This dominant clinical teaching focus on knowing that and knowing about, with little focus on knowing how and when causes clinical educators to overlook the kinds of learning experiences and clinical teaching practices that help new nurses develop life-saving, situated clinical nursing assessments and interventions.
©2018 Patricia Benner, R.N., Ph.D., FAAN, Lisa Day, R.N., Ph.D.
EducatingNurses.com July 31, 2018
Recognizing the nature of whole clinical situations is the most essential ability in nursing and is a skill pervasive in the daily practices of expert nurses (Benner et al. 2010, pp. 17-65). Practicing nurses use clinical reasoning and judgment to solve situated clinical puzzles daily. The best clinical teaching and learning is always situated in a particular context and temporal sequence of changes in a patient’s clinical condition. To rescue patients, and to anticipate and prevent patient crises, clinicians must learn how to recognize early changes in the patient’s condition and reason through practical situations that change – sometimes rapidly – over time. This requires learning how to engage in on-the-spot clinical inquiry while marshaling the available resources to manage an evolving or impending patient crisis. These central aspects of daily nursing performance require perceptual acuity and wholistic grasp of the nature of the situation (e.g. a situation of respiratory distress, hypovolemic shock, early sepsis, and so on). Yet clinical teaching seldom focuses on patient and clinical problem engagement by the learner. Often teaching in clinical settings, much like in academia, devolves into didactic sessions on theory, procedures, protocols, and the latest practice guidelines. While necessary, these areas of content are not sufficient to improve new nurses’ skills in clinical reasoning and judgment and will not result in improved clinical performance leading to improved patient outcomes.
Yet, what images come to mind when you think about clinical learning? Many teachers imagine the general clinical implications of disease states, recovery trajectories, patho-physiology, pharmacology, practice guidelines, policies, and the steps to the latest procedures. But clinical teachers and learners would agree that knowing the scientific facts and other formal, decontextualized concepts, including general practice guidelines, procedures, and algorithms for patient care, while necessary, is not sufficient to practice safely and effectively as a nurse. Nurses must develop situation-specific, practical, problem-solving skilled know-how that enables them to grasp 1) the significance of the whole situation and of clinical trends as they evolve, 2) notice subtle changes in the patient’s clinical condition, engage in clinical detective work solving clinical puzzles, and communicate changes and recommendations to the health care team. Decontextualized teaching about pathophysiology, signs and symptoms and so forth teach “knowing that” (e.g. detailed features of cardiac failure) and “knowledge about” (lists of signs and symptoms of various clinical conditions) but knowing about decontextualized elements of clinical conditions does not necessarily teach the student to recognize these elements in context. Although central and paramount to best nursing practice and to good patient outcomes, a wholistic grasp of the nature of the clinical situation and situated knowledge use is usually not the deliberate focus of clinical teaching or learning. Clinical teaching tends to focus on “knowing that and about” particular clinical conditions and disease states. Yet the clinician needs to be able to recognize when disease states are manifesting themselves and use that knowledge with appropriate timing and sequencing of interventions in specific evolving situations. This dominant clinical teaching focus on knowing that and knowing about, with little focus on knowing how and when causes clinical educators to overlook the kinds of learning experiences and clinical teaching practices that help new nurses develop life-saving, situated clinical nursing assessments and interventions. In this paper, we discuss the importance of wholistic grasp in nursing practice demonstrated by clinical teachers for the novice to competent stages of skill acquisition. We emphasize the vital role that situated coaching and learning, directly from whole practice situations play in the development of clinical reasoning skills and good clinical outcomes. And we make recommendations for including this kind of clinical teaching and learning in both practice and educational settings.
Wholistic Grasp and Novice to Expert Skills Acquisition
It bears repeating: recognizing the nature of whole clinical situations is the most essential ability in nursing (wholistic grasp) and is a skill pervasive in the daily practices of expert nurses (Benner et al. 2010, pp. 17-65). As we all know, no one starts out in any practice as an expert. According to the Dreyfus model of skill acquisition, expert performance is gained progressively through six stages: novice, advanced beginner, competent, proficient, expert and, finally, mastery (Benner, et.al. 2009; Spinosa, et. al. 1999). Even though the Dreyfus model of skill acquisition is widely accepted and referenced in nursing education and practice (Benner, 1984, Benner, et.al., 2009), educational research and teaching practices are just now emerging from the dominance of a representational or information-processing view of the mind and of human intelligence (Dreyfus & Taylor, 2015 Dreyfus, 1986; Alva Noe, 2009; Lakoff and Johnson, 1999). The representational or intellectualist view of the mind is exemplified by the information processing model of the mind. Information processing views of human thinking is a common, though outdated view of human intelligence. This is a good example of a “representational view” of the mind where the central assumptions are that, according to H.L. Dreyfus (1986, p. 431) “(1) mental processes are sequences of rule-governed operations and (2) that these operations are carried out on determinate bits of data (symbols) which represent features of or facts about the world (information, but only in a technical sense of that term.” Dreyfus goes on to say that that this view of human intelligence leaves out the ways that the person’s engagement in the situation determines what is noticed, or ignored. As Dreyfus (1986, p.432) notes, “we are always involved in a situation or context which seems to restrict the range of possible meanings without requiring explicit or exhaustive consideration of the range of context-free alternatives.” While representational views of the mind are no longer supported in current neuro-cognitive science, they remain entrenched in pedagogical approaches used in academia. This has major negative consequences for clinical teaching and learning which is necessarily contextual, i.e., influenced by the nature of the clinical situation and the sequencing or timing of events.
The representational, information processing model of human intelligence conflicts with the novice-to-expert model. The novice-to-expert model, rests on an understanding of human intelligence as situated – that is, embodied and socially embedded – and reliant on perceptual acuity and a wholistic grasp from a stance of engagement in a situation. A representational view holds that humans represent real situations encountered in the world as elements in the mind and analyze them in terms of abstract concepts and ideas. According to this view, human intelligence is created through the acquisition of general theoretical concepts and constructs that one then mentally manipulates and applies to interpret elements of a situation and solve problems in the world. This disengaged, objective stance cannot account for the engaged responsiveness of the everyday, skilled action of the expert nurse, or any expert human skilled actor. Experts perceive and directly notice changes, similarities, and contrasts while immersed in real situations that are experienced as similar or distinct from past whole clinical situations. If experienced expert clinicians had to resort to formal characteristics, or concepts about disease alone, they would not be able to recognize the exceptions, novel or unusual aspects of clinical situations; such as lack of expected progress, or direct evidence of deviations from the usual clinical trajectories. Expert nurse clinicians, like all expert human problem solvers, grasp – that is, understand the nature of – the whole clinical situation (Bourdieu, P. 1980: 1990). By first grasping the nature of the whole situation, the expert can make sense of the information involved and gain a sense of what is salient in practical clinical situations as they change across time. Grasping the nature of the whole situation allows the clinician to see and make sense of the parts in relation to the whole. For example, low blood pressure is viewed in the context of hypovolemia, or heart failure, or anaphylaxis, and other common causes of low blood pressure. Clinicians are always engaged in understanding the particulars they perceive in relation to the generalizations about disease states extant in textbooks.
Moving through the Dreyfus skill acquisition trajectory requires developing the perceptual acuity, and skills of involvement and engagement that allow one to learn directly from specific clinical situations, clinically reason, and develop clinical judgment in particular clinical situations. Through direct experience in practice, whether in actual or simulated clinical situations, nurses learn to grasp whole situations, identify the most important aspects of changing situations, and respond appropriately in action, to all of the essential elements of clinical reasoning and judgment. Nurses at all levels of skill continuously learn from and in practice. Novice through competent nurses will especially benefit from clinical teachers who are skilled in guiding them in developing and refining their skills of perceptual acuity in recognizing the nature of the whole situation and engagement with the situation, including the patient, family, and caregiving team. Situated coaching by the clinically experienced teacher allows the novice nurse to recognize the nature of the whole situation and make progress toward becoming an expert.
Situated Clinical Coaching and Learning
Novice nurses (typically first-year nursing students) who have had no clinical experiences require clinical teachers to break the situation down into simpler features and gradually build to the new nurse’s understanding to a more complex level of understanding the nature of the whole clinical situation. This is because the novice has no clinical experiences to draw upon and nothing in their experience to compare with the current situation. This lack of clinical experience is not a lack of interest or motivation, nor a character flaw, but an unavoidable blind spot due to lack of experience. The novice level of practice requires a simple to complex approach to teaching that relies on rules, theoretical constructs, and concepts as a way to frame a new situation. From there we subvert the students’ progress if we assume that breaking the clinical situation down into simple elements and require that learners use a linear nursing process of problem-solving, or ask learners to force clinical experiences into theoretical models that omit essential aspects of the clinical situation. The dominant clinical situated teaching-learning approach should focus on the salient aspects of the particular clinical situation. Situated coaching enables the novice to understand that the nature of the whole situation is necessary for the novice to understand the parts of the situation in relation to the meaningful whole. Since the novice often cannot recognize the nature of the whole clinical situation, the clinical teacher adds the wholistic grasp of the nature of the situation, such as this is a case of hypovolemia or heart pump failure.
As noted in an earlier EN article, (Rethinking Clinical and Classroom Teaching and Learning), while “simple to complex” teaching strategies are essential for novices, the strategy of breaking the situation down into simpler parts reaches its limits quickly, and novices and advanced beginners need situated coaching to help them recognize the nature of the whole clinical situation, that is, to have a wholistic grasp. Clinical reasoning requires understanding the parts of the situation in relation to the whole. Once nurses gain experiences that allow them to move from novice to beginner skill level, breaking down the situation into simpler elements creates a barrier to further development of the skills needed for rapid and situated performance. When novice nurses gain some clinical experience and move to advanced beginner skill level, they begin to encounter more complex clinical situations that require them to engage in rapid problem solving and immediate responses to meaningful aspects of the whole clinical situation. These situations demand that the nurse recognize the significance of the whole situation in order to determine which of the details is most concerning and demands immediate interventions. Because beginner nurses are unable to give a weighted value to multiple elements, analytic strategies of breaking the clinical situation down into simple elements quickly leave the beginner nurse lost in the forest of multiple individual trees. Facts and elements proliferate and flatten out so that the beginner can neither grasp the meaningful whole nor appreciate the salience of different aspects of the situation.
If the clinical teacher continues to focus on the simple parts as the only way to move the learner toward complex clinical reasoning, the beginning clinician is left with no guidance on making sense of the whole and no way to develop a sense of salience in actual clinical situations. By sense of salience, we mean that some aspects of the situation just stand out as more urgent or significant.
To assist newer nurses to move from decontextualized understandings based on decontextualized theory to the engaged, situated knowledge use required for clinical reasoning and judgment, the most effective clinical teachers deliberately coach new nurses to develop habits of mind that allow them to learn directly from whole practice situations. These habits include curiosity, attentiveness, openness to what is noticed in the situation, and a willingness to engage with and become involved in the patient’s situation in its own terms. Many potential learning impediments result when students do not have good skills in patient and clinical problem engagement. For example, clinicians talk about problems of over-identifying with the patient and becoming flooded with feelings. It is equally a problem to wall off feelings so that the possibilities of attunement are blunted or shut down. The ability to notice relevant aspects of the situation requires openness and curiosity. The beginning nurse can feel a generalized anxiety over the demands of learning or a fear of making errors. At this beginning stage, dampening emotional responses and focusing on the simple elements of the necessary tasks can lower anxiety and improve technical performance, and situated coaching can guide the learner to tune into the situation without increasing disruptive anxiety. By coaching the beginner to attend to the whole situation, including their own emotions, the clinical teacher can help the beginner’s emotional responses become more differentiated and more attuned to particular situations. This differentiated emotional response is the beginning of gaining a sense of salience and developing a wholistic grasp of the situation. With this kind of coaching early on, when the beginner moves to the competent stage, they can safely notice and attend to vague or global emotional responses as a sign that they do not fully understand in the situation. At this point, they have a developing sense of when they do or do not have a good clinical grasp of the situation. These emotional senses of the situation are crucial to early problem search and identification and are the sources of problem discovery and early warnings about patient changes.
Recommendations for Clinical Teaching and Learning in Practice and Education
As teachers and learners, we might think that the ability to notice and attend to relevant changes in a situation and notice aspects that are more or less important are “character traits” that one either has or does not have. But this is a false assumption. They are learned and habituated skills. These habits of mind, including general traits of attentiveness, skills of patient and problem engagement, and curiosity, are aspects of skilled know-how that are learned in context, and skilled clinical teaching and situated coaching can facilitate this learning. The excellent clinical teacher avoids misattributing lack of understanding for character flaws such as disinterest or disengagement.
Clinical Teaching Strategies to Facilitate Learner Engagement with Whole Clinical Situations
Situated coaching refers to coaching and questioning in specific clinical situations, so the learner is guided to notice aspects of the situation that they have not encountered before or do not understand the implications for interventions. High fidelity clinical simulations, with debriefing, the use of unfolding clinical cases, and situated coaching for understanding the nature of the whole clinical situation can help nurses, recognize the nature of whole clinical situations, and identify significant changes in the patient’s condition across time.
The Tanner Model of Clinical Judgment (Tanner, C., 2006) and the Lasater (2007) Assessment Rubric for Clinical Judgment take into account this stage of “noticing” or perceiving relevant aspects of the clinical situation as an essential first stage of clinical reasoning. Tanner (2006) and Lasater (2007) call attention to the role of perception in situated practical problem solving across time in their view of clinical reasoning and judgment in nursing. Perceptual grasp, i.e., making sense of the situation (Weick & Sutcliff, 2015), is at the heart of reliable practical reasoning in a wide range of complex situations, such as nursing, medicine, firefighting and so on. The clinician must be interpersonally engaged both to the patient-family, and the nature of the clinical situation, i.e. what is at stake for the patient in the situation, and how the clinical situation is evolving? Perception, the skill of noticing relevant aspects of a clinical situation, requires skillful engagement both with the problem and the person(s) involved. Perceptual acuity is much less studied than judgment, yet one can only make judgments about what is perceived. Hence, good clinical judgment hinges on skillful engagement, attunement to the situation, and perceptual grasp of the whole clinical situation.
Focused learning on how to reason clinically in high risk clinical situations requires openness, attentiveness, curiosity and situated coaching on the part of teacher teacher and learner.
The clinician must also be able to get information about available clinical and interventional resources as situations arise (Benner, Kyriakidis & Stannard, 2011; Benner, Tanner & Chesla, 2009). When clinicians enter new clinical environments, it takes a while to learn experientially how to function fluidly. For example, many situations get left to chance and luck, (e.g., from the more mundane, essential, knowledge about where supplies are kept, to who are the best clinicians for solving different clinical puzzles, and how to solicit the help that is needed in an evolving clinical situation).
Deep clinical learning is fostered when the student must make sense of the situation (Weick & Sutcliff, 2015) and make appropriate unprompted interventions. The direct contact with real clinical cases, whether re-created as unfolding cases or simulated, enables the student to practice ‘recognizing and understanding whole clinical situations’ and making unprompted decisions and interventions (See, Dreyfus & Taylor 2015). This is the nature of human situated thinking in action as opposed to views of human intelligence and knowledge development in terms of information processing or formal concepts that mediate between the situation and the thinker’s perceptions and thinking (Dreyfus, 1986). While the mind is best prepared by sensitizing theory concepts and knowledge, it is wrongheaded to conclude that the mind requires those theoretical constructs for grasping and solving practical problems in the real world (Dreyfus,1986). While this is how early Artificial Intelligence (AI) built “thinking machines” it failed to mimic the intelligence and thinking abilities of human thinkers. The current views of AI mimic human thinking using neuro-nets that closely resemble human experiential learning, where right answers lead to new approaches and abandonment of failed problem-solving approaches.
Many clinical learning opportunities are lost due to a learner’s inability to notice or understand the stakes and risks in particular clinical situations, along with the lack of available clinical coaching in the moment and context.
A clinical simulation that closely mimics real changes and the timing of those clinical changes offers the opportunity for situated coaching both in pre-briefing, debriefing, or situated coaching during the simulation. Such simulation strategies augment teaching and learning in clinical practica, where situated coaching is often unavailable in the moment.
In the last EducatingNurses.com article (Higher-Order Productive Thinking in Clinical Teaching and Learning), many readers concluded that no satisfactory substitutes exist for real clinical assignments of total patient care in clinical practica, but this was not the author’s intent. Instead, the intent was to communicate that simulated high fidelity clinical cases augment and strengthen clinical learning (i.e., are essential teaching-learning, but cannot completely replace, direct clinical learning in practice.) When the actual thinking and skilled know-how demands of unfolding clinical situations are understood by teachers, these clinical demands can be more effectively simulated and learned outside real clinical settings. We support direct experiential learning in well-designed clinical assignments, and a range of simulation substitutes such as unfolding unprompted real cases, and understand that total patient care assignments in clinical settings are not the only possibility for direct clinical learning. Clinical practica are essential to prepare nurses for practice, but the whole patient care model cannot be the only way approach to clinical teaching and learning, especially with today’s overloaded and scarce clinical sites (see Lasater, K., Nielsen, A. (2007). In order to design front-line clinical learning, i.e., how to clinically reason across time, we need to study and articulate what are the most crucial aspects of clinical learning required for situated clinical reasoning and good clinical judgment (for example, learning to detect early changes in patient’s clinical condition, how to draw on critical resources for managing the patient’s needs).
Oregon Health Sciences Campus and Oregon Nursing Education Consortium (OCNE) researched and implemented concept based clinical practica where the students learn the clinical manifestations of clinical phenomena such as fluid and electrolyte imbalance. In their clinical practica, students study a concept in depth such respiratory distress, or sepsis with actual patients on a unit.
Students study their assigned patient’s charts, interview the patients, and gather information from laboratory tests, and vital signs, and so on about critical turning points in the patient’s clinical problem (e.g. sepsis, electrolyte imbalance, respiratory distress). Students then come together to compare and contrast what each has learned from their situated study of clinical manifestations and implications of patient’s responses to interventions and changes and improvement, or decline in the patient’s condition over time. Unfolding authentic cases in the cases can be powerful in simulating unprompted clinical decisions as demonstrated by Lisa Day.
We believe that by more clearly articulating the nature of clinical teaching and learning, i.e., teaching the recognition of the nature of the whole clinical situation, clinically reasoning across time through changes in the patient, and or changes in the nature of the clinical situation (Benner, et.al., 2010), comparing and contrasting past whole concrete clinical situations with current ones, clinical detective work and puzzle solving, knowing how and when in context, comparing the particular to the general and so on, can transform clinical teaching and learning, making it more contextual and realistic in relation to clinical practice.
To move students from novice to beginner and ultimately to expertise or mastery requires that students develop the skill to recognize the nature of whole clinical situations and clinically reason and intervene, based upon a situated understanding of the nature of the clinical situation. In order to transform clinical teaching and learning, we need to change how we understand what is required for clinical teaching and learning.
Developing “clinical detectives” requires tutoring their skill to grasp the whole clinical situation with its subtle changes and trends including cultivating situation-specific, practical, problem-solving skills and know-how, and the ability to communicate patient changes and recommend relevant interventions to the health care team. Getting there from here requires that clinical teaching leave behind representational or information-processing views of the mind that imagine that formal concepts and abstract principles are to be the only access to understanding clinical situations. By its nature, clinical learning requires open-ended inquiry into the situation and noticing subtle distinctions between whole real clinical situations. Knowing how and when requires more than learning decontextualized theoretical constructs that fractionate both transitions in the patient’s clinical condition and nursing practice. Instead, clinical education must embrace situated teaching and learning that both relies upon and fosters perceptual acuity and a wholistic grasp of clinical situations. Only by doing so will nurses become the clinical experts that all the recipients of nursing care need, and without which the health care team does not succeed.
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