Patricia Benner, R.N., Ph.D. FAAN, 2017
Our pedagogies of clinical and classroom teaching are still lodged firmly in the old-fashioned artificial intelligence mode (outdated cognitivism) and outdated neuroscience models about how the brain works. Old-fashioned artificial intelligence and cognitivism ignore the necessary role of embodied skilled know-how and perceptual grasp of actual clinical situations for any form of higher order thinking and sense-making.
Thus, Merleau-Ponty’s (2002, Transl.) claim that the representationalist accounts of our most basic and pervasive forms of learning and skillful action are mistaken, and that a different account is required, can be defended not only on phenomenological grounds, but on neuroscientific grounds as well.
-Hubert L. Dreyfus (2014, p. 245)
We have been emphasizing the imperative of integrating classroom and clinical teaching in many of our articles. Students need to learn in an integrated way the context for using the knowledge they gain in the classroom. We found in the Carnegie Study that classroom teaching in nursing education emphasizes knowing that, knowing why and knowing about; i.e., abstract theory, formal explanations and survey descriptive knowledge. A current major area in educational research focuses on the discontinuities between understanding and using knowledge in context and the abstract decontextualized learning of science, and principles in the classroom; i.e., knowing-about and knowing that. Most nursing students, especially during the first year and one-half of nursing, have little or no clinical imagination for contextualizing, or thinking about clinical situations where knowledge of science and nursing theory might be relevant. Teachers may be unaware of the student’s lack of clinical imagination. Knowing that, and why and knowing how and when are higher-level cognitive abilities. In any clinical practice (medicine, nursing, law, and so on), learning both knowing that and knowing why is essential to becoming an expert. Of equal importance — learning how and when while also learning a sense of salience; meaning that some things just stand out as urgent or more or less important in a clinical situation.
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 decontextualization 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.
The example I have used in past articles is that of accurately measuring a blood pressure, contrasted with interpreting what that blood pressure means in understanding the trends and trajectory of a particular patient’s blood pressure related to that patient’s history. So, narrow application of blood pressure-taking techniques are not the same as interpreting and understanding the meaning of a blood pressure reading in a particular patient. Interpreting the meaning of a blood pressure in the context of a particular patient’s illness trends is a great example of using knowledge in the particular case, i.e. knowing how and when.
Bourdieu (1980) has written much about the distinctions between direct perceptual grasp and holistic understanding of a whole situation, characteristic of local knowledge and human expertise in any practice. All practical situations are too complex to be captured completely by breaking the situation down into formal elements. This phenomenon, called the “limits of formalism”, is solved by practical holism by the human mind. For example, the expert clinician recognizes the nature of a whole clinical situation, and proceeds from that understanding, and from the relevant situated skilled know-how (Dreyfus & Wrathall, 2014 Benner, Tanner & Chesla, 2009) gained over time in actual clinical practice. Expert clinicians use high fidelity whole past experienced clinical situations for their perceptual grasp of the nature of the whole clinical situation. For example, “this is a situation where respiratory distress” is the primary concern at this time; or “this is a situation of heart failure, or volume depletion”. Actions and further assessments flow from this experience-based holistic grasp of the situation. Human beings encounter a real world of perceptual understandings, and meaningful distinctions. Those who teach first-year nursing students (novices) must help the student understand the nature of the whole situation prior to their experiential learning to do so. This world of everyday perception and coping is pre-reflexive, even within a highly reflective practice. As Dreyfus and Taylor point out in their book, Retrieving Realism (2015):
…It seems clear to us that there is an important place for what we might call the prereflexive in our everyday world, in this kind of everyday grasp of our surroundings, establishing an equilibrium with them, which we described in Chapter 3, following Merleau-Ponty. We can in fact see a place for two modes of such prereflexive understandings: the prelinguistic, on one hand, and the pre-propositional on the other. Pp. 84-85.
It is a pedagogical mistake to omit the powerful role of non-representational thinking, and perceptional grasp in teaching any situated skillful coping, perceiving and thinking in a clinical practice. This is why deductive approaches to teaching and learning have grave limits in learning a complex practice such as nursing and medicine. Dreyfus (2008) has taken up the pre-reflexive skill of seeing essential for clinicians that is overlooked in mere telepresence of a camera strapped on the head of a practitioner. The clinician has to position him or herself to get a good perceptual grasp of actual clinical situations and this cannot be captured by the camera strapped on the clinical teacher’s head. The clinician needs to adjust their bodily position for the best grasp of the situation at hand. Stuart Dreyfus (2008) gives the example of pre-conceptual learning in baseball as outfielders learning how to move to catch a ball. Might it bounce? Should they move back? This is all learned by direct experiencing fielding balls. This direct non-conceptual learning is also essential in any practice discipline such as nursing or medicine. As Dreyfus states in explicating Merleau-Ponty and Samual Todes:
The brain basis of comportment, therefore, cannot be an equilibrium formed in the brain alone [or with abstract conceptual thinking alone], but a tendency toward equilibrium of the active organism in the situation that reflects the meaning of that situation for the organism. (Dreyfus, 2014, p. 246-247)
This is not a subject we can fully explicate and illustrate in one article. In the following months, we will give examples of how this is relevant in clinical teaching and learning. But you can review our videos where teachers are using unfolding real cases in the classroom for excellent examples of teaching for perceptual grasp as well as conceptual understanding.
This month’s video is a “discussion trigger” that focuses on raising students’ level of consciousness and also their perceptual acuity about the patient’s perspective on being admitted to the hospital. Dr. Elizabeth Cohn portrays a hospital patient who throws her food tray in frustration about her situation in the hospital. Possible discussion questions are myriad. The students may come up with their own. But here are a few that may get you started:
*What do you think are the patient’s major concerns?
*What are some the causes of her confusion and anxiety?
*For the patient, what is the most important aspect of this illness experience?
*How does the life-world of this patient figure into her concerns?
*How might you address the patient’s concerns about her illness and about her family caregiving?
As a teacher what aspects of the students’ clinical imagination would you like to see developed by viewing this patient’s concerns?
In the coming months we will look at the relevance for current neuroscientific and phenomenological understandings of how the human mind works in situated thinking and action.
In particular we will take up Dreyfus’ observations on the distinctions between human expertise and OFAI. To give an advanced organizer for teachers and learner to think of in terms of the pedagogical implications of thinking about distinctions between narrow rational-technical approaches (OFAI), we will explore the distinctions that Dreyfus (1997) discusses in What Computers Still Can’t Do listed here:
The Role of the Body in Intelligent Behavior
In thinking about human learning we need to take into account how the human mind is both embodied and socially embedded. This is why actual situated clinical learning and coaching whether in an unfolding case, simulation, or an actual clinical situation are necessary to learn the skilled coping of nursing, medicine, social work, teaching, and other practice disciplines. The skills of seeing, i.e., perceiving relevant aspects of particular clinical situations are both embodied, in terms of positioning the body for the best or optimal perceptual grasp of the situation.
The Situation: Orderly Behavior Without Recourse to Rules.
The nature of the whole situation, guides the clinician in understanding how to proceed, what to pay attention to, what information to gather, what interventions might be urgent and so on. Much research in education focuses on situated thinking, and engaged skillful coping (Lave 1996, Dreyfus, 1997; Benner, Hooper-Kyriakidis & Stannard,(2010). Often the practical solving of problems may demonstrate theoretical knowledge that the student does not yet understand, e.g. solving Bayesian statistical problems in baseball statistics through a practical understanding of how statistics are relevant in baseball. The holistic grasp of the nature of the situation allows human experts to deal with complex situations without getting lost in identifying every possible variable, a problem of endless regress, or infinite listing of variables in practice situations. So an understanding of the salient aspects of a situation helps the nurse to function in the moment to do what is needed based upon what is most significant about the patient’s situation.
The Situation as a Function of Human Needs
Dreyfus (1997, p.372) notes:
We are at home in the world [think of clinical nursing practice world] and can find our way about in it because it is our world produced by us in the context of our pragmatic activity.
Nurse educators often talk about teaching their students how to take the “action step”, by knowing where to find the essential emergency medication and even how to open and prepare it for use. The second apprenticeship in professional education is teaching students how to get around in the world of practice. This world contains many goal directed practices, e.g. allaying the patient’s fears and misunderstandings about their clinical condition or treatment, receiving or giving report, checking the patient’s physician orders, helping the patient to understand the foreign world of clinical practice and so on. The student has to learn to get around in the practice by way of understanding what the patient needs for optimal recovery.
For example, in a difficult task of weaning a patient from the respirator, the clinician and patient herself, may not believe that they will be able to get off the respirator, but through patience, skill, and past experience with weaning patients from respirators, the patient and clinician may succeed, even though it is ambiguous from beginning to end. It may even seem improbable, before and after the patient has been successfully weaned from the respirator. This is skillful coping on the part of both patient and nurse, along with trust and a collaborative partnership to achieve a difficult goal. It is precisely the kind of learning that prepares the student to be more practice ready, and better prepared to directly learn from clinical experience.
Educators planning for clinical teaching and learning need to understand how to structure clinical experiences so that students gain capacities to get around in the practice world, understanding the goals and needs that respond to what is significant and salient in that world. This discussion will continue in the next months as we focus on integrating clinical and classroom teaching and how current understandings from neuroscience on how human beings learn can better guide our clinical teaching and learning (rather than narrow objectives and pedagogies shaped by OFAI).
References and Bibliography
Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Stanford: Carnegie Foundation for Teaching and Learning.
Benner, P., Hooper-Kyriakides, P., Stannard, D. (2010, 2nd Ed.) Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach. New York: NY. SpringerBourdieu, (1980) The Logic of Practice. Stanford, CA: Stanford University Press.
Dreyfus, H., Taylor, C. (2015) Retrieving Realism. Cambridge: MA: Harvard University Press.
Dreyfus, H.L., Wrathall, M.A. (2014) Skillful Coping: Essays on the phenomenology of everyday perception and action. Oxford, UK: Oxford University Press.
Dreyfus, H.L. (2008) On the internet. Thinking in Action. New York, NY: Routledge
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.
Lave, J., Murtaugh, M.,&de la Rocha, O. (1984). The dialectic of arithmetic in grocery shopping. In B. Rogoff&J. Lave (Eds.), Everyday cognition (pp. 9–40). Cambridge, MA: Harvard 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)
Merleau-Ponty, M. (2012) Phenomenology of Perception.
Donald A. Landes (tr.),Abington-on-Thames, U.K.: Routledge University Press.
Noe, A. (2009) Out of our Heads. Why you are not your Brain and Other Lessons from the Biology of Consciousness. New York, NY: Hill and Wang.
Noe, A. (2004) Action in perception. Cambridge, Mass.: M.I.T. Press.
Rosch, E., & Lloyd, B. B. (Eds.) (1978), Cognition and categorization. Hillsdale, NJ: Erlbaum.
Saljo, R., Wyndhamm, J., (1993) “Solving everyday problems in the formal setting: An empirical study of the school as context for thought.” IN: Chaiklin, S., Lave, J. (1993) Understanding Practice. Cambridge, UK: Cambridge University Press. Pp. 327-342.
Saxe, G. B. (1991). Culture and cognitive development: Studies in mathematical understanding. Hillsdale, NJ: Erlbaum.Saxe, G. (1999).
Shapiro, L. (2010) Embodied Cognition. New York, NY: Routledge
Sullivan W. & Rosin, M. (2008) A New Agenda for Higher Education: Shaping a Life of the Mind for Practice 208, Carnegie: Stanford
Todes, S. (2001) Body and World Cambridge, Mass.: M.I.T. Press