that I could get a sense of exactly how she saw the patient so I could help her navigate a way to get where she needed to go. Does that make sense?
(This story exemplifies how a supervisor endeavours to be ‘present’ with her registrar and occupy the space of uncertainty that the registrar inhabits. She puts herself in the shoes of the registrar. The registrar’s problem has become hers; ‘How was I to know?’)
With-holding
‘With-holding’ is the second theme. It was interpreted from the supervisors’ stories as a disposition through which they respect their registrars’ autonomy and ‘withhold’ from offering direct instruction. The addition of the hyphen to create ‘with-holding’ also refers to how the supervisors also patiently work with, and support, their registrars as they learn. This was sourced from interpreting seven stories shared by GPS1, GPS2, GPS4, GPS8, GPS5, GPS6 and GPS7.
In this theme ‘with’ has the meaning of being with the registrar. A literal meaning of the word ‘holding’ is grasping. It can also mean supporting and preventing falling. ‘With-holding’ as a theme expresses a disposition that skilfully balances restraint, support and respectful intervention, if needed. An example of ‘with-holding’ follows. This is derived from the subtheme ‘trying telepathically’. This story from GPS8 comes from an account of when she was directly observing a registrar’s consultation:
So my role in that … I saw my role there as not to say to the registrar look, just give her some (of the requested medication). That would have easily diffused the situation but wouldn’t have been the appropriate thing to do because it would have made the registrar look silly and also I’m not sure that that was the appropriate course of action, because I wasn’t the doctor, I was just observing. So I felt the most appropriate course of action was to involve the doctor that knew this patient well. I was telepathically trying to get the registrar to call the supervisor (the usual general practitioner), but I didn’t actually say that, so I just thought I will defuse the tension by just asking the patient a question that’s not related to her pain management.
(The reference to telepathy is consistent with the dual idea of ‘with-holding’, meaning there is no direct telling or interfering during the consultation. However, GPS8 can also be seen to support the registrar to realise she needed to call the patient’s usual general practitioner. This is a good example of wisely guiding, which is the proposed meaning of ‘with-holding’. GPS8’s actions can be interpreted as a double disposition of being synchronously ‘withholding’ and ‘with-holding’.)
Path-marking
The third theme is ‘path-marking’. This is about the dispositions supervisors use when they identify significant learning opportunities for their registrars. These are moments that matter in the registrars’ learning pathways. This was sourced from interpreting seven stories shared by GPS1 (two stories), GPS2, GPS3 (two stories), GPS7 and GPS9.
The path as a journey of learning is the key idea. ‘Marking’ is the act of making a mark. Although supervisors expressed that they preferred a non-interventionist stance, as expressed in ‘with-holding’, their stories also revealed times when more direct approaches needed to be taken. This is when they mark, meaning they identify, in some of the registrars’ interactions with patients moments as being important learning opportunities. An example of ‘path-marking’ from GPS3 follows. This is derived from the subtheme ‘being obliged to provide care’. The story line here is that a registrar visits an aged care facility and is confronted by the high-care patients there. She tells her supervisor that she does not want to be involved in providing aged care. For GPS3, the response is direct:
I actually said to her, I said, ‘I think you really need to think hard about that, because you know, front and centre of this is that person’s dignity. They are still a person, we’re obliged to care for them, and their dignity should be front and centre of what we do, not your reaction.’
(The significance of this story is anchored by the words ‘centre of what we do’. This disposition is an unambiguously ethical stance and presented as a professional obligation. The ‘path-marking’ is that the registrar needs to turn up and look after these patients. It is unacceptable for the registrar to be absent.)
Discussion
This is novel research
This is novel research because there are (to date) no identifiable research reports on the tacit knowing of general practice supervisors. Despite the absence of previous studies, we have been able to show that the tacit knowing of general practice supervisors can be researched phenomenologically and expressed in stories leading to themes. Furthermore, we posit why it is characterised as tacit, and why it is important in developing situational awareness, as well as further training and research.
Why general practice supervisors’ tacit knowing is tacit
We offer two considerations that deem tacit knowing to be tacit. First, the traditional notion of knowledge as having informational content, which can be formulated with language and directed into facts, definitions and explanations, sits in contrast to our position that the nature of supervisors’ tacit knowing is dispositional. As a phenomenon, it is predominantly enacted and learned in real-life situations.
This means it cannot be abstracted into fully explicit propositions of knowledge. The result is that tacit knowing can be ignored in a worldview where propositional knowledge is the metric of value.
Second, because tacit knowing is routinely enacted by supervisors, its familiarity can make it simply ‘just what they do’. Our research offers insights into the ways this assumed ordinariness seems to blend naturally into clinical supervision relationships. What makes them tacit, is because they are unrecognised, or taken for granted.
Situational awareness and real-world learning
Our research participants shared how they are called upon to offer their expertise in changing contexts of different places, times and relationships. They described how navigating the complexity of supervising requires tacit knowing. This is characterised by being situationally aware and agilely working with ever-changing boundaries between communication and action.15 ‘Tacit’ in this context is not about fully explicable and predictable knowledge, but about knowing what matters in the ‘here and now’ and over longer time frames of a registrars’ training. Tacit knowing plays an important role here as explicit rules for situational awareness and responses are not evident nor sufficient. Because it is not about predictable performance, which can be explicitly taught, general practice supervisors tacit knowing offers ways to help registrars learn from experiences in the real world.
How can these themes help other general practice supervisors?
We have sourced our findings from the stories of nine colleagues. Their accounts have shown that their tacit knowing is embodied in who they are and enacted through their skilful dispositions that require situational awareness and responses. The outcome of this research is that we now have a start in further understanding this expertise and developing the linguistic means to help other supervisors recognise and further enhance their tacit knowing. These can be used to improve the guidance of their registrars and the training of novice supervisors, as well as stimulating further research.
Limitations
Hermeneutic phenomenology uses a first-person approach to explore lived experiences and their meanings. This could be viewed as a limitation if formulated propositions are expected. Our study used a useful collection of 47 stories from a small sample of general practice supervisors. Further research is needed, and different findings are possible with larger samples containing different interviewees in different primary care settings. In addition, the lack of other research papers on supervisors’ tacit knowing limits our ability to comment upon any comparable work.
Conclusion
Rather than describing supervision as the use of rules, protocols and planned strategies, supervisors’ tacit knowing was revealed in their dispositions. We found their tacit expertise to be embedded in their relationships with their patients and registrars and enacted in the complex contexts of providing both patient care and clinical supervision. Our research offers a novel language to reveal those aspects that have been regarded as tacit. This work gives us the means to access, reflect upon and share the nature of supervisors’ tacit knowing more widely. Now we can tell more about what we actually know, as we support and guide our registrars.