Lisa Day, RN, PhD, CNE, Vice Dean for Educational Innovation, WSU
Patricia Benner, RN, PhD, Professor, Emerita, UCSF
In our last article (EducatingNurses.com, July 30), we began a series on clinical teaching and learning. In this article and forthcoming follow-up articles, we weave two major perspectives together to characterize key aspects of the practice of excellent precepting.
It is difficult to overestimate the significance of excellent precepting for patient safety and new nurse success. The effective situated teaching provided by the best preceptors is vital to learning in any new clinical setting. This video interview introduces Alyssa Boldt, an RN from Sacred Heart Hospital in Spokane, WA, who has been a preceptor for 7 years, and is highly recognized by her colleagues as an excellent clinical teacher. Boldt shares her insights about the challenges and rewards of precepting and reflects on her continued development as a teacher. As a preceptor working with new graduate nurses or with nurses new to the clinical area, she focuses on situated clinical learning with the goal of producing nurse clinicians who are ready to engage in highly reliable clinical performance. She avoids over simplification and encourages her orientees to stay curious as they formulate and seek answers to clarifying clinical questions. She stays close when required and is ready to offer guidance or even step in and take over when a patient’s situation requires this, and is more hands-off when she thinks that the new nurse is ready for more independence. This prioritizing of patient needs while also attending to the orientee’s learning and development is just one example of Ms. Boldt’s skills in navigating the complex terrain of hospital nursing.
Preceptors like Ms. Boldt and other nurses engaged in clinical teaching, play an important role in the effectiveness, safety and future of clinical institutions. In order for complex organizations such as hospitals to be effective, local specific knowledge, some of which changes daily, must be learned and passed on to others. The body of practical knowledge in health care is so large that clinicians might easily lose track of what and how they have learned different aspects of their practice. Teaching new members of a team helps preceptors keep track of this knowledge as they notice, articulate, and explain how they have learned to manage complex patients and busy clinical units across time. Teaching others helps preceptors articulate and make visible how they have learned to manage the logistics of their daily schedules while also engaging in high level clinical reasoning and judgment as patients change across time.
In this interview about precepting newly graduated nurses, Alyssa Boldt focuses on encouraging the new nurse to be inquisitive, to take initiative in asking questions and become more reliable in expecting and managing the unexpected. As integral to her practice, Boldt introduces the key tenets to developing highly reliable organizations. Her taken-for-granted assumptions, common to highly reliable organizations, are that change and the unexpected are to be expected.
The first perspective demonstrated by Boldt’s precepting lies in developing mindful infrastructures in work communities that foster high reliability (Weick & Sutcliff, 2007). The second perspective on clinical teaching and learning draws on the work of Jean Lave and Etienne Wenger (Lave and Wenger 1991, and Wenger, 1998) and focuses on social learning theory, situated learning and the nature of social learning in practice communities.
In the past 10 years. the American Hospital Association has begun a campaign to teach and extend the habits of mindfulness to create a shared mindfulness infrastructure to improve patient safety and reliability of clinical reasoning (Organizing for high reliability. http://www.aha.org/education-events/brain-based-strategies-improve-process-improvement-deployment-and-health-care-high reliability Accessed 10-1-2018). This AHA seminar states, “High reliability requires focusing on teams and teamwork, in a very unconventional way, where each team within an organization is a microcosm of sorts, each with its own need for a mindful infrastructure that defines its level of teamwork and ultimately, its ability to perform. Central to team performance is the role of the team leader [we include clinical preceptors as part of the leadership team] and the shared vulnerability that team leadership has with the team.” We focus on the role of expert precepting as central to developing organizational high reliability, and will continue this theme over the next few articles.
High Reliabilty Organizations (HRO), (Weick and Sutcliff (2007, 2nd Edition) point out that “expectations can get you in trouble unless you create a mindful infrastructure that continually does all the following:
- Tracks small failures
- Resists oversimplification
- Remains sensitive to operations
- Maintains capabilities for resilience
- Takes advantage of shifting locations of expertise”
Weick and Sutcliff (2007) go on to point out that, “Moving toward a mindful infrastructure is harder than it looks because it means people have to forgo the ‘pleasures’ of attending to success, simplicities, strategy, planning and superiors.” Shortcuts, snap judgments, incomplete information, and inattentiveness are enemies of high reliability. It is notable that preceptor Alyssa Boldt incorporates mindfulness in her precepting practice. She is always aware of attending to the performance of the new nurse, while deliberately fostering independence and allowing the new nurse to practice and extend his or her clinical reasoning skills.
Alyssa Boldt describes her situated coaching by identifying what is likely to be most and least important for each assigned patient on any particular day. She plots out what can be anticipated, and strategizes for “staying ahead of emerging clinical situations.” She warns against imagining that a slow day will stay slow, and coaches preceptees to stay ahead of schedule in case the unexpected happens. These habits of mindfulness contribute to high reliability. Without this kind of precepting, new nurses are left to learn by trial and error with little or no prompting for habits of attentiveness, and mindfulness. Lack of situated coaching in situations of novelty, or lack of prior experience undermines reliability, and slow down the development of clinical reasoning skills. Alyssa Boldt teaches her preceptees to recognize subtle clinical changes in patients across time, and also teaches planning structures such as coordinating breaks, essential practical local knowledge that must be mastered by all newcomers.
Situated teaching and learning through the notion of legitimate peripheral participation and social learning in a practice community, introduced by Lave and Wenger (1991) and Etienne Wenger (1998), are the second essential perspectives on excellent precepting. For example, in Boldt’s practice community, members who are most knowledgeable in particular clinical areas are known among the staff and readily refer to and consult one another. The success of this cardiac unit is evident in that most newly hired nurses stay on in the unit, or eventually transfer to intensive care units within the same hospital. The retention of hard-earned local experiential learning is facilitated by excellent precepting that encourages legitimate peripheral participation within a community of practice.
Lave and Wenger (1991) define legitimate peripheral participation as central to learning how to be an effective team member: “By ‘legitimate peripheral participation’, we mean to draw attention to the point that learners inevitably participate in communities of practitioners and that the mastery of knowledge and skill requires newcomers to move toward full participation in the sociocultural practices of a community. ‘Legitimate peripheral participation’ provides a way to speak about the relations between newcomers and old-timers…and how newcomers become part of a community of practice.” (Lave and Wenger, 1991 P. 29).
In her interview, Alyssa Boldt shares a story of precepting an orientee who is 4 weeks into an 8-week orientation that is an example of effective and safe use of peripheral learning. They are caring for an 80-year-old female patient with pneumonia who has been stable all day. Toward the end of the evening shift, the patient calls out that she is having trouble breathing. Ms. Boldt and the orientee enter the room to find the patient in tri-pod position, struggling to catch her breath. Recognizing the orientee’s ‘deer in the headlights’ look, Boldt assigns the orientee to take the patient’s vital signs. Meanwhile, Boldt quickly evaluates the situation by asking the patient a few questions to assess the patient’s mentation and breathing while thinking out loud for the benefit of the orientee. Together they call the rapid response team and the patient is treated for rapid atrial fibrillation.
This story is an excellent example of legitimate peripheral participation (Lave & Wenger, 1991). According to Lave and Wenger, a practice is learned through social participation in a community engaged in that practice. Through situated clinical coaching, preceptor Boldt facilitates the orientee’s involvement in legitimate work within the community that matches the orientee’s skill level (i.e., accurate assessment of vital signs) and situated performance ability (i.e. performance that doesn’t require perceptual grasp of the meanings of the patient’s vital signs in this specific context). In this situation, Alyssa Boldt saw that the orientee was overwhelmed and immediately assigned a familiar, safe task she knew the orientee could do—take vital signs. This was a perfect way to keep the orientee involved in the action in a legitimate way; that is, knowing the patient’s vital signs is important in this situation and the orientee is capable of completing this task. But in addition to keeping the orientee actively involved, the preceptor also brought the orientee into the community of practice further and extended the orientee’s experiential learning by thinking out loud while she took over the more complex aspects of responding to a significant change in the patient’s condition. Gradually, as the orientee spends more time in the environment, gains more experience and skills, and gains a sense of salience (perceptual grasp of what is most and least important in the clinical situation), the orientee’s participation will become more complex and independent.
In her interview with Patricia Benner, Alyssa Boldt, who works with orientees with varying levels of experience, describes her satisfaction in helping new nurses integrate into the culture of the unit, gain confidence and develop their clinical imagination. To accomplish this, the preceptor must strike a balance between directly supervising and instructing and stepping back so that orientees can construct their own clinical grasp of the nature of the situation. The preceptor’s goal is to coach the new nurse’s understanding of the particular patient’s unique clinical situation, support responses to this patient’s situation, while allowing the learner to understand, firsthand, the nature of the situation. Learning to respond to the patient’s clinical situation and doing what needs to be done are central aspects of experiential learning that develop clinical imagination by anticipating and responding to changes in the patient’s clinical condition. All of this is done while keeping a primary focus on safe and effective care of multiple complex patients on this busy unit. This is a tall order and one we know RN preceptors everywhere fulfill daily with student nurses, new graduate nurses and experienced nurses who are orienting to a new clinical unit.
In this series on clinical teaching and learning, clinical preceptors like Alyssa Boldt describe how they move beyond narrow rational technical assumptions about “directly applied” clinical science and theory and move to a more dynamic understanding of using clinical knowledge in rapidly changing clinical situations. Here, we make a distinction between the situated use of clinical knowledge, and mere application of techniques, e.g. inserting an IV, Alyssa uses her clinical knowledge of what is most and least salient in the situation to augment the orientee’s performance, while keeping the patient safe. The best clinical preceptors demonstrate how situated clinical coaching makes it possible for nurses at all levels of experience to learn directly from practice, to develop their understanding over time, of whole clinical situations, and to attend to what is most relevant for immediate and nuanced clinical interventions. This process, whereby newcomers are brought into a complex practice like nursing, is necessarily social and demonstrates how central learning is to practice and how practice is the history of that learning (Lave and Wenger, 1998 p. 96).
These varied forms of constructive learning in practice – that is, of firsthand development of a perceptual grasp of the nature and meanings within specific clinical situations – are very different from ‘template matching’, which is a narrow application of formal concepts or theoretical constructs to actual clinical situations. This is why clinical learning requires situated clinical coaching in actual, whole clinical situations as they unfold. Simulation learning with rich clinical scenarios or unfolding case studies comes closer than abstract textual descriptions of practice because with simulation situated action is added and sequenced. Embedding learning in a context of clinical concerns where what is needed changes over time makes it possible for new nurses to learn the nuances present within events and signs and symptoms as they evolve. Teaching students to memorize a list of signs and symptoms of clinical situations falls short of a direct perceptual grasp of nuanced, differentiated perceptions of actual clinical situations. Matching a list of abstract signs and symptoms to actual clinical situations leaves out direct perceptual grasp and understanding of the meanings inherent in actual clinical situations. The situated coaching that the best preceptors engage in invites new nurses into a unique community of practice in a unique care environment and helps them – as Alyssa Boldt describes – integrate into the culture of that unit and develop shared social understandings of patients’ clinical conditions. The nursing practice in these units – or, communities of practice as Lave and Wenger (1991; 1998) call them – consist of shared histories of learning; learning is the source of the social structure that emerges within a community of practice like a nursing care unit, and learning shapes and reshapes the community over time.
Alyssa Boldt describes the interaction between the nurses on her unit, including the orientees, as demonstrating relationships of mutual support and learning as they engage together in the shared enterprise of providing best care to patients. By engaging in the joint pursuit of this shared enterprise, the nurses share their practical and skilled know-how through situated coaching as well as through artifacts that reflect and reify the practice among nurses with different levels of experience. Participation in direct learning in clinical situations and reification are complementary. Through the interaction of participation in nursing practice and the embodiment and reification of different aspects of that practice, nurses negotiate shared meanings (Lave & Wenger, 1998). Alyssa Boldt describes two examples of the interaction between participation and reification of her own practice that she shares with her orientees: her use of an online resource for procedures; and her use of an organizing form (her “brain sheet”) on which she conveys clinical meanings.
When Ms. Boldt is confronted with an unfamiliar procedure, it is important to her to point out to her orientees that there is a resource she consults and that they, too, can consult. The online Lippincott Manual is an attempt to make a part of nursing practice into a tangible object, to represent this part of nursing practice in a set of concrete steps and, as such, to make what is abstract manifest. In the complex patient care environment where the nurse is situated, the Lippincott, or any other manual of nursing procedures the nurse might use as a resource, interacts with participation in the community of practice as nurses read, discuss, and adapt the written procedures to the unique needs of the patients. Similarly, Ms. Boldt’s one-page notes organizer, a handwritten paper that she calls her “brain,” is a reification of her participation in the practice that makes this participation into a material object: a piece of paper with a computer-generated outline of general categories. For example, her ‘brain sheet’ contains information about a patient’s IVs, meds, intake and output, vital signs, on which she writes notes specific to one particular patient by hand. Thus, the paper is a thinking tool that demonstrates and helps clarify her clinical grasp and organizes her clinical thinking about the particular in this unique patient’s individual situation.
Wenger (1998) notes that reification and participation work together. One without the other can lead to missed cues, and mistaken understandings of the clinical situation:
…reification always rests on participation: what is said, represented, or otherwise brought into focus always assumes a history of participation as a context for its interpretation. In turn, participation [acting in the clinical situation] always organizes itself around reification because it always involves artifacts, words, and concepts that allow it to proceed….participation and reification transform their relation, they do not translate into each other.” (1998,p.22).
Wenger (1998) points out both participation and reification are necessary: “When the stiffness of its form renders reification obsolete, when its mute ambiguity is misleading, or when its purpose is lost in the distance, then it is participation that comes to our rescue.” This is illustrated by Boldt’s description of the use of her paper ‘brain’. Boldt’s well-developed reified “brain” helps her remember and construct clinical issues that might come up for particular patients. This ‘reified brain’ is both a thinking and memory tool. It is essential that the “brain sheet” be constructed meaningfully and uniquely for each patient. Yet, as a reification that arises from, and is dependent on, participation in a living practice, it cannot be slavishly followed; it is a stimulus for thinking and discovery, not a mere checklist. It easily becomes less relevant if the patient’s condition changes rapidly. As Wenger (1998) points out: “Participation is essential to repairing the potential misalignments inherent in reification” [such as changing relevance or emergence of new clinical issues]. When the stiffness of its form renders reification obsolete, when its mute ambiguity is misleading, or when its purpose is lost in the distance, then it is participation that comes to the rescue.”
Alyssa Boldt illustrates how she alternates between participation in the form of direct engagement with the patient and preceptee, and with her pre-planned concerns written on her “brain sheet”. In the early stages of information technology use in hospitals, one hope was to get rid of the nurse’s need to write so much patient information down on paper, but it was soon discovered that the handwritten nurses’ notes were essential to memory and grasping the most salient aspects of particular patient’s care. So, Wenger (1998) sees participation (eg: direct patient engagement, assessment and action) and reification (eg: brain sheets and checkists) as complementary and corrective of each other in practice.
One of the enemies of reliability in unexpected clinical situations is over-reliance on reification such as usual recovery trajectories after surgery or even care plans for the day. This is why we offer both mindful infrastructures for high reliability performance (Weick and Sutcliff, 2007) and Lave and Wenger’s (1991) work on situated social learning. In addition, we refer to Wenger’s work on the interplay between direct learning from performance and artifacts, such as patient care guidelines and strategies for strengthening communities of practice. Without excellent clinical teaching and learning from preceptors such as Alyssa Boldt’s reliability in patient care, quality of worklife, and retention of new hires would all falter. Preceptors and communities of practice hold much local knowledge and experiential learning, but if this is not taught with compassion, and understanding of the demands on the newcomer, we will continue to be plagued by high turnover, and failure to meet the unexpected effectively.
We have just touched the tip of the iceberg of the knowledge, skill, and situated social learning inherent in precepting. We will continue to explore the artistry and effectiveness of precepting in the next article and video with a different preceptor. Precepting gives insights into the nature of direct experiential learning from whole concrete cases. Ultimately with this series, we want to make a case for changing clinical teaching and learning pedagogies from a narrow technical application of knowledge to pedagogies that focus on the recognition of whole clinical situations, perceptual grasp of subtle changes in patients’ clinical conditions across time, and situated learning in actual practice communities. Nurses are knowledge workers and clinical practice settings are places of learning and knowledge development. Preceptors are at the heart of this local situated knowledge and knowledge development.
Weick, K. , Sutcliff, K. (2007 2nd Ed.) Managing the unexpected. Resilient performance in an age of uncertainty. San Francisco: CA: Jossey-Bass, John Wiley & Sons
Lave, J., Wenger, E. (1991) “Situated learning legitimate peripheral participation” New York: Cambridge University Press.
Wenger, E. (1998) Communities of practice. New York: Cambridge University Press.