“…concept-based curricula must not only attend to formal concepts in the general…”
Patricia Benner, R.N., Ph.D., FAAN Copyright October, 2nd, 2016
Many nursing curricula are using selected formal concepts to organize courses and curriculum. When students learn concepts in one context, it is expected that they will carry that understanding of the concept to other different clinical situations, allowing the curricula to be streamlined according to mastery of the most relevant concepts. Yet this is the weakest rationale for structuring a curriculum based upon concepts since research has not borne out the transfer of decontextualized concepts to context laden, particular situations (Elstein, Shulman and Sprafka 1978); and by Chase and Simon, (1973). Nasir and Hand (2008) point out: “Studies of learning in settings outside of school have documented differences in individuals’ abilities to solve problems across settings, illustrating that cognition and learning can vary significantly by context (Lave, Ochoa, & de la Rocha, 1984; Nasir, 2000; Saxe, 1991, 1999).”
Concepts are powerful and essential in any practice discipline.
Guiding a curriculum through careful selection of central concepts for deep learning through situated use of the concepts ensures that students deal with what is generalizable with the goal of understanding the situated inter-relationships of the salient concepts. Concepts are a powerful way to organize a curriculum, as long as other essential organizing strategies such as foci of care are included. For deep learning it is necessary to revisit concepts in more and more complex clinical situations. Students also need to learn strategies for exploring the particular clinical situation in relation to the generalizations offered by the concept. Concepts allow students to recognize generalizable features of syndromes, and features typical of pain, infection, depression and so on. Concepts are developed through removing particularity. However, using concepts to organize a curriculum is a necessary but insufficient approach to learning situated thinking and clinical reasoning across time in a clinical situation. For example, nursing and medical students must learn the nature of the inflammatory response to infection, and the nature of suppression of the inflammatory response in general, but must go further to recognize the particular aspects of clinical situations in relation to the general features of inflammation. Concept-based curricula must not only attend to formal concepts in the general, or as they are applied to “ideal situations” such as an ear infection, but must also attend to how concepts are used in different and varying particular situations. Situated thinking and knowledge use ( forms of productive thinking) are essential in any practice discipline (Benner, Hooper-Kyriakidis & Stannard, 2009; Lave, J. (1996) In Chaiklin, S., Lave, J p. 3-32).
Concepts also present a problem related to the limits of formalization when educators attempt to teach all relevant concepts in a practice discipline. The limits of formalization refers to the infinite lists (regress) when one tries to list all the relevant decontextualized concepts in any practice. A professional practice such as medicine or nursing use too many concepts to list, explicate or illustrate fully in a complex practice with multiple clinical goals. The number of concepts used in any practice discipline are not only too numerous to list, they cannot supplant the additional learning required across settings, and through the range of particular relevant situations of use. It can be a misleading ‘hidden curriculum’ if students imagine that knowing formal concepts and generalizing them across patient population is all they need to learn (Day & Benner, 2015). In addition, there are always relationships between concepts to one another.
The Oregon Health Sciences Consortium for Nursing Education (OCNE) developed a Spiraling Curriculum that is based upon using concepts in different foci of practice, while introducing increasingly complex inter-relationships of concepts to one another. (See Christine Tanner interview, Glenise McKenzie interview excerpts later in this newsletter). We commend this approach to teaching concepts in increasingly complex contexts. The same central concepts and competencies are re-introduced in new contexts and in levels of complexity as the OCNE curriculum proceeds. Using concepts in context was discussed in the June, 2015 EducatingNurses.com newsletter as “understanding the import and nature of expectation in social context for knowledge use and thinking” (Subscribers can read the full article here):
Dr. Jean Lave has led much of the thinking in the field of learning in context or situated thinking and action. Dr. Lave notes in the compilation of original research, Understanding Practice, Perspectives on Activity and Context (Chaiklin & Lave, 1996).
Theories of situated activity do not separate action, thought, feeling, and value and their collective, cultural-historical forms of located, interested, conflictual, meaningful activity. Traditional cognitive theory is “distanced from experience” and divides the learning mind from the world. (Lave, 1996, p. 7).
Lave’s research demonstrated for example, that math students can solve practical situated problems, such as understanding making change when shopping, where they may make errors when doing the math in a formal abstracted context. Salojo and Wyndham in the same text (Chaiklin and Lave, 1996) point out in the same book of writings on learning in a social practice states:
The Cartesian legacy [separating activities of mind and body from the social context and world of activity] of maintaining a strict line of division between mental and the practical in characterizing research has, however, fostered the assumption that ‘the only true domain of psychological study is internal mental activity’ and consequently, to regard ‘the problem of how social and physical context influences individuals’ mental processes as unimportant or secondary’ (Wertsch & Stone, 1985, Kvale, 1977). (Salojo and Wyndham, 1996).
All practice disciplines such as nursing, law, medicine, and social work require more than one-time exposure to the use and implications of using concepts such as communication, inflammation response, pain, leadership and so on, to organize courses and curricula. This is because practice disciplines require more than mere application of concepts to well-known practice situations where the concept is relevant.
In the early iterations of concept-based curricula research in medicine (Elstein, Shulman and Sprafka (1978); by Chase and Simon, 1973), the theory was that the only thinking process involved in using concepts in practice was application of relevant concepts to relevant situations. In this focus on generalization, perceptual acuity and understanding of the nature of a particular situation were left out of the considerations for concept use in particular practice situations. This narrow, rational-technical understanding of concepts works best for techniques, and procedures and not so well for whole complex practice situations. Typical practice situations are open-ended, ambiguous with multiple inter-related concepts in play. Also trends across time essential to understanding the situation must be considered if the student is not to be reduced to snap-shot reasoning. This was explored in an earlier EducatingNurses.com article: 3/27/2013 Re-conceptualizing the Curricular and Pedagogical Uses of Concepts in Nursing Education (Subscribers can read the full article here):
Research has demonstrated that practice educators tend to over-estimate the amount of generalization and transfer of conceptual knowledge across practice contexts. This is because how the conceptual knowledge comes into play and how the clinician draws on that knowledge is quite different in different contexts. As de Groot noted with chess-playing many years ago when he found that chess grand masters (de Groot, 1965) were not distinguished by their formal concepts, or even thinking deeply or having a well rehearsed set of heuristics. Rather, their superior performance stemmed from memory and perception, a conclusion also reached by Elstein, Shulman and Sprafka (1978) and by Chase and Simon, (1973) two cognitive psychologists:
Chess skill depends in large part upon a vast, organized long-term memory of specific information about chess board patterns… [template or pattern recognition has since been ruled out as a factor here]…Hence, the overriding factor in chess skill is practice. [Positive and negative links between synapses occur with no conscious memory of the situation; see Dreyfus Interviews] a repertoire of information takes thousands of hours to build up, and the same is true of any skilled task ….That is why practice is the major independent variable in the acquisition of any skill (Chase and Simon, 1973, p.279 as cited by Elstein, Shulman and Sprafka (1978 p. 276).
The models of rational thought based upon generalization and narrow criteria reasoning (snap-shot reasoning) ( Taylor, 1993 and Sullivan and Rosin, 2008 ) cannot be understood by “analysis of formal logical properties alone” as Elstein, Shulman and Sprafka (1978) point out in their research findings along with Wason and Johnson-Laird (1972):
For some considerable time we cherished the illusion that [using formal logic to construct psychological models of reasoning] was the way to proceed, and that only the structural characteristics of the problem mattered. Only gradually did we realize that there was no existing formal calculus which correctly modeled our subjects’ inferences, and second that no purely formal calculus would succeed. Content is crucial, and this suggests that any general theory of human reasoning must include a semantic component (Wason and Johnson-Laird, 1972, pp. 244-245).
Studying medical problem solving, Elstein, Shulman and Sprafka (1978) converge on the same conclusions drawn from logic in chess play:
The differences between experts and weaker problem solvers are more to be found in the repertory of their experiences, organized in long term memory, than in the differences in the planning and problem-solving heuristics employed (Elstein, Shulman and Sprafka, 1978, p. 278).
As noted in the bracketed comments above, since these landmark research studies, neuroscience has concluded that rather than explicit “organized representation in the mind,” long term explicit memory, tacit memory and “knowing-how” regions of the brain are involved in highly skillful knowledgeable performance (Noe, 2009; See EN: Dreyfus ).
Concepts are best introduced in a situated way, both in terms of the research related to the concept, and practice in using the concept in particular practice contexts that alter the way the concept is used. Redundancy in teaching the concept is managed by re-contextualizing the use of the concept across the age continuum, and in disease, developmental stages of the patient, health or injury situations. Also as new concepts are introduced, the student is best served by learning inter-relationships between concepts and situated use of the concepts. Increasingly, educators are paying attention to a critically needed additional agenda in higher education, particular in the professional practice disciplines. That agenda involves the learner’s ability to use information in actual clinical practice situations (Sullivan & Rosin, 2008). “Using knowledge” is more than mere application of theory, rules, or principles, or technique in practice. Using knowledge requires productive and creative thinking as well as clinical imagination. Using knowledge well requires that the clinician grasp the nature of the clinical situation and recognize what knowledge, evidence, and theories are most relevant (salient) to that situation.
The Spiraling Oregon Nursing Education Consortium (OCNE) consensus based curriculum (used by all 14 schools in the consortium), is a great example of a highly effective use of concepts embedded in foci of care, and in essential nursing competencies in order to for students to learn situated clinical reasoning.
Practice in an environment with a continuing shortage of nurses, requiring competence in clinical judgment, compassionate relationship-centered care, interprofessional teamwork, teaching and guiding others to give care, using health care technology, and participating in system wide efforts to improve quality of care and provide for patient safety. (OCNE, March, 2012 p. 6)
Tanner outlines the goals of the OCNE Curriculum as:
- Identifying the discipline’s most important concepts
- Addressing the most prevalent health issues
- Learning skills in context
- Developing skillful judgment-situated cognition
Concepts were presented in the context of four major foci of care, developed by IOM:
- Recovery from acute illness
- Management of chronic illness
- Health promotion
- End of life care
Contextualizing concepts in practice solves the problem of the limits of formalism (trying to capture all of the relevant concepts in a practice discipline) of trying to scaffold a practice discipline on concepts detached from practice. Concepts are embedded in the major four foci of practice, using the most prevalent diseases, issues of health promotion, and public health (Lecture by Dr. Christine Tanner on the OHSU website entitled: “An Innovative Nursing Education Network to Promote High Quality, Compassionate Health Care” 2015).
In any practice discipline, perception and understanding come before explanation is possible. In other words, in actual clinical practice, the practitioner has to notice what concepts are in play by recognizing nature of the whole situation. In addition to the relevant use of concepts, the nurse must come to the situation with discipline-specific and inter-disciplinary understandings of notions of good practice and what risks and goods are at stake in the particular situation. This is part of the nurse’s forming practice-based identity (Benner, 2011; Nasir & Hand, 2008). These notions about what are the best ends in a particular situation govern how, when and which concepts are brought to bear in the particular practice situation. Student nurses learn situated notions of good through reflecting on their clinical practice. As a student’s character, skills and identity as a nurse develops, their ability to recognize the nature of whole clinical situations, and notions of good practice at stake in the situation expands (Benner, 2005). For expert practitioners, notions of good practice are often deeply held, and form the background of perception and understanding of the practice situation. For example, an expert nurse does not have to “figure out” whether a resuscitation effort should continue on a patient who has legally chosen a Do Not Attempt to Resuscitate Order. That is a taken for granted notion of good practice. Yet the particular situation calls for a good clinical grasp of the nature of the patient’s condition, and how to go about discontinuing the resuscitation with the least discomfort for the patient and/or distress for the family. Indeed the situation may be rife with disagreement about what should be done for the patient, within the family. My point is that straightforward “rule-following” or mere “concept application” is usually inadequate to address the nature of the whole clinical situation. Application of concept use or rules, must considered in the context of the situation, timing, patient preferences, and notions of good practice.
When educators talk about “transfer of learning,” they typically imagine that the student will apply generalized knowledge to specific situations. A more accurate account of transfer of knowledge from on situation to another is a situated dialogue between the general and the particular. For example questioning the clinical situation about commonalities, similarities, family resemblances with other real whole concrete clinical situations (Benner, 2000, Dreyfus and Dreyfus,1986; Engle, 2006; Greeno, 2009). Learning science has been exploring “transfer of learning” as more than mere application of concepts. For example Engle (2006) states:
Purely content-oriented explanations of transfer make one crucially flawed assumption: If learners have the right kind of knowledge at hand and know that it is applicable in a particular context, then they are going to use it. In contrast, I argue that transfer involves not just knowing but doing, and that doing inherently involves an exercise of human agency. Thus, if transfer is going to happen, I argue, it is necessary that learners choose to use what they have learned, although there is certainly no requirement that such choices be made consciously (Engle, 2006, p. 455)… Thus, the more related that learning and transfer contexts are considered to be, the more likely—all other things being equal—that students will transfer content between them. Engle, 2006, p.455).
Clinical practice requires both generalization (i.e. what can be said to be statistically or generally true about a particular disease or patient population) and a grasp of the particular manifestations and inter-relatedness in a particular clinical case. The logical and practical differences between generalization and situated cognition are central to clinical learning and clinical reasoning. Both generalization, understanding the general aspects of the clinical situation and situated thinking about the particular in relation to the general are required for transfer of knowledge to specific contexts and for expert clinical practice, whether it be nursing, medicine, social work or any practice discipline. It helps to review the logic of formal concepts and the use of generalization, and the logic of relating the particular to the general. Below are some contrasts between explanation and understanding in situated thinking about the particular related to the general. Note that both are required for any practice discipline:
“General” Refers to Explanation and Evidence Based Findings
- Detached Snapshot Reasoning (One moment in time is summarized the present is the practitioner’s focus).
- Aggregated Cases Used (Nurse learns what happens in general).
- Fabrication of Cases Based on Means for Explanation not a Problem (“Making up cases based on the general can help the student understand and explain the typical patient’s responses.)
- Aggregated means about objective elements. (Generalization eliminates the particular, the outliers, and focused on what can be said about a patient population or disease in general.)
- Comparisons of Means, and Frequency in aggregated cases. (Comparisons between diseases and cases are made based on statistical means and modes, and simple frequency.)
Clinical Expertise Requires Reasoning Between the General and Particular
- “Particular” Refers to “Situated Cognition” Understanding and Reasoning in a Particular Clinical Situation
- Engaged Thinking and Action across Time (Clinical reasoning about changes in the patient across time…trends and trajectories).
- Particular Cases Required (Understanding requires, particular history and unfolding of the case).
- Fabrication of Patient Responses creates a problem (Fabrication of particular patient responses is unreliable, therefore when means, or generalizations are used, they should be stated as “generalizations” not particular cases.)
- Singular Universal Paradigm Cases needed for understanding (In nursing as well as biology, scientific study of physiological systems or general outcomes in a disease needs to be augmented by actual experiences and trajectories of particular persons to be clinically understood as a whole trajectory, or the unfolding of an illness and responses to treatment).
- Commonalities, Similarities and Contrasts between real whole cases are required. (The logic of commonalities, similarities and contrasts are the appropriate language for capturing what “usually happens” or what might be expected in a particular patient’s unfolding illness.)
Selecting the most relevant and frequently used concepts in a curriculum, and ensuring that these concepts are taught in increasingly complex clinical situations can make any curriculum more powerful and useful to students. Deep learning as opposed to superficial facts related to “know that” can be emphasized. Concepts need to be framed by students engaged in anticipating using the concept in multiple contexts, and in their future practice. Students co-author their understanding of how to use concepts in multiple situations, and in relation to other relevant concepts in any situation. A nurse’s practice-based identity is involved, as noted above (Benner,2005). To imagine that concepts will easily or automatically be transferred from one situation to another, through generalization alone, is an oversimplication and misleading. To imagine that decontextualized concepts provide deep learning about when, where and how the concept is relevant in particular situations is a myth that will weaken teaching and learning based upon concepts in a practice discipline such as nursing or medicine. Imagining that use of concepts for generalization alone, instead of relating particular cases, in context, to the general, through paradigm cases, commonalities between real whole clinical situation passes over current learning research, and Dewey’s proposal that doing in integrally related to understanding. Engle (2006) concludes in his research article on transfer of learning:
…the core idea that has been developed here is one that Dewey proposed long ago. It is that generalization is the result of participating in activities that are ‘broad in scope,’ something that he claimed could be produced by an education that fosters ‘greater individualization on one hand, and a broader community of interest on the other’ (Dewey, 1916, p. 87). (Engle, 206, p. 493)
Developing a curriculum that effectively uses concepts in multiple contexts requires presenting concepts in multiple contexts and in multiple foci of practice.
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