Student presents idea

Focusing on Student Learning: Seeking High Reliability in Nursing Education

By Patricia Benner, R.N., Ph.D., copyright 2016

The scholarship of teaching and learning encompasses a broad set of practices that engage teachers in looking closely and critically at student learning in order to improve their own courses and programs, and to share insights with other educators who can evaluate and build on their efforts. Hutchings, Huber & Ciccone (2011, loc. 337).

It is a professional hazard that when asked what students are learning that teachers will respond with a description of what they are “teaching”.  I ran into this problem dramatically when our daughter was in the second grade. I would go to student-teacher conference armed with questions about our daughter’s learning. I was concerned about her learning in math and reading. But the teacher would only respond with what she was “teaching”. I think she sincerely believed that what she was teaching equaled what her students were learning. It is a new day in education. We must assess what our students are learning and not learning. Furthermore, we need to know not just about predictive test scores for State Board Nursing Exams, but also the extent to which our students are practice-ready or not.

The Carnegie Foundation for the Advancement of Teaching has been focused on The Scholarship of Teaching and Learning and more recently on Improvement Science in Education, particularly K-12 education. And I want to add the notion of evaluating whether our nursing schools are highly reliable in preparing nursing students to be safe and effective nurses in the complex, rapidly changing environments that they encounter. Nursing education has been focused on starting a robust program of research on clinical nursing issues. And this research mission will always be central to knowledge development in nursing. But to develop highly reliable schools of nursing, we must also engage in the science of learning, systematically studying the impact of our teaching on learning.

In the new videos we introduce this month, Rhonda Vander Sluis, who was a nurse educator at the University of Oregon Health Sciences University and Dr. Mark Christian, demonstrate an active Scholarship of Teaching and Learning. Rhonda Vander Sluis uses unfolding clinical case studies to “flip” her classroom.

Students come to class prepared to present their unfolding clinical case. Dr. Mark Christian describes his work in helping Rhonda improve the learning of her students.

Oregon School of Nursing, at Oregon Health Sciences University (OHSU), has engaged in an ongoing program of improving teaching and learning outcomes of their students. They, along with their partnering schools in the Oregon Consortium of Nursing Education (OCNE), contribute to a Teaching Learning Commons where teachers submit their educational ideas and materials to a shared online repository of successful approaches to teaching and learning particular topics. Teachers also get together to share their most successful breakthroughs and ideas that they’ve tried in their classes. This is probably one of the reasons we heard from the OCNE students that most of their teachers were excellent and similar in their approaches to teaching and learning. Students could move from one class to another feeling assured that the teaching and learning would hold onto the quality that they had experienced in their last class. They had collectively developed a “Teaching and Learning Commons”. They had made their teaching public, and were actively engaged in improving teaching and learning in all of the OCNE participating schools.

Under the leadership of Dr. Christine Tanner, OHSU and OCNE have paid attention to Boyer’s work on the Scholarship of Teaching and Learning and the work of Carnegie Scholars, Dr. Pat Hutchings, and Dr. Mary Taylor Huber (2005 & 2011). Taylor and Hutchings (2005) describe making teaching and learning a point of learning and a shared practice among teachers and students:

A rather extraordinary development is underway: the emergence in higher education of a teaching commons, where ‘Communities of educators committed to pedagogical inquiry and innovation come together to exchange ideas about teaching and learning, and use them to meet the challenges of educating students.’ (Huber and Hutchings, 2005, p.x)

Two influential Reports of the Carnegie Foundation, called for teaching to be practiced as serious intellectual work. What ‘serious intellectual work’ means, how it can be developed, supported, evaluated, recognized, and rewarded, has been the subject of lively debate ever since. But no one doubts that it means, at least, teaching with an informed critical eye on one’s students’ learning. Teaching, in this view, takes into account theory, inquiry, and evidence about learning, and like other intellectual pursuits, is enriched by participation in a wider community of people similarly engaged. It’s in the working groups, conferences, and other forums (face-to-face, print, and online) that comprise a campus’s own teaching commons that local knowledge about teaching and learning truly becomes ‘community property’ (Shulman 1993), as people share, critique and build on insights from their own and other’s work.

In his forward to the book The Advancement of Teaching: Building the Teaching Commons, Dr. Lee Shulman, then President of the Carnegie Foundation for the Advancement of Teaching, laments that the teaching life is usually a life of solitude, a private experience, left without the experience of shared teaching learning discoveries of other teachers. Teaching and learning are shared practices based on socially embedded practice knowledge, science, technology, human and natural sciences. What if you had two faculty members share a teaching innovation or assessment strategy that is work in every faculty meeting? What if you shared preview segments of excellent teaching from EducatingNurses.com at the faculty meeting? You would be using faculty meetings to form a teaching commons, and focus on the bread and butter of schools of nursing, improving teaching and learning.

Much knowledge lies unexamined and tacitly in the individual practices of teachers. In the 2016 Scholarship Reconsidered, Priorities of the Professoriate, Expanded Edition by Ernest L. Boyer, Drew Moser (Todd C. Ream, John M. Braxton Associates. San Francisco: Jossey-Bass and Palo Alto), Carnegie Foundation boldly states that effectiveness of teaching should be the primary criterion for promotion of faculty, and learning outcomes must be at the forefront of evaluating teaching effectiveness. To effectively evaluate the reliability of our teaching, we must assess what our students are learning in our various venues of teaching and learning. Educational research has lain dormant in the last 30 years as nursing schools have developed impressive research programs to study the science central to the practice of nursing. But with ever increasing problems with curriculum overload and superficial coverage of too many areas of content, it is time to stop and seriously consider what is most and least important for nursing students to be both test ready and practice ready.   Are students actually learning what you think they are learning? And have you selected the most significant areas of practice and knowledge that students will need upon graduation?

Learning to Think and Act Like a Nurse

Thinking and acting like a nurse require being situated in clinical practice situation. Yet we found very little of this contextual, situated, engaged thinking-in-action in classroom teaching in our Carnegie Study site visits. Providing abstract concepts, without situating how those concepts are relevant in actual clinical situations teaches only about the subject, or knowing that or about the concepts. In order to be prepared to think and act like a nurse, students must be given opportunities to use knowledge in actual situations.

In practice disciplines, teachers sometimes imagine that there is a clear, reliable, evidence-based knowledge to convey to the students, and that it is their job to teach this information in the most precise, incisive way possible. The goal is to present the required information so that students have all the information required to be good nurses.  Yet this view of teaching, as mere transmission of selected certified knowledge, does not effectively teach our students how to think in actual practice situations.  This kind of transmission of “knowing that” does not automatically lead to “knowing how”.

Transmission of certified knowledge does not teach the requisite questioning and inquiry skills for informed situated practice with real clients, families and communities.  Particular clients, patients, communities, populations are best served in the context of their particular histories, concerns, health promotion needs as well as illness and injury care.

The student under the “organized knowledge transmission regime” can accidentally, or through osmosis, come to expect to find no puzzles, no mysteries in practice.  They can mistakenly come to expect to know all that is required to practice.  They can come to mistake the more complex issues in thinking like a nurse to be mere issues of procedural-technical knowledge and knowing that and about the practice. They will not experientially learn that practicing is always a way of knowing and inquiry when one is engaged in doing and improving that practice.  New discoveries and puzzles actually abound in clinical practice.

Students of master teachers will be brought to their practice arena with curiosity and a commitment to excellent self-improving practice over time.  The student will be given an access to the practice in the best way to learn.  Learning in response to curiosity, attentiveness, confusion, practice breakdown or just to the unknown is central to being human.  As human beings we are pre-disposed to be curious, open and interested in our world (Dreyfus, 2014; Longergan, B. (position 1052; 1992).

Master teachers in a practice discipline manage to embody the three professional apprenticeships that are universal for all practice disciplines (Benner, Sutphen, Leonard & Day (2009):

  1. Cognitive, Theoretical and Scientific
  2. Practice Know-how and Clinical Reasoning
  3. Ethical Formation and Comportment

Master teachers do not just know about these domains of knowledge, they embody the knowledge and deeply understand the practice of their specialty area of practice.  As Bain (2004) points out, the best teachers know their fields most deeply. Aristotle’s way of stating this is that, “Teaching is the highest form of scholarship.”  What has changed since Aristotle’s formation is the current focus on learning.  What do students learn while studying with the teacher?  How does exposure to a master teacher alter the student’s career?  If we take as an example master teacher, Bert Dreyfus, we can see that he inspires passion, curiosity, engagement, and ongoing discovery in his students.  The learner who is engaged and curious, and who expects incongruities, the possible lack of full or accurate information; sets about by being curious, engaging in inquiry and staying open to learn from the world.  Lonergan (1957; 1992) considered curiosity and the quest to know to be essentially human and “prior to insights, concepts, and words, it presupposes experiences, images.” Dreyfus would add to Lonergan’s list about what is involved in learning; embodied skilled know-how and everyday coping.  Aristotle also put “wonder” or interest, curiosity, attentiveness, and engagement as the basis of all learning.  And all these writers agree that learning is always about something. Something prompts curiosity.  Curiosity is there without teachers, but master teachers grasp that curiosity and inquiry are already within the learner’s capacities, propensities, and they create a learning environment that is full of possible explorations, questions, puzzles and even mysteries. (EducatingNurses.com, April 29, 2015).

Nurse educators have been overly influenced by a highly representative simple rational calculation as the form of clinical reasoning and judgment. Clinical reasoning is a form of situated practical reasoning that must take into account immediate historical reasoning in the actual clinical patient care encounter across time. Educational research has pointed to the significance of practical reasoning in all disciplines (Sullivan and Rosin 2009). In a book entitled The Hidden Curriculum, (Day and Benner, 2016), the authors include a narrow rational technical model of education, and an outdated view of a representational mind:

In recent years, the education-practice gap has widened greatly and most frequently reflects advances in practice that are not yet taught in schools. Healthcare settings have become more complex and multilayered with regulations and technologies that change rapidly. At the same time, nursing school curricula, teaching, assessment and grading have emphasized theory and elevated decontextualized content over the practical, context-dependent know-how that allows nurses to navigate complex healthcare systems; knowledge acquisition is emphasized while situated knowledge use is all but ignored. For students learning a practice, abstract theories and decontextualized content are sometimes necessary but never sufficient. Nurse educators know this and nursing schools incorporate clinical learning into the official curriculum. But the message students get from the hidden curriculum – that is, the implicit and unconscious devaluing of practice-based learning in context and the privileging of theory-based content knowledge – is different…. These empirical assumptions are further demonstrated and supported by a common notion among academic nurse educators that student nurses must be taken out of the practice setting in order to learn the concepts and theories associated with nursing in an abstract and decontextualized way before they can apply these concepts and theoretical knowledge in practice. Many nursing courses are structured to enact this truism: professors deliver abstract theory via classroom lectures and test students’ knowledge of concepts and content before they move them to laboratory and clinical settings for application exercises. This model is further supported in nursing education by the appeal of theories that assume learning is a purely cognitive endeavor involving the acquisition and organization of content in the mind; knowledge is understood as formal cognitive mental representation that gains clarity and strength when it is separated from context. The higher importance of theoretical understanding over situated, practical know-how is further emphasized by evaluation strategies; although student nurses do spend time learning in practice settings, they are most often graded on written assignments and exam scores that mimic the multiple choice questions found on the licensing exam for registered nurses (NCLEX-RN) (Day, Benner, 2015).

This broad topic of learning to think and like a nurse in actual clinical situation is a major question ripe for research in the Scholarship of Teaching and Learning in Nursing education and practice. Assessment of situated learning might be based upon the following type of questions:

  • How effective are your nursing students in learning to respond in the most clinically relevant ways in actual clinical situations?
  • How effective are your students in prioritizing what is needed for the patient’s clinical condition, and concerns? This kind situated thinking, after recognizing the nature of the whole, actual clinical situation, is one of the most relevant learning outcomes in any clinical practice.
  • How is this essential aspect of practice best taught and best learned?
  • How can we assess the student’s ability to recognize the nature of the whole clinical situation, and articulate the nature of that clinical situation to other clinicians?

To get to this vital form of assessing students’ learning to engage in situated clinical reasoning and evaluation of changes in patients’ condition across time, we will have to abandon our assumptions about formal de-situated use of formal theories and concepts.  We need to be moving to a much better understanding of situated grasp of what is most and least salient, what is highest and least priority in the immediate clinical situation. We must stop thinking of categorizing (classifying) information or formal properties under formal abstract categories as productive thinking and use of knowledge in clinical situations. We cannot assess learning based upon the ability to correctly classify or subsume items under formal categories. While classification is essential for information management, it is not sufficient for knowledge use, i.e., situated thinking in action. Note Logstrup considers “mere application of knowledge” a form of techne, a rational sorting procedure. For example, students who learn to accurately measure a blood pressure have applied technical knowledge. Students, who learn to interpret the meaning of blood pressure readings in a specific clinical context, have learned to “think productively”. They have learned to use knowledge in a specific situation. This is why we prefer the terms knowledge acquisition and knowledge use, and try to integrate both when possible in learning. Active, productive thinking is required for clinical reasoning and judgment in nursing practice. Logstrup, who is influential in European nursing circles:

Application and subsumption are unproductive processes. They presuppose understanding and cognition but are themselves neither understanding or cognition, only perhaps a control upon them…We are inclined to denigrate knowledge to subsumption…This has its place. We cannot help doing so nor can we manage without it. Only, in the meantime we have abandoned cognition [thinking] in a productive sense. Subsumption is not cognition but an application of what we have come to know, an application in which we test whether our cognition was correct (Logstrup, 1995,pp140-141).

Understanding Our Teaching in Terms of What Students are Learning

Many of the questions we ask about student learning can translate into questions about patient education and patient experience. But more importantly, assessing what our students are learning is central to be highly reliable nursing educators. We have much to learn about our students’ learning. Asking questions about student learning can open up our teaching, make it accessible and public to others. We can continuously improve our teaching through the scholarship of teaching and learning. As Dr. Mark Christian notes in his video this month, “We have everything to learn and gain by making our teaching public and accessible to others,” and engaging in assessing learning in our own classrooms is the first step. Neuro-physiological discoveries on learning has not yet sufficiently impacted education and student learning assessment. With an interest and knowledge of burgeoning neurosciences, nurse educators could be on the forefront of transforming pedagogical strategies based on the new learning science. Here are a few aspects of neuroscience changes in the understanding of the mind and learning that we should be thinking about as nursing educators:

  • Revolution in Neuro-Cognitive Science. Neuro-Net is the closest analogue to brain functioning that we have, where links between new learning are established through experiential learning. This is very different from the outmoded models of old-fashioned Artificial Intelligence. (Noe, 2009).
  • Representational Mind and Rational Calculation, Out. Embodied Realism and Immersion in experience, In: Our cultural imagination of the work of the mind is that we represent things formally, through schemes and explicit tenets and principles in the mind. This is not how the mind works! (Noe, 2009; Dreyfus and Taylor, 2015) Yet most of our testing/formal assessment tools are based upon this “meditational epistemology”…i.e., that the brain represents things and the mind mediates between the world and the knower through these representations.
  • Skills of Engagement and Human Curiosity are Central to all Learning. We imagine that the will or strength of motivation are central to learning. Indeed they play a role, but they are not nearly as important as natural curiosity born of engagement in actual situations with problems to solve. Lonergan (1992) points out that it is natural, a given, that human beings are curious; an impediment to openness and curiosity is required for it to be blocked. When teachers teach in the old fashioned banking model of just transferring information from their minds, texts, learning materials to the student, students learn that curiosity is not needed. All the puzzles have already been solved!
  • Situated Embodied Learning. Traditional cognitive theory is “distanced from experience” and divides the learning mind from the world. (Lave, 1996, p. 7). Unfortunately many using a concept based curriculum, imagine that all is required is learning the concept and that students will be able to generalize that concept to all kinds of situations where the concept is relevant. This overlooks the nature of productive thinking required for using knowledge in context. For example, pneumonia and flu conditions share many general concepts of inflammation, yet these two conditions are hard to distinguish in actual clinical manifestations of flu and pneumonia. In addition to the general concepts about an inflammatory response and the nature of infections, nurses and physicians must be able to distinguish which condition is manifesting itself in actual clinical practice. Clinicians must learn how use their conceptual understandings about the general, and add to them many perceptual and situated thinking skills to distinguish these two clinical entities in practice. The is the same issue that Chaiklin and Lave (1996) point as a gap in educational research and  learning science: “the problem of how social and physical context influences individuals’ mental processes is overlooked in educational research” (Chaiklin & Lave, 1996).
  • A Revolution in the Understanding of the Embodied Mind Situated in the World. Alva Noe (2009) points out in his accessible book on the latest in neuroscience, Out of our Heads, we must get beyond thinking that mind/brain/head are the only sources or influences on thinking. He points out that “The last 25 years have witnessed the gradual shaping of an embodied, situated approach to the mind…” Our minds never act in a vacuum. All our encounters with the world are emotionally accessed, and embodied. We as human experts can never be experts if we are de-situated, i.e. given only abstract principles separated from how they are manifested in the world. Educational researchers, such as Chaiklin and Lave (1996), call for research on how situated practical problem solving is both required and central to learning. Noe (2009) goes on to point out that embodied situated thinking has been “ignored in neuroscience, in mainstream linguistics, and, more generally in the domain of consciousness studies.”  Embodied situated thinking is ignored in learning science and educational research.
  • Bringing Mind-Body-World Back Together. Leaving behind a representational view of the mind means that we, in practice, in assessment need to leave behind the Cartesian Mind Body Split. We also have to develop more terms between the formal measurements of the mental (e.g. I.Q. tests, Attitudes, Beliefs, Explicit preferences and so on) and more terms between the formal measurements of the mind and the formal measurements of the mechanistic physiological body (e.g. genome mapping, biochemistry of cells, functions of organ systems in interaction). We cannot get along without these formal measurements. That is not the point. They are necessary, but not sufficient! Here are some middle terms that we need to design our learning and assessments of learning around. We will need contexts of engaged embodied skillful know-how, and situations of productive thinking about how to use knowledge in particular situations. Between  the formal measurements of the thinking mind and the measured physiological body are in-between aspects of the situated, skillful body. The body we dwell in, through our skills, habits and practices, and language is a social-sentient (social, feeling, and engaged) body. Thinking about the in-between terms of the explicit measurable mental attributes, and the measured, mechanistic physiological body, lies our everyday engaged, social sentient body. Perceptual grasp (essential to recognizing the nature of the whole clinical situation), embodied intentionality (eg., placing a needle for best access to a vein), taken-for-granted background meanings, habits, rituals, practices – all of these depend on the skillful social, sentient body. Embodied learners are immersed in the world and when not impeded, are curious and learn from experience through the social, sentient body.

References:

Bain, K. (2004) What the best college teachers do. Cambridge: Ma: Harvard University Press.

Boyer, E.L., Moser D/(Todd C. Ream, John M. Braxton Associates (2016) Scholarship Reconsidered, Priorities of the Professoriate, Expanded Edition Francisco: Jossey-Bass and Palo Alto), Carnegie Foundation.

Chaiklin, S., Lave, J. Understanding Practice: Perspectives on Activity and Context (Learning in Doing: Social, Cognitive and Computational Perspectives). Cambridge, MA: Cambridge University Press.

Day, L., Benner, P. (2015) “The Hidden Curriculum in Nursing Education, Ch. 12” in Hafferty, FW & O’Donnell, JF, (Eds.)The Hidden Curriculum in Health Professional Education. Lebanon: NH: Dartmouth College Press, University Press New England.

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

Dreyfus, H.L.  (2014)  (Edited by  M.A. Wrathall) Skillful coping. Essays on the phenomenology of everyday perception and action.  Oxford, UK: Oxford University Press.

Dreyfus Interview with Patricia Benner: (http://www.educatingnurses. com/mastery-in-teaching-with- hubert-l-dreyfus/)

Hutchings, P., Huber, M.T. & Ciccone, A. (2011) The Scholarship of Teaching and Learning Reconsidered. Insittuional Integration and Impact. San Francisco: Jossey-Bass.

Logstrup, K. (1995)Meataphysics (Vol. 1)Milwaukee, WI: Marquette University. Pp. 140-141.

Lonergan, B. (position1052; 1992) Insight, a study of human understanding. Toronto, Canada: University of Toronto Press.

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

Dr. Pat Hutchings, and Dr. Mary Taylor Huber (2005 & 2011). Hutchings and Taylor (2005) descri

Shulman, L. (1993) The Wisdom of Practice, Essays on Teaching and Learning and Learning to Teach. Sam Francisco, CA: Jossey-Bass and Palo Alto: Carnegie Foundation.

Sullivan, W., Rosin, M. (2008) A New Agenda for Higher Education, Shaping a life of the mind for practice. San Francisco: Jossey-Bass & Palo Alto: Carnegie Foundation for Teaching.

Taylor-Huber, M., Hutchings, P. (2005) The Advancement of Learning, Building the Teaching Commons. With Foreword by Lee S. Shulman. San Francisco: Jossey-Bass and Carnegie Foundation.

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