Needed: Clinical Leaders for Excellent Nursing Practice

Eloise Balasco Cathcart. MSN, RN, FAAN

Director of Education, EducatingNurses.com Patricia Benner, MSN, R.N. Ph.D., FAAN.

Executive Director, EducatingNurses.com 

“Most acute care units are now staffed with less seasoned nurses. Many young nurses don’t experience that awe when they watch a mentor intuitively grasp that the patient is crashing, even before any data exists. I remember how humbling it was for me to watch my preceptor quickly take action when I never even realized there was a problem. If you don’t see that level of expert practice, it is probably not surprising that many newer nurses think they are performing at a higher level than they may be.”  (Sherman, 2024)

The nurse engaged in the direct care of patients and families is living out the core work of the profession and the mission critical work of the healthcare system and as such, is the most important nurse in any organizational design. Those of us who are nurse educators or nurse executives also have consequential roles in meeting the ethical mandate of the profession.  Nursing faculty have numerous opportunities to teach and mold pre-licensure and graduate students for eventual expertise in clinical and advanced practice roles. Nurse executives have profound responsibilities to create and lead care environments where nurses can perform their best work and continuously expand, refine, and strengthen their practice. All of us, regardless of the role we have, must share the commitment to achieve excellence in practice for the profession to survive and thrive.

In 2021, the nursing workforce experienced the most dramatic exodus of workers since annual workforce data collection began in 1982 (Buerhaus and Hayes, 2024) and many of those who left were expert clinical nurses. Patricia Benner’s research has demonstrated that the practice itself is a way of knowing, so it follows that the development of expertise requires the new nurse “to learn from the practice as well as learn how to learn from the practice” (Benner, P. and Benner, J. 2024). Staff nurses who have evolved from mastering the tasks of patient care to living out the highly skilled know-how that is the essence of expert nursing practice and who are recognized as clinical leaders are instrumental to that process. By working side by side with these clinical nurse experts, new-to-practice nurses learn how to engage in astute clinical reasoning in patients’ rapidly changing clinical conditions and to master the skill required to perform complex interventions to keep patients safe when margins for error are slim or non-existent.  They also learn how to relate to patients and families in ways that respect and support their dignity and concerns in the midst of changes in the patient’s clinical condition.

But what happens to new-to-practice nurses when there are not enough clinical experts to guide them into the chaotic world of clinical practice?

Expert clinical practice:

Expert clinical nurses know more than what to do; they know how and when to do what is needed.  The practical wisdom of the expert nurse may not be articulated well in theory or explained by science but can be demonstrated by experts who relinquish a reliance on rules and maxims dictating what one should do.  Expert nurses respond instead with experience based wisdom about particular clinical situations using the clinical and moral skills learned from past similar and contrasting clinical situations (Benner, Hooper-Kyriakidis, Stannard, 2011).

In addition to mastering the skilled know-how of the practice, expert clinical nurses have undergone the personal transformation necessary to build the clinical judgment, clinical imagination and ethical comportment which serve as their most important leadership tools.  They are clear about their purpose and have the courage to live it; their expert clinical know-how enables them to skillfully navigate the complex and sometimes chaotic world of clinical practice (Craig and Snook, 2014).  Clinical experts have mastered the relational skills which allow them to build trust and sustain relationships with a myriad of people in the practice environment. Recognizing that each person comes to the workplace with different notions of how to work with others, clinical leaders embrace and manage conflict with respect for the other’s perspective and values, facilitating a collaboration which allows patient care agendas to move forward (Cathcart, 2014).   Clinical experts have developed the character that enables them to live out the clinical and ethical demands of engagement and responsibility in a complex clinical practice (Benner, Tanner & Chesla, 2009; Sullivan and Rosin, 2008).

Traditionally, new-to-practice nurses have turned to expert clinical leaders working alongside them in patient care units when they have been uncertain or flummoxed by their patient’s situation and need confirmation of their own clinical judgment (Benner, Tanner, Chesla, 2009).  Clinical leaders are the nurses who are asked to “come and take a look at my patient – I’m not sure what’s happening or what to do”.  They are clinical leaders within the health care team who consistently drive solutions rather than wallow in problems or dysfunction. The ethical mandate to ensure that the right, timely and good thing is done for patients is clear to them, so they are generous and respectful in sharing their knowledge and skill with less experienced colleagues and maintain a watchful eye on patients assigned to less experienced nurses (Cathcart and Greenspan, 2012).

New-to-practice nurses need clinical nurse experts to teach them not only the “what” and “why” of the practice but also the “how” and “when,” which includes recognizing early warnings of critical changes in patients’ clinical condition.  Clinical experts help new nurses safely deliver instantaneous therapies in response to patients’ physiological changes and to instantiate what the best in nursing practice can be by demonstrating clinical and moral imagination in complex clinical situations.  The ability of the new nurse to grasp what matters and what is relevant to attend to in clinical situations can only be learned experientially.  Learning this skilled know-how and clinical judgment requires situated coaching by expert practitioners who have a well-developed sense of salience about what is most urgent with high clinical priority and what is of lesser urgency.

Current Challenges in Developing Expert Practice:

Long-standing concerns of practicing nurses, such as insufficient staffing levels, work designs and staffing that do not match the actual clinical performance demands of nurses, not feeling listened to or supported at work, the desire for higher pay and the emotional toll of nursing work were exacerbated by the COVID-19 pandemic, and most healthcare settings are struggling to accommodate the unparalleled rapid workforce disruptions and acute staffing shortages experienced since then (Martin, et al, 2023; Pappas,2024).  The resultant departure of highly experienced expert nurses has caused some hospitals to report that 50% of their nursing staff is comprised of new-to -practice nurses. Even specialty hospitals which previously hired only experienced nurses now report that 40% of their staff have three or fewer years of experience.  It is not unusual to hear that the most experienced nurse in a patient care unit has been practicing for six months.

It is often necessary to assign new graduate nurses to preceptors who themselves are hovering at the advanced beginner or competent stage of practice development. These preceptors often lack sufficient clinical experience and are still learning how to cope with the responsibility that comes with nursing practice. They lack the authoritative knowledge, skilled ethical comportment, and clinical imagination of the expert nurse, and practice on these patient care units may feel “flat,” or may be ridden with high rates of “failure to rescue” (Clarke and Aiken, 2003).  One nurse leader observed that there is “a lack of soul” in the practice; that how nurses connect with patients to offer comfort and connection, humanity, dignity, and reassurance into to their patients’ worlds of illness and treatment is missing.

New-to-practice nurses often enter the workplace with the aim of making strong connections with patients and coworkers, but they often feel overburdened by the simultaneous need to master multiple procedures required in complex patient care.  The unrelenting need to complete a myriad of non-clinical tasks diminishes their time with patients. The pandemic prevented them as students from caring for the usual number of actual patients and thereby limiting their ability to learn the subtle and complex skills of involvement. Simulation was substituted but even the most well-planned simulations cannot capture nuanced skills of involvement or perceptual grasp of clinical changes in patients across time.  Consequently, these new nurses are often at a loss to know how to relate to seriously ill patients or how to recognize early changes in patients’ clinical condition. The responsibility and fast pace of the practice may feel overwhelming to new nurses when expert clinical nurses are not immediately available to offer guidance about how to administer rapid treatment, how to make a case to a provider for urgently needed changes to a patient’s treatment orders or offer perspective about a medication error.  New nurses rely on “rapid response teams” when patients’ clinical conditions worsen, but the judgment about when to institute these emergency measures and the feeling of incompetence a new nurse may have when moved aside by others who have come to rescue their patient may painfully remind the new graduate of their lack of experience-based knowledge and skilled know-how. Not having experience-based judgment and a sense of salience which allow meaningful situations to stand out as more or less important make the advanced beginner period of learning hazardous and exhausting (Benner, Tanner, Chesla, 2009).  The disillusionment, stress and job dissatisfaction which often ensue for new nurses are reflected in high rates of turnover or the decision to leave the nursing profession (Song and Kim, 2023).

The alertness, awareness and capabilities of front-line staff are essential for safe patient care and contribute to organizational viability and reliability in complex high-risk situations. But when the nursing staff is primarily composed of new-to-practice nurses who lack experience-based clinical reasoning skills, safe and effective, patient care suffers and the incidence of “failure to rescue” rises (Clarke and Aiken, 2003).  The fact that inexperienced nurses outnumber those with in-depth clinical experience and expertise is a critical and rightful concern of all who are responsible for insuring quality and safety in healthcare settings (Weick and Sutcliffe, 2015; Wears and Sutcliffe, 2020).

Two Ways to Intervene:

There may be an expectation that new graduate nurses should be fully functional immediately upon entering the workforce, but no practitioner can be beyond their level of clinical experience.  The practice of advanced beginners is directed by “orders”, rules, procedures, protocols, and guidelines.  Advanced beginners miss subtle cues of a patient’s rapidly changing situations as they struggle to match the patient’s actual presentation with textbook descriptions of expected signs and symptoms (Benner, Tanner, Chesla, 2009). They are easily overwhelmed by the sense of multiple urgent competing tasks that they find impossible to complete efficiently and carry an exaggerated sense of responsibility.

Two strategies which may help prepare nursing students to be more practice-ready and then to facilitate the practice development of advanced beginners merit consideration, especially when expert clinical leaders are scarce.

The first recommendation is to ensure that nursing students are practice ready. The Carnegie National Study of Nursing Education has described three professional apprenticeships upon which pre-licensure nursing education programs should be built. These apprenticeships reflect the embodied skilled knowledge that must be integrated, modeled, or demonstrated by the practitioner-teacher and include:

  • The cognitive apprenticeship – the intellectual training that provides the academic and theoretical knowledge base required for nursing practice and that teaches the student how to think in ways important to the profession;
  • The practice apprenticeship – clinical reasoning and skilled know-how that teaches students how to think and solve problems in actual clinical situations. Students should learn how to reason across time through changes in the patient or changes in the clinician’s understanding of the patient’s conditions and concerns;
  • The formation and ethical comportment apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the student is introduced to having an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes (Benner, Sutphen, Leonard, Day, 2010).

Teaching for practice readiness requires a shift from using superficial descriptive language about nursing practice that delineates decontextualized “knowing that and about” to language that describes situated thinking-in-action across transitions in patients’ clinical condition (Benner, Hooper-Kyriakidis, & Stannard, 2011). Such narrative descriptions (Taylor, 2016) illustrate clinical reasoning about the particular case through transitions in the patient’s clinical condition and help students learn the “how and when and why” of excellent practice.  The goal of teaching nursing practice is for the student to learn knowledge acquisition and knowledge use in particular clinical situations and how to live out the skilled know-how that is the essence of expert nursing practice.  Practice is not static and requires more than mere application of generalized knowledge to unique clinical situations.  Rather, practice is dynamic, requiring that the nurse be able to accurately read the patient’s situation, learn how to reason across transitions in patients’ critical, rapidly changing clinical conditions and institute responses that are required. Using unfolding case studies based on an actual patient situation and language that describes clinical reasoning, situated thinking in action, and the ability to triage and prioritize the patient’s most urgent care needs are effective pedagogies to achieve this goal and best help newly graduated nurses to be practice ready (Chan, G., & Burns E.M. (2021).  Rather than emphasizing “snapshot” linear models of scientific reasoning such as the Nursing Process, teachers should model situated thinking-in-action and clinical reasoning across transitions in patient’s clinical conditions (Benner, Sutphen, Leonard-Kahn, & Day, 2010; Benner, Hooper-Kyriakidis, Stannard, 2011; Benner, P., 2022)). Carefully guided clinical practicum time should be maximized, and simulation should be an enhancement rather than a replacement for actual time given to learning directly from practice. Video exemplars of expert teaching strategies along with accompanying in-depth scholarly papers can be found on this website; the reader is particularly directed to Urgent Need: Teaching Strategies that Promote Lifelong Experiential Learning (Benner, P; September 26, 2023) and Enriching and Extending Experiential Learning from Clinical Practice: Why Learning from Practice is Indispensable (Benner, P and Benner J; January 9, 2024).

The second imperative is that chief nurse executives build narrative cultures that promote the collection and dispersing of clinical narratives for two reasons: first, to make widely visible and accessible expert nursing practice that is within the health care systems they lead; and, secondly, to provide administrative structures within which new nurses can enhance experiential learning by sharing, discussing, and comparing their clinical learning experiences with each other and with expert colleagues.

A major responsibility of the Chief Nurse Executive is to interpret for the healthcare system the ways in which nurses contribute to the mission, goals, and financial viability of the enterprise. But too often, nurse executives rely on decontextualized accounts of explicit knowledge and data that can be codified, measured, and generalized to make decisions, manage risk, and promote change. Such explicit knowledge and data assume a world independent of context in which answers are universal and predictive and where tacit skilled know-how and clinical judgments about patients across time are left out or are thought to be of lesser value (Nonaka and Takeuchi, 2011; Cathcart and Greenspan, 2013). The evaluation of quality, safety, and productivity achieved primarily through the application of metrics is rightfully an organizational priority, but the caring practices and clinical reasoning that constitute the foundation of safe and effective nursing practice cannot be captured by metrics alone.  The danger in attempting to do so is that the countable and measurable tasks and procedures performed by the nurse are misconstrued for the totality of nursing practice. The life-saving contributions of the nurse, such as clinical reasoning and managing rapidly changing clinical situations are undescribed and unrecognized (Cathcart, 2008).  

Because the ways in which nurses prevent and mitigate financial risk are not widely described, accounted for and discussed, nursing is seen as a cost burden rather than an asset in health care accounting practices (Pappas, 2024). Expert clinical nurses can see early changes in patients’ clinical conditions, discern what requires attention and what is inconsequential, and institute therapies which often lead to good patient outcomes rather than deleterious consequences, so expert practice is highly efficient and effective (Benner, Hooper-Kyriakidis, Stannard, 2011).  But unless the expert nurse’s account of the situation is heard and understood, this practice remains covered up and marginalized, giving rise to the notion that “a nurse is a nurse”.  The data-driven and cost-driven American health system, will not improve patient outcomes or reduce “failures to rescue patients” without a clear understanding of the value added by adequate expert nursing care (Pappas, 2024).

Because practice is learned in dialogue with actual clinical situations as they unfold, new-to-practice nurses need to hear narratives of expert practice to develop clinical know-how and situated thinking-in-action (Benner, Hooper-Kyriakidis & Stannard, 2011).  Narrative comes closer than any other approach to describing actual nursing practice, and narrative pedagogy comes closest to demonstrating the experiential learning required for good clinical practice development (Taylor, 2016).   Reflection and dialogue on actual clinical practice situations set up the new nurse’s readiness for the continuous learning acquired directly from clinical experience and foster changes in the nurse’s practice which are essential to achieving expertise.  Experiential learning comes from having one’s preconceived notions turned around in particular clinical situations so that one’s clinical perception and understanding are enriched (Benner, Hooper-Kyriakidis, Stannard, 2011).  Articulation of practice through narrative allows for interpretation of the clinical nurse-author’s story with emphasis on their perceptual grasp and reading of the clinical situation, the clinical reasoning, judgment, and their skilled know-how embedded in the actual situation, along with the nurse’s concerns, intents, and the patient’s outcomes. All of these areas of expert nursing practice require narrative accounts and as Taylor (2016) argues, narratives are substitutable for this kind of engaged and situated knowledge.

Good leaders look to nurses engaged in direct patient care for answers to challenging patient care situations, so collecting exemplars of best practice will provide a broad understanding of practice on the front lines and provide opportunities to reimagine and restructure care delivery models to insure safe and effective nursing care. Utilizing first-person accounts of actual practice situations that are meaningful to front-line expert clinical nurses provides younger nurses with vivid examples of clinical imagination and ethical comportment of expert nurses (Benner, in press).  Read Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/Families. (Benner, P.; October 12, 2022) 

Intentionally creating opportunities for new nurses to speak about their experiences validates the value and worth of nursing as it is actually practiced rather than how it is described in textbooks.  Reflecting on their practice keeps new nurses connected to the good in the practice and shows its value to the organization – factors which have been closely linked to retention of today’s younger workforce. Giving voice to the work of the new clinical nurse and to the practice of their expert colleagues is an effective way for nurse leaders and colleagues to recognize them and can demonstrate more meaningful acknowledgement than the often-provided pizza lunches.

The tendency to restrict “knowledge” to what can be verbalized or documented contributes to the failure to realize how much embodied skilled know-how and knowledge exist in nurses’ astute clinical reasoning and caring practices. One nurse in a large urban cancer center said this about her experience of narrative writing: “I’m often asked what exactly it is that I do all day. It is difficult to explain what is involved in preparing for clinic and taking care of post-op patients in an office. I often settle with trivializing my day-to-day work. But my experience described in this narrative highlights two of the things that I love about my position. First is the opportunity to build durable and strong relationships with patients over time that themselves became a form of treatment and healing. In a way, we become experts in our patients, understanding what’s normal for them and picking up on nuances that might otherwise be missed.  Second is the opportunity and encouragement to continually seek out knowledge and expertise and utilize this daily. Knowing the pathophysiology of disease and its management and knowing my patients allow my clinical hunches to often pay off for them.”

References:

Benner, P. (In Press) “Studying Expert Ethical Comportment and Preserving the Ethics of Care and Responsibility Embedded in Expert Nursing Practice.”  M. Fowler, (Ed.) Nursing Ethics, 1800’s to the Present: An Archeology of Lost Wisdom and Identity. New York: Routledge In Press ISBN 9781032200729.

Benner, P. and Benner, J., (July 16, 2023). “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” EducatingNurses.com

Benner, P., Hooper-Kyriakidis, P, and Stannard, D.  (2011). Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach. 2nd Ed. New York: Springer Publishing Co.

Benner, P., Sutphen, M., Leonard, V., and Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass.

Benner, P., Tanner, C., and Chesla, K. (2009). Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. 2nd Ed. New York: Springer Publishing Co.

Buerhaus, P. and Hayes, R. (2024). Leveraging nursing strengths: listening to nursing needs: A keynote paper from the 2022 Emory University Business Case for Nursing Summit.https://doi.org/10.1016/j.outlook.2023.101993.

Cathcart, E. (2008). The Role of the Chief Nursing Officer in Leading the Practice: Lessons from the Benner Tradition. Nursing Administration Quarterly. 32(2). 87-91.

Cathcart, E.B, and Greenspan, M. (2012). A new window into nurse manager development: Teaching for the practice. Journal of Nursing Administration. 42(12). 557-561.

Cathcart, E. (2014). Relational work: At the core of Leadership. Nursing Management. 45(3). 44-46.

Chan, G. K, & Burns E.M. (2021) “Quantifying and Remediating the New Graduate Nurse Resident Academic-Practice Gap Using Online Patient Simulation. Journal of Continuing Nursing Education. Vol.52 (5) 240-249).

Clarke. S. and Aiken, L. (2003). Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing. 103(1). 42-47.

Craig, N. and Snook, S. (2014). From purpose to impact: Figure out your passion and put it to work. Harvard Business Review.92(5). 105-111.

Martin B, Kaminski-Orturk, N, O’Hara C, Smiley R. (2023). Examining the impact of the COVID-19 pandemic on burnout and stress among US nurses. Journal of Nursing Regulation.14(1): 4-12.

Nonaka, I. and Takeuchi, H. (2011). The wise leader. Harvard Business Review. 89(3). 58-67.

Pappas, S., et al. (2024). Maximizing the potential value of the nursing workforce. Nursing Outlook. https://doi.org/10.10.16/j.outlook.2023.102016.

Sherman, R. (2024). Managing defensive staff. January 29. Emergingnurseleader,com.

Song, Y. and Kim, J. (2023). New graduate nurses’ competencies, organizational socialization, and turnover intention. Journal of Nursing Administration. 53(12). 675-682.

Sullivan. W. and Rosin, M. (2008). A New Agenda for Higher Education: Shaping a Life of the Mind for Practice. Stanford, CA: The Carnegie Foundation for the Advancement of Teaching.

Taylor, C.  (2016) The Language Animal. The Full Shape of the Human Linguistic Capacity.  Cambridge Mass., Harvard University Press Belknap Imprint.

Wears, R. and Sutcliffe. K. (2020). Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. New York: Oxford University Press.

Weick, K. and Sutcliffe, K. (2015). Managing the Unexpected: Sustained Performance in a Complex World. 3rd Ed. Hoboken, NJ: John Wiley and Sons.

Nurse with patient in hospital bed

Enriching and Extending Experiential Learning from Clinical Practice, Why Learning from Practice is Indispensable

January  2024

Patricia Benner, R.N., Ph.D., FAAN
John Benner, Doctoral Candidate University of Washington, Seattle, WA

The primary goal of clinical assignments is for students to experientially learn directly from practice what cannot be learned any other way or from any other sources. This is as much about learning how to learn from clinical experience as it is in gaining insights from particular experiences. Through skillful coaching and questioning, we can give students the habits of thought and articulation of experiential learning that will lead them to develop into expert nurses over the course of their career through ongoing and cumulative and connected experiential learning.

It is misleading to imagine that experiential learning in clinical assignments is merely learning to “apply” science and theory to clinical situations without making space for ways clinical experiences create and refine theories and create the possibility of gaining nursing expertise. We must use clinical assignments to teach nurses to create a dialogue in their practice between relevant theories, scientific knowledge and the particularites of context and the patient’s changing clinical conditions. This is what makes Alasdair MacIntyre’s definition of the nature of a practice so prescient when he claims that ‘A practice is a socially embedded form of knowledge, that is self-improving.’ It is also why Albert Borgmann (2003) points out that theory depends on practice as a source for theory development while practice as a socially-embedded form of knowledge is self-sustaining. As Joseph Dunne notes:

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)

Charles Taylor (1995; 2016) points out that practical reasoning differs from speculative reasoning which is contemplative, detached, and certain. By contrast, practical reasoning is engaged, involved, active, depends on the specifics of the situation and occurs in transitions across time in the situation.  Hans Gorge Gadamer weighs in on this discussion about the nature of practice by observing:

 “Theory has become a notion instrumental to the investigation of truth and the garnering of new pieces of knowledge. That is the basic situation in terms of which our question, What is practice?, is first motivated. But we are no longer aware of this, because in starting from  the modern notion of science when we talk about practice, we have been forced in the direction of application of science. (p.69)

“But the knowledge that gives direction to action is essentially called for by concrete situations in which we are to choose the thing to be done; and no learned and mastered technique can spare us from the task of deliberation and decision. As a result, the practical science directed toward this practical knowledge is neither theoretical science in the style of mathematics, nor expert know-how in the sense of a knowledgeable mastery of operational procedures (poiesis) but a unique sort of science. It must arise from practice itself, and, with all the typical generalizations that it brings to explicit consciousness, be related back to practice.  In fact that constitutes the specific character of Aristotelian ethics and politics.  p. 92   

Practice is more than “application of science,” as Gadamer points out. Clinical reasoning is a form of practical reasoning. Clinical reasoning seeks to solve evolving clinical problems with most clinical situations requiring new experiential learning for the novice, advanced beginner and competent and in novel situations, for proficient and expert levels of skill acquisition. Safe experiential learning requires situated coaching, often in the form of demonstration, and always in the form or articulating, clarifying and confirming what clinicians think they have learned in a clinical situation.

Learning any practice discipline requires learning practical reasoning which goes beyond “critical thinking” and scientific reasoning as Sullivan and Rosin point out:

…Practical reason, once central to the educational tradition that stemmed from the rhetorical and humanistic studies of the European Renaissance, has been all but eclipsed by a focus on utility, on the one side, and on analytical reasoning, on the other…For practical reason, the focus is on thinking that is oriented toward decision and action. Because of this, we take exception to the way critical thinking is currently understood and promoted.
…Teaching for practical reasoning is concerned with the formation of a particular kind of person—one who is disposed toward questioning and criticizing for the sake of more informed and responsible engagement. Such persons use critique in order to act responsibly, as it is the common search for ways to realize valuable purposes and ideals that guides their reasoning. Practical reason grounds the academy’s great achievement—critical rationality—in human purposes that are wider and deeper than criticism…In the end, practical reason values embodied responsibility as the resourceful blending of critical intelligence and moral commitment (Sullivan & Rosin, p. xvi, 2008).

Preparing students to exclusively pursue applying theory to practice, at the expense of experientially learning new knowledge  directly from clinical practice through solving and learning from practical clinical problems have been the topics of two prior articles. In this article we will offer strategies for enriching and extending experiential learning based upon learning directly from caring for particular patients as their clinical condition changes across time. This post builds on the EducatingNurses.com article posted on July 16, 2023: “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” We began that article with the assertation that: “Educators in all practice disciplines have erred on the side of thinking that all knowledge is just a matter of “applying” what is conceptually and technically already known… a rational-calculation approach…”. We went on to explain:

 “Theories often elucidate or enhance understanding in particular clinical situations, but it is a mistake to imagine that the direction of influence is always from theory that is applied or used in practice, rather than expecting to learn directly from practice. [Such a stance] naively [assumes] that there are, in existence, theoretical understandings or evidence-based-practices fitted to all practical situations, regardless of their context and clinical particularitiesIn nursing education, “putting theory into practice” is over-emphasized. Using practice as a source of new knowledge insights that may dispute or disconfirm a theory, or create revisions and enrichment of theories, is less often pointed out and [little effort is made to articulate new knowledge discovered in practice.]

The authors followed up on the July 16th, 2023 article with the September 26th article entitled: “Urgent Need for Lifelong Experiential Learning,” noting:

A dominant rational-technical view presents practice as a mere application of techniques, scientific knowledge, theories, formal concepts and guidelines to practice situations [has severe limitations in capturing actual knowledge embedded in nursing practice] (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 as accurately measuring a blood pressure]. 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 [through changes in their clinical condition].

In this follow-up article, we present strategies for enriching and extending students’ experiential learning that can be expanded, adapted by faculty and students in ways useful for all clinical practice experiential learning.

Clinical Preparation for Care of Particular Patients

We recommend that students, when possible, be consecutively assigned to patients with similar and contrasting clinical conditions to foster comparisons and experiential learning. Students can help with this by identifying similar and comparable patients required for future assignments. The student’s comparisons between similar and contrasting cases allow for a deeper understanding of how the cases are similar and dissimilar, in ways not possible if the clinical conditions of past and current patients are un-related and not comparable. Past and present comparisons set up a natural dialogue between the particularities of each case in relation to the general, making it possible for the student to engage in a dialogue between particular cases, and the scientific generalizations generated by patient population statistics. This dialogue between the particular and the general is essential to good clinical practice and for experientially learning from practice.

Advanced preparation is crucial to experiential learning from practice. Studying the patient’s chart and studying the relevant clinical issues related to a particular patient’s clinical condition prior to working with the assigned patients is a key learning opportunity in itself. Coaching on what to look for, or what should stand out in a chart or clinical presentation of particular patients, provide the opportunity to focus the novice’s attention on what questions to ask, and what clinical information is relevant in the particular case.

By creating clinical assignments with comparable cases, narrative comparisons and contrasts between cases can be made by students and faculty in ways that reveal new insights and clinical understandings generated by each case. Narrative comparisons between particular cases are central to learning to make clinical judgments about a particular case in relation to similar and contrasting cases along with differences between the particular patient and statistical generalizations of the patient population.  Dewey (1969) emphasized the importance of connecting to the particular learning situation and making comparisons with new learning experiences across time. Experiential learning in such comparative judgments is the backbone of developing expertise in clinical reasoning and judgments related to changing clinical conditions in patients along with patient’s responses to interventions.

All clinicians need to experientially learn to create lines of inquiry and dialogue between the clinical facts of a particular patient and knowledge gleaned from generalized population statistics and scientific knowledge about the patient’s clinical condition. The student needs to attend to the patient’s co-morbidities, and particular clinical history. This dialogue between the particular and the general creates an essential habit of thought of making continuous comparisons with past clinical understandings gained from experience and comparisons of the particular case to relevant population statistics and generalizations. This involves more than “applying theory” or “generalized statistics” to a particular case. A habit of thought and practice of making comparisons between relevant past and current cases are essential to creating cumulative, and increasingly nuanced clinical reasoning and judgment. When students learn each clinical situation as an island of isolated facts and events, they often fail to develop such comparative judgments (Rubin, 1996, 2009). When clinical reasoning is taught through the ‘snap shot reasoning,’ such as a linear reasoning approach of the Nursing Process (the scientific reasoning or rational problem-solving process) without planned comparisons between similar and contrasting cases, they often fail to notice essential qualitative distinctions, similarities and variations between past and current cases (Benner, 2022; Taylor 1995). This is why we recommend having the student develop an understanding of the practical, situated basis for clinical reasoning and judgment, which is a science-using form of practical reasoning (Taylor, 2016; 1995; Rubin, 1996, 2009  Benner, 2022). In practical reasoning, the nurse or physician starts by noticing and clarifying the nature of the particular patient’s present clinical condition in relation to their immediate past, as well as their longer clinical history. Clinical reasoning requires situated thinking in action, with constant comparisons between patient’s immediate and prior clinical conditions. Various modes of thinking and problem solving are required for clinical reasoning. For example, often the clinician engages in detective work, thinking back to the immediate past, or “modus operandi” thinking, examining the immediate past for possible clinical causes for the patient’s current clinical condition. When clinical assignments are related to one another, this kind of thinking is more accessible to the novice nurse, because the related, but distinct patient trajectories are at the forefront of the student nurse’s mind for comparison and analysis.

Clinical Care Preparation Guide

We recommend a series of clinical questions for the student to explore and consider when preparing to care and initiating care for a patient, rather than a formal nursing care plan, in order to emphasize the open-endedness, curiosity, and responsiveness to be fostered by the nurse’s lines of inquiry. This is not an exhaustive list! We encourage adding and enlarging on our suggestions:

  1. What is the nature of the patient’s current clinical condition. Is it in a state of rapid change, or relatively stable? What changes might be anticipated in this patient’s clinical condition in the time of your care of the patient?
  2. What are the immediate treatment goals and how are those goals to be accomplished by the patient treatment and management plan?
  3. How has the patient’s clinical condition changed across time?
  4. Upon meeting the patient, and establishing rapport, assess how the patient is currently feeling. Are there any recent changes? Does the patient sense they are feeling better, worse, or “about the same” since admission, since yesterday and earlier in their hospitalization?  What are the patient’s/families’ major concerns about the patient’s condition and their current care?
  5. What are possible risks to the patient’s clinical stability? How might signs and symptoms of these risks show up?
  6. What are the patient’s/families’ understandings of the patient’s illness, and plans for treatment and discharge? Are there any key patient/family questions or misunderstandings of the patient’s clinical condition and treatment?
  7. What kinds of patient/family education might be needed for this patient?
  8. How might this patient’s care and clinical condition compare to  prior patients with similar diagnoses and treatment plan?
  9. Please list any additional questions that you may have about caring for this patient.

Faculty and student can mutually plan to discuss and debrief about the care of each patient, using these clinical preparation guidelines. The student is expected to compare this patient’s care with their past similar and contrasting cases. To enhance experiential learning, students can each share, discuss and compare their learning experiences with each other, becoming an effective learning community, whose aim is to gain experiential learning insights from one another. This is a habit of thought that will enhance life-long learning from future clinicians in practice.

Post-Care Debriefing and Comparisons with Current and Prior Cases

The student is asked to narratively describe in writing their observations, assessments, and any new insights or knowledge gained in caring for this patient. What did they actually do to care for the patient? Candor, and questions about the care of the patient are encouraged. The faculty should meet with their students to debrief directly about the students’ narrative statements, and/or prepare written comments and questions on the written narrative. The student may request a faculty student consult to clarify their understanding and learning from the clinical assignment.

Articulation:  Join with the student in identifying and describing new insights or knowledge experientially gained by the student in caring for this patient. By articulation, we mean: “Giving public-accessible language” to new knowledge, questions, insights gained in caring for this patient in terms of understanding the patient’s clinical condition, treatment, patient’s understanding of their illness, treatment and management plan. Often students have a sense of the situation that they cannot fully express, and asking clarifying questions and for more elaboration on the student’s observations and sense of the situation can better disclose and articulate new knowledge gained experientially is useful. Did the patient/family express specific concerns or questions?  The goal of articulation is to uncover and express knowledge and understandings as they emerge from practice. This is true for existing theories, such as a nurse identifying how attachment bonds are being reinforced or undermined in Neonatal ICU care. Clear articulation of the actual situation and clinical learning are critical for fleshing out poorly articulated and under-examined knowledge, such as getting to know a patient and helping them maintain their sense of personhood in the midst of illness and hospitalization (See Benner, et. al, 2010). Such learning is enriched when well described, articulated, and developed within a clinical learning community.

One of the aims of the student’s narrative account is to better understand both the student’s formal and informal assessments of the patient and family experience and concerns. The students should be instructed that their narrative accounts should include their own observations and taken-for-granted assumptions and changes in those assumptions over the course of caring for patients, as they come to understand more of the patient’s illness and plight. For example, if the student thought that the patient seemed worried or anxious, what made the student think that? Vivid descriptions are clarifying. Questions such as: “What meanings and understandings did you gain about the patient’s statements? Demeanor? Questions? Silence? How did your understanding of the patient and the patient’s situation evolve over time?” or “What were some signals you saw in the patient that alerted you to adjust your care? Questions like these can help uncover taken-for-granted assumptions and meanings in the situation.

Other useful questions for students are:

“What insights did you gain about the most disruptive aspects of the illness on the patient’s lifeworld? What patient statements and patient observations led to your assessment of the impact of this illness on the patient’s lifeworld?”

“Describe your understanding of the patient’s responses to any attempts to educate the patient about their illness, treatment or self-care goals for the patient. If possible, capture patient’s specifically described concerns, and responses to their illness, and patient education information that you gave related to self-care.”

“How would you compare this patient’s and family situation to a patient you have care for in the past with a similar or contrasting clinical condition?”

“Describe key insights, knowledge and questions raised in the care of this patient.  How do your observations and insights compare with your observations of other similar and contrasting patients?”

“Knowing what you understand now about this patient, how would you change your care for this patient, if you could start over from the beginning?”

We suggest that such advanced clinical preparation for patient care, and narrative accounts of patient care experiences that give public language to the student’s learning experiences, observations, insights and questions extending that learning into questions, insights and comparisons with whole comparable or contrasting cases extend experiential learning and make it more visible and memorable. Developing this narrative memory of learning from caring for particular patients is an essential step towards developing cumulative wisdom that leads to expertise in clinical practice.

It is this narrative ability to articulate, give evocative and clear descriptions to observations and insights learned experientially from practice that creates expertise over time. Clinical expertise is exemplified by the ability to notice early warnings and critical changes in patients’ clinical condition, or development of qualitative distinctions, such as the different bluish coloring of the skin related to low blood sugar versus cyanosis, or changes in levels of consciousness (Benner, Hooper-Kyriakidis & Stannard, 2010). Perceptual grasp of subtle clinical changes can only be learned directly from seeing, recognizing, clarifying and confirming such clinical changes and qualitative distinctions directly through observations and situated coaching. Articulating and clarifying experiential learning is facilitated when it is a shared learning experience with a community of learners. Situated coaching about recognizing qualitative distinctions and subtle early changes in patients’ clinical conditions can speed up the student’s learning, preventing costly trial and error learning. Perceptual grasp and the ability to recognize such qualitative distinctions in practice are forms of skilled know-how and must be learned experientially through direct observation, questioning, and situated coaching from others in actual practice. Students can be taught to ask clinical experts questions about how they recognize early changes in the patient, and thus facilitate situated coaching and the solicitation of comparative observations and judgments from expert clinicians. Students can be effectively coached and taught how to facilitate their own experiential clinical learning while encouraging learning about the experiential learning gained by their and nurse colleagues. This will happen only if students and faculty  understand how essential it is to help students discover and articulate knowledge and skilled know-how lodged in their own and classmates’ and  clinical practice and also in expert nursing practice that they observe.

References

Benner, P., (Oct.12, 2023) “Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/Families.” EducatingNurses.com.

Benner P, & Benner, J., (July 16, 2023) “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” EducatingNurses.com.

Benner, P. & Benner J., (Sept. 26,2023) “Urgent Need for Lifelong Experiential Learning,” EducatingNurses.com.

Borgmann, A. (2003) Power Failure. Grand Rapids, MI., Brazos Press.

Dewey, J. (1969) Experience and Education. A Touchstone Book Simon and Schuster.

Dunne, J. (1997) Back To the Rough Ground: “Phronesis” and “Techne” in Modern Philosophy and in Aristotle, Notre Dame Ind., Notre Dame Press.

Gadamer, Hans-Georg (1981) ”What is Practice? ” In:  Reason in an age of science. Translated by Federick G. Lawrence. Cambridge, Mass. The M.I.T. Press.

Rubin, J. (1996; 2009) “Chapter 7 “Impediments to the development of clinical knowledge and ethical judgment in critical care nursing,” pp.171-198. In Benner,

Tanner & Chesla, Expertise in nursing practice, Springer.

Sullivan, W. & Rosin, M. (2008) A New Agenda for Higher Education: Shaping a Life of the Mind for Practice. Stanford, CA.,  The Carnegie Foundation for the Advancement of Teaching.

Taylor, C. (2016) The Language Animal, the Full Shape of Human Linguistic Capacity. Cambridge, MA: The Belknap Press, Harvard University

Taylor, C. (1995) Explanation and Practical Reasoning.” In Philosophical arguments. Cambridge MA: Harvard University Press. (See pp. 51-53).

Nurses assisting a patient

Urgent Need: Teaching Strategies that Promote Lifelong Experiential Learning

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:

  1. 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.
  2. What were the top priorities for your caregiving and clinical reasoning in caring for this patient and family?
  3. What did you learn from caring for this patient and family?
  4. What are any unanswered questions that you might have?
  5. How would you improve the care you gave this patient today if you had the opportunity?
  6. 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.

Conclusions

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.

 References

Benner, P. (Feb. 6, 2022) “Enriching the Practice Apprenticeship During a Time of Limited Clinical Placements: Integrating Classroom, Online and Practice Teaching. EducatingNurses.com.

Benner, P. (2022) “Overcoming Descartes’ representational view of the mind in nursing pedagogies, curricula and testing.” Volume23, Issue4 Special Issue: The role of philosophy in the nursing world, Oct. 2022.

Benner, P. (2021) “Novice to Mastery: Situated Thinking, Action, and Wisdom” In. Teaching and Learning for Adult Skill Acquisition: Applying the Dreyfus and Dreyfus Model in Different Fields. Eds. Elaine Silva Mangiante, Kathy Peno, &: Jane Northup) Information Age Publishing.

Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011) Clinical Wisdom and Interventions in Acute and Critical Care, Second Edition: A Thinking-in-Action Approach. New York: Springer.

Benner, P., Tanner, C.A., Chesla, C.A. (2009) Expertise in Nursing Practice, Second Edition: Caring, Clinical Judgment, and Ethics Second Edition. New York: Springer.

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Carnegie Foundation, Stanford, CA., Jossey-Bass, San Francisco

Benner, P. (2001) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Commemorative Edition. Upper Saddle River: Prentice Hall.

Chan, G., Burns, E.M., Jr. (2021) “Quantifying and Remediating the New Graduate Nurse Resident Academic-Practice Gap Using Online Patient Simulation. Jo. of Contin Educ Nurs. 52(5)pp. 240-247.

Collins, C. (1985) The Last Dogma of Empiricism. PhD thesis, Berkeley, CA: University of California

Deslauriers, L., Mc Carty, L.S., Miller, K.. Kestin, G. (Sept. 2019) “Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom.” National Academy of Sciences, 116 (39) 19251-19257.

Dewey, J. (1969) Experience and Education. A Touchstone Book Simon and Schuster.

Dunne, J. (1997) Back to the Rough Ground. Practical Judgment and the Lure of Technique. University of Notre Dame Press

Doolittle, N. (1990)“Life after Stroke.” University of California, San Francisco, School of Nursing, Department of Physiological Nursing.

Eyler, J. R. (2018) How Humans Learn: The Science and Teaching and Learning in Higher Education) First Edition. West Virginia University Press.

Fewster-Thuente L. &Batteson, T.J.,“Kolb’s Experiential Learning Theory as a Theoretical Underpinning for Interprofessional Education,” Journal of Allied Health , SPRING 2018, Vol. 47, No. 1 (SPRING 2018), pp. 3-8 Published by: John Colbert

Gallagher, S. (2009). Chapter 3, Philosophical Antecedents of Situated Cognition” pp.35-51 in Cambridge Handbook of Situated Cognition, 200 Eds. Robbins, Philip, Aydede, Murat. . Cambridge, MA: Cambridge University Press.

Gallagher, S. (2005) How the Body Shapes the Mind. Clarendon.

Gallagher, S., & Zahavi, D. (2021) The Phenomenological Mind, 3rd Ed. Routledge.

Geertz, C. (1977) The Interpretation of Cultures. New York: Basic Books

Good, B. (1994) Medicine, Rationality and Human Experience: An Anthropological Perspective. New York: Cambridge University Press.

Heidegger, M. (1965) Being and Time. Transl. John Macquarrie & Edward Robinson.

Kavanagh, J. M., Svedra, C. (2017) “A Crisis in Competency: The Strategic and Ethical Imperative to Assessing New Graduate Nurses’ Clinical Reasoning.” Nurs. Educ. Perspect. Mar/April. 38(2): 57-32.

Kavanagh, J.M. & Sharpnack, P.A. (2021) “Crisis in Competency: A Defining Moment in Nursing Education” Online Journal of Issues in Nursing. 26: 2.

Kerdeman, D. (2004). “Pulled up Short: Challenging Self-Understanding as a focus of Teaching and Learning. In J. Dunne & Hogan, P. (Eds) Educaiton and Practice> Upholding the Integrity of Teaching and Learning (pp144-158).London: Blackwell.

Kleinman, A. (1988) The Illness Narratives: Suffering, Healing and the Human Condition. NewYork: Basic Books.

Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York: Basic Books

Lave, J, & Wenger. E. (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.

Lave, J. (1996) “The practice of learning, the problem with “context.” In: Chaiklin, S., Lave, J. (1996) Understanding Practice. Cambridge, UK: Cambridge University Press. pp. 3-32. (see p.7)

MacIntyre. (1981) After Virtue: A Study in Moral Theory. University of Notre Dame Press.

Merleau-Ponty, M. (1962) Phenomenology of Perception. Transl. C. Smith. London: Routledge.

Noe, A. (2009) Out of Our Heads: Why You Are Not Your Brain, and Other Lessons from the Biology of Consciousness. New York: Hill and Wang.

Robbins, P., & Ayede, M., Eds. (2009) Cambridge Handbook of Situated Cognition. Cambridge University Press.

Rubin, J. (1996, 2009) “Chapter 7 “Impediments to the development of clinical knowledge and ethical judgment in critical care nursing.” In Benner, Tanner & Chesla (Eds.), Expertise in Nursing Practice (pp.171–198). Springer

Schon, D.A. (1984) The Reflective Practitioner. How Professionals Think in Action. New York, Basic Books.

Sullivan, W. M., Rosin, M. S., (2008). A New Agenda for Higher Education: Shaping a Life of the Mind for Practice (1st edition). Jossey-Bass.

Taylor, C. (2003) Modern Social Imaginaries. Duke University Press  Books.

Taylor, C. (2016) The Language Animal, the Full Shape of Human Linguistic Capacity. Cambridge, MA: The Belknap Press, Harvard University.

Weick, K. Sutcliffe, K. (2015, 3rd Ed.) Managing the unexpected. Resilient Performance in an age of uncertainty. Jossey-Bass.

Weick, K. (1995) Sensemaking in Organizations. Los Angeles, CA. Sage,

Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines

Educators in all practice disciplines have erred on the side of thinking that all knowledge is just a matter of “applying” what is conceptually and technically already known, a rational-calculation approach

Patricia Benner, R.N., Ph.D. FAAN

John Benner, Doctoral Candidate at University of Washington, Seattle, WA

Experiential learning directly from practice is central to all practice disciplines. Practice situations are filled with particularity, nuances, complexities of the particular patient’s clinical conditions such as, co-morbidities, sensitivities, past illnesses, and chronic illnesses that require experiential learning on the part of students and all practicing nurses. Because nursing practice is changing and advancing, and contextual and patient particularities will always exist, the need for clinical experiential learning never goes away. The clinical environment itself is always changing. Health care teams and institutions have their own particular resources and availability of specialists depending on the time of day and what current patients need to be examined and treated. In addition, all technologies require experiential learning and adaptation in general and in relation to particular patients. Learning to use technologies in multiple contexts always requires first-hand experiential learning. The need for specific kinds of experiential learning by nurses and students are not always recognized and well-articulated. For example, for nursing students, and newly graduated nurses, facilitating experiential learning requires assisting the student to articulate and understand what they are learning and need to learn in caring for specific patients.  Experiential learning is defined by Gadamer (2013) as a turning around of mistaken pre-understandings or preconceptions of a situation or adding nuances to one’s understanding or perceptual grasp of a clinical situation. New insights to the meanings and significance of a clinical situation as it unfolds and changes across time also requires experiential learning. No one can be beyond experiential learning; clinicians must experience many unfolding clinical situations and connect them to similar and different situations in order to learn how to clinically reason in particular unfolding clinical cases.

Theories often elucidate or enhance understanding in particular clinical situations, but it is a mistake to imagine that the direction of influence is always from theory applied or used in practice, rather to expect to learn directly from practice, or to naively believe that there are, in existence, theoretical understandings or evidence-based-practices fitted to all practical situations regardless of their context and clinical particularities. In nursing education, “putting theory into practice” is over-emphasized, and using practice as a source of new knowledge insights, that may dispute or disconfirm a theory, or create revisions and enriching of theories, is less often pointed out and utilized to articulate knowledge gained from practice.

John Dewey (1969) points out that experiential learning requires connection, i.e., engagement, openness, responsiveness, and curiosity in the practical situation, and continuity, that is, an ongoing dialogue and inquiry from past to the current experiential learning. In a practice discipline such as nursing, this ongoing dialogue between what one has learned experientially from past clinical experiences and is then enriched or better understood in future clinical experiences is typical and common. Dewey’s (1969) two central tenets of experiential learning of connection and continuity require a historical, biographical narrative by the learner that creates a dialogue of continuous links between past and current experiential learning. A narrative understanding of learning from clinical practice over time requires that the clinician compares past with current  clinical learning. This requires that the clinical learner stay open and curious about extending and enriching experiential clinical learning across time. In safe clinical practice (Benner, Tanner & Chesla, 2009) experiential learning must be related and have continuity with past learning experiences.  This is how one develops  experience-based expertise (Benner, 2021; Benner, Tanner & Chesla, 2009).

We propose that students develop a habit of creating a first-person-experience-near narrative accounts of  experiential learning in clinical practice situations that include their concerns, questions, puzzles, insights and comparisons with other past similar and contrasting past clinical situations from engaging in patient care and clinical reasoning across time about particular patients (Geertz, C. (1973). We claim, with Charles Taylor (2016) that the nature of narrative understanding is unsubstitutable for an adequate account of experiential learning in practice. As Taylor (2016) states in his chapter “How Narrative Makes Meaning” narrative is essential and not substitutable for practical reasoning and experiential learning:

I want to defend the idea that stories give us an understanding of life, people, and what happens to them which is peculiar (i.e., distinct from what other forms, like works of science and philosophy, can give us) and also unsubstitutable (i.e., what they show us can’t be translated without remainder into other media).

What can we communicate about people and life in a story? A story often consists in a diachronic [evolving in time] account or condition (usually the terminal [or concluding] phase came to be. This can illuminate things in various ways. It often gives us an idea of “how things came to be”, in the sense of explaining why, or giving causes. It can also offer insight into what this terminal phase is like:  we can perhaps now appreciate more its fragility or permanence, ort value or drawbacks, and the like. The story can also give us a more vivid sense of the alternative course not taken, and so how chancy, either lucky or unlucky, the outcome was. And it can also open out alternatives in a wider sense, it can lay out a gamut of different ways of being human…Pp.281-282. P. Now everybody would probably grant my first assertion above, that narrative constitutes a way of offering insight into causes, characters, values, alternative ways of being, and the like. But many would baulk at the second affirmation, that this form is unsubstitutable . Of course, it may be in some cases, but the thesis here is to the effect that valid insight in the above matters can be given in story which cannot be transposed to the medium of science, atemporal generalization and the like. (Taylor, C. 2016, P.292.)

Clinical reasoning across time about clinical situations through changes in the patient and/or changes in the clinician’s understanding of the patient’s clinical situation is a science-using form of practical reasoning (Benner 2022, Oct. 12; Benner, Hooper-Kyriakidis, & Stannard, 2011) It requires narrative understanding and accounts (a chronological story of an unfolding clinical history) to capture  changes in a patient’s clinical condition and any changes in the clinicians’ understanding of that clinical condition across time. A narrative account can depict the specific nature of a patient’ clinical changes as they become clearer with the patient’s evolving clinical condition, and the accruing clinical evidence of changing vital signs, laboratory and diagnostic data that become available about the patient’s clinical condition.

Too often accounts of experiential learning are couched only in terms of conceptual or theoretical knowledge removed from context. These decontextualized theories or concepts may not capture all the nuances of change in understanding of the situation, significance of changes in the patient along with the significance of context in the clinical situation that shape the clinician’s insights about the nature of the patient’s clinical condition across time and the appropriate steps to take along the way.

Expert nurse clinicians do not just engage in mere “application of knowledge (or rational calculation) they use appropriate knowledge in specific clinical situations which is a higher form of productive thinking than mere application of knowledge (See Blooms’ Revised Taxonomy, 2001).  For example, a return demonstration of measuring a blood pressure is mere application of knowledge, whereas interpreting the meaning of blood pressure changes or trends in a particular patient, indicates a situated of use of clinical knowledge.  Expert nurses, and astute experiential clinical learners develop new clinical understandings, an astute perceptual grasp of the nature of a clinical situation. They develop a new sense of meaningfulness of the whole situation (called “sense of salience”), where the relative importance of situations are perceived and understood without having to figure out what is most and least significant, (e.g. in a situation of respiratory arrest for clinicians familiar with respiratory arrest). Observant attentive clinicians develop new clinical knowledge that allow for nuanced distinctions like the recognition of a particular shade of blue unlike cyanosis that is associated with very low blood sugars (A different shade of blue is described and confirmed by clinical colleagues ( Benner, EducatingNurses.Com Feb. 6, 2022).

A practice such as nursing or medicine, is not a mere carrying out of an interiorized formal theory; rather, it is a dynamic dialogue in which understanding is refined, refuted, changed, enhanced, and at the very least filled with nuances and qualitative distinctions that are not fully captured in abstract theoretical terms, or even generalizations from population statistics that may not fit a particular clinical situation (Benner, P. 2001 p. 308). Examples of experiential learning directly from practice may be, for example: Directly observed, perceived  changes in the patient’s color, demeanor, feel of skin color, turgor, level of anxiety as well as contextual and relational changes. It is impossible to interpret or use theory in actual clinical situations where one does not have experience-based understandings that fit  the current clinical situation. Practice-based experiential learning points to what the student learns directly from practice which may include tacit knowledge, perceptual and situational awareness, a vast amount of perceptual grasp of changes in patients’ clinical condition across time, as well as relational aspects of patients’ coping with their illness, dependencies and receiving care.

Learning directly from practice can be enhanced by theoretical understandings of psychological aspects of suffering and coping, pathophysiology, nursing theories related to stress and coping, and social and illness transitions. However, the ground for theory-use in practice is based upon gaining an experience-based first-hand understanding of manifestations of illness, patient concerns, clinical reasoning across time as the patient’s clinical condition changes, perceptual grasp of  those changes, a sense of salience about what is most and least important in a changing clinical situation. Note these aspects of situated clinical reasoning requires more than an abstract application of theory and/or use of generalizations without creating a dialogue between and understanding of the particular situation and the generalizations from research and theory.

The attentive curious nurse gains new insights and understandings directly through experiential learning in practice. Learning how and when as well as learning a sense of salience. A sense of salience is having experience-based perception of some things standing out as more or less urgent or more or less significant without having to figure out which things are meaningful…why they stand out.)  Having a sense of salience is a higher order productive kind of thinking because it requires situated thinking in context. “Knowing that and about” clinical knowledge, is important but not sufficient. Knowing how, when and why in context of actual unfolding clinical situations are also necessary for accurate clinical reasoning, and appropriate situated use of knowledge.  “Knowing that and about” can be apprehended, learned from books, but situated knowing how can only be learned experientially in practice. Educators in all practice disciplines have erred on the side of thinking that all knowledge use is just a matter of “applying” what is conceptually and technically already known, a rational-calculation approach. However, the “application” model of knowledge  (a form of rational calculation) is too narrow to capture situated understanding of contextual issues, clinical changes across time, meanings and qualitative distinctions in the clinical situation and situated thinking-in-action. Thus, mere 1:1 application of knowledge is seldom sufficient, nor is it the only approach to clinical learning and understanding required in clinical practice. Prescribed return demonstrations of skills with no clinical context or meanings of a patients’ clinical condition are too decontextualized, and consequently stop short of clinical understanding and knowledge, because they lack the necessary situated use of knowledge. Using knowledge in actual situations requires understanding the nature of the whole situation, what is most and least important in the particular clinical situation (an accurate sense of salience).

A sense of salience, i.e., what is of highest priority and greatest threat to the patient’s well-being, along with understanding the most relevant causes of a patient’s current clinical condition, including the effects of therapeutic interventions are central aspects required for good clinical reasoning. All clinicians must engage in understanding patient changes across time and be able to explain the most likely causes and effects of the patient’s current clinical condition. The most accurate terms for this thinking capacity are clinical reasoning and situated cognition (Benner, 2022 Oct. 12; Benner, Hooper-Kyriakidis, Stannard, 2011; Lave and Wenger, 1991; Lave, 1995; Lave, 1996). Clinical Reasoning is a science-using form of practice-based knowledge embodied, socially embedded and extended through direct experiential learning from practice. Current embodied, socially and contextually embedded views of the mind, learning and knowledge-use have implications for all practice disciplines. Current neuro-science and cognitive views of the mind include situated, embodied intelligence, skilled-know-how in context, and social embeddedness of the thinker/knower (a socially extended, embodied, and contextually, emotionally imbued interactive mind (Merleau-Ponty, 1962; Robbins P. and Ayede, M. 2009;  Collins, 1985; Benner & Wrubel, 1989; Lave & Wenger, 1991; Damasio, 1999; Lakoff & Johnson, 1999; Noe, 2010; Gallagher & Zahavi, 2021; Benner, 2022). This embodied, emotionally imbued perceptual grasp, and socially extended view of the mind refutes a Cartesian representational mind that is falsely imagined to reside within the head…a mind separated from the body in the world (Gallagher, 2009; Noe, A.2009; Benner, 2022; Benner, In Press). The current neurocognitive science view of the mind is that the mind is interactional and extended out into an environment replete with embedded meanings and embodied and skillful responses to actual practical situations. The embodied, contextually embedded skillful, experienced person develops a sense of salience about what is important and unimportant in familiar situations. The extended mind is made possible by the embodied, and contextually embedded mind. A common pedagogical error in teaching experienced learners is to teach as if teaching to a novice, decontextualizing (objectifying) thought apart from the person’s situated experience-based participation in the world (Noe, 2009; Dreyfus 1997; Dreyfus and Taylor, 2015; Benner, Tanner & Chesla, 2009). The Cartesian view of the representational inner mind and the older computational models of the brain in Old Fashioned Artificial Intelligence, fit the behaviors and thoughts of an inexperienced novice, but fail to account for the neurological evidence of how the experienced or practiced mind embodied, embedded and extended in already meaningful environments and social interactions, actually thinks, and learns (Dreyfus & Taylor, 2015; Tayor, 2016).

First-person-experience-near narrative accounts of the situated thinking-in-action of clinical reasoning support learning clinical reasoning directly from clinical situations when they:

Describe situations as they unfold,

Include the contextual and timing issues,

Articulate the learner’s thinking and concerns about in the situation.


Students’ best preparation for learning from clinical experience, is a mind expecting to learn not only what is anticipated, but also the ability to notice the unexpected and unanticipated.


The professional disposition of curiosity and openness to learning from practice are essential to  becoming an expert nurse (Benner, Tanner & Chesla, 2009; Benner, 2021; Benner, P. (2022). Such experiential learning is facilitated by encouraging the student to both tell and write about their experiential learning and then reflect on what they have learned, giving it accessible and understandable public language. Such articulation of the meanings and insights of experiential learning creates a biographical narrative of learning across time which in turn, further extends and facilitates clinical learning.

As Louis Pasteur noted, chance favors the prepared mind. Students’ best preparation for learning from clinical experience, is a mind expecting to learn not only what is anticipated, but also the ability to notice the unexpected and unanticipated. Their clinical imagination must not be shrunk down to only “applying theory” or “putting theory into practice” because when the student is curious, attentive, and responsive to the situation, they can discover new knowledge in clinical experiences not yet articulated and not yet theorized about, not yet fully understood or explained.

References

Benner, P. (In Press) “Teaching and learning clinical reasoning
Maximizing human intelligence, expert clinical reasoning, scientific knowledge and decision-making supports.” In Lipscomb, M. Ed. Nursing Philosophy. Routledge.

Benner, P. (Oct. 12, 2022) “Clinical reasoning: A science-using form of practical reasoning that includes a concern for responsible actions towards patients/families. EducatingNurses.com.

Benner, P. (Feb. 6, 2022) “Enriching the Practice Apprenticeship During a Time of Limited Clinical Placements: Integrating Classroom, Online and Practice Teaching. EducatingNurses.com.

Benner, P. (2022) “Overcoming Descartes’ representational view of the mind in nursing pedagogies, curricula and testing.” Volume23, Issue4 Special Issue: The role of philosophy in the nursing world, Oct. 2022.

Benner, P. (2021) “Novice to Mastery: Situated Thinking, Action, and Wisdom” In.  Teaching and Learning for Adult Skill Acquisition: Applying the Dreyfus and Dreyfus Model in Different Fields. Eds. Elaine Silva Mangiante, Kathy Peno, &: Jane Northup) Information Age Publishing.

Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011) Clinical Wisdom and Interventions in Acute and Critical Care, Second Edition: A Thinking-in-Action Approach. New York: Springer.

Benner, P., Tanner, C.A., Chesla, C.A. (2009) Expertise in Nursing Practice, Second Edition: Caring, Clinical Judgment, and Ethics Second Edition. New York: Springer.

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Carnegie Foundation, Stanford, CA., Jossey-Bass, San Francisco

Benner, P. (2001) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Commemorative Edition. Upper Saddle River: Prentice Hall.

Benner, P., & Wrubel, J. (1989) The Primacy of Caring. Addison-Wesley/ Prentice Hall. Upper Saddle Back River.

Bloom, B.  (2001) A Taxonomy for Learning, Teaching and Assessing: A revision of Bloom’s Taxonomy of Educational Objectives. Eds. L.W. Anderson, D. Krathwahl. Longman.

Collins, C. (1985) The Last Dogma of Empiricism. PhD thesis, Berkeley, CA: University of California

Damasio, A. (2005) Descartes’ Error: Emotion, Reason and the Human Brain. Penguin.

Dewey, J. (1969) Experience and Education. A Touchstone Book Simon and Schuster.

Dreyfus, H.L., & Taylor, C. (2015)  Retrieving Realism. Harvard University Press.

Dreyfus, H.L (1997) Kierkegaard on the Information Highway. Routledge.

Gadamer, H-G. (2013) Truth and Method. Bloomsbury Revelations.

Gallagher, S. (2005) How the Body Shapes the Mind. Clarendon.

Gallagher, S., & Zahavi, D. (2021) The Phenomenological Mind, 3rd Ed. Routledge.

Gallagher, S. (2009). Chapter 3, Philosophical Antecedents of Situated Cognition” pp.35-51 in Cambridge Handbook of Situated Cognition, 200 Eds. Robbins, Philip, Aydede, Murat. . Cambridge, MA: Cambridge University Press.

Geertz, C. (1977) The Interpretation of Cultures. New York: Basic Books Good, B. (1994) Medicine, Rationality and Human Experience: An Anthropological Perspective.New York: Cambridge University Press.

Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York: Basic Books

Lave, J. (1995) Mind, Culture and Activity. New York, Taylor and Francis.

Lave, J. (1996) “The practice of learning, the problem with “context.” In: Chaiklin, S., Lave, J. (1996) Understanding Practice. Cambridge, UK: Cambridge University Press. pp. 3-32. (see p.7)

Lave, J., & Wenger, E. (1991) Situated Learning. Legitimate Peripheral Participation. Cambridge University Press,

Noe, A. (2009) Out of Our Heads: Why You Are Not Your Brain, and Other Lessons from the Biology of Consciousness. New York: Hill and Wang.

Robbins, P., & Ayede, M., Eds. (2009) Cambridge Handbook of Situated Cognition. Cambridge University Press.

Taylor, C. (2016) The Language Animal, the Full Shape of Human Linguistic Capacity. Cambridge, MA: The Belknap Press, Harvard University.

Dr. Benner on Nursing Process & Clinical Reasoning Process

VIDEO: Teaching Clinical Reasoning – Helping Students Become More Test and Practice-Ready

COMPANION ARTICLE

COMPANION VIDEO 1

COMPANION VIDEO 2

 

Patricia Benner on the nature of clinical reasoning, and the importance focusing on key aspects of clinical reasoning in practice: situational awareness, rapid clinical reasoning, and thinking-in-action.

A better understanding and teaching of clinical reasoning will make students more test-ready and more practice-ready. This is especially relevant to help new graduates for the upcoming National Council State Boards of Nursing Next Generation RN NCLEX Exam and the new AACN Essentials Document emphasis on clinical reasoning and work-role competencies (AACN Essentials Document, 2021). With all this emphasis on clinical reasoning, it is a good time to thoughtfully consider how we are defining, teaching, and improving clinical reasoning in nursing education.

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Creating Safe Learning Environments that Encourage Growth and Active learning.

Patricia Benner, R.N. Ph.D., FAAN, John Benner, Doctoral Candidate

New graduate nurses face heavy patient loads, daily life-or-death decisions, nursing work groups with high-turnover rates, and inexperienced co-workers, all made more difficult by the new levels of hospital care demands created by the COVID-19 epidemic. Evidence grows that new graduates are not prepared to meet the current challenges to perform optimally, collaborate with care team members, prevent, and catch mistakes, and deliver quality (Brown, J., Hart, L. Wludyka, P., 2022; Chan & Burns, 2021; AACN 2021; Kavanagh & Szweda, 2017).  What teaching practices, in clinical, simulation and classroom cultures prepare nurses ready to face the current demands of practice? What teaching practices and emotional climates for learning promote or deter practice-readiness of newly graduated nurses?

Many nurse educators believe that because nursing is a high stake and demanding profession, they should make the classroom reflect these high stakes reality, including the emotional climates of practice demands, hoping to inoculate their students against the stress of their future professional lives. Aware that the knowledge base required for skilled nursing is large and complex, educators present as much information in the short time they have by focusing on information giving in classroom lectures and high reading and written assignment loads. Consequently, most nursing students confront cognitive overload in their courses (Benner, Sutphen, Leonard-Kahn & Day, 2010) that limits the amount of usable information a student can integrate.

Complex learning is disrupted when a stressful, pressured leaning environment prevails. Remembering more, complex, nuanced knowledge requires minds free from a fight or flight mode found in high stress environments. The emotional climate of the classroom directly impacts students’ learning outcomes. It is the primary responsibility of the educator to set that emotional tone and set and maintain behavioral expectations to promote learning relationships and emotional tones that are safe, civil and conducive to mastering complex learning.

Nursing Practice and Teaching requires High Levels of Interpersonal and Helping Skills

Central to nursing are caring practices, and how we teach should be congruent with the relational aspects of nursing. Student-teacher relations should be attentive, connected, confer dignity, respect, recognition and knowledge of students’ talents, learning, interests, challenges, and concerns. Small things like making sure you know and pronounce students’ names correctly, and giving students an opportunity introduce themselves are small recognition practices that communicate interest and care. Ice breakers, small conversation starters such as “what song most describes your first day of clinical?” or lighthearted questions like that spark personal reflection in pair-share or small group conversations get students talking about themselves and serve to invite participation in low stakes conversations prior to more challenging questions.

In her book “Creating and Sustaining Civility in Nursing Education,” Dr. Cynthia Clark makes several evidence-based suggestions for first day of class practices that help set a tone for inclusive and civil classrooms (Clark, 2017, pp. 192–197).  These suggestions include the following recognition practices and norm setting because as the saying goes, “you never get a second chance to make a first impression.”

  1. Send out a welcome email 1-2 weeks before class starts with location and schedule information and an agenda for the first day.
  2. Start the class with greetings that allow students to give a brief introduction about themselves.
  3. Have students create folded paper name tents to facilitate learning names.
  4. When possible, attach digital images to the roster to help you learn names more quickly.
  5. Use the syllabus to set behavioral and learning expectations (along with communicating assignments and session topics) for the course and go over the syllabus in detail on the first day. Include your teaching philosophy, late assignment policy,
  6. Co-create discussion norms with your students like ones below. These norms can be based on school of nursing norms as well as professional standards.

Here is an example of discussion norms Dr. Clark uses in her own classroom:

  • Engage in respectful interactions
  • Listen well while others are speaking
  • Assume goodwill; encourage and inspire each other
  • Respect differences and be open to other points of view
  • Make thoughtful contributions to group work
  • Be on time and respect one another’s time
  • Use electronic and media devices for class purposes only
  • Sit near the door in anticipation of phone/text message
  • HAVE FUN! (Clark, 2017, p. 206)

A safe classroom does not mean a classroom without discomfort and challenge! A peaceful classroom is not one without conflict, but where inevitable conflict is resolved skillfully. Astute teachers pose authentically challenging ethical dilemmas that will cause students to disagree and it is essential that teachers establish norms for how disagreements of opinion can be effectively and respectfully discussed. Making explicit discussion norms at the start of the course provides the foundation for constructive disagreement, lively debates, and inquiry without preset answers. Classroom learning climates should support students’ natural curiosity. Students are active learners by nature and passive only when this natural drive to engage is suppressed. Curiosity is natural but can be thwarted in classes where information giving dominations and students become passive recipients, blocking their naturally occurring curiosity (Lonergan, 1959). Active learning is far more effective learning in terms of fostering the retention and situated use of knowledge.

Formation in nursing requires that students and faculty encounter and address issues of systemic bias in health care, and especially their own hidden biases. Such consciousness raising requires a safe and confidential classroom climate for learning (Beard,  2021). Unfortunately, the values of emotional safety and civility can become screens for people with privileged identities to hide from the discomfort of revealing and discussing the ongoing nature of racial, gender and other forms of identity-based discrimination that they benefit from regardless of their intent (Blaisdell, 2018). It is not only possible, but necessary, to engage with this discomfort compassionately and effectively confront what biases we as teachers, or our students are experiencing. When considering classroom civility and safety with regards to identity-based discrimination, begin from the perspective of seeking safety for the most marginalized identities, in question, and work up from there. For example, in covering topics of ablism in health care, first consider the experiences and concerns of students with disabilities in your class. Students should be encouraged to speak from their own experience rather than speaking for people or groups to which they do not belong.

Just as people living in polluted communities have traces of those contaminants in their bodies, regardless of their healthy intentions, all people growing up in societies with biases (i.e., ALL PEOPLE) will to some degree absorb those biases and must have learning experiences that allow them to recognize and resist those biases. Students and even teachers will inevitably express stereotypes or enact other microaggressions, just as people downwind of chemical spills or industrial zones will have traces of the pollutants in their bloodstream and show symptoms to varying degrees. The solution to this is not to “cancel” or “call out” students for punishment or shame, but rather call in students with more accurate information, or appropriate terms and support them taking accountability in order to foster greater empathy towards one another (Ross, 2019).  The teacher’s responsibility is to model accountability, respect and caring in any class or communication with students, and this means also being open to being called-in yourself. When you have made a mistake, thank students for bringing your attention to the mistake, identify what you can do to make amends and take immediate action to correct the mistake. For example, should you mispronounce a student’s name or misgender a student and are corrected by them, thank them, use the corrected language, and don’t make a scene about how changing your behavior may be difficult for you. Show your respect and care by correcting your language and moving on if no further repair is needed. Teacher responsiveness to correcting their own blind-spots models showing the kind of respect and care you expect students to treat each other and their clients with.

Teaching Better Than We have been Taught

Teachers can unwittingly teach as they, themselves have been taught. Assessing one’s teaching style, relationships with students, quality of learning environments and emotional climates can allow for consciousness raising about how well one’s teaching facilitates students’ learning. Uncovering metaphors for teaching and examining one’s own role models used for teaching can foster critical examination and improvement of teaching strategies and emotional climates for learning.   Are teaching styles growth-oriented? Do they create active learning? (See Benner, 8/16/2019). An educator’s metaphors for teaching set up the kinds of environment and learning opportunities they create. Does a teacher view themselves as a fountain of knowledge, or their students as blank slates waiting to be filled (a banking metaphor)? These kinds of metaphors lead to one-way information giving and create passivity in students.

Paulo Freire (1970, 2000) introduced the banking metaphor as a dominant and oppressive metaphor for teaching. In Freire’s banking metaphor, the teacher is the primary agent and instigator in the classroom, depositing information to passive students who are taught to receive information, rather than engage in the classroom as active inquirers and learners who generate, discover, uncover, disclose, and create new knowledge. Information-giving was the dominant mode of instruction observed in nursing education classrooms in The Carnegie Study of Nursing Education (Benner, Sutphen, Leonard-Kahn, & Day, 2009) with “classifying” and “categorizing diagnoses” a frequent strategy for how information was presented. These kinds of tasks do not line up with how nurses actually  use their knowledge in practice nor do they stimulate experiential learning that fosters clinical reasoning, nor the situated use of knowledge in actual clinical situations (Benner, 10/12/22b).

The Cartesian representational view of the mind cannot account for the precognitive, direct perceptual grasp of reality and other forms of intentionality, essential to learning (Benner, 2022a; Benner, In Press). Everyday experiential learning is generated by meaningful, purposeful, skilled behavior, self-defining commitments, engagement with others and with concerns and projects. Perception and skilled know-how are connected to the person’s concerns, and agency, and member-participant involvement with projects, and relationships in actual situations rather than being mediated only by pre-existing mental representations (Dreyfus, 1990; Dreyfus, 1992; Dreyfus & Taylor, 2016; Benner, 2022a; Benner, In Press, Benner & Wrubel, 1989). A Situated Cognition View of the mind gives a better account of experiential learning (Lave & Wenger, 1991; Robbins & Ayede, 2009).

EducatingNurses.com has presented examples of excellent teachers who have described and demonstrated their metaphors for teaching that position themselves and students for active learning and collaboration: Dr. Linda Felver (Benner, 8/22/2019) has two metaphors; “making soup” and “improvisational acting,” which are highly compatible with each other and offer a stark contrast to a banking and “Sage on stage metaphors. Felver’s two metaphors create the interactive, inquiry-oriented learning required in any practice discipline. In describing her invitation to students to join her in making soup together on the first day of class, she brings a large pot with many soup ingredients to make her point. She is confident that each student brings essential ingredients for learning and enrichment. Dr. Felver’s metaphor of ‘making soup with students’ is a perfect counter to the banking metaphor of teaching, where students are viewed as passive recipients of information rather than sources of knowledge, questions, and other ingredients based upon their diverse backgrounds, and students’ experiential learning.

With the second metaphor—improvisational art, Linda Felver strives to capture the lively original insights from her students that create new understandings in her science classes, in this case, pathophysiology. From Dr. Felver’s perspective, each student comes with a wealth of their own life experience of health promotion and illness prevention. Each comes with life-long encounters with healthcare that have cultivated insights, questions, and perspectives. Dr. Felver lives her metaphors in her classroom. She expects to learn from her students and that her students will learn from each other. They will become an active learning community, making a delicious pot of soup where the sum is greater and richer than any one person’s contribution could be, teacher included. They will create the art of inquiry and understanding in their improvisational use of concepts, clinical experiences, and questions about how patient experience and health care delivery could be improved. (Benner, 8-16-2019 p. 1.)  Her two metaphors demonstrate inclusion, respect for diverse experiences, students’ rich life and clinical experiences, in an expectation for a learning community where everyone has valuable contributions.

Assessing the kinds of student questions and interaction reveals the kind of learning community being created in your classroom. For example, how often do student to student interactions occur in the classroom? Are most interactions teacher generated?  How often do students generate student to student questions, puzzles, lines of inquiry in the classroom with and without being prompted by the teacher?

Dr. Cynthia Clark developed a Civility Index for Faculty teachers can use in evaluating their own classroom practices. (Clark, 2017, p. 191) that we have included below with its scoring rubric.

Teaching from a Stance of Knowing Students and Their Concerns

Like expert nurse clinicians engaging in caring practices that focus on “knowing the patient” (Tanner, Benner, Chesla, & Gordon, 1993) likewise, teachers must understand their students’ approaches to learning, their interests and motivation.  To do situated coaching in clinical learning, teachers need to understand their students’ strengths and interests in learning, as well as areas where they are unsure or struggling. Former President of the Carnegie Foundation for Advancement of Teachng, Dr. Lee Shulman often noted that students’ greatest learning disability is the invisibility of the student.

Most students struggle, with their increasing knowledge and awareness about the possibility and dangers of making a mistake, particularly around medication administration (Rodriguez, 2007).  Bringing these fears into classroom discussions is as essential along with readings on medication errors (Benner, Sutphen, Leonard-Kahn, Day, 2010 See p.100, educator, Dianne Pestolesi’s account of making a serious medical error). Nursing students become keenly aware that they could make a clinical mistake (error in medication or treatment, critical omission, and so on) in ways they had not anticipated, and this can prompt a considerable source of anxiety and worry by students (Rodriquez, 2007).  Fear of making a clinical mistake cannot be removed, but can be discussed, and precautions taught, along with the ethical and appropriate actions for disclosing errors (Rodriguez, 2007). Once students can more openly address their concerns about making errors, and understand them as a serious and common risk in health care, strategies for checking for accuracy, seeking clinical consultation, and equally important, ameliorating and correcting errors by honest and quick reporting of any medical error can help students better prevent and cope with the risks of making errors (Benner, Sutphen, Leonard-Kahn & Day 2010, P. 100).

Characteristics of Safe, Generative Learning Environments:

Four important characteristics for creating safe and positive learning environments are  Safety; Engagement; Connectedness; and Support  (Owusu-Ansah, Kyei-Blandson, 2016)

Safety:

physically, emotionally, and mentally. Students must feel safe to fail since failure is a major impetus and ever-present possibility in experiential learning (Eyler, 2018). The power of failure experiences for learning is blocked if the emotional climate is one of censure, blame and shame. Failure is a powerful form of learning in safe environments. Simulation can be a safe learning environment for learning from failure, without shame, blame or intimidation.  Some educators will coach a student to prevent a failure in a simulation, seeking to avoid embarrassment over a failure, but this robs the student of a safe opportunity for learning from failure. Failure and risk cannot be removed from nursing practice but work and school climates can be created for accepting and learning from failure without inducing blame, shame or guilt.

Unfortunately, some teachers adopt teaching approaches that intimidate or create anxiety in students, thinking that strictness and highly structured learning expectations, encourage attention and learning. But “strictness” and “high standards” are NOT the same as academic rigor, and often intimidate students, causing anxiety that interferes with learning. Some teachers are unaware that their teaching and relational behaviors are anxiety producing and stressful for students. Or if they are aware of high anxiety levels in their classrooms and student interactions, may not know how to change the emotional tone of their classrooms and teacher-student interactions.  It can be useful to have a trusted nurse educator, or learning specialist observe your teaching and assess the learning climate your relational teaching style creates for students. Learning specialists can offer insights and alternative approaches to create a more supportive and effective learning climate.  Nurse educators teach students how to engage in helping and caring practices with patients. It is incongruous and creates conflicted messages, if teachers,’ in kind, do not model helpful, caring stances and attitudes toward their students.

Engagement

is essential to effective and collaborative learning environments. Students need engagement, interaction, collaborative learning with the classmates. Such an engaged learning community increases student to student learning and expectations and skills  in collaboration. One student’s experiential learning shared can enhance classmates’ insights and openness to experiential learning in their clinical practice.

Ethical comportment in teaching shows up in how the teacher creates engaged, safe and interactive learning environments.

Learning design specialists are good at assessing and helping teachers diminish “cognitive overload,” a major problem in nursing education (Benner, Sutphen, Leonard-Kahn & Day, 2009. Not only do teachers need to attend to overloading their curricula with more “information” than can be covered effectively in within the time frame of the curriculum, each lesson/classroom/seminar, and clinical learning must be designed to minimize cognitive overload. Cognitive overload creates anxiety for students and teachers without improving their knowledge base. While responsibility and planning for the emotional climate of teaching and learning rests largely with the teacher, students too have responsibility for contributing to an engaged, interactive, emotional climate for learning.

During the reign of cognitivism (Dreyfus & Dreyfus, 1988), a view of the mind as an information processing computer dominated, the role of emotions as the portal for attentiveness, perception, and learning were all but ignored. In the information processing model of the mind, emotion was seen as disruptive “noise” that interfered with rationality and thinking. While emotions such as anxiety, fear and a sense of alienation stemming from a sense of not belonging, and other disruptive emotions block perception and learning, at the same time perception and learning require positive emotions related to curiosity, openness and receptivity, attunement, and interest. Additionally, the emotions accompanying curiosity, such as excitement and engagement, are essential for perception and learning. These positive emotions are linked to rationality, discernment, and judgment (Damasio, 1994; Dreyfus, 1992; 2009).

Strategies for including emotions such as openness, responsiveness, excitement, etc. include designing assignments that stimulate the students’ curiosity and interest. For example, use of short student videos or students’ description and discussions of new insights gained or changes in understanding based on a clinical experience, help students connect with and share experiences of curiosity and interest that energize learning. These classroom disclosures about student learning, and students’ insights about changes in understanding (‘ah-hah experiences’ can infuse the class with a contagion and enthusiasm for learning. Another effective strategy is the use of first-person experience-near narratives about clinical learning (Benner, Hooper-Kyriakidis, Stannard, 2011).

In sum, emotion is a gateway for perception, attunement, and more. Objectified, removed, decontextualized information is not quickly, noticed, learned nor remembered. It lacks emotional connection, embodiment, and situatedness. Adding significance and positive emotions of engagement and connection make online learning more salient and exciting (Brown, Collins, Duguid, 1989).

Connectedness

refers to the students’ sense of connectedness to what they are learning and with whom they are learning. Learning is enhanced and increased through peer learning. Connectedness can be easily lost in online classes if careful attention is not given to student-to-student interactions and student-initiated questions. Group learning projects, discussions and sharing of experiential learning from clinical simulations and clinical practice are other strategies for making courses dialogical, highly interactive and connected.

Support

of students’ learning through open, inquiry-oriented learning climates are essential. and often requires enlisting campus levels of assistance and resources for students having learning difficulties. Having to rapidly implement online learning has been a challenge for nursing students and faculty during the COVID-19 restrictions to face to face meetings. The transition to online learning was rapid, often leaving limited time for developing effective online courses. Students with children, or family members also working at home who required care and support often disrupted students’ online learning. Understanding and support for managing demands outside the classroom can help our students managing complex adult demands in addition to their education (See Benner, 2/5/2021). Strategies for engagement and interaction require more careful planning and design in an online learning context.

Conclusion:

Supportive learning environments do not occur without planning, design and a commitment on the part of faculty and students.. Open, safe, connected, lively learning environments are not a luxury, they are essential to good learning outcomes!

References

Benner, P., (In Press) Teaching and Learning Clinical Reasoning: Maximizing Human Intelligence, Expert Clinical Reasoning, Scientific Knowledge, and Decision-Making Supports. Philosophy in Nursing. Routledge.

Benner P. (2022a) “Overcoming Descartes’ representational view of the mind in nursing pedagogies, curricula and testing.” Nursing Philosophy : An International Journal For Healthcare Professionals. 23: e12411p.1-5 DOI: 10.1111/nup.12411.

Benner, P. (2022b October 12 ) “Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/families.”  EducatingNurses.com https://www.educatingnurses.com/clinical-reasoning-a-science-using-a-form-of-practical-reasoning-that-includes-a-concern-for-responsible-actions-towards-patients-families/

Benner, P. (2021, February 5). Faculty Appraisals and Experiences in Switching to Online Teaching-Learning as a Result of the COVID-19 Pandemic. Educating Nurses. https://www.educatingnurses.com/faculty-appraisals-and-experiences-in-switching-to-online-teaching-learning-as-a-result-of-the-covid-19-pandemic/

Benner, P. (2020, June 11). Designing Online Nursing Education Based Upon Learning Science and High Impact Learning Strategies. Educating Nurses. https://www.educatingnurses.com/designing-online-nursing-education-based-upon-learning-science-and-high-impact-learning-strategies/

Benner, P. (2019, August 22) “Linda Felver: Making Soup.” https://www.educatingnurses.com/?s=Linda+Felver+Making+Soup

Benner, P. (2019, August 16) Beyond the “Banking and Sage on Stage” Metaphors for Teaching and Learning—Better Metaphors and Teachers who Foster Discovery and Transformational Learning.

Benner, P., Hooper-Kyriakidis, P., Stannard, D. (2011) Clinical Wisdom and Interventions in Acute and Critical Care, Second Edition: A Thinking-in-Action Approach, New York: Springer.

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation.  Jossey-Bass, Carnegie Foundation for the Advancement of Teaching.

Benner, P., Tanner, C.A., Chesla, C.A. (2009) Expertise in Nursing: Caring, Clinical Judgment and Ethics, 2nd Edition. Springer.

Benner, P. (2000) “The roles of embodiment, emotion and lifeworld for rationality and agency in nursing practice.” Nursing Philosophy. 1(1)5-19.

Benner, P., Tanner, C., Chesla, C. (1996 ; 2009) Social Fabric of Nursing Knowledge.  American Journal of Nursing 97(7) 16B-D Nurse Practitioner Supplement. (condensed from Expertise in Nursing Practice.)

Benner, P. (1991) “The Role of Experience, Narrative and Community in Ethical Comportment. Advances in Nursing Science.  1991 Dec;14(2): Pp.1-21.    Benner, P. & Wrubel, (1989) The Primacy of Caring. Addison-Wesley.

Blaisdell, B. (2018). Beyond discomfort? Equity coaching to disrupt whiteness. Whiteness and Education, 3(2), 162–181. https://doi.org/10.1080/23793406.2019.1569477

Brown, J.S., Collins, A., Duguid, P. (1989) “Situated cognition and the culture of learning.” Educational Researcher. 18, 32-42.

Brown, J., Hart, L., Wludyka, P. (2022) “Practice Readiness Among Nurse Residents.” The Journal of Continuing Education in Nursing Vol 53, No 9, 2022 Chan, G., Burns, E.M., Jr. (2021) “Quantifying and Remediating the New Graduate Nurse Resident Academic-Practice Gap Using Online Patient Simulation. Jo. of Contin Educ Nurs. 52(5)pp. 240-247.

Clark, C. M. (2017). Creating & sustaining civility in nursing education (Second edition.). Sigma Theta Tau International.

Damasio A. (1994) Descartes Error: Emotion, Reason and the Human Brain, New York: Putnam.

Descartes R. (1628) (1970) Rules for the direction of the understanding. E.S. Haldane & G.R.T. Ross (eds), The philosophical works of Descartes, two volumes reprint, Cambridge: Cambridge University Press.

Dreyfus, H.L., (1992) What Computers Still Can’t Do. A Critique of Artificial Intelligence. Cambridge, Mass: M.I.T. Press.

Dreyfus, H.L. (1991) Being in the World: A Commentary on Heidegger’s Being and Time, Division 1. MIT.

Dreyfus, H.L., Taylor, C. (2015) Retrieving Realism. Cambridge, Mass.: Harvard University Press.

Freire, P. (1970; 2000) Pedagogy of the Oppressed, 50th Anniversary Edition. Bloomsbury Academic Press.

Lave, J. &  Wenger, E. (1991) Situated Learning. Legitimate Peripheral Involvement. Cambridge University Press.

Kavanagh, J.M., Szweda, C. (2017) “A Crisis in Competency: The Strategic and Ethical Imperative To Assessing New Graduate Nurses. Nurs. Educ. Perspect. 2017 Mar/Apr;38(2):57-62

Lonergan, BJ (1959) The Collected Works of Lonergan, Vol. 10 Topics in Education. University of Toronto Press. P. 119.

MacIntyre A. (1981) After Virtue: A Study in Moral Theory, Notre Dame, IN: University of Notre Dame.

Noe, A. (2010) Out of our Heads. Hill and Wang.

Owusu-Ansah, A., Kyei-Blankson, L. (2016) “Going Back to the Basics: Demonstrating Care, Connectedness, and a Pedagogy of Relationship in Education.” World Journal of Education, v6 n3 p1-9 2016.

Robbins, P., Aydede, Eds. (2009) The Cambridge Handbook of Situated Cognition. Cambridge Univ. Press.

Rodriguez, Lori (2007) “Student and Faculty Experiences of Practice Breakdown and Error in Nursing School.” University of California School of Nursing Doctoral Dissertation.

Ross, L., J. (2019, January 2). Speaking Up Without Tearing Down. Learning for Justice, Spring 2019(61). https://www.learningforjustice.org/magazine/spring-2019/speaking-up-without-tearing-down

Rowbotham, M. A. (2010). Teacher Perspectives and the Psychosocial Climate of the Classroom in a Traditional BSN Program. International Journal of Nursing Education Scholarship, 7(1). https://doi.org/10.2202/1548-923X.1808

Tanner, C., Benner, P., Chesla, C., & Gordon, D. (1993) The phenomenology of  knowing a patient.  Image: The Journal of Nursing Scholarship, 25(4), 273-280.

An Introduction to Classroom Discussion Triggers

by Patricia Benner, copyright 1-30-2015

In honor and appreciation for my Mentor in Nursing Education, Dr. Rheba De Tornay, and with encouragement and examples from Dr. Sarah Shannon at University of Washington, I am introducing the Pedagogical Strategy of “Discussion Triggers”, a provocative, often dramatic introduction to a topic for discussion, inquiry, and problem-solving.  As a background, I am using a dialogue with Dr. John R. Stone on the topic of Interprofessional Collaboration, Health Care Equity and Civic Professionalism that was a Plenary Address at the September 2014 American Society for Bioethics and Humanities (ASBH) in San Diego, California. The topic is very much in the forefront of health care in terms of improving patient safety and increasing access and quality in health care.  In reviewing the video, you could choose to use any portion of it in your classroom, with planned stopping points to have students discuss and ask questions what they have just heard.  In reviewing the Plenary Dialogue, you may also find small sections of the video that would serve as a discussion trigger in a class on interdisciplinary collaboration or teamwork.  In addition, I have selected one 12 minute discussion trigger that I selected from the original Plenary Dialogue as a good example. (This discussion trigger no longer resides in the longer video tape from the Plenary Dialogue.)

The goal is to create an engaged connected dialogue, and to avoid random disconnected comments with little or no relationship to the conversation.

URL’s from YouTube and other media sources are provided as additional examples of discussion triggers around safety. We have added a drop down menu item this month which includes other video examples taken from Improvisational Actor Simulations, as well the suggested YouTube-based Discussion Triggers.

Enhancing the Depth and Thinking Levels in a Classroom Discussion

Students should come to class prepared to discuss the topic of interest, in this example, teamwork, Civic Professionalism, or interdisciplinary collaboration and communication. Students are coached to listen to one another’s responses, and respond with clarification, a counter example, or a related question that would deepen and enrich the discussion.  Active listening, and acknowledgement of others’ contributions in ways that build on others’ contributions, in terms of clarification, understanding and further extending problem solving and different points of view on the topic are essential dialogue skills that the teacher is trying to foster in the classroom discussion.  In adding their questions, or extensions, or disagreement with another student’s comments, students, should first paraphrase their interpretation of the previous student’s comment before adding their counterpoints, agreement or questions.  In an era of rapid social media exchanges that are short, and seldom measure up to an engaged dialogue, students need to experience directly what a dialogue requires; understanding, active listening, paraphrasing of others’ comments and offering of extensions to understanding and questioning.  This is the art of dialogical conversation.  It is a deliberate pedagogy that needs to be learned in classrooms and seminars.

Topical Issues Covered in this Bioethics and Humanities Plenary Address: The thesis of the Plenary Panel with Drs. Benner and Stone, who both convey respect and active listening, is that profession-centric health care needs to shift to a more population health and patient/family care focus. When individual profession-centric health care professionals focus more on their specialties than on health care access and creating a healthier population, problem-solving and dialogue becomes debased and falls into disarray.  The current confusing, competing markets in health care, along with polarized political positions, set the stage for this dysfunctional atmosphere.

A discussion about how we can improve interprofessional collaboration and inclusiveness-based  health care, based on improved interprofessional collaboration is this month’s video topic, featuring a discussion between Patricia Benner, R.N., Ph.D. and Dr. John R. Stone, M.D., Ph.D. Interdisciplinary colleagueship and mutual respect among health professionals are central to developing a unified authentic voice about what changes need to be made within professional education and service to transform the current expensive and less than reliable healthcare system.  Civic Professionalism a good starting point because it focuses on the citizen responsibilities and the notions of good practice that puts the patient’s needs first.  Many people from the health care service sectors have pointed out that professional educational systems do not attend to what is needed in our rapidly changing health care delivery systems, because they may become so focused on the aims for their professional achievements and careers are within the professions.

In our American Society for Bioethics and Humanities dialogue, Dr. John R. Stone argued for more democratic interprofessional relationships, and for concerted efforts by the policy and health care system leadership to help solve health care inequities that cause disparate health outcomes for the under-insured, and uninsured people below the poverty line. Autonomy as a central professional value in technical professions cannot address collaborative and interprofessional responsibilities to put the patient’s and population health first and foremost.  William May (1985) points out that professionals are taught to be critical, and skeptical, and this skepticism doesn’t lend itself to respectful listening, and may generate power struggles and hierarchical disagreements that may become profession-centric, disrupting the moral mandate to place the patient’s needs and well-being foremost. In the end, physicians, nurses, respiratory therapists, and the whole health care team do not want to cause harm to the patient, but clinical situations can be ambiguous and interpersonal hierarchies can prevent respectful listening within the health care team. Dramatic safety improvement occurred in the airline industry when pilots were required to listen to co-pilots and others in the cockpit, just as team members were required to speak up about dangers and possible errors that the pilot did not notice or acknowledge.

Few think that the current levels of spending can be stopped without a more rational and concerted focus on the three goals of increasing the health of the population, improving the quality and safety of the patient experience, while decreasing costs of healthcare.  These goals will require moving out into the community, into the workplace, schools, and other settings to increase access to health care. In this column, I revisit an earlier column, published on EducatingNurses.com April, 30, 2012 entitled “Interprofessional Education:”

Civic professionalism puts the focus on the citizen role of professional to deliver effective health at reasonable costs, and in a trustworthy way and the centrality of the citizen’s need for effective care in order to fully participate in society. Technical professionalism that focuses on autonomy and control by professional groups focused on work benefits to healthcare professionals, and/or economic and intellectual achievements of professionals lacks the moral voice of a civic professionalism based upon improving society by responsible and effective healthcare.

Interprofessional teamwork requires that professional share the same notions of good central to healthcare, the well-being and health of citizen patients and families. IPE requires a shift away from profession-centrism and/or professional self- interests that clearly block the transformative impact of IPE on improving our healthcare institutions. Professionals have to work as partners in education and service sectors equally sharing the responsibility for solving the major practice-education gap and lack of fit, and for the three urgent three goals of improving our healthcare. Contrasts between Civic Professionalism, an older form of professionalism contrasts with the current dominant model of Technical Professionalism where the focus is on the sociological characteristics of professionals:

  •     Autonomy
  •     Control over Membership in the profession
  •     Possession and Control over a Body of Scientific Knowledge and Technological Procedures

Civic Professionalism focuses on the citizen responsibilities of the professional and on the citizen needs, vulnerabilities and strengths of the client, patient, resident, families, communities and population. A democracy cannot function without a robust and effective cadre of civic professionals to support the citizenry in their pursuit of happiness, well-being and participation in society.  Conferees by and large are in consensus that professional education should be interdisciplinary with the patient at the center of the team, and that each professional group needs to hold common professional goals around improving care, lowering costs and improving the health of the society.  Rather than status, power, autonomy and control, IPE shares these common goals with foremost in any situated clinical care: The well-being of the patient, client, community, population.

IPE seeks to solve the problems of disparate and hierarchical expectations of professional performance for the sake of patients and population health.  Just as hierarchies and status inequities create real safety hazards in the aviation industry, so do such social behaviors and systems create barriers to clear, effective communication among professionals, and ultimately safety and quality of healthcare. Professions have a tendency to foster adversarialism (May).  Scott Reeves, PhD, the new director for the Center for Innovation in Interprofessional Education at the University of California, San Francisco and current Editor-in-Chief of the Journal of Interprofessional Care  notes that the Rationale for IPE include the following:

  •     Improve interprofessional communication
  •     Enhance collaborative competencies
  •     Reduce interprofessional rivalry
  •     Restrict duplication
  •     Enhance practice
  •     Improve quality

All of these are both goals and a rationale for IPE, and they require a vision for civic professionalism, increased trust and mutual respect among healthcare professionals, as well as a better understanding of the knowledge and skills of each professional group. Excellent IPE requires interaction, knowledge and mutual respect among all members of the healthcare team, including patients, and family members.

Pedagogical strategies for Excellent IPE include:

  •     Seminar and small group learning
  •     Simulation with focused debriefing on interpersonal dynamics as well as clinical performance as a result of effective teamwork;
  •     Focus on interprofessional teamwork in clinical placements that also include debriefing opportunities
  •     E-learning, unfolding case studies with interprofessional communication and social media

Each of these strategies and yet-undiscovered approaches can contribute to improved IPE and healthcare quality.  Professionals are taught to think critically, stand alone, and often behave skeptically among their colleagues. This is what May (1985) means by adversarialism in the professions.  But in a Civic Professionalism, critical thinking is not considered sufficient. The goal must be focused on the well-being of the patient. A climate of competency, evidence-based practice, interprofessional mutual respect and trust, are all required for this.  Of course there are built-in role distinctions and educational preparation of the professionals.  Social workers, nurses, physicians, physical therapists function best when their competencies are used to the best advantage.  Interprofessional teamwork requires communication, collaboration and leadership…without any one professional having a fixed inflexible role.

There are functional built-in role distinctions among professionals that serve the patient well. For example, nurses being present in the healthcare setting most continuously and being responsible for titrating therapies, and providing effective early warnings about the patient’s condition to healthcare providers would prefer to provide an early alert, that may not turn out to be a problem (though they recognize the risks of false warnings), than err on the side of not alerting healthcare providers to ambiguous but potentially urgent problems.  On the other hand, healthcare providers, who must take responsibility for errors of un-needed or ineffective intervention, would prefer to err on the side of “waiting” to evaluate and confirm the need for intervention to premature and potentially a mistaken intervention. This is a built-in functional distinction between professional roles that can and usually does serve the patient well.  Strategies for improving communication between professional disciplines such as SBAR (Heinrich, Bauman & Dev, 2012; Thomas, Bertram & Johnson, 2009) can make this functional distinction even more effective through clearer communication about expectations, assessments and recommendations.  This functional distinction need not ever turn into a hierarchical power play, as long as the patient’s best interest is first and foremost for all professional team members.  Each professional team member, in the end, must want the patient’s best outcome more than they want to be in control, or remain “in charge.”

The Veterans Administration Hospitals have formed effective Centers for Excellence in Primary care, in which Yale University, Fairfield University and the VA Center of Excellence in Primary HealthCare IPE present exciting possibilities for the effectiveness of IPE Primary Care. They characterize workplace learning in IPE as follows:

  • Unscripted: Requires workers to go beyond approaches learned previously in order to resolve novel and poorly defined work challenges
  • Collaborative: Requires workers to enhance or replace their collective expertise as changes in technology and work processes necessitate the development of new skills
  • Distributive: Requires team leadership to be determined by expertise germane to the question at hand rather than artificial hierarchies VACHS, Yale University, & Fairfield University

Such effective innovations are encouraging and point the way forward. Yet, we have a long way to go in IPE.  We found IPE is “thought about”, and on paper and in wish-dreams in the schools we studied and in the faculty surveys done in the Carnegie National Study of Nursing Education. But in the schools we studied and the faculty and student surveys, few have developed sustainable innovative programs that reach all healthcare professionals. Dr. Dan Berwick states:

In order to maximize the services received we are going to need to quit being so insular and build upon already existing infrastructures related to subsidized housing programs, homeless programs, social services, schools, and the many other structures and systems that already exist that we essentially ignore.  Overall, if we are truly primarily a service industry touching a massively wide breadth of life issues and challenges, then we need to figure out how to leverage emerging technologies (smart phones with cameras, texting, Internet), emerging human platforms (i.e., texting, Twitter, Facebook, networking communities, etc.), and become maximally flexible, adaptive, and able to interweave our services into the lives of those who depend on us for knowledge, diagnosis, treatment, and support.  (Dan Berwick Josiah Macy Jr. Foundation, April 1, 2012)

At the Macy Conference, Dr. Dan Berwick illustrates the above principles for excellent primary care with the following successful dimensions of the Anchorage Native Primary Care Center (NUKA)

Dimension 1: Caring for a defined population or list – new goal

Defined list – patient panel, registered list – and responsibility for the list;

Ability to generate disease tracking data; ability to track requirements for effective intervention; longitudinal coordinating relationships as primary backbone of system.

Dimension 2: Barrier free team-based care – new structure

Care delivered by a team – not all doctors; all working at the top of their license;

Same day access – delays in access will divert to other care locations. Provision for ‘ad hoc’ contacts – e.g. after hours phone access, urgent-care/walk-in visits, and email.

Mind and Body back together – imbedded behaviorists

Dimension 3: Redefining relationship to specialists – new relating

Redefinition of role of specialists with primary care – consulting, procedures

Movement of care from just illness care to include secondary prevention (optimal management of already existing health issues).

Dimension 4: Shifting to deliver “health” not just “disease care”

Effective incorporation of primary prevention, including connectivity to other community resources – building on their existing infrastructures.

Becoming truly customer driven more completely, self-care, family-care.

Dr. Berwick concluded:

These four components or dimensions of healthcare were initially developed as the four requirements for an effective primary care system, but really they are the same requirements of the entire healthcare system, as well as an effective longitudinal primary care platform.  By the way, it is important to note, that in this context primary care is not capitalized and therefore may or may not include or be primarily centered on Primary Care physicians.

Berwick identified the following six “wasteful” expenditures in the current healthcare system that could trim 11 trillion dollars from our healthcare system over the next nine years:  over-treatment; failures to coordinate care; failures in healthcare delivery; excessive administrative costs; excessive healthcare prices; fraud and abuse. An ethically-centered civic professionalism could go a long way in reducing all these wastes. One correction alone, will not solve the problem of wasteful overspending, with poor outcomes, but it is clear that must be involved in all these “waste problems”. This transformation has to be about the patient, client, community and population not focused on professional self-interest and compartmentalization. Transformed IPE will go a long way in transforming our healthcare system into one that we can be proud of. (extracted from EducatingNurses.com Newsletter “Interprofessional Education, 4/30/2012).

I learned a lot in the conversation with Dr. John R. Stone and even more in the preparation of the conference by reading Dr. Stone’s work (2013;  2012; 2010a; 2010b; 2010c; Stone, J.R., Dula, A, 2008).  This public forum enhanced communication about the moral sources for improving the health care system through a shared vision of Civic Professionalism and shared concerted interprofessional efforts at inclusiveness and interprofessional collaboration. Interprofessional education is essential for improving our health care system, so that nurses, physicians and all health care professionals enter their profession with the notions of improving the health of the population, improving health care quality, and the patient’s experience, along with reducing health costs. I hope that the discussion with Dr. Stone will stimulate discussions in your classrooms!

 

References:

Thomas, CM, BertramE., Johnson D. (2009) “The SBAR communication technique: teaching nursing students professional communication skills.”Nurse Educ.<http://www.ncbi.nlm.nih. gov/pubmed/19574858> Jul-Aug;34(4):176-80.

Heinrichs WM<http://www.ncbi.nlm.nih. gov/pubmed?term=%22Heinrichs% 20WM%22%5BAuthor%5D>, Bauman E<http://www.ncbi.nlm.nih.gov/ pubmed?term=%22Bauman%20E%22% 5BAuthor%5D>, Dev P<http://www.ncbi.nlm.nih.gov/ pubmed?term=%22Dev%20P%22% 5BAuthor%5D>. (2012) SBAR ‘flattens the hierarchy’ among caregivers. Stud Health Technology Inform. 173  175-182.

William F. May, “Adversarialism in America and the Professions” in Community in America, p185-201, Ed. C.H. Reynolds and R.V. Norman Univ. Calif. Press, 1985).

Stone, JR. Ethics & “Medical” Judgment: Whose Values? What Process?Cambridge Quarterly of Healthcare Ethics. 2013;22(4):404-406.

Stone, J.R. (2012). Elderly & older racial/ethnic minority healthcare inequalities: Care, solidarity, and action. Cambridge Quarterly of Healthcare Ethics, 21(3): 342-352.

Stone, J.R. (2010a). Saving and ignoring lives: Physicians’ obligations to address root social influences on health-moral justifications and educational implications.Cambridge Quarterly of Healthcare Ethics, 19(4): 497-509.

Stone, J.R. (2010b). Mrs. J: Culture & healthcare ethics committees. Cambridge Quarterly of Healthcare Ethics, 19(4): 537-540.

Stone, J.R. (2010c). Non-payment and non-care: Ethics and continuity of care.”Medical Care, 48(6): 495-497.

Stone, J.R. & Dula, A. (2008). Race/ethnicity, trust, and health disparities: Trustworthiness, ethics, and action.” In S. Kosoko-Lasaki, C.T. Cook, & R.L. O’Brien (Eds.) Cultural proficiency in addressing health disparities (pp. 37-56). Sudbury, MA: Jones & Bartlett.

Thomas, CM, Bertram E., Johnson D. (2009) “The SBAR communication technique: teaching nursing students professional communication skills.”Nurse Educ.<http://www.ncbi.nlm.nih. gov/pubmed/19574858> Jul-Aug;34(4):176-80.

Dr. Benner & Dr. Chan on Rapid clinical reasoning in a clinical crisis

A Rich First-Person Narrative Account of Rapid Clinical Reasoning, Situational Awareness and Situated Thinking in action.

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Dr. Garrett Chan, RN, PhD, FAAN,  provides a clinical example from his own practice as an expert Emergency Department Nurse. Please reflect on the nature of his clinical reasoning, his situational awareness, and his rapid mobilization of the surgical team, as well as how he considered the significance of informing the wife of how critically ill and at risk for dying her husband was prior to surgery. Dr. Chan made it possible for the wife to have a meaningful last opportunity to speak with her husband before he went into surgery.  This narrative provides a rich example of how important it is to learn directly from such practice narratives to enrich our clinical imagination, articulate knowledge embedded in practice and make the significance of rapid clinical reasoning in an acute situation.

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Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/Families.

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Patricia Benner, R.N., Ph.D. FAAN

Professor Emerita, University of California, San Francisco School of Nursing.
Copyright 2022

This month’s video presents a lecture by Patricia Benner on the nature of Clinical Reasoning, and the importance of focusing on key aspects of clinical reasoning in practice: situational awareness, rapid clinical reasoning, and thinking-in-action. Better understanding and teaching of clinical reasoning will make students more test-ready and more practice-ready.

Nurse educators are currently focusing on teaching clinical reasoning in order to increase the practice readiness of new graduate nurses (Brown, J., Hart, L., Wludyka, 2022; Chan & Burns, 2021; Kavanagh, & Sharpnack, 2017).  The goal is to prepare new graduates for the upcoming National Council State Boards of Nursing Next Generation RN NCLEX Exam (Dickison, et al, 2016) and the new AACN Essentials’ Document emphasis on clinical reasoning and work-role competencies (AACN Essentials Document, 2021). With all this emphasis on clinical reasoning it is a good time to thoughtfully consider how we are defining, teaching, and improving the teaching of clinical reasoning in nursing education.

Conceptual confusion over definitions, purposes, and context of clinical nursing abound (Gonzalez et al, 2021). This paper explores definitional and qualitative distinctions and different purposes of 1) scientific reasoning exemplified by the Nursing Process; 2) critical thinking; and 3) clinical reasoning, a form of science-using practical reasoning across time. We begin with a brief definitions and overview of each of these major ways of thinking:

The Nursing Process is based on the Scientific Reasoning Process, which is a linear information processing approach aimed at achieving absolute “yes” or “no decisions at discrete points in time. The Nursing Process is also comparable to Classical Decision-Making Model, or Rational Choice Model, with the component linear sequential parts being:

  1. Identify the problem;
  2. Generate a set of possible solutions;
  3. Evaluate each option;
  4. Select and implement the best option

(Hays, 2013; Schram & Caterino, 2006). The Nursing Process, the Scientific Reasoning Process, and the Classical or Rational Decision-Making Models are all forms of snapshot reasoning, (Taylor, 1995; Taylor, 2016) with a primary focus on achieving absolute “yes” or “no” or clearly delineated decisions at particular points in time.

 

Critical Thinking: Critical thinking is often confused with “clinical reasoning.” Critical Thinking, in philosophy, is thought of as abstract, analytical thinking, focusing on utility (Sullivan & Rosin 2008). In nursing “critical thinking” is often thought of as non-biased sound judgment (Facione & Facione 2008). The National Carnegie Study of Nursing Education (Benner, et. al., 2010) found that most nurse educators defined critical thinking as good, sound, unbiased, and rational thinking. At the extreme end of philosophical definitions and practices, critical thinking or critical rationality, is thought of as deconstructing all “received views” which are not effective and critically reconceptualizing the problem anew, from the ground up (Crowe &O’Malley, 2006).

Clinical Reasoning is a perfect analogue for “practical reasoning”. The term, Practical Reasoning” is examined and written about extensively in philosophical literature (See Charles Taylor 2016; 1995). Practical reasoning, of which clinical reasoning is a good example, considers puzzles and problems in encountered in one’s life or situation (in this case, clinical nursing practice) that create the need for figuring out the nature of the problem and its solutions, usually in particular contexts and time frames. Clinical reasoning uses science and requires situated thinking-in-action of an engaged intelligent agent, acting responsibly in a problem situation on behalf of a client with the aim of resolving an unfolding clinical problem. Clinical reasoning in nursing and medicine and other healthcare disciplines involves solving clinical puzzles, situations or problems. The aim of clinical reasoning is to figure out and assess the nature of the clinical problem, its causes, and the most efficacious interventions, while being keenly aware and observant of essential qualitative distinctions and notions of good central to the specific clinical situation and the particular health care practice involved. Here, we specifically address clinical reasoning in nursing practice. Christine Tanner (2006) describes clinical reasoning as follows:

“Clinical reasoning” is the term I will use to refer to the processes by which nurses and other clinicians make their judgments, and includes both the deliberate process of generating alternatives, weighing them against the evidence, and choosing the most appropriate, and those patterns that might be characterized as engaged, practical reasoning (e.g., recognition of a pattern, an intuitive clinical grasp, a response without evident forethought)… Good clinical judgments in nursing require an understanding of not only the pathophysiological and diagnostic aspects of a patient’s clinical presentation and disease, but also the illness experience for both the patient and family and their physical, social, and emotional strengths and coping resources (Tanner, 2006, p. 204)

This paper argues for an emphasis on teaching for clinical reasoning as a realistic rehearsal for practice where nurses exercise situation-awareness where the nurse recognizes the nature of the particular clinical situation and what is at stake for the patient. The nurse clinically reasons across time in rapidly changing situations with the goal of reaching sound clinical judgments, leading to responsible actions based upon timely actions for the patient’s well-being. This paper also argues for increased study of knowledge embedded in front-line expert nurse clinicians’ clinical knowledge and rapid clinical decisions, to better understand the required Situational Awareness (Endsley, 2018) for expert rapid clinical reasoning (situated thinking-in-action across time) in collaboration with and on behalf of the patient and the whole health care team.

Nursing and medicine, involve a rich, socially embedded, situated skilled clinical know-how, based upon experientially developed perceptual skills, learning how and when to intervene in particular clinical situations, along with well-developed abilities to create a dialogue between the particular clinical situation with population statistics and generalizations expressed in the form of patient-care standards and guidelines for care (Benner, Tanner, Chesla 1996; 2009; Benner, Hooper-Kyriakidis, 1999; 2010; Montgomery, 2005).

Clinical knowledge and clinical reasoning skills are developed in practice communities through learning from clinical experience, often refined in comparing similar and contrasting cases. It is tempting to misinterpret clinical reasoning, a science-using form of practical reasoning (Benner, Hooper-Kyriakidis, Stannard, 1999; 2010; Montgomery, 2005) by reading back into it, a scientific reasoning process, exemplified as the “Nursing Process” or “The Rational Decision-Making Process.” But this is mistaken because clinical reasoning involves recognizing and responding to changes in the patient’s clinical condition across time. Actual transitions in the patient’s clinical condition are studied across time. In addition, the goals of the engaged, embodied, intelligent clinician’s reasoning focuses on behalf of the patient’s well-being. Both unfolding changes across time and concern for the particular patient’s well-being are excluded and ignored in an “outside-in” objectified linear scientific reasoning process (the Nursing Process). Clinical reasoning is not a form of “criterial reasoning” or a formal application of singular theoretical concepts or single algorithms. Such criterial reasoning, application of single algorithms, or single theories may offer insights, but also often conflict with the multilayered and often conflicting clinical interventions and co-morbid illnesses and patient-specific sensitivities to interventions. Clinical reasoning often involves modus-operandi thinking where the clinician reasons backward much like a crime detective figuring out what and how the chain of events in a particular situation caused the current clinical situation, “M.O.” (Modus Operandi) of the crime.

In our study of nurses who had at least 20 years of nursing experience, but who were not considered proficient or expert clinicians, we found that the thinking of these ‘non-proficient and non-expert nurses,’ was reduced to cause-effect thinking. These nurses were consistently missing the skills of patient involvement and the integration of the notions of good practice, or qualitative distinctions in practice, along with patient goals and concerns required for expert practice. The nature of the expert’s responsible engagement and sense of responsibility for the patient’s well-being did not figure into their “cause and effect” form of reasoning. They were disengaged and disconnected to the patient’s experience. They often did not remember many of the essential clinical details or personal characteristics of the patient and family (Rubin 1996; 2009). As Jane Rubin, (1996; 2009) writes:

I suggested that the structure of the practice of the nurses in this group is responsible for the inadequacies of the care they provide. If this is the case, the general form of the remedy for these inadequacies is clear. Whatever the psychological difficulties or moral shortcomings of these nurses, their fundamental problem is their lack of knowledge of the qualitative distinctions that are embodied in expert nursing practice. As we have seen, these nurses are at least somewhat aware of this problem. Their awareness manifests itself in their wish to make a difference and to have a genuine sense of agency. The solution to this problem, then would seem to be neither psychotherapy nor ethics courses—important as these are in other contexts—but a form of nursing education that is governed by the goal of improving clinical and ethical judgment by focusing on the goods specific to nursing practice and the skills that allows nurses to achieve them (Rubin, 2009 p. 197).

In their nursing education, these nurses learned to think of their decision-making processes as limited to causes and effects and related to the scientific reasoning process and formal use algorithms and applying formal criteria. They had not learned to connect their clinical decisions and understandings of the patient’s clinical condition with their responsibility towards patients, families, communities, and patient populations nor to notions of good internal to the practice of nursing. They failed to notice qualitative distinctions associated with good patient outcomes. In other words, their clinical reasoning was not characterized by attuned, caring practices on behalf of the patient’s concerns and well-being nor a well-founded clinical understanding of the patient’s clinical condition and concerns.

In our research on skill acquisition in nursing, we found that persistent disengaged, standing over against situations, in a detached way, limited what nurses could notice in clinical situations. Disengagement and detachment limited experiential learning, blocking the development of proficient to expert performance. Proficient and expert performance depends on the use of narrative memory of past whole concrete clinical experiences. And typically, these inexpert nurses, who based their reasoning and action on primarily on cause-effect thinking, algorithms, and formal generalizations about disease or injury statistics did not attend to, nor readily recognize changes in patients’ condition across time and had little narrative memory of particular cases. Consequently, they typically failed to recognize early warnings of the patient’s clinical conditions because they were disengaged rather than attuned to the patient’s clinical situation (Rubin, 1996; 2009; Benner, Tanner & Chesla, 1996; 2009).

Proficient and Expert Nurses, as defined by the Dreyfus and Dreyfus Model of Skill Acquisition research (Dreyfus, 2017; Dreyfus & Dreyfus, 1986; Benner, Tanner, Chesla, 1996; 2009; Benner, 2021: Dreyfus & Rouse, 2021) do not rely on formal rules, or lists of signs and symptoms to perceptually grasp the nature of whole evolving clinical situations. Rather, proficient to expert clinicians use experience-based judgments, situational awareness and skilled know-how, based on the experience of past whole concrete cases they have experienced, that are similar, comparable or contrasting to the current clinical situation (Endsley, 2018). In familiar clinical situations, proficient and expert nurses do not rely on lists of signs and symptoms but rather on memory of past whole concrete cases.

William Sullivan and Matthew Rosin (2008) call for a new agenda in higher education, one that focuses on preparing students’ minds for a life of practice. This new agenda blends practical reasoning (i.e., clinical reasoning) with critical rationality and addresses the problem of conflating clinical reasoning (practical reasoning) with scientific reasoning or critical thinking. They point out that:

…Practical reason, once central to the educational tradition that stemmed from the rhetorical and humanistic studies of the European Renaissance, has been all but eclipsed by a focus on utility, on the one side, and on analytical reasoning, on the other…For practical reason, the focus is on thinking that is oriented toward decision and action. Because of this, we take exception to the way critical thinking is currently understood and promoted.
…Teaching for practical reasoning is concerned with the formation of a particular kind of person—one who is disposed toward questioning and criticizing for the sake of more informed and responsible engagement. Such persons use critique in order to act responsibly, as it is the common search for ways to realize valuable purposes and ideals that guides their reasoning. Practical reason grounds the academy’s great achievement—critical rationality—in human purposes that are wider and deeper than criticism…In the end, practical reason values embodied responsibility as the resourceful blending of critical intelligence and moral commitment (Sullivan & Rosin, p. xvi, 2008).

Practical Reasoning is demonstrated in research observations and interviews with the following burn nurse who engages in rapid clinical reasoning. The following clinical observation and nurse’s narrative interview illustrate the notions of good and practical concerns for the patients’ well-being attended to by the expert nurse’s clinical reasoning across time through transitions in the patient’s clinical condition and changes in the patient’s risks and need for protective and preventive interventions. The nurse’s sense of responsibility for the recovery and well-being of her patient and her situated skilled know-how for caring for acute burn patient along with the relevant use of science are marshaled for her reliable, responsible care of the patient:

Clinical Reasoning; Situational Awareness; Situated Thinking in Action: Administering Pain Medication to a Burn Patient with Sleep Apnea

During a clinical observation, an expert burn nurse details the patient’s current condition and therapy. She discusses a breakdown caused by small doses of valium and fentanyl but immediately recognizes the patient’s adverse and unpredictable response to the two simultaneous interventions, withdraws both, and moves on to another pharmacological agent more successfully:
Nurse:

His respiratory status is a concern and I won’t give him valium again because I didn’t trust his reaction to it. Basically, the fentanyl took a long time to actually work, and then it caught up with him and then it took a long time for him to get rid of it. Hence, he oxygenated well, but his PaCO2 was too high. It was 58, and he had severe sleep apnea. Severe. Even during the rest of the [scrubbing of the burn areas], we had to keep continually waking him up, and with the fentanyl, he just didn’t wake up very well and we had to sit on him a while [delay the washing and debriding of the wound]. In the process of all this, his blood pressure went really high, which is not usual. Systolic was 200 at one point, and his diastolic was 120 I believe. So, I just put a bunch of pillows behind him to try to bring his chin forward. I talked to the doc and gave him some nifedipine. His heart rate went really high, 160 to 175. This was all happening at one time and basically, I think that he was having sleep apnea, and he was very very groggy, and even though I kept asking him about his pain and he kept saying, ‘No, my pain is fine,’ I think he had underlying pain that he couldn’t articulate because he was too groggy. Once I finally bugged him enough and his meds worn off enough and he started waking up a little more, he then could articulate that he had a little pain and I gave him just a smidgen of morphine, and his heart rate started coming back down again. And by that time, the nifedipine had assisted with his blood pressure, and I think he’s doing better.

Int: So, you think his hemodynamics were pain-related?

Nurse: I don’t think they were all pain-related. I think probably the stress also [influenced them]. But I was concerned that we did have some deeper problems going on because I wasn’t sure how well he was oxygenating. We had a blood gas and he was oxygenating fine, but because he has all four extremities burned and both ears, it’s hard to get a pulse oximeter reading. Right now, we happen to be lucky; it happens to be working. But it was really intermittent and I felt like I was struggling so, at one point, because there were all of these things happening, I was really unsure what was going on. And I didn’t want to give him…I wanted to give him something to control his blood pressure because he kept denying pain to me. But I was also concerned, I didn’t want to [vaso]dilate him too much, because he is a little bit hemodynamically dry. I’m not totally sure where we were because we were a little bit dry, although now he looks a lot better (looking at urine output in the urimeter). So, all those thoughts were going on and basically, once he woke up a little bit more and wanted something to drink, he realized, ‘Oh, my hands are hurting.’ So, after giving him a little bit of morphine, his heart rate came down. His blood pressure had already come down some with the nifedipine. As far as his burn status fluids go, he is doing well… We’re going to put him on a CPAP mask. I talked to him about [the sleep apnea] at home he said, ‘yes,’ his wife states that he does stop breathing during the night and that he is exhausted in the mornings when he wakes up. He said as long as he breathes in the morning–he always wakes up, so I said, ‘Have you ever had it treated’, ‘No, there’s no reason, I always wake up.’ (laughs) Okay, there you have it. So, we’re going to put him on a CPAP mask now, that’s why I’m waiting for respiratory to call back. And we want to make sure we keep pulses in his fingers, and that’s what she’s (the orientee) checking right now. He doesn’t really have circumferential radial or arm burns over here, but because of the edema that will be created with the fluids we’ve given him, we just want good circulation down to his fingers. And then he’s got more burns on his right hand, so his right hand will be even more important to check on (Observational Interview. Benner, Hooper-Kyriakidis & Stannard, 2010 p.).

This observational interview captures clinical reasoning, a form of practical reasoning, and demonstrates the nurse’s responsible actions for the good of the patient. She is concerned about oxygenation of the patient’s fingertips because of the edema in the patient’s arms caused by the infusion of large volumes of intravenous fluids, and the potential long-term harm that could result from diminished blood perfusion because of the resulting edema. As she notes: “We just want good circulation down to his fingers.” Good science-using thinking across time through transitions in the patient’s condition is evident in this narrative interview, where the expert burn nurse’s primary engagement is linked to the patient’s survival and well-being in concert with the assessment of his clinical condition and pathophysiology across time and through changes in the patient’s clinical condition. This “situated thinking-in-action” (Benner, Hooper-Kyriakidis, 1999; 2010) account of expert nursing knowledge, situational awareness, closely associated with expert perceptual grasp and performance (Endsley, 2018) and situated skilled know-how can be contrasted to radically differing formal, static accounts of “knowing that and about” found in clinical textbooks and procedure books. For example, the burn nurses’ knowledge would be limited to descriptions of formal explicit knowledge, such as ‘the ability to determine the percentage and nature of the damaged tissue of the burn patient’. While this formal “knowing that and about burns” is essential knowledge for the nurse, it does not capture the operating knowledge and skilled know-how required for clinical reasoning, judgments across changes in the patient nor about how to intervene and make sense out of the patient’s condition as it unfolds (Benner, Hooper-Kyriakidis & Stannard, 1999; 2010; Weick & Sutcliff 2015; Hays, 2013).

As noted earlier, clinical reasoning, a perfect analogue for practical reasoning, as described and defined by Charles Taylor, a noted philosopher and thinker on practical reasoning:

Practical reasoning is a reasoning in transitions. It aims to establish, not that some position is correct absolutely, but rather that some position is superior to some other. It is concerned, covertly or openly, implicitly or explicitly, with comparative propositions. We show one of these comparative claims to be well founded when we can show that the move from A to B constitutes a gain epistemically. This is something we do when we show, for instance, that we get from A to B by identifying and resolving a contradiction in A or a confusion which A screened out, or something of the sort. The argument fixes on the nature of the transition from A to B. The nerve of the rational proof consists in showing this transition is an error-reducing one. The argument turns on rival interpretations of possible transitions from A to B, or B to A…The form of the argument has its source in biographical narrative. We are convinced that a certain view is superior because we have lived a transition which we understand as error-reducing and hence as epistemic gain (Taylor, C., 1970, p.72).

Not all rapid clinical reasoning across time has the quality of achieving epistemic gains in understanding the nature of the patient’s changing clinical condition or changes in the clinician’s understanding of the patient’s clinical condition. Sometimes the clinical reasoning begins with a well-founded understanding of the patient’s diagnosis and clinical condition.  But clinical reasoning is always concerned with changes in the patient’s condition across time. For example, in a case of a patient with well-defined pulmonary edema, who has a confirmed susceptibility to pulmonary edema, due to heart failure, the focus may be on figuring out how to recognize early signs of pulmonary edema and preventing it. No error reduction in the understanding of the clinical situation is necessary because the causes (heart failure) of the pulmonary edema are already well-established. A differential diagnosis of pulmonary edema caused by an allergic response, for example, does not come up as an open question because pulmonary edema has been proven to be caused by the patient’s heart failure. This well-understood and documented problem does not create an unnecessary problem list.

In the burn patient’s case above, the role of undiagnosed sleep apnea, and later discovery of the patient’s history of drug use, influenced the nurse’s understanding and treatment of his pain, hypertension, perfusion, oxygenation and guided the management of his elevated carbon dioxide levels. As this case illustrates, clinical or practical reasoning is not strictly a linear process. As noted earlier, the clinical reasoner may engage in modus operandi thinking trying to retroactively figure out what triggered a clinical cascade of events, e.g., hypertension, and apnea. The patient’s sleep apnea was undiagnosed prior to this severe burn. Thus, practical reasoning is similar to detective work (Modus Operandi thinking), reasoning backward in time, about potential causes of the cascade of clinical events for the patient.

The mistaken assumption that clinical judgment mimics scientific reasoning, is often based upon the folk psychology that all high-level mental functioning depends upon a representational, Cartesian view of the mind (Benner, 2022; Descartes, 1637; 2016; Dreyfus & Taylor, 2015; Taylor, 2016). This representational view of the mind theorizes that learning and perceiving the world is done primarily by the brain, rather than by an integrated and synergistic functioning mind of a socially embedded, engaged embodied person. This representational view of the mind does not match current neuro-cognitive science (Endsley, 2018) or research on how competent to expert performers, engaged in experienced-based skillful coping, perform in situations, where they have a deep familiarity and background skilled know-how, based upon experience-based familiarity of the situation (Benner, Tanner, Chesla, 1996; 2009).

Expert clinical reasoning requires a deep background understanding that allows nurses to perceptually grasp and attune to the particular unfolding clinical situation in the context of what is understood about the particular patient’s co-morbidities and about population statistics about patients with similar diagnoses, the notions of good internal to nursing practice, and the nurse’s responsibility for the best outcomes and well-being of the patient. The temptation of cognitivists, holding to a representational view of the mind, is to break the situation down into isolatable elements, and use algorithms, and formal criteria for making “yes and no” decisions at particular points in time (what Taylor, 1995 calls “snapshot” reasoning). Skilled know-how and perception and perspective become invisible to the cognitivist, using an information-processing approach to describe how clinicians are thinking and acting.

Clinical reasoning through transitions by an engaged agent is not in keeping with naturalistic scientific reasoning that bases judgments on formal objective elemental or isolatable criteria. The scientific approach oversimplifies and ignores multiple causal sources and the impact or outcomes that can be witnessed and understood by an intelligent agent’s situated first-hand observations of events, and ongoing feedback about the changes in the patient’s condition resulting from their interventions (Taylor, 2016). For example, the need for perceptual grasp by an engaged proficient to expert clinician, the necessity of keeping track of the changes in the patient’s clinical condition across time and make the “best call” or best sense of the clinical situation, in terms of diagnoses and clinical interventions, urgently needed by the patient at different points in time are all essential aspects of clinical reasoning as a form of situated practical reasoning. This expert practice of nurses is instantiated hourly by nurses and demonstrates the essential role of the intelligent, embodied, expert clinician engaged in the situation. In the example from the burn nurse, this entailed treating the patient for sleep apnea to solve the problem of high levels of carbon dioxide in the blood and titrating the patient’s pain medications carefully to ensure good oxygenation and perfusion. It also entailed ensuring that the perfusion of blood in the patient’s fingertips was adequate.

Superior mechanistic reasoning is not sufficient for good clinical reasoning for many reasons, including leaving out the engaged embodied intelligent agent’s role in understanding unfolding clinical events, clinical reasoning, as well as the temporal, changing dimension of clinical reasoning. Mechanistic 17th-century science cannot give an accurate account of how good clinical judgments are made in rapidly changing clinical practice situations. Expert clinical reasoning based upon absorbed coping, in a familiar world of practice, is not the same as “rote” repetitive responses in the thoughtless re-enactment of past situations, nor is it the same as a rote following of guidelines or rules. The actor is solicited by the context and the situation’s demands for sense-making and skillful responses based upon actual sequential changes in the patient across time. In clinical reasoning, the time sequence and particulars of the situation matter as well as the documented transitions and changes in the patient’s clinical condition. Perceptual grasp of the best perspective on the nature of the situation is essential for appropriate actions, attuned to responsibly meeting the demands of practice-based internal notions of the good and qualitative distinctions inherent in the situation (Benner, 2021; Dreyfus, H.L. 2017; Benner, Hooper-Kyriakidis, Stannard, 1999; 2010; Sullivan & Rosin, 2008).

With this perceptual acuity, comes a coupled experience and science-based knowledge about what to do in the situation. Clinical expert practice typically unfolds without “hypothesis-testing” or formal criteria reasoning on the part of the expert clinician. The expert clinician must be attentive to changes in the patient’s condition across time and recognize the salience (i.e., meaning and relative importance) of those changes for the patient’s treatment from his or her past clinical experience, use the best scientific evidence for clinical reasoning and for selecting treatments, and draw on definitive tests and expert medical advice for the patient’s particular unfolding situation.

Summary and Conclusions

Much can be gained in preparing student nurses to be more practice-ready by realistically teaching students to engage in clinical reasoning across time through changes in the patient’s clinical condition, and/or changes in the clinician’s understanding of that clinical condition, integrated with intelligent responsible action on behalf and in collaboration with the patient (Benner, Hooper-Kyriakides, & Stannard. 1999; 2010). We do students a disservice when we teach them to imagine that they are using the nursing process (a scientific or rational problem-solving process) rather than a science-using process of clinical reasoning (a form of practical reasoning). It is equally a problem to use an overly-simplified information processing model to represent or approximate clinical reasoning across changes in the patient’s clinical condition by conjuring up snapshot reasoning with the posing and testing of hypothesis so that students do not get a realistic rehearsal in the smaller incremental gains in clinical understanding across time in unfolding clinical situations. Students can benefit by producing and reading many narrative accounts of expert situated thinking-in-action typical of non-emergency unfolding clinical situations as well as fast-paced clinical reasoning in emergency situations. Their situational awareness and their clinical reasoning across time can be enhanced by studying multiple clinical narratives of situated-thinking-in-action of actual clinical reasoning as engaged in by expert clinical nurses as exemplified in the book, Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach (Benner, Hooper-Kyriakidis, & Stannard, 1999;2010).

Central to human intelligence in a complex highly skilled practice, such as nursing, medicine, chess, or driving a car in demanding situations, is how situated thinking-in-action and human skilled know-how and embodied human intelligence work in concert in real-world contexts. Fine-tuned performance of perceptual-motor skills that consider and recognize, based upon relevant experience, the salient (the most relevant, highest priority) demands of the situation, are essential for intelligent, proficient, expert, and mastery levels of performance in the Dreyfus Model of Skill Acquisition. When the situation becomes puzzling, or understanding of the situation breaks down, as it often does in complex practices such as medicine, or nursing, the performer must have recourse to the best, most situation-relevant content associated with the standards and research related to best practices. A switch over to detached scientific reasoning, as a result of the loss of a good perceptual grasp of the most salient aspects of the particular clinical situation causes the loss of proficient and expert performance (Dreyfus & Dreyfus, 1986), and should be done only when the engaged agent can no longer understand/make sense of the situation. Without this perceptual grasp or changed perspective on the nature of the clinical situation and what went wrong (a best account), the clinician won’t be able to choose the best course of action or the most effective clinical interventions.

Through experiential learning, clinicians gain expert skilled-know-how in recognizing the nature of whole clinical situations. For example, from witnessing many clinical cases of pulmonary emboli, the clinician can make an early call for chest x-rays, and lab tests to determine whether a pulmonary embolus is the cause for a patient’s respiratory distress. Other similar examples of perceptual skilled-know is the recognition of early sepsis; early recognition of hemorrhage and impending shock; especially during the compensatory physiological responses to hemorrhagic shock; recognition of changes in the stages of labor; recognition of an infant’s intolerance of patent ductus arteriosus, and many more examples of perceptual clinical grasp that lead to early warnings of changes in a patient’s clinical condition and the ability to rescue patients in acute distress (Benner, Hooper-Kyriakidis, Stannard, 1999; 2010). Expert clinicians can grasp the nature of patient changes, based on experiential learning from similar and contrasting past whole clinical cases. This experience-based understanding of real-world events turns out to be the best model of the world because it is context-related, more nuanced, and considers the sequence of events and timing in the situation along with the responsibilities of the clinician to the patient’s well-being.

A better understanding and teaching of clinical reasoning will make students more test-ready and more practice-ready. This is especially relevant to help new graduates for the upcoming National Council State Boards of Nursing Next Generation RN NCLEX Exam and the new AACN Essentials Document emphasis on clinical reasoning and work-role competencies (AACN Essentials Document, 2021). With all this emphasis on clinical reasoning, it is a good time to thoughtfully consider how we are defining, teaching, and improving clinical reasoning in nursing education.

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References

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VIDEO: From Novice to Mastery-II, The Dreyfus and Dreyfus Model of Skill Acquisition in Nursing Practice

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Patricia Benner Presents the stages of the Dreyfus Model of Skill Acquisition based upon research observations and interviews of Advanced Beginners to Mastery 1 and 2 nurses. Narrative examples of each stage are provided below.

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