Enriching the Practice Apprenticeship During a Time of Limited Clinical Placements: Integrating Classroom, Online and Practice Teaching

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

Copyright February 6, 2022

We will explore ways to enrich the Practice Apprenticeship in order to improve practice-readiness of nurse graduates (Chan and Burns, 2021; Kavanagh & Sharpnack, 2021) in the midst of limited clinical placements due to the COVID Pandemic. We examined the Ethical Comportment and Formation and Cognitive Apprenticeship in the last two issues. This, like our exploration of all three professional apprenticeships, is a collaborative project with HealthImpact.com under the leadership of Dr. Garrett Chan.

We begin with a critique of the Nursing Process as an effective way to clinically reason and explore an approach to clinical reasoning that more closely matches how nurses actually think and reason — key changes to make nursing graduates more “practice-ready.” A linear nursing process approach which is an analog to the scientific problem solving process is essentially an information management tool that results in snapshot judgments at particular points in time. A nursing process approach to clinical reasoning fails to capture the realities of situated, embodied, engaged reasoning across transitions in the situation required for clinical reasoning. Clinical reasoning, a form of practical reasoning, (Taylor, 2016), requires reasoning across time about the particular through changes (clinical transitions) in the patient and/or changes in the clinician’s understanding of the situation (Benner, Hooper-Kyriakidis & Stannard, 2010). The Tanner Clinical Judgment Model captures clinical reasoning well as a form of practical reasoning (Tanner, 2006).

Experiential learning takes place in all the apprenticeships, but is particularly central to the practice apprenticeship and ethical comportment and formation apprenticeship. The clinician, through experiential learning in practice, develops a sense of salience, where some things just stand out as more or less important (Benner et al. 2010; Bosque, 2012). Developing a sense of salience is how human expert thinkers overcome the limits of formalism. The “limits of formalism” points to the practical inability to complete an explicit formal listing of all aspects of practical situations with the outcome of proliferating of variables possibly relevant to the situation. The limits of formalism is a key point of failure for earlier forms of AI that could not solve the frame or context problem (operate with a background understanding of the situation) nor completely formalize practical situations (Dreyfus, 1992). In a familiar practice setting, expert human problem-solvers typically enter a practice situation with a deep background understanding of the situation with a sense of salience about what is of highest priority and urgency. Experts move forward from that stance of a deep background understanding and sense salience, much like a hiker experienced on a particular hike grasps the nature of the terrain and can see alternative approaches because they are familiar with the terrain.

All complex practices such as medicine, nursing, law, teaching, social work, and so on require “apprenticeships.” In practice disciplines, an apprenticeship approach is also required in the classroom in order to foster understanding of practice situations and to teach “knowing how and when,” in addition to “knowing that, about and why.” As both Drs. Carol Durham and Lisa Day point out, in a practice like nursing, learners require teachers and mentors who can guide them by role modeling, direct demonstration, situated coaching, informal, and formal explanations, exemplars, illustrations, and more. Teaching students how to engage in situated thinking-in-action is at the heart of the Practice Apprenticeship.

Clinicians engaged in nursing practice will need to move from a novice’s inability to recognize real-life clinical manifestations to an astute perceptual grasp of clinical signs and symptoms and a perceptual grasp of the nature of whole clinical situations such as: ‘Is this a case of respiratory distress, evidence of a panic attack, or possibly an acute heart attack?’ The rapid decision-making of actual practice makes it impossible to formally analyze all possible causes and clinical significance of a patient’s clinical manifestations or build up one’s understanding of the situation element by element, de novo. Expert clinicians assess the patient based on their sense of salience, an experience-based knowledge of the most likely causes of the signs and symptoms for a particular patient at a particular point in time. The expert clinician enters the clinical situation advantaged by a deep background understanding of the situation based upon experience in prior whole clinical cases. The clinical narrative of care by expert nurse, Emily Dever, below, about a rapidly evolving clinical crisis for an infant, illustrates an expert’s sense of salience and effective situated thinking-in-action. It also demonstrates an expert’s rapid clinical decision-making, addressing multiple contextual layers of complexity, such as the level of experience of team mates, the infant mother’s responses and needs and more.

In contrast, the Advanced Beginner nurse caring for the infant on the night shift in this narrative, had minimal clinical experience and thus, lacked a sense of salience, and consequently did not recognize the severity of the infant’s clinical condition. Most Advanced Beginners, new graduate nurses and senior nursing students (Benner, Tanner, Chesla 2009), tend to take stock of a situation using decontextualized cues such as checklists and routines or even formal hypotheses, all of which have too much information irrelevant to the situation. This is too time-consuming because excessive listing of less salient information related to the situation and prevents the nurse from being effective in clinically reasoning for rapidly changing emergencies. Students can safely practice rapid interventions in realistic unfolding simulations in a simulation laboratory or an online simulation that call for unprompted student assessments and interventions according to their urgency and priority (Chan and Burns, 2021). In these simulations it is essential that the pace and time-urgency matches real rapidly unfolding clinical crisis situations. Students must be allowed to fail in simulation labs and online simulations (Eyler, 2018) because failure, if not accompanied by shame or blame, is one of the most memorable and powerful ways to learn. Often educators want to prop up the student’s sense of success in a simulation by preventing any wrong decisions or actions. This is unfortunate because it denies the student’s safe learning about mistaken actions or understandings in a safe environment, where no real patient incurs harm. Discovering that one is wrong and why is profoundly meaningful and memorable, and simulation experiences allow for this discovery with no risks to patients while offering a great learning opportunity for students. Discovering one’s misconceptions and mistakes also teaches students how to handle errors in their clinical practice.

Instead of indicating a planned on-the-job training period, we use the term “Apprenticeship,” here and in the Carnegie Studies of education of professionals, to include informal teaching and learning actions over time and in one-on-one mentor/teacher-student relationships. (Benner et al. 2010). Mentoring, role modeling, and situated coaching cannot be achieved in brief, busy, “on-the-job-training” events. One cannot reliably learn a complex practice requiring perceptual grasp, a sense of salience, clinical reasoning across time, situated thinking-in-action, and skilled know-how, without well-practiced teachers providing this kind of apprenticeship teaching and learning. Teachers need to embody and model situated skilled know-how in practice drawn from their own first-hand-situated experiential learning. Whether in real clinical placements or in simulations, without expert situated coaching, inexperienced students will flounder, and fail to grasp the significance of the patient’s clinical manifestations and what is at stake for the patient in particular unfolding clinical situations, (Chan & Burns, 2021).

In the current video in EducatingNurses.com, Dr. Carol Durham describes work to improve the simulation of clinical reasoning amid diminished clinical access to patients during the international COVID Pandemic. She points out the importance of using story, first-person-experience-near narratives, that describe situated thinking-in-action and knowledge use. Enriched practice apprenticeships that teach clinical reasoning from a stance of understanding the nature of whole clinical situations, a sense of salience and situated thinking-in-action are needed in nursing school, and in school-to-work internship and preceptorship programs.

Dr. Lisa Day encourages that we engage in more upstream thinking in the practice apprenticeship in order to prevent disease and injury rather than focusing on treating diseases and injuries after the fact. She recommends fuller inclusion of the family in the care of the patient. She also encourages nurse educators, nursing students, and nurses alike, engage in preventative care in order to promote healthier communities. Dr. Day also points out the need to teach students to pay attention to what is particular in the care of each patient. She encourages educators to create a dialogue between the particular and the general, in both the classroom and clinical settings, in order for students to become astute clinicians who know how to notice and respond to the particular patient’s needs in everyday clinical situations. She urges educators to work harder to include issues of the social determinants of health, improved equity in health care, and health care education for specific patient populations. Dr. Day masterfully demonstrates how to integrate clinical learning in the classes. You can get a sense of how she prepares her unfolding case studies  here.

With increased online learning, Dr. Day encourages teachers to improve their abilities to create learning communities and enhance student dialogue and discussion, which are part of social learning, crucial to all learning. To do this, she splits up a three-hour class into one hour of prepared videotaped lecture, one hour of classroom discussion, and one hour of teaching-learning situated knowledge use in unfolding clinical case studies. Both Drs. Day and Durham suggest enriching teaching and learning within practice apprenticeships through the use of unfolding clinical cases, and clinical narratives in online, remote, and hybrid teaching.

Dr. Carol Durham, Professor, at University of North Carolina, School of Nursing points to Donna Dier’s classic understanding of embodied skilled know-how:

“Skills are thought to be the rudiments of more complicated things, and therefore rote, unchanging, mechanical. But the acquisition of skill is neither easy nor automatic. Once learned, however, a skill is absorbed into the banks of memory and the fibers of the nervous system, so it can be called up and counted upon with instant reliability. Carefully learned skills free the mind for analysis, for decision-making, for innovation, and choice. Skill implies mastery, but skill mastery does not define excellence in practice. It is only one of the springboards from which a leap to excellence becomes possible.” (p.66) Diers, D. (1990). The art and craft of nursing, American Journal of Nursing, 90(1), 65-66. http://www.jstor.org/stable/3426230

As Donna Diers astutely points out, situated skilled know-how requires far more than the technical mastery of clinical skills in a skills lab, or abstract knowledge, i.e., “knowing that, about and why.”

Situated thinking-in-action and skilled-know require more than the “doing of a skill.” Embodied, situated skilled know-how in a practice requires more than mere “application” of knowledge or “how to do an isolated skill.” It requires the situated perceptual grasp of when and why the skill is needed and how to adjust skilled performance, based upon the patient’s particular clinical situation as it changes across time. Such situated skillful use of knowledge in specific and varying clinical situations is a form of higher-order productive thinking. It is an example of situated knowledge use rather than the mere application of generalized, decontextualized knowledge. As educators, we rely on Bloom’s (Krathwohl, 2002) taxonomy as we create learning objectives, but Bloom’s nomenclature of “application” of knowledge does not capture the higher-order thinking involved in situated knowing-how, i.e., the knowing when and why the particular skillful use of knowledge is relevant. For example, within a narrow rational technical perspective, learning to “do” a blood pressure measurement is truly a “mere application” of knowledge. However, knowing when to measure a blood pressure due to clinical signs and symptoms, and how to interpret that blood pressure across time for a particular patient, go beyond mere application of knowledge. They are examples of higher-order productive thinking.

We are hampered in academic and practice settings by using decontextualized accounts of “knowing that or about or why” in describing and freezing knowledge at singular points in time rather than providing accounts of situated of knowledge across time through transitions in the patient’s clinical condition. Formal descriptions of “knowing that, about or why” are necessary but not sufficient because they do not capture the situated perceptual clinical grasp, clinical reasoning, and thinking-in-action that make higher-order productive use of knowledge possible in particular situations. This situated thinking-in-action, use of knowledge across time is richly demonstrated in Emily Dever’s expert narrative below. Below is a narrative written by Emily Dever, M.S.N., that describes situated thinking-in-action, perceptual grasp, and the recognition and naming of the qualitatively different “look of the blue” discoloration of the skin associated with extremely low blood sugars.

As you read this narrative, contrast this expert nurse’s clinical reasoning, rooted in, direct experience, and an awareness of history with a typical Nursing Process approach or a decontextualized listing of “knowing that, about and why.” Try to list all the different overlapping areas of formal knowledge and skills and see how they relate to the timeline of the patient’s needed rapid assessments and interventions (Benner, Hooper-Kyriakidis & Stannard 2010). You will encounter the limits of formalism (the inability to make explicit and list all relevant variables in a practical situation), but you will also hopefully come to appreciate how written accounts of decontextualized “knowing that, about and why” (generalized accounts of knowledge) cannot articulate, i.e., give adequate expression to this kind of rapid perceptual grasp, clinical reasoning across time, clinical skilled know-how and situated thinking-in-action. This is why we recommend using narratives and unfolding case studies in addition to lecture or didactic PowerPoint presentations of decontextualized knowledge when teaching clinical reasoning. When we lack such unfolding first-person, experience-near-narrative accounts, we fail to accurately describe what expert nurses actually do in clinical situations, how they think and act in particular clinical situations, and why their situated thinking-in-action and knowledge use are so critical to early warnings and astute interventions that save patient’s lives.

A Different Shade of Blue

by Emily Dever, MSN Copyright by Emily Dever

“Joy” was a 3-month-old with a congenital heart defect. Mira [RN] had picked her up at 0500 when the previous RN left. She “thought the defect was a hypoplastic right”. I vaguely recalled Joy being here within the past month and that she had pulmonary stenosis as well, but I had never cared for her. “I’ll read the doc’s H & P when report is over,” I thought to myself and let Mira continue. Joy had come in last night in respiratory distress, had been intubated and a central line placed. No drips and, except for some sedation PRN, sounded like the night was pretty uneventful after that. Nursing didn’t seem to know what had started her spiral leading to the intubation. I glanced over at the central monitor; it wasn’t alarming, but Joy’s heart rate was 215. I asked where she had been running as I got up to go to her room. “A little tachyon and off but she’s been fine,” was the reply. Mira is a new grad and didn’t seem alarmed at the HR. I wondered why her alarm limits were set so out of range. As I was headed to the room, my attending pediatrician was about 5 feet away, I looked at him and asked if Joy had been echoed and that she was very tachy. He replied that “cardiology didn’t want an echo last night but that they weren’t “in house” and that perhaps when they came in this morning, they might change their mind and order one.” I replied back that “she’s your patient right now, would YOU like to order an echo and that way when they arrive and order one, it can already be in process or done?” He didn’t reply but got my point and I went to the room.

All the lights were out, and even in the dark I could see that Joy was dusky blue. Her biox [O2 sat] wasn’t picking up. I put one hand on her, and I knew why- she was ice cold peripherally. She was intubated, eyes closed, nasal flaring, retracting and I could hear her wheezing from the side of the bed. Centrally she felt hot and that jogged my memory that she had a brain injury that caused her to have temp instability as well. I couldn’t palpate a radial pulse but found her brachials easily. I thought to myself, “at least she shouldn’t be too hypotensive as well but her cardiac output is definitely down”. I quickly flipped the vent 100% breaths button and decided not to bag her. Sometimes children, particularly heart babies and BPD (Bronchopulmonary Dysplasia) children, do worse when you interrupt the circuit and attempt to bag. They’re sensitive to the volumes and get out of sync and start to clamp down harder. I’m sure Joy had a little combination of both. I decided not to yell out to the night shift as mom was asleep on another cot at the foot of the bed. I hustled to the doorway, looked at them all, and said, “No one leave! She’s about to code”. I asked the secretary to page RT and tell her I needed her right away then turned the nursing station to Dr. B. who was on the phone with cardiology. I looked right at him and said, “I need you NOW, she looks like —-!” Everyone responded.

I flipped on the overhead lights. Mom didn’t budge. Something in Joy’s color made my gut go off and I asked the night EMT to get a dex [glucose] for me from a heel stick. I asked the night gang to hang some normal saline and to get some meds while I completed a little more assessment to determine what was going on. Dr. B. came in. I’d already made up my mind that while I started getting labs and assessing the situation that he had about 3 minutes to start giving me orders before I called the ICU attending to come down. Dr. B is wonderful, but all the ER docs are pediatricians, not extensively trained in intensive care management. Most are straight out of the program here at Children’s. It’s not their fault, but they just don’t get to practice the critical thinking skills needed for these patients, and I’d found this out the hard way before. Dr. B agreed Joy looked pretty bad and added “she looked fine when I was in here at 0630.”

As I found my central line and was drawing off labs, I looked up and sighed relief to see Dr. M., one of the ICU attendings, strolling in a little way behind. The night EMT informed me that he couldn’t get any blood from Joy for a dex by heel stick. I thought it would be quicker and worth a try while I was accessing the line, but she was too clamped down. “It’s ok, the central line drew pretty easily, and I’m running the whole iSTAT” and Lori took the sample to run for me. I was still debating whether this was cardiogenic, septic, or something else. Dr. M had followed her all night and didn’t feel it was cardiogenic, no Lasix, and RT was here, and back-to-back treatments were started. Joy’s blood pressure was in the mid-80s by Doppler. I started the NS bolus, tried some Ativan for sedation and some Tylenol that I was doubtful she’d absorb. Her axillary temp was 39.5! I knew it was higher since her perfusion was poor. I placed some cool packs under the blanket behind her scapulas and prayed she wouldn’t seize. Her dex came back less than 20 and I started a D10 bolus. It clicked!! I thought to myself “that’s why my gut went off with her color.” It wasn’t quite the shade you see with hypoxia; it’s what I had seen several times over the last year with profound hypoglycemia…. sort of a grey-blue, hard to describe but just plain ugly.

The treatments and sedation were helping. Her flaring and retractions diminished and the wheezing ceased. She was moving good air. Guess that validates the non-cardiogenic part. I was on my second NS bolus and was again questioning the fluid with her cardiac status. Dr. M had been in touch several times over the night and was looking back through the I/O sheets. I hadn’t even had time to look at her chart. Looked like Joy had responded a little too well to her earlier Lasix. It was shortly after that her HR began to climb and she was dry. He declined my offer to hook up a CVP.

I tried to arouse mom and fill her in on what was going on. Even though the room was calm, I couldn’t believe that with 2 MDs and 5 other staff members in the room resuscitating her baby that she hadn’t bolted upright. She was arousable but not awake and rolled over to snore. Something made me think she was more aware than she was letting on. With all the horrible things she’d been through with Joy, combined with her young age (about 16 years old), this was her way of coping. For now, I let her be. Joy was responding nicely to the treatment plan. It’s amazing what a little sugar and fluid (among other things) can do for you.

Joy was responding and looked 200% better. Her perfusion was better, her labs were better, and her HR was calming down to the 170-180 range. Her BP dropped into the ’70s as her perfusion improved, we knew it would improve once her fluid status and temp were better under control. We were having trouble synchronizing the vent for her, even with sedation. Dr. M tried different vent modes and bagging rates/volumes. In the end, he decided we needed to paralyze her and take control so she could rest, and we could ventilate better. I gave more sedation and started the sedative drip before the first dose of a paralytic. I talked with Dr. M, and we decided to leave any remaining paralytic doses PRN, for now, to see if we could overcome this. She did much better after the paralytic. Joy is fragile. She doesn’t have any reserve and the slightest stressors can set her into a spiral…. hence, her repeated admissions with distress and respiratory failures. I still couldn’t get a feel for what had led to her initial distress this time. Dr. M and I conferred on various theories.

Things were under control within an hour or so. I made a mental note to check on Mira next time I worked with her. I wanted to make sure that she was okay and if there was anything I could help her learn the “red flags” of pediatrics. It’s a horrible feeling to give someone a report and then find out the patient isn’t quite as you thought they were. I also wanted to send Dr. M. an e-mail thanks for his uncanny sense of timing and for making rounds in the ER. None of the other attendings do. Maybe he’d help change that for us.

Joy continued to do well and stabilized nicely… I’d only needed one more dose of paralytic and Joy had a bed on ICU north by 11:00. Mom still had not been more than arousable with head nods for me and I conferred with social work. They knew Joy and her mother well and followed them closely. Since they had a longstanding rapport with mom, they were going to meet her upon transfer to ICU. I called report to Pediatric ICU and while I was on the phone, mom came out and asked the secretary when Joy would be transferred. The secretary had stated she wasn’t sure but probably not too long. Mom had left the unit. After 20 minutes, mom had not returned, and I was ready to transport Joy to the Pediatric ICU. Our EMT knew mom and went out to search the cafeteria and smoking huts for her. He looked everywhere and couldn’t find her. I didn’t want to scare her, and the paging operators won’t page families back to units, so I opted to transfer Joy to her ICU bed and continue to search for mom. Joy’s transfer went smoothly. She was a totally different patient than the one I found at 7:15. Mom returned around 1:00. She had gone to the NICU for a meeting. Joy had been a long-term NICU and PICU patient and I was glad that mom had relationships and services that provided support for her.

Joy was a complex patient. I wish that her symptoms had not progressed to such a status and had been in check much sooner. Even though I can’t explain it to anyone, I still believe there is a different color of “blue” that accompanies profound hypoglycemia versus other “blue” states like hypoxia. I guess I’d say it’s more of a grey-purple than blue. Joy’s certainly not the first hypoglycemic or complex patient that I’ve cared for. I’ve just never really thought of hypoglycemia as having a particular color change associated with it, and I’m sure not every patient is the same. It’s one of those things you always think about but sometimes is further down your list of troubleshooting. It moved up my list. It’s fun to see the facial expressions of my seasoned colleagues when I mention it. They all stop and think about it for a moment, some laugh, and others slowly nod their head and agree, followed by a story like “You know, I remember this patient….” It’s nice when we can share stories and learn from each other. [Names changed to ensure confidentiality] Copyright c 2004, Emily Dever, From Benner, Kyriakidis, and Stannard (2011) Clinical Wisdom and Interventions in Acute and Critical Care, A Thinking-in-Action Approach. P.52. (Clinical Narrative copyrighted by Emily Dever).

Commentary

This expert narrative demonstrates rapid clinical reasoning and decision-making beyond what is possible in the Nursing Process model. Using this narrative as a focal point for a class would provide students with the opportunity to study and reflect on an expert’s clinical reasoning across time. Doing so would provide opportunities for a high fidelity practice apprenticeship, helping students develop their own emerging senses of salience, and provide opportunities for discussion. We recommend using a flipped classroom approach (rather than asking students to read this narrative in class and write about it as an assignment). In a flipped classroom approach, students read and make their written reflections before in-person class time. The instructor then facilitates sharing what students observed and adds their knowledge to highlight and develop their sense of salience and clinical reasoning. The following are points you might highlight among students’ reflections, or you might point out as novices are likely to miss some of them.

Expert Nurse Emily Dever demonstrates a perceptual grasp of baby Joy’s dire clinical situation and immediately notifies all staff not to leave because of an imminent emergency. This decisive action before confirming her perceptual grasp with complete evidence saves precious time, allowing for timely assessments and interventions. In the narrative, we get an account of Dever’s clinical grasp of the situation as it develops. She is functioning in the Emergency Department with an infant who requires pediatric intensive care immediately and marshals the resources needed in the E.D. Though Emily Dever has never cared for this patient, she remembers the most salient aspects of her clinical condition from previous admissions: “Joy has a hypoplastic right heart…I vaguely recalled Joy being here within the past month and that she had pulmonary stenosis as well, but I had never cared for her.” She also remembers that Joy also had a brain injury which caused instabilities in her body temperature. This is the kind of memory that occurs with a strong sense of salience about the clinical meanings and implications of a particular patient’s pathophysiology, which is typical of expertise. Emily coaches the physician to get an immediate echocardiogram, understanding that it would be needed urgently to diagnose the source of this patient’s extreme condition. She makes a rapid and critical decision not to interrupt Joy’s mode of ventilation, fearing that a potential disruption could cause further deterioration of respiratory status. As she explains her action: “BPD (bronchopulmonary dysplasia) children, do worse when you interrupt the circuit and attempt to bag.” This demonstrates Expert Nurse Emily Dever’s ability to use knowledge in a critical, fast-paced situation. She immediately responded to this infant’s extreme hypoglycemia, which resonates with prior times she has seen the dusky grey look that she has seen with hypoglycemia before, and that gave her “pause” when she first saw infant Joy.

The qualitative distinction, “a different shade of blue,” is a good example of practice being a way of knowing and the need to follow up on such clinical distinctions made in practice with further documentation and research. Research studies on this particular description of skin color change that occurs with extreme hypoglycemia could improve the ability to clinically recognize hypoglycemia and immediately do tests for blood sugar levels. The dusky greyish color that Emily Dever describes is a qualitative distinction that can only be quantified by a blood test for hypoglycemia; nevertheless, it is an indicator that can point to the best assessment. Sight recognition of extreme hypoglycemia could also alert clinicians, patients, and family members of patients with diabetes to test for low blood sugar levels. This qualitatively distinct clinical sign “a different shade of blue” gives clinicians a direct source of knowledge from clinical practice that can and should spur more clinical research, demonstrating that clinical practice is a source of knowledge in its own right. Emily is aware that she may need to get medical back-up if the less experienced physician does not respond quickly enough in this rapidly changing emergency. This demonstrates collaborative practice at its best, supporting and enhancing each team member’s different clinical experiential knowledge. Emily Dever also coaches the new graduate nurse compassionately, understanding that this recent graduate would feel horrible about not picking up on this patient’s critical condition. She also coaches the pediatrician who has limited critical care experience. Emily adjusts her usual management of the patient’s high fever by adjusting for poor perfusion by placing cool packs under the blankets directly on the patient’s skin. While handling this fast-moving crisis, it is notable that Emily makes sure that the infant’s mother, who is present and then missing, is attended to but not asked to do more than she can manage in the duress of the situation.

It would be next to impossible to formalize all the knowledge and background experiential knowledge that enabled Emily Dever to function so expertly in this fast-paced critical situation. However, through such a rich and clear story, as told by the expert nurse who experienced the situation first-hand, we can learn much about the everyday work of perceptual grasp. In addition, we learn about the clinical recognition of the qualitatively distinct appearance of hypoglycemia, and the kind of modus operandi thinking (detective thinking of reasoning back in time) required to manage and respond effectively to such a fast-unfolding situation.

Teaching in the practice apprenticeship must not be reduced to mere “doing” of preconceived clinical or theoretical knowledge, nor a limited rational-technical strategy of applying general knowledge to particular clinical situations. Engaging in clinical practice requires clinical reasoning across time; gaining a sense of salience for a particular practice so that some things can stand out as more or less important (high fever, respiratory distress, kinds of pain responses and so on) without having to figure everything out on the spot; perceptual grasp of the nature of the whole clinical situation and context so that the particular patient’s history, co-morbidities, in clinical presentation are considered in rapid-responses to a clinical crisis.

In Educating nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard-Kahn, 2010), we called for enriching the teaching and learning in nursing beyond abstract “knowing that, about and why” to situated thinking and reasoning about how and when, i.e. the higher-order productive thinking of situated use of knowledge in an unfolding clinical situation that changes across time, and/or whose understanding by clinicians change across time; and for use multiple types of thinking but a clearer understanding of clinical reasoning, so that it is understood as a form of practical reasoning across time, with constant comparisons with changes in the patient across time (revealing trends and trajectories) rather than primarily a form of critical thinking (Sullivan and Rosin, 2008; Dreyfus, 1988), or snap-shot reasoning at particular points in time (Taylor, 2016; 1993). The above clinical narrative and many others from different domains of nursing practice exemplify realistic situated thinking-in-action in a rapidly changing clinical situation (Benner, Hooper-Kyriakidis, & Stannard 2010).

Enrich your teaching and learning in the practice apprenticeship by using such first-person, experience-near narratives that can demonstrate perceptual grasp, sense of salience, and situated knowledge use and rapid clinical decision-making in quickly changing and crisis clinical situations. Thank you, Emily Dever!

References

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

Benner, P., Hooper-Kyriakidis, P. Stannard, D. (2010) Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach. Springer.

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

Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.

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

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