Higher-Order Productive Thinking in Clinical Teaching and Learning

Higher-Order Productive Thinking in Clinical Teaching and Learning

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Situated Learning, Understanding Learning as Embodied, Embedded in Context, and Extended in Interaction with Context — A Video of Situated Use of Knowledge in Clinical Learning

EducatingNurses.com, Patricia Benner, R.N., Ph.D. FAAN   March 10, 2018

Practice-based learning requires that the student learn directly from practice, not just apply theory, but through attentiveness and curiosity gain new insights and understandings directly through experiential learning in practice. Learning how and when as well as learning a sense of salience (salience means that some things just stand out as urgent or more or less important) are forms of higher order productive thinking because they require situated thinking in context. Learning how and when are both essential for clinical reasoning and situated knowledge use in actual situations. Educators in all practice disciplines have erred on the side of thinking that all knowledge use is just a matter of “applying” what is known conceptually and technically. However the “application” model of knowledge use is too narrow, and consequently misleading. Using knowledge in actual situations requires understanding the nature of the whole situation, what is most and least important in the particular clinical situation (a sense of salience—a sense of the meaning of a whole situation).

A situated sense of salience and understanding the most relevant causes of a patient’s clinical condition and the effects of the therapeutic measures are essential for good clinical reasoning. All clinicians must engage in understanding patient changes across time and explanation of the most likely causes and effects of the patient’s current clinical condition. The most accurate terms for this thinking capacity are clinical reasoning and situated cognition (Benner, Hooper-Kyriakidis, Stannard; Lave and Wenger, 1991; Lave, 1996), a form of practice-based knowledge embodied, socially embedded and extended. Current embodied, socially and contextually embedded views of the mind and knowledge have implications for any practice discipline. The current Neuro-Science and Cognitive views of the mind include: the extended, embodied, and contextually embedded and interactive mind. This view goes beyond the Cartesian representational mind that supposedly exists within the head (Gallagher, 2009; Noe, A.2009). This current view of the mind is interactional and extended out into an environment replete with embedded meanings that solicit responses. The embodied, contextually embedded skillful, experienced person has developed a sense of salience about what is important and unimportant in familiar situations. The extended mind is made possible by the embodied, and contextually embedded mind. For the experienced learner, a common pedagogical error is decontextualizing (objectifying) thought apart from the person’s situated participation in the world (Noe, 2009; Dreyfus 1997; Dreyfus and Taylor, 2015). The Cartesian view of the representational inner mind and the older computational models of the brain in Old Fashioned Artificial Intelligence, fit the behaviors and thoughts of an inexperienced novice, but fail to account for the neurological evidence that the experienced or practiced mind is embodied, embedded and extended in interacting with already meaningful environment.

The previous EducatingNurses.com newsletter article pointed out the mistaken imagination that clinical learning and situated cognition mimics the Old Fashioned Artificial Intelligence modeled on the computer:

Human experts do not think or learn like the old-fashioned formal, explicit, artificial intelligence that was built upon logical, rational assumptions. This narrow view of rationality used in OFAI assumed that human minds used representations and generalizations applied to practical situations. The old-fashioned AI (OFAI) left out any role of holistic grasp of the situation and the role salience (a deep background understanding of the significant aspects of a situation that must be addressed immediately). With OFAI, particularly evident in clinical cases and perception of actual whole practical situations were left out. Hubert L. Dreyfus’ critique of OFAI led to a revolution in the approach to artificial intelligence. Now the newer artificial intelligence machines and programs are more closely modeled on how the mind works in dealing/coping with the everyday world (Dreyfus, Wrathall Ed. 2014). The newer AI uses neural networks that are designed to learn from repeated exposures to practical problems. While still not a perfect mimicking of human learning, these machines deal with many of the problems that the OFAI did not address. With the neural networks, fuzzy recognition of practical situations can be accomplished. Also, through strengthening links between what works and diminishing links that do not work, the neural networks can improve performance over time with repeated exposure to practical problems. This approximates learning and fuzzy recognition that is quasi emotional in perceptual grasp in human beings.

Our pedagogies in academia have mimicked OFAI. We attend to de-contextualization and breaking situations down into isolated (non-overlapping) elements (often in the form of criteria generated for yes and no decisions), that are explained and summarized by formal concepts or theories. This strategy for generalizing across clinical situations is pervasive in academia, and in most practice disciplines (Sullivan and Rosin, 2008). While generalization is useful, it is insufficient to teach a clinician a sense of salience in actual clinical situations. With teaching and learning only about the general, the student does not learn to think about and recognize distinctions, contrasts, and relationships between the general and particular. This narrow rational-technical approach focuses on a direct 1:1 correlation between precepts. Unfortunately, the exclusive use of the precept misses much of the perceptual holistic grasp and deep understanding of actual clinical situations. Perceptual grasp of essential distinctions between clinical situations and within an unfolding history of a patient’s condition, the particular in relation or contrast to the general, is essential for clinical reasoning and judgments about the particular (Rethinking Clinical and Classroom Teaching December 2017, EducatingNurses.com)

Ignoring what is directly learned, or capable of being learned directly from first-person contact with the situation from practice unintentionally devalues clinical learning. Beyond the first year Novice Stage (Benner, Tanner & Chesla, 2009), the experienced learner can encounter rich contextual content learned through perceived contrasts and similarities from prior clinical experiences. For example, “Concept Mapping” [i] is a great and fitting learning approach to examining and contrasting formal concepts used in studying a group of research articles. However, to have students do concept mapping of their fresh, layered contact with real clinical situations unwittingly assumes that direct experience must be translated into decontextualized formal concepts in order to count as “knowledge.” Mapping only formal concepts in the student’s particular clinical situation blunts and overlooks layered, unfolding temporal aspects of the situation that play a key role in clinical reasoning in the particular situation; e.g., sequencing and meaning of events. Formal concepts also overlook essential perceptual aspects such as qualitative distinctions in changes in the patient’s condition, or changes in wounds and so on, (e.g. patient is less confused, and more able to stay on a topic today; wound has healthy-looking new granulated tissue with very little exudates). “Formal Concepts” get their generalization power by leaving out perceptual, contextual aspects of the clinical situation. And it is this very contact with the rich reality of clinical situations that development of expert clinical reasoning requires (Dreyfus and Taylor, 2015).

For clinical experiential learning, students require skills of interpretation and understanding, much like they use in narrative accounts of real events. Narratives include sequencing of events for understanding. Reflecting on the unfolding of clinical cases helps the student to learn reasoning across time about the particular, through changes in the patient’s clinical situation and/or changes in the clinician’s understanding of the clinical situation (e.g. “I thought the patient was volume depleted, but the patient’s heart was failing and unable to move blood effectively in the cardiovascular system.” See, Benner, et.al., 2010). Having students narrate their understanding of the unfolding case they have just experienced can teach situated thinking, but de-contextualizing or objectifying that experience through listing plausible formal concepts in the situation, removes the thinker from the layered, textured, contextual and sequential aspects of the situation.

The pedagogical approach of translating direct learning from clinical situations into formal concepts overlooks, and unwittingly devalues, what can be learned directly from the particular clinical situation. In any clinical or practice discipline, non-conceptual learning is essential for advanced levels of expertise, and mastery (Dreyfus, 2014 ). Stuart Dreyfus uses the example of the outfielder’s non-conceptual learning of how to catch a field ball in baseball. The catcher over time learns when to move up on the ball to catch a “fly ball”; when a ball is likely to bounce before the catcher can get to it, when to run back, deeper in the field for the catch (Dreyfus, 2014). Similarly, the feel of a patient’s veins is non-conceptually learned over time by nurses learning to insert I.V.’s and doing veni-punctures to draw blood. While the nurse may give reasonable explanations for their decisions about which veins would work for I.V.s, this qualitative assessment is first learned across time by comparisons of the qualities and states of many patients’ actual veins. Other examples of perceptual (non-conceptual) learning are situations where anger is escalating; or patient is less stable when standing or walking. Sharpening students’ skills and astuteness in comparing whole clinical situations increases their noticing capacity, and sense of salience in actual clinical situations.

Teaching students to value only application of formal concepts in order to learn clinical reasoning about particular patients is misleading, because it overlooks the importance of non-conceptual and perceptual learning occurring in actual clinical situations, as well as what can be learned directly from past whole clinical cases and brought forward to new similar or contrast cases. Relational skills and skills of engagement with patients are essential to learning directly from clinical experience. In our research, we have learned that without good skills of engagement, nurses do not become experts, presumably because they close off much of the information that they would learn communicating with patients and much of what they would notice and learn from being and attentive and engaged with the patient’s concerns related to their illness (Benner, Tanner, Chesla, 2009; Benner Kyriakidis, Stannard, 2010; Kyriakidis, 2018, Personal Conversations with Dr. Kyriakidis about her research on ‘nurses learning in practice’).

First person experience-near accounts about the student’s clinical experience reveal a lot about the student’s communication and relational skills. For example, if the students’ narratives reveal little about the patient’s life and concerns, as a listener, you learn little about the patient and family, the listener has to wonder and inquire about the extent that the student nurse was engaged with the patient and family life, and concerns (Benner, Hooper-Kyriakidis, Stannard, 2010). If the nurse does not know the patient and family in terms of concerns, habits, practices, and skills, then assessments of the patient will be missing much essential knowledge for understanding of the patient/family life as well as meanings of the patient’s illness.

What are the teaching and learning implications of a more up-to-date understanding of learning sciences and neuro-scientific understandings of a post-Cartesian non-representational mind? You can add to these implications, given below, by thinking of your own most successful practice-based teaching-learning exercises. Here are some teaching-learning strategies for clinical teaching that can sharpen students’ powers of perception, conceptual and non-conceptual learning about whole clinical situations:

Narrative Accounts of Real Clinical Situations as they Unfolded for the Student

  • By having students retell their clinical experience with particular patients you can pick up on their sense of the whole situation, and sense of salience. For example, where did the narrative begin and end? What were the concerns of the student in relation to their understanding of the whole situation? What kinds of questions or puzzles did the student express in the narrative? You and/or other students can help the student unpack hidden or untold aspects of the story by asking questions about puzzles or silences in the story: “Why was the adolescent boy angry at his father for leaving during chemotherapy? First-Person-Experience-Near Narratives (Geertz, 1977) can help you examine and make visible significant aspects of context and timing of actions in the stories. Stories are both sequential and circular, in that, the unfolding of timing of events in the story are usually revealed and that narrators, can always inject earlier overlooked aspects of the story as in: “I forgot to mention that I was concerned about his blood pressure earlier” and so on. In reading and understanding narratives of actual clinical situations, the teacher models openness, curiosity, interest and attentiveness in the clinical situation. These are essential attitudes and habits of an excellent practice-based learner. (See Newsletter entitled: “The Role of Narrative Pedagogies to Bring Clinical into the Classroom” and “Integrate Knowledge Acquisition with Knowledge Use,” April 7, 2014, for more specific guidelines on using narratives of clinical practice for teaching and learning.)

Debriefing on Clinical Learning after Clinical Practicum

In the Carnegie study (Benner, et. al., 2009), we found that “clinical debriefing” was often turned over to adding content that had been omitted during classes, so that the valuable learning time of reflecting on practice, and learning directly from practice was shortchanged. But we also found that many teachers used clinical seminars effectively, by going over the students’ learning experiences and new insights learned from patients.

Developing astute clinical judgments about complex clinical concepts and phenomena require deeper learning in clinical assignments that focus on comparing and contrasting patients who demonstrate the clinical phenomena of concern. The brief video clip below (available to all readers of this newsletter) is great example of a very effective clinical debrief from Oregon Health and Science University. In this video, Linda Brown, R.N., M.S., demonstrates how she develops and works with assigning students in-depth study of key concepts during their clinical time. We observed her concept based class on Electrolyte and Fluid Balance in a pediatric population. A concept-based clinical provides a wonderful opportunity to learn to make a clinical judgment case to other clinicians based directly on the patho-physiological implications of patient data.

In concept focused clinical experience, rather than give total patient care, each student has been assigned to study from the chart and directly from patient assessment, and questioning of nurses or physicians caring for the patient, questions about the particular patient risks for dehydration, or other forms of fluid and electrolyte imbalance. This is a great example of the logic of situated clinical reasoning–situated cognition. The students examine the variations and particularities of the broad general concept of fluid and electrolyte imbalance. For the clinician, the higher-order thinking required is to examine the particular in relation to the general, and vice versa. Rather than mere “application” of a general concept, (e.g., identifying the relevant broad general concept involved) the student must examine variations and particularities of formal concepts manifest themselves in actual situated clinical practice. This is a great example of the deeper learning required in clinical practice. The particularities of clinical situations also show up in errors, as well as a broad range of unique variations encountered in practice.


When students had a patient care error, or a difficult patient-care situation, teachers often met with student prior to the debriefing, and asked if the student would be willing to tell his or her classmates about an error, or a difficult situation with a patient. Students were often willing indicating ‘that they would not want their classmates to make the same mistake or fail to recognize another similar patient/family concern.’ This kind of response affirms the tradition of an ethic of self-improving practice, and taking responsibility for helping fellow nurses improve their practice. Kerdeman (2004) calls this “being brought up short in practice” which is an essential part of experiential learning and consciousness raising in any learning arena. All professional practices share this kind of socially linked responsibility for practice improvement. Such learning, along with discoveries that one had been mistaken about a pre-understanding and then turned around by actual experience are great examples of “formative” clinical learning. In such a change in understanding, learned experientially, the student develops some aspect of skill, character or habits directly from practice. Such experiential learning is the hallmark of the third Universal Apprenticeship in Practice Disciplines: “Ethical Comportment and Formation of any practice discipline (Benner et. al., 2009).

Do You Have any Examples of Patients/Families Learning or Gaining Insights on their Clinical Situation?

These open-ended questions call for the student to be curious and attentive to the patient’s learning during their hospital stay. These can also reveal unanswered questions, or confusion on the part of the patient. Or, the student may be surprised by the learning and insights gained by the patient during their hospitalization. Questions about the patient/family learning about the patient’s illness can enhance the student’s understanding of the patient/family experience. Also, the student can gain insights about the patient/family concerns and learning during their hospitalization. A better understanding of the patient/family concerns can enhance situated coaching of the patient/family about an illness trajectory and what they expect in terms of what kind of care will be required after discharge.

Particular Questions Formed by Students and Teachers about the Student’s Presented Clinical Situation—Unpacking the Story and Stretching the Student’s Clinical Imagination

Student and faculty guided articulation, paraphrasing one’s own understanding and verifying it with the clinical learner, are great ways to encourage reflection on practice and learning directly from practice. Probing questions that demonstrate curiosity and attentiveness to details of the story can enhance clinical imagination. By actively listening to the students’ narrative account of their clinical experience, faculty can open the story and enhance understanding by the student. The goal is to enhance the student’s imagination and curiosity. Often students are so focused on their goals for the patient they miss finding out about what the patient’s concerns and questions are. Asking questions about the student’s experiential learning can shift that focus to one of seeking to understand their patients’ experience and concerns.

Ask the student about any silences, puzzles or hidden patient/family concerns, in their care of the patients.

Through questioning, help the student name any silences, puzzles, or hidden ambiguous patient-family concerns. Helping the student articulate any silences, puzzles or concerns enables them to engage in conversation with the patient/family directly about their unarticulated concerns.

What does the patient think caused their particular illness, e.g. stroke, heart attack, cancer?

In everyday language, get the story of the patient’s illness and their understanding of how and what brought the illness on. They may have understandings of the illness that influences how they think about recovery and their future. For example, patients who have a stroke sometimes think that the “falling down” associated with their stroke was the cause of the stroke. Medical Anthropologists have called how patients/families understand an illness and its causes, “informal models of an illness”. (Good, B. 1994; Kleinman, A.1988). Here’s a sample question to understand informal models of an illness: “What do you think brought your illness on?” This question is open ended enough to capture their informal models of disease causation and cure or recovery. Nurses are often the health care team members who bridge the gap between the patient’s informal models of causation and cure with the more scientific medical explanations.

What does your patient think is required for their recovery?

Often students assume that the patient holds a scientific causal view of causation and recovery from an illness, and do not ask questions about the patient/family understanding of the illness, nor their imagination of what will be required (experienced) for recovery. This kind of questioning about informal views of illness and recovery clarifies the patient/family concerns and perhaps misconceptions about their illness (See Good, 1994).

Did you check for any drug interactions or conflicting treatments at cross purposes evident in the patient’s regimen of care?

If the student has not considered possible out-dated lab tests, contraindicated mixing of medications due to negative drug interactions, prompt them to do this search in the patient’s MR on the following day. One of the metaphors for clinical learning at University of Washington School of Nursing in Seattle, Washington is to encourage students to be detectives, seeking out overlaps, or conflicting aspects of the patient’s treatments or medication, or outdated, but continued collection of lab work and so on (Benner, et. al., 2009).

What kind of discharge plans have been made for the patient?

To find out current discharge planning, the student can ask the patient, check the MR, or phone the relevant Discharge Planner. Are there missing aspects to the discharge plan? What does the patient/family imagine about discharge?

How will you Improve on the Patient-Care You Gave Today, Tomorrow?

This question was asked in the majority of clinical debriefings we observed in the Carnegie National Study Nursing Education (Benner, et. al., 2009). It is a great example of teaching for formation by encouraging students to develop a self-improving practice. This question stimulates reflection on how to make improvements in sequencing, scheduling, and/or carrying out therapies ordered for the patient and more. This question focuses on formation of the student nurse, since it encourages ongoing improvement of practice. Continuous improvement across time is one of the key criteria of recognizing and encouraging robust practice-improvement. In addition to science, increasing knowledge development, and policies that support good practice are essential sources of continuous improvement in practice. A practice that doesn’t continue to improve is more like a historical museum (classified and fixed in time) than a living and growing professional practice.

As we continue this series on clinical teaching and learning we will examine how to facilitate learning directly from practice through reflecting on and interpreting meaning, actions and insights gained from clinical experience.


  1. [i] I am indebted to Dr. Laurie Gottlieb, Professor at McGill University, Montreal, CA for this fitting example for the use of “Concept Mapping”



Benner, P. Rethinking Clinical Education, EducatingNurses.Com January, 2018.

Benner, P., Sutphen, M., Leonard, V., Day, L. (2009) San Francisco: Jossey-Bass, Carnegie Foundation (Palo Alto, CA)

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

Benner, P. Hooper-K yriakidis, P. Stannard, D. (2010 2nd Ed.). Clinical Wisdom and Interventions in Acute and Critical Care: A thinking-in-action approach. (2nd). New York, NY: Springer.

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

Dreyfus, H.L. (1997) What Computers Still Can’t Do. Cambridge: MA: MIT Press.

Dreyfus, H.L. and Dreyfus, S.E. (1982) Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. New York: Simon and Schuster.

Dreyfus, S.E. (2014). System 0:  The overlooked explanation of expert intuition. Chapter 2 in M. Sinclair (ed.), Handbook of Research Methods on Intuition. Edward Elgar Publishers, Cheltenham.

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

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

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

Hooper-Kyriakidis, P(2018) Personal Conversations with Dr. Pat Hooper-Kyriakidis on her research on learning in practice. In Progress.

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

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

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

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

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.



Patricia Benner


  • Theresa Bucy says:

    Thank you for this timely piece! The pendulum has swung quite far in the direction of conceptual teaching and use of simulation to replace clinical. In their places, those practices have value. However, abandoning actual clinical time spent in a context and communicating with people Is not supportive if the new nurse’s need to become familiar with the practice setting. That familiarity is essential to ultimately being able to identify variations that require the nurse’s attention.

  • Donna Hedges says:

    I agree that new nurses must become familiar with caring for patients and families in the actual practice setting. Active time in the clinical setting, however, is complicated by the lack of clinical sites available to schools of nursing, especially in areas that are saturated with nursing programs. In addition, one speaker at a national conference identified the fact that the major hospital system in her area gave priority to BSN over ADN programs thereby necessitating her program to develop activities outside the clinical setting in order to fulfill the clinical hours for their program. Another complicating factor is that of increasing student enrollment leading to numbers of students in a clinical group exceeding state board requirements for faculty to student ratios. In this case, faculty are given the task of designing “creative” ways to meet clinical hours. Simulation, while not equal to the experience of hands on actual patient care in a clinical setting, provides an environment in which students can develop critical thinking through learning from each other as well as from “mistakes” and debriefing during high fidelity simulation.

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