Patricia Benner, R.N., Ph.D. FAAN
Professor Emerita, University of California, San Francisco School of Nursing.
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:
- Identify the problem;
- Generate a set of possible solutions;
- Evaluate each option;
- 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:
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.
American Association of Colleges of Nursing (2021) The ESSENTIALS: Core Competencies for Professional Nursing Practice.
Benner, P. (2022) (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., Stannard, D. Hooper, P. (1996) “A thinking-in-action approach to teaching clinical judgment: A classroom innovation for acute care advanced practice nurses. Advan. Practice Nursing Quarterly.1(4) 70-77.
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., 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.
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.
Crowe, M., & O’Malley, J. (2006) “Teaching critical reflection skills for advanced mental health nursing practice: a deconstructive–reconstructive approach.” Jo. Advances in Nursing 56 (1) 79-87.
Dickison, P., Xiao-Luo, Kim D., Woo, A, Muntean, W., Bergstrom, B. (2016) “Assessing Higher-Order Cognitive Constructs by using an Information-Processing Framework. Journal of Applied Testing Technology, Vol 17(1), 1-19, 2016.
Dreyfus, H.L., Taylor, C. (2015) Retrieving Realism. Cambridge, Mass.: Harvard University Press.
Dreyfus, S.E. (2014) “System 0: The overlooked explanation of expert intuition”In M. Sinclair, Ed. Handbook of Research Methods on Intuition (pp.15 -27).Chapter: 2 Edward Elgar
Dreyfus, H.L., (1992) What Computers Still Can’t Do. A Critique of Artificial Intelligence. Cambridge, Mass: M.I.T. Press.
Dreyfus, H.L., Dreyfus, S.E. with Thom Anthanasiou (1986) Mind Over Machine. The Power of Human intuition and expertise in the era of the computer. New York: New York: The Free Press.
Dreyfus, H.L. (1986) “Misrepresenting Human Intelligence.” Thought Vol. 61 #243. (December 1 986) Pp. 430-441.
Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities involved in directed skill acquisition (ORC 80-2). Berkeley, CA: University of California, Berkeley, Operations Research Center.
Ennen, E. (2003) “Phenomenological coping skills and the striatal memory system.” Phenomenology and the Cognitive Sciences 2: 299–325, 2003.
Endsley, M.R. (2018) “Expertise in Situation Awareness” pp. 714-741 (In, K.A. Ericsson, R.L. Hoffman, A. Kozbelt, A.M. Williams, Eds.) Cambridge Handbook of Expertise and Expert Performance, 2nd Ed.) Cambridge University Press.
Facione, N. & Facione, P. (2008) Critical Thinking and Clinical Reasoning in the Health Sciences: An International Multidisciplinary Teaching.
Geertz, C. (1987) “Deep Play: Notes on the Balinese Cockfight.” In Rabinow, P. & W. Sullivan, (Eds,) Interpretive Social Science: A Second Look. University of California Press.
Gonzalez, L., Nielsen, A, Lasater, K. (2021) “Developing Students Clinical Reasoning Skills: A Faculty Guide.” 60 (9) 485-493.
Hays, J. (2013) Operational Decision-Making in High Hazard Organizations. Drawing a Line in the Sand. Ashgate
Montgomery, K., (2005) “How doctors think. Clinical Judgment and the Practice of Medicine. Oxford University 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.
Ryle, G. (2009). The concept of mind: 60th anniversary edition (Anniversary ed.). London: Routledge.
Schram, S.F., Caterino, B. (eds.) (2006) Making Political Science Relevant
Tanner, C. (2006) “Thinking like a Nurse: A Research-based Model of Clinical Reasoning. “ Jo. of Nursing Eduction. Vol. 45, No. 6, p.2004. June, 2006.
Taylor, C. (2016) [The language animal, the full shape of human linguistic capacity. Cambridge, Mass: The Belknap Press, Harvard University.
Taylor, C. (1995) Explanation and Practical Reasoning.” In Philosophical arguments. Cambridge MA: Harvard University Press. (See pp. 51-53).
Weick, K. Sutcliffe, K. (2015, 3rd Ed.) Managing the unexpected. Resilient Performance in an age of uncertainty. Jossey-Bass.
COMPANION ARTICLE COMPANION VIDEO 1 COMPANION VIDEO 2