07/14/2013

Bringing Clinical and Classroom Together: Integrative Pedagogies

Patricia Benner copyright 2013

Enrich your classroom by thinking about and reviewing new strategies; it will help you align your teaching with learning goals. To that end, I’ve put together pedagogies highly recommended for bringing together both classroom and clinical aspects of learning how to think and act like a nurse.  This may trigger ideas, reflection, and pedagogies you have developed over time in your teaching.  Let’s make this a learning community; please share your ideas and reflections with your colleagues about your teaching.  We look forward to your responses!

The three apprenticeships held in common in all professional education are:
  1. The cognitive apprenticeship of knowledge, theory and science;
  2. The clinical practice apprenticeship of gaining clinical skilled know-how, situated   knowledge use and clinical reasoning in practice;
  3. Ethical formation and ethical comportment.

The word “apprenticeship” is being used metaphorically here to describe embodied skilled know-how that must be integrated, and usually modeled or demonstrated by a practitioner- teacher.  In other words, reading about signs and symptoms is not the same as being able to actually recognize when these are present in patients. These three apprenticeships, held in common by all professional education should be integrated in all teaching and learning settings, while being developed for nursing domain-specific teaching and learning. For example, these professional apprenticeships are taught differently for physicians, lawyers, engineers, and so on, depending upon the nature of the practice, and relevant knowledge to be used in practical or clinical situations. The nursing domain-specific characteristics of teaching/learning in these three apprenticeships include first-person experiential learning, the demand for clinical reasoning, integrated knowledge acquisition and use in clinical situations. In addition, students need to draw upon psycho-social and humanities knowledge and skills, and a highly developed understanding and scientific knowledge use in health promotion, illness prevention, caring practices, and acute illness and injury. These three apprenticeships work best when they are taught together in a situated way.

Normal and patho-physiology must be integrated for the nurse’s iterative situated use of both.

Nurses are so centrally concerned with assessing shifts from normal to alterations from normal in their practice, that they indeed, might be considered “practicing physiologists”, especially in today’s highly physiologically monitored patient care, characterized by response-based therapies that require alteration, based upon the patient’s responses.  The nurse needs an integrated knowledge use of shifts between normal and patho-physiological responses of patients. The student nurse needs deep learning about normal and pathological physiology as it is manifested and used in practice, whether that practice be in the acute care/trauma settings or in community, long term care, home care or psychiatric health settings.

Pedagogies in all settings, but particularly in the classroom, should create an active learning climate that engages students’ interest in the learning goals at hand. Situated learning exercises within the class can be used to help the student to use knowledge as it is being presented.

The pedagogies of contextualizing and situating knowledge use are particularly relevant and engaging for students.  For example, students readily engage in the presentation of patients or family members describing their lived experience with an illness.  Also “experience-near-first person” narratives of nurses at different levels of practice are particularly evocative for student engagement and learning.  Simulation, even within a large group setting of the classroom, can make the classroom come alive with relevance-creating active engagement and learning of students involved in a classroom simulation, either online, or in person.

Pedagogies for Creating Clinical Imagination and Patient-Focused Care

Literature of patient’s experiences, for example, pathographies, nurse generated literature, medical and nursing literature on their practice, historical accounts of health care and clinical experience can be used to expand the student’s clinical imagination for practice. For example, typically it requires the expansion of the student’s clinical imagination to realize that recognition practices for the patient as a person and evidence that the patient has been heard and understood, is usually therapeutic, and trust-building between the patient and the nurse.  Also how the nurse listens, attends, notices and articulates accurately the patient/family concerns creates the possibility of more openness, disclosure and possibility in the clinical situation.

Creating Collaborative Learning Communities

In each learning setting some form of a collaborative learning community is possible. In large class groups, it might be good to formally organize learning communities of 6-8 members so that they can be assigned a focus of learning to teach and share with the rest of the class. For example each learning community could be designated and the expert consultants on respiratory care; cardiac assessment and support; or septic shock.  The goal is for the whole class to learn these areas, for example in an acute medical-surgical class. But the resident experts provide additional exercises, even in-service classes available in local health care settings; engage with a respiratory and physical therapists, and recommend additional readings.  Classroom presentations, power point presentation, clinical learning centers and other assignments could be developed within the “expert consulting groups.”  Students assigned to the same clinical rotations almost always forge a learning community in the pre-clinical preparations, and post-clinical debriefings.  One strong learning experience told by one student can become a vicarious learning experience for the whole clinical group.

Consciousness-Raising: Creating dialogues with the student’s life-world experience, assumptions, beliefs, coping approaches to illness, rehabilitation, birth, death, and suffering

Each student needs to reflect on the family coping styles deeply ingrained in their own familial and cultural habitus that will or will not serve them well as a professional nurse.  For example, extreme discomfort with anger, conflict, helplessness, suffering will frequently occur in patients who are under duress due to injury or illness. But if the student feels embarrassed, or helpless, or even victimized by anger, they will not be able to be helpful in clinical situations where patients or families are angry.  The learning goal for the student is to expand their understanding of the coping resources of anger, and their own repertoire of responses, and communication patterns.  Pedagogies of consciousness-raising are required for the student to encounter their own background impediments to effective professional caregiving. Narrative pedagogies in the form of journals can be extremely useful for this, especially having the student uncover and reveal their areas of negative bias and inhibitions with being with patients who are disfigured, suffering, angry and so on. An open, trusting and affirming emotional learning climate is essential for consciousness rising.

Two broad interpersonal skills are required for all nurses:
  1. The skill of involvement—that positive project of engaging in helpful and therapeutic relationships with patients
  2. The remedial level of boundary work, sorting out what is within the patient’s world and plight, and what is related to one’s own world. Both are essential skills of involvement and must be developed throughout nursing school

This is a major area of formation that is primarily learned experientially and through the examples of others. Again, narrative journals, and also first-person-near accounts with effective and break-down situations in their working with patients can be useful for articulating and clarifying the skill and knowledge of relational learning.  Students may develop their own desk-top printed books on what they learn from their patients, each year of nursing school. This is a major portion of the silent and hidden curriculum that is central to student’s learning. Much can be gained from bringing it in from the margins. Student-generated narrative texts, journals, and reflection can be powerful sources of learning basic and more advanced skills of engagement with patients and their problems. .

Integrating in-hospital care, and follow-through learning about discharge planning and home care helps students bridge the gaps between acute care, clinic care, and home-care.

Selected follow-through cases each semester could create more depth and breadth in the student’s learning. Follow-up phone calls and home visits with home-care agency nurses could bridge the gaps that occur in understanding usual patient trends and trajectories.

Teaching for a sense of salience and grasp of the most relevant aspects of the patient’s care, now and in the immediate future

In the first year of nursing school, clinical educators will need to frame and augment the student’s grasp of the most salient aspects of the patient’s care.  As the student progresses, and has more experience with particular patient populations, they should be asked, guided, and coach to form the best grasp of the current clinical situation. Situated clinical questioning is an essential pedagogy for the ongoing development of a sense of salience in under-determined clinical situations for student nurses. Developing a sense of salience becomes taken for granted background meanings and understandings of what is most and least important in immediate clinical situations.  For example different, clinical aspects are salient in caring for a patient with an acute head trauma, a post-operative open heart patient, and a new post partum mother.

Clinical evaluation for patient safety

With each patient care assignment, students should be taught and expected to evaluate all medications for the patient for drug dosages, patient allergies, interactions, purpose and correct dosage, correct route, patient, and I.V. administration compatibilities and contraindications of all medications . Increasingly, such safety is enhanced by computer based medical record and pharmacy systems, however the nurse is the patient’s last line of defense for catching over-looked problems with patient medications. If a patient is receiving a dosage level or a medication not usually or clearly indicated for the patient’s disease or symptom, they should find out why the particular medication and dosage are being given.

Teaching for Needed Action and Implementation Steps

In most practice disciplines, and in nursing particularly, it is essential that the student learn how to follow through in all their clinical knowledge to practical action steps. Rapid implementation of patient interventions becomes even more important in the rapid pace of emergency nursing interventions (e.g. where the external defibrillator is located, how to access emergency power and so on). Or for example, in addition to knowing that a pacemaker set and internal pacing wires may be needed during a surgery, requires that the nurse also be prepared to make those pacing wires immediately available during surgery. Likewise student nurses must learn where emergency drugs are stored and how to procure them immediately during an emergency. It is not sufficient for the student to know about the possibility of needing an emergency medication such as Narcan, or Atropine, but where such medications can be found for emergency use and how the nurse can gain access to the drug.  Likewise, reconstituting and mixing drugs that may be used in emergencies should be learned in advance.

Learning to make a case for a needed patient intervention, assessment or attentiveness

Students need to communicate in their nursing reports to other nurses, physicians and health care team.  Making a case for an intervention is part one’s advocacy and safety role whether the case be clearly defined, or an early warning about subtle evolving patient changes. Communicating one’s assessment’s and rationale for a needed intervention in clear, cogent cases is best accomplished through a clear narrative clinical understanding of changes in the patient across time. SBAR and other standardized tools for making a case can be useful, but they will only be as useful as the student nurse’s accurate grasp of the clinical situation and clear reasoning about the patient’s clinical condition.  Sometimes nurses and students will encounter a poorly understood clinical situation, perhaps early changes when the patient is still compensating for their physiological disturbances. In that case, the nurse or student needs to shift gears and explain that the situation is ambiguous; that a clear case for what is going on is not yet evident, and it would be helpful to have a second opinion, or even the assessment of a rapid response team.  The less experienced nurse will more likely feel uncomfortable in requesting a second opinion when the clinical data are unclear, but with more experience, and perhaps a failed “early warning” the nurse will become more confident in requesting a consult when the patient evidence is still unclear.

7 Comments

  1. Pamela D Sims MSN, RN

    07/16/2013 at 9:56 am — Reply

    Excellent information for myself and others who engage and challenge ourselves and the next generation of nurses..Thank-you!

  2. Tom Dolan

    07/16/2013 at 8:28 pm — Reply

    The language of instruction in almost all nursing programs whose teachers

    will see this article is English. Ought not the article be translated into the English

    language for the convenience of the vast majority of its readers ?

  3. Deborah Rushing

    07/17/2013 at 4:45 pm — Reply

    Again, you have given me “food for thought” to alert my new clinical faculty about ways to enhance clinical teaching!

  4. Patricia Benner

    07/30/2013 at 11:02 pm — Reply

    These newsletters are intended to stimulate thinking and imagination about teaching nurses. So I am glad that they are thought provoking for you Pamela Sims and Deborah Rushing.

    To answer your question Tom, I would need specific questions. You are right the newsletter is aimed at graduate level educators who are deeply familiar with actual clinical nursing practice, and who are familiar with reading nursing education research. I would be happy to respond to specific questions about phrases, or concepts that seem to be in a foreign language!! Thanks!

  5. Patti Warkentin

    10/02/2013 at 6:31 am — Reply

    I so appreciate the integration of “thinking” and “acting” in this invigorating post. Having practiced nursing for over 35 years, I now find myself in the delicious role of facilitating the learning journey of undergraduate nurses at OHSU School of Nursing. I found my soul alight as this post unfolded the concepts of “clinical imagination” and “collaborative learning communities”. I look forward to continued learning, expanded vision and innovation. Thank you. Patti Warkentin M.Ed. RN BSN

  6. Edelmira Castillo Espitia

    11/16/2013 at 11:39 am — Reply

    This article would be very usefull for us. After having you here talking about these issues, faculty became very aware of the need to improve our teaching. Tthanks so much for helping us in this process. Edelmira

  7. Jane Smeaton

    04/05/2014 at 11:38 am — Reply

    As a soon to be graduate of a MSN program I wanted to share how wonderful your articles are and how they have provided me with much food for thought as I consider how I will impact nursing education. As a current nurse manager I applaud your comments related to teaching the student the theory and clinical knowledge but the practical steps are just as important when in those situations. Jane Smeaton, RN

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