Innovative Teaching Approaches to Help Students become Practice-Ready
Patricia Benner, R.N., Ph.D., FAAN
John Benner, Doct. Cand. University of Washington, Seattle.
Amid an acute nursing shortage, new nurses enter practice with limited experience, creating patient safety problems, high cost of orienting, high stress and dropout rates for new graduates. The problem is highlighted in research. ( Kavanagh, J.M.; Szweda, C., 2017; Kavanagh, J.M 2021 ; Chan & Burns, 2021). New graduates have difficulty with clinical reasoning, defined as a science-using form of practical reasoning across time about changes in the patient’s clinical condition and/or changes, is the clinician’s understanding of the clinical situation (Benner, Kyriakidis, Stannard, 2011; Sullivan & Rosin 2008). Clinical reasoning requires practice-based experiential learning that needs study and public language, along with the development of each clinician’s habit of comparing cases across time. Multiple gaps and impediments to learning directly from practice exist in nursing education and lack of focus and articulation, i.e., naming and reflecting on what is being learned in practice by nursing students is a major cause and lack of skills for life-long learning from practice and accountability for practice-readiness.
Some of the impediments to facilitating experiential learning directly from practice are:
A dominant rational-technical view that presents practice as a mere application of techniques, scientific knowledge, theories, formal concepts and guidelines to practice situations (Lave & Wenger, 1991; Lave, 1996). This rational-technical view conflates and confuses the mere application of knowledge, theories, techniques to practice with the intelligent, situated use of knowledge in particular clinical situations. Situated-use of knowledge is a form of higher-order productive thinking that goes beyond mere application of knowledge…for example, a direct demonstration of “applying” specific procedures accurately, out of the context of practice. Such a rational-technical view of knowledge describes knowledge as “knowing that and about,” while failing to give accounts of “knowing how and when” and situated-thinking-in-action, the mainstay of clinical reasoning about particular patients across time.
- 1. A rational-technical view “mere application” of knowledge does not consider clinical reasoning across time through changes in the patient, and/or changes in the clinician’s understanding of the situation, with concern for the responsibility for the well-being of the patient.
2. An outdated representational view of learning (Benner, 2022; Benner, 2024, available now; Noe, A., Gallagher, S., & Zahavi, D., 2021, Gallagher, S., 2009, Robbins, P., & Ayede, M., Eds., 2009, Collins, 1985; Merleau-Ponty, 1962) holds that the mind works by perceiving the world, by using formal concepts, ideas, templates, schema, theories located in the mind in order to understand the world This representational view of how the mind works was first formulated by Descartes (1628). Descartes’ “mediated epistemology” or representational view of the mind (Taylor, 2016) is disproven by current studies of how the mind works (Dreyfus & Taylor, 2015; Taylor, 2016), yet a representational view of the mind comprises largely unexamined, taken-for-granted assumptions about learning and how the mind works. This representational view of how the mind works plays out in many social practices, curricula, and pedagogies in academia, in general, and nursing, in particular (Benner, 2022; Benner, P. 2024, available now). Unwittingly, taken-for-granted meanings and understandings of the mind shape the social practices of teaching and learning and assume that practice is knowledgeable only through applying theories, formal concepts, and scientific generalizations. While all practice disciplines are based on and use science and theories, practice, to qualify as a professional practice is constantly being improved and further developed by intelligent practitioners dealing with the contextual and particular demands of practice. The experienced-based knowledge gained by intelligent and actively learning clinicians is overlooked in a Cartesian view of how the mind works. Learning directly from practice is a source of knowledge in its own right. The Cartesian, representational view of the mind overlooks immersion in and direct perceptual grasp of the world. (Lave & Wanger, 1991; Gallagher, 2009).
3. Practice is poorly understood and reduced to mere “doing,” when doing is mistakenly separated from thinking. Facilitating and articulating experiential learning requires a robust definition and view of practice as a socially embedded, self-improving, form of practice-based knowledge that is experientially gained knowledge and guided by notions of good internal to the practice (MacIntyre, 2007; Dunne, 1997). When practice is reduced to “mere doing” with no understanding that thinking, knowledge, and doing are intertwined, (Dreyfus, 1990; Heidegger, 1926;1965), it is misunderstood. Practice is never passive, or completely dependent on application of mental concepts or representations. Practice is constituted by particularities, timing, and contextual aspects embedded in the situation. (Benner, Feb 6, 2022). While good practice is intertwined with situated use of science and useful theories, clinical reasoning, and skilled-know require more than generalizations from science and theory. (Benner, Feb. 6, 2022). Situated practice-based knowledge that uses science and theories requires experiential learning related to patients’ particular co-morbidities and sensitivities along with understanding of timing, context, mastering and adapting technology use, and local organizational knowledge. Nursing practice is a socially organized and embedded form of science and theory using knowledge worked out daily and further developed by intelligent practitioners.
4. Nursing practice knowledge is typically described as decontextualized “knowing that and about” leaving out “knowing how, when and why.” These two distinct ways of describing nursing knowledge (“knowing that and about” and “knowing how and when”) uncover the distinctions lodged in actual practice. “Knowing how and when” include situated thinking-in-action, unfolding clinical reasoning across time, situational awareness, attuned caring practices and clinical judgment. This kind of situated knowledge is even more important given the context of today’s instantaneous therapies. Nurses administer “instantaneous therapies”, using standing physician orders to manage acute and rapidly changing clinical care. Instantaneous therapies began in the early 1970’s made possible by prevalent use of Intravenous fluids, medications, and the constant monitoring of cardiac rhythms and cardiovascular dynamics. The clinical efficacy and possibilities of instantaneous therapies gave rise to intensive care units, and the practice of physicians practicing hospitalist care to patients. Instantaneous therapies are no longer limited to patients in intensive care units but are now pervasive in today’s high acuity levels of all hospitalized patientsnthat require astute monitoring of all patients by nurses. In the current context of high patient acuity and the pervasiveness of instantaneous therapies, descriptions of nurisng knowledge urgently need to include situational awareness, and situated clinical reasoning, the “knowing how, when and why” in addition to the decontextualized accounts of “knowing that and about” patient care.
5. Fostering experiential learning in nursing education is hindered by the predominant use of passive instructional strategies of information giving in PowerPoint based lectures. In the Carnegie National Study of Nursing Education (Benner, Sutphen, Leonard-Kahn, Day, 2010) we found that classroom teaching did not usually integrate clinical learning with classroom learning. Classroom teaching was not very interactive, and had almost no active learning. Typically, classroom instruction was governed by PowerPoint-guided formal lectures. Little or no attention was given to having students reflect upon or give narrative accounts of their experiential learning from practice. Often interaction within the classroom was limited to “call and response,” where the teacher had a specific answer in mind (Benner, Sutphen, Leonard-Kahn & Day, 2010). This is not surprising because many nursing faculty had not studied learning science, nor had formal education in teaching and learning. Most educators teach as they were taught and very few were taught using active learning strategies, as the traditional lecture format dominates academia and serves as the social imaginary (Taylor, 2003) of “good teaching” even though it is obsolete. Active learning strategies, such as articulating clinical reasoning in unfolding cases through group and individual problem solving are needed to make students practice-ready. A lack of educators’ attention to students’ experiential learning in practice makes it difficult for students to develop an ongoing and cumulative understanding about insights and new practice-based knowledge gained experientially.
Speaking of “social imaginaries” this bias toward obsolete lecture-based instruction is something students hold as well. Harvard Researchers (Deslauriers, et al. 2019) have conducted research that demonstrates that students prefer passive expert teacher lectures to active learning and are poor judges of how much they are learning from passive listening to lectures. Deslauriers, et.al. (2019) report:
In this report, we identify an inherent student bias against active learning that can limit its effectiveness and may hinder the wide adoption of these methods. Compared with students in traditional lectures, students in active classes perceived that they learned less, while in reality they learned more. Students rated the quality of instruction in passive lectures more highly, and they expressed a preference to have “all of their physics classes taught this way,” even though their scores on independent tests of learning were lower than those in actively taught classrooms (Deslaurier, et. Al., 2019, p.19254).
Facilitating Experiential Learning
Often faculty and students alike, seek to put their experiential learning into formal theories, and abstract concepts that fall short of capturing the range and content of meanings and insights from their experiential learning. Kolb’s theory of experiential learning illustrates this common assumption that posits that the goal of experiential learning is to turn it into theoretical abstractions from actual situated learning.
Kolb’s Stages of experiential learning are concrete experience, reflective observation, abstract conceptualization, and experimentation (Fewster-Thuente & Batteson, T.J., 2018). Kolb’s model does not direct the learner to first engage in understanding and describing the meanings, context, significance, and the situated use of knowledge, e.g., “For the sake of what concern or clinical issue?” For example, abstract terms such as pointing to concepts evident in the learning experience such as “communication” or “collaboration” stop short of describing the actual communication, i.e., the intent, actions, and content of the communication and collaboration (Fewster-Thuente & Batteson, T.J. 2018)
Instead, we recommend focusing on the meanings experienced and articulated, described by the learner, in terms of their current experiential learning and how it relates to past experiential learning (Dewey, 1959). Kolb’s model of experiential learning moves too quickly to reflective observation on and about the situation, skipping over an engaged understanding and articulating of the meanings in the situation. Schon (Schon, D.A. 1984) makes the distinction of reflection in action and reflection on situations. Reflecting on situations is more of an “outside-in” account rather than an engaged account of one’s understanding. Kolb’s model of experiential learning ignores the step of first making sense of the situated experiential learning, and giving public language to that sensemaking. Much of what is known in expert nursing practice is taken for granted by experts, having been learned experientially in practice, and thus, often lacks good public descriptive language that makes the knowledge accessible to others.
Articulating, giving clear and descriptive language of what has been experientially learned directly from practice comes first. The goal is to help students develop ongoing integrative, narrative descriptions of experiential learning. Practice is a way of knowing in its own right and contains front-line knowledge development. (Weick & Suttcliff, 2015). Formal concepts, and theories get their power of generalization by leaving out meanings, perceptual grasp of qualitative distinctions, and contextual aspects of particular clinical situations. Aspects of patients’ clinical condition (e.g. the patient’s wound has healthy-looking new granulated tissue with very little exudates or the patient is less confused, and more able to stay on a topic today;) are examples of qualitative distinctions made by the clinician. The task of the clinician is to create a dialogue between the particular and the general. Generalized evidence-based guidelines may be misapplied if particular patient co-morbidities or sensitivities or other aspects of the situation are overlooked. It is this practice-based experiential learning from the richness and complexity of particular clinical situations that fosters the development of expert clinical reasoning (Dreyfus and Taylor, 2015; Benner, Hooper-Kyriakidis, & Stannard, 2011).
Clinical experiential learning is best captured in historical, narrative accounts of real unfolding events that demonstrate the clinician’s understanding of the situation. Narratives include sequencing of and relationships between events. In clinical practice, the student must learn to reason across time about the particular, through changes in the patient’s clinical situation and/or changes in the clinician’s understanding of that situation. For example, “I thought the patient was volume depleted, but the patient’s heart was failing and unable to move blood effectively in the cardiovascular system” (Benner, Hooper-Kyriakidis, & Stannard, 2011). This kind of knowledge and understanding gain in clinical reasoning makes the clinical situation better understood with fewer diagnostic misunderstandings and errors. Some clinical data become clear and well-established, ruling out other clinical interpretations. Having students narrate their understanding of an unfolding case can make situated thinking visible and open for reflection. The opposite of this is a sort of checklist approach that removes a nurse’s thinking from the clinical context eg. “name five reasons a patient might have elevated blood pressure.” It is more effective to ask a question like “Given this patient’s clinical transitions, what are some possible reasons their blood pressure is elevated?” (Weick, K., 1885)This practice-based experiential learning is essential to practice-readiness and to the development of expertise.
Translating direct learning from clinical situations immediately into formal concepts overlooks and unwittingly devalues what can be learned directly from the clinical situation. Knowledge and situated thinking-in-practice may not yet be captured, described or well-articulated in existing theories or scientific studies. Practice is constituted by socially embedded knowledge of its practitioners who learn experientially how to discern the relationships between the particular to the general. This socially embedded knowledge often contains perceptual recognition that allows for early warnings leading to systematic detection of clinical changes. Nursing knowledge is being developed daily in nursing practice, waiting to be discovered and articulated. Increasingly, through the practices of High Reliability Organizations (Weick & Sutcliffe, 2015), attention is being paid to what front-line knowledge workers learn as they experience both successes and failures in practice. This strategy used in High-Reliability Organizations often uncovers new experiential learning and knowledge gained directly from practice.
All clinical practice disciplines have socially embedded knowledge from non-conceptual learning. The existence of “non-conceptual learning” is not recognized in our common Cartesian accounts of how the mind works. Stuart Dreyfus uses the example of the outfielder’s non-conceptual learning of how to catch a field ball in baseball. The catcher, over time. learns when to move up on the ball to catch a “fly ball”; when a ball is likely to bounce before the catcher can get to it, or when to run back, deeper in the field for the catch (Dreyfus, 2014). Similarly, the feel of a patient’s veins is non-conceptually learned over time by nurses learning to insert I.V.s and doing venipunctures to draw blood. While the nurse may give reasonable explanations for their decisions about which veins would work best for I.V.s, this qualitative assessment is first learned across time by nurses’ comparisons of the qualities of touch and states of many patients’ actual veins. Other examples of perceptual (non-conceptual) learning are situations where clinicians begin to recognize when the escalation of patient anger is likely to move to violence; or the patient is now less stable when standing or walking than earlier. (Dreyfus, S.E., 2014; Benner, 2021).
Sharpening students’ skills and astuteness in comparing whole clinical situations increases their noticing capacity and the development of a sense of salience in actual clinical situations. While all nurses must start with textbook lists of signs and symptoms, it is only through seeing them presented live in real clinical situations that nurses can most effectively identify them in their nuanced presentations. The ability to use real-world experience as the basis for interpreting clinical situations marks the qualitative leap to the proficient stage in the Dreyfus Model of Skill Acquisition (Benner, 2021; Dreyfus 2017).
Teaching students to value only application of formal concepts to learn clinical reasoning about particular patients is misleading and pedagogically unsound. It overlooks non-conceptual and perceptual learning occurring in actual clinical situations, as well as what can be learned directly from past whole clinical cases. As Joseph Dunne (1997, 378-380) astutely points out:
A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any junction only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners (Dunne, 1997, pp. 378-380).
In a study of nurses with twenty or more years of practice, but who were not considered to be expert clinicians by their colleagues (Rubin, J. 2009) Jane Rubin found that these nurses couched their thinking in terms of “cause and effect,” had little narrative memory or description of their clinical experiences, and made few clear qualitative distinctions about patients. These nurses did not develop a self-improving practice with notions of good and qualitative distinctions embedded in their practice (MacIntyre, 1981). Jane Rubin’s conclusion was that these nurses had internalized a vision of their practice as a form of scientific problem-solving and had failed to develop a narrative of experiential learning from their practice over time. Their lack of engagement in the nuances of patient care, evidenced in their poor narrative memory of individual cases over time, result in the inability to make nuanced qualitative distinctions that expert nurses are able to make.
Another type of non-conceptual learning is the relational skills of engagement with patients and their situations. In our research (Benner, Hooper-Kyriakidis, 2011), we have learned that without good skills of engagement, nurses do not become experts as evaluated by the Dreyfus & Dreyfus Model of Skill-Acquisition (1988; Benner, 2021; Benner, 2001). Relational skills of engagement with patients are essential to learning directly from clinical experience. Disengagement causes nurses to close off much of the information that they would learn communicating with patients and much of what they would notice and learn from being attentive and engaged with the patient’s situation related to their illness (Benner, Tanner, Chesla, 2009; Benner Kyriakidis, Stannard, 2010).
Pedagogical Strategies That Foster Experiential Learning from Practice
Using Student Clinical Narratives to Facilitate and Enhance Experiential Learning:
It is a well-established pedagogical strategy to have students verbally share within their clinical practice group what they have learned directly from practice. Unfortunately, nurse educators are typically more focused on having students relate what they have learned from practice to relevant theories and science. This unintentionally gives the impression that nothing new or insightful has been gained directly from practice that requires noticing and articulating. However, after studying students’ clinical nursing narratives, I can attest to still learning something new or gaining a more nuanced understanding of nursing practice from listening to students and nurses’ clinical narratives. For example, one year in a Master’s level class, students presented narratives with eleven distinct meanings, with practical examples of what they all called “Patient Advocacy.” For example, when we highlighted the meanings in each of the Patient Advocacy narratives, we found examples such as “Giving the silent patient their voice; Preventing exhausting scheduling of diagnostic tests; Running defense for a patient whose different physicians had ordered conflicting and incompatible therapies; Discovering dangerous drug interactions among the patients’ medications; and “following the body’s lead.” The richness of the varying understandings of “patient advocacy” would have been missed without the specific accounts of patient advocacy in particular clinical situations. The general theoretical term Patient Advocacy hides the range of actual kinds of patient advocacy and the qualitative distinctions exemplified above.
Can you describe and compare your experiential learning in this clinical situation with experiential learning from a past contrasting or similar clinical situation?
The goal of this pedagogical strategy is to help students develop continuity and connections between their clinical experiential learning. The student may give an example of making a mistake in a past clinical situation that they avoided in this situation. They may describe surprises or unexpected patient responses in the clinical situation, due to expectations that they developed from past clinical experiential learning. Then the experiential learning from surprises or failed expectations becomes an exploration of the nature and cause of the surprises and can produce a richer understanding of the current clinical situation. Helping students develop a deliberate exploration of their experiential learning across time can enrich their understanding of their own learning across time.
Learning From a Clinical Concept-Focused Clinical Practicum.
Instead of total patient care, in a concept-focused practicum, students’ clinical assignments focus on complex clinical concepts and phenomena. In concept-focused clinical practice, particularly complex clinical phenomena such as fluid and electrolyte balance is assigned by giving students several patients with fluid and electrolyte imbalances. The students carefully study the patients’ charts, compare cases, and then present their findings to their clinical classmates. Each student is expected to do a comprehensive study of the patient’s fluid and electrolyte status from studying patients’ charts, and direct patient examination. Such a focused clinical syndrome or issue enriches the student’s situated clinical reasoning and situated cognition. The students examine the variations and particularities of the broad general concept of fluid and electrolyte imbalance through studying multiple patients. This clinically-focused study requires higher-order thinking and examining the particular in relation to the general. The focus is not on applying or merely explaining relevant concepts but gaining a deep-situated understanding of the multiple causes and strategies to manage fluid and electrolyte imbalances. Students gain a better understanding of both causes and management of fluid and electrolyte imbalances in their patient population. Variations and particularities of how formal concepts (e.g., fluid and electrolyte balance in hospitalized children) show up and are understood and managed in particular patients with distinct illness conditions. This kind of in-depth exploration with multiple patients can develop deeper learning especially when the experiential learning of all becomes available in a highly interactive learning community.
Learning from Errors and Failures.
Learning from failure (Eyler, 2018) is an essential part of all learning, but particularly important in health care where the stakes are so high. We found in the Carnegie Study (Benner, Sutphen, Leonard-Kahn, & Day (2009) that students readily shared their mistakes in practice to gain insight and prevent their classmates from making a similar error. The debriefings on errors were gripping and offered support and corrective responses related to the causes of the errors. Teachers usually met with the student prior to the debriefing, to find out whether the student felt too vulnerable or exposed. In all the situations we observed, there was a culture of safety that had been developed that made it possible for the students to share and reflect on the causes and ways to prevent similar errors in the future. Students often indicated that they would not want their classmates to make the same mistake or fail to recognize another similar clinical situation. This kind of response affirms the tradition of an ethic of a self-improving practice (MacIntyre, 1981) and taking responsibility for one’s own errors—helping fellow nurses improve their practice. Kerdeman (2004) calls this “being brought up short in practice” which is an essential part of experiential learning and consciousness-raising in any learning arena. Failure, of course, is never the learner’s goal, but as Eyler (2018) states, learning from failure creates one of the most powerful learning opportunities. Where the stakes of making errors are high, as they are in nursing and medicine, it is a moral mandate to learn from one’s errors and to make that learning available to other clinicians. All professional practitioners share this kind of socially linked responsibility for improving safety and quality in practice. Learning from failure is central in a self-improving practice. Such learning is “formative” in developing a professional identity that admits the risks and inevitability of making errors, even while trying to avoid them. In response to “being brought up short,” students can develop new skills, character strengths and habits, especially in a safe, supportive engaged learning environment. Such experiential learning is the hallmark of the third Universal Apprenticeship in Practice Disciplines: “Ethical Comportment and Formation (Benner et al., 2009).
Highlighting and Enhancing Experiential Learning Through Reflection:
Here is an example of a clinical observation and response sheet designed to help students reflect on their experiential learning. Notice how these questions require students to articulate their clinical reasoning and concerns in an unfolding clinical situation:
- Please give a narrative account (story form) in first-person, from your understanding and perspectives, complete with concerns and questions about caring for your patient today. Please describe the patient’s illness experience and trajectory as you understand it.
- What were the top priorities for your caregiving and clinical reasoning in caring for this patient and family?
- What did you learn from caring for this patient and family?
- What are any unanswered questions that you might have?
- How would you improve the care you gave this patient today if you had the opportunity?
- What questions and insights will you carry forward, based on what you learned from caring for this patient?
Such narrative reflection helps the student develop an expectation and a habit of learning from practice. Faculty and other students’ questions that demonstrate curiosity and attentiveness to details of the narrative of clinical learning can enhance clinical imagination, understanding, and development of descriptive language for what the student learns. It connects their learning with past clinical learning while also reflecting on possible expectations for future practice.
By actively listening to the students’ narrative account of their clinical experience, faculty can open up taken-for-granted, hidden background and unarticulated aspects of the student’s clinical reasoning. Such inquiry and reflection can enhance the student’s clinical imagination and curiosity. Often students are so focused on their clinical plans and treatment goals for the patient, that they miss finding out about what the patient’s concerns and questions are. Asking questions about the student’s clinical reasoning and concerns can shift the student’s focus to one of seeking to understand their patients’ experiences and needs.
Through questioning, faculty can help the student name any silence or aspects of the situation not clarified in the narrative. Helping the student articulate any silences, puzzles or concerns expands their understanding and clinical imagination and may even provide them with new kinds of questions to ask patients and their families.
Through insightful questions faculty can assist the student in understanding the patient’s story of their illness. Patients and family members may have understandings of the illness that influences what they expect their recovery or illness trajectory might be in the future. For example, patients who have a stroke sometimes think that the “falling down” associated with their stroke was the cause of the stroke (Doolittle, N. 1990). Medical anthropologists term patients/families’ understanding of an illness and its causes, “informal models of an illness” ( Kleinman, A.1988).
Open-ended questions about patients’ informal models of their illness call for the student to be curious and attentive to the patient’s concerns and experience. These questions can also reveal confusion on the part of the patient about their illness and treatment. A better understanding of the patient/family concerns can enhance situated coaching of the patient/family about an illness trajectory and what they expect in terms of what kind of care will be required before and after discharge.
How will you Improve on the Patient-Care You Gave Today, Tomorrow?
This question was asked in the majority of clinical debriefings we observed in the Carnegie National Study of Nursing Education (Benner, et al., 2009). It is a great example encouraging students to develop a self-improving practice. This question stimulates reflection on how to make improvements in sequencing, scheduling, and/or carrying out therapies ordered for the patient. It also gives the student a chance to reflect on what they may have missed in their care for the patient. This line of questioning encourages formation of the student nurse’s understanding of his or her practice and encourages the expectation of ongoing improvement of practice.
Learning directly from practice is hampered by outdated understandings of how the mind works and how people learn. The pervasive Cartesian understanding of learning and perception depending on formal concepts, lodged in the mind hinders facilitating experiential learning and understanding practice as a way of knowing and knowledge development. The solution to this is to teach students to reflect and articulate what they are learning in practice so they can relate the generalized theories they learn as novices to real clinical manifestations in all their particularities and nuances.
Developing a self-improving practice begins in nursing school. Teaching nursing students to learn through reflecting on their clinical narratives makes it possible for them to uncover emerging knowledge and unanswered questions. Faculty can help students articulate their experiential learning creating continuity between past and current clinical situations (Dewey, 1969). This can create a habit of lifelong learning in practice and pave the way for their development of expertise.
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