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

John Benner, Ph.D.C., University of Washington

One of the ‘taken for granted’, hidden assumptions about teaching and learning in most of academia, including nursing education, is guided by a disproven Cartesian view of how the mind works, based upon Descartes (1644; 1993; Dreyfus and Taylor, 2015; Taylor, 2016; Robbins P, Aydede M. (eds.) ,2008. Damasio, 2005). This mistaken assumption is that the most valuable knowledge is theoretical, existing beyond the details of individual cases and places. In this view, the mind observes and comprehends the world as a detached objective observer, filtering and synthesizing information to create the theories that ultimately must guide action. In this “top-down” view, practice comes from theory, thus the goal is always to put “theory into practice” by taking formal theories and using them to guide nursing practice. It is “top-down” because abstract mental representations (like textbook checklists) direct nursing practice.

While we do not negate the value of thinking theoretically about practice,,, who would deny the value scientific and theoretical knowledge for learning and engaging safe nursing practice? What we are critiquing here is a totalizing view that all practice knowledge is limited to theoretical knowledge (exclusively captured by formal theories, schema, templates and formal concepts lodged in the mind, with no consideration for the embodied skillful knowledge gained in daily life from dwelling in and perceiving the world). This Cartesian, representational, “totalizing” view of “applying theory to practice” is a form of rational calculation, or “mere application of theory,” rather than a situated productive inquiry of the relevance of theories to particular situations. Such a representational view of the mind leaves out current neuro-cognitive scientific evidence that experiential learning includes embodied skilled know-how and situational understanding essential to all the practical wisdom and knowledge embedded in actual nursing practice (or medical or legal, or educational practices and so on). A Cartesian, representational view of the mind leaves out practical know-how; embodied, situated skilled know-how, the human expertise of “fuzzy recognition” or the kind of “family member fuzzy recognition through family resemblances” Wittgenstein, Ludwig. (2001) [1953].

Alasdair MacIntyre (1981) defines a practice as a form of “socially embedded knowledge, that is self-improving, with notions of good internal to the practice.” Albert Borgmann, ( 2003) points out, practice can do without theory, but theory cannot do without practice, because practice provides the “rough ground” of experiential practical learning that generates “situated thinking-in-action” and that provides the ground for theoretical thinking. In actuality, the mind draws on perception from the “bottom-up,” i.e., perceptual grasp from directly experiencing the world as a skillful, intelligent embodied person dwelling in a meaningful world (Taylor, 2016).

To be able to comprehend/perceive the world only through formal theories and concepts would be extremely impoverished. A person with a “representational” mind only would pass over (ignore) their direct perception and access to the world, itself. Such a formal concept/theory representational view of the mind would pass over all the aspects of the world already known, from daily practical encounters in with familiar environments. It would be equally ignorant and unenlightened, to ignore theoretical and scientific knowledge about the human experience of illness, of pathophysiology, stress and coping and so on. Our point here is that the socially embedded and embodied person directly apprehends and experiences practical situations, making sense of them in their own terms and in terms of the practical situation’s uniqueness and their familiarity. . Novelty, strangeness, and uniqueness can be perceived by the embodied skillful perceiving agent, without the restrictive and constraining requirement of form concepts and theory being required for all perception.

It is understandable that educators would seek to simplify learning and access to practical clinical situations through theories, since there are fewer theories and concepts than the vast range and variety of practical everyday skilled know-how perceptual grasp of meanings of practical clinical situations. Imagine the perceptual grasp and recognition practices that are experientially learned by labor and delivery nurses enabling them to recognize and become attuned to women who are in different stages of labor. Another example is how, early on, nursing students learn about the manifestations of respiratory distress in actual patients. They have been introduced to respiratory physiology and pathophysiology, but in practical clinical situations they perceive, firsthand, the signs and symptoms of respiratory distress (e.g. the look of cyanosis, sternal retractions, labored breathing, air hunger and so on) and are taught what do for the patient to improve respiration and oxygenation based upon the causal sources of the patient’s respiratory distress. Through experiential learning from many patients in respiratory distress, expert nuses can directly perceive and grasp, and recognize the immediate treatment implications for acute respiratory distress in particular patients without making a “problem list”.

Currently most teaching strategies are based upon rational calculations about “applying theory” to clinical situations top down, rather than inductively seeking to understand the nature of clinical situations bottom up, i.e. what is most salient (most and least significant, relevant and important) in clinical situations. How does one come to recognize early clinical warnings of impending serious clinical changes in patients’ clinical condition? Nurses develop a sense of salience, where the clinical situation becomes meaningful and some things in the clinical situation just stand out as more or less important, along with what interventions that may be needed. Situational understanding, complete with a sense of salience is experientially learned through repeated and varied clinical experiences. This experiential learning is accelerated through skilled preceptorship and situated coaching to help nurses notice and prioritize the most and least important aspects of a particular patient’s condition. All expert practicing nurses must experientially learn to create a dialogue between the general (e.g., population statistics, scientific clinical guidelines), and the particular patient and his or her clinical situation. The patient may have many sensitivities, along with multiple co-morbidities that won’t be covered or predicted by generalizations from population statistics.

Narrative Accounts are Essential for Capturing and Extending Experiential Learning

Expertise in nursing requires developing an understanding of the particular clinical meanings in situations. Developing nursing expertise depends on experiential learning through exploring and understanding the relationships between particular patients and population statistics used in scientific studies, Describing situations only in formal concepts and theories will reduce the student’s perceptual grasp of the nature of actual complex, unfolding clinical situations of particular patients. Expert clinicians are required to recognize the manifestations of signs and symptoms in a particular patient as they unfold across time. Memorizing categories and particular classes of signs and symptoms is necessary, but not sufficient for clinical understanding. Students must understand the meanings and clinical implications for a patient’s signs and symptoms, including the significant contextual aspects of the situation.

Charles Taylor (2016) makes a strong claim for the un-substitutable descriptive function of narratives in order to understand the meanings embedded in unfolding clinical situations. Narratives (stories) can capture the context of clinical situations, how they unfold and change across time, along with their altered meanings in particular clinical situations.

As Taylor (The Language Animal) states in his chapter “How Narrative Makes Meaning”:

I want to defend the idea that stories give us an understanding of life, people, and what happens to them which is peculiar (i.e., distinct from what other forms, like works of science and philosophy, can give us) and also unsubstitutable (i.e., what they show us can’t be translated without remainder into other media).

What can we communicate about people and life in a story? A story often consists in a diachronic [evolving in time] account or condition (usually the terminal [or concluding] phase came to be. This can illuminate things in various ways. It often gives us an idea of “how things came to be”, in the sense of explaining why, or giving causes. It can also offer insight into what this terminal phase is like: we can perhaps now appreciate more its fragility or permanence, ort value or drawbacks, and the like. The story can also give us a more vivid sense of the alternative course not taken, and so how chancy, either lucky or unlucky, the outcome was. And it can also open out alternatives in a wider sense, it can lay out a gamut of different ways of being human…Pp.281-282. P. Now everybody would probably grant my first assertion above, that narrative constitutes a way of offering insight into causes, characters, values, alternative ways of being, and the like. But many would baulk at the second affirmation, that this form is unsubstitutable . Of course, it may be in some cases, but the thesis here is to the effect that valid insight in the above matters can be given in story which cannot be transposed to the medium of science, atemporal generalization and the like. (Taylor, C. (2016) The Language Animal, P.292.)

Narrative accounts are essential for capturing and communicating clinical reasoning about a patient’s clinical condition as it changes across time. When nurse educators and preceptors use narratives in this way, newer nurses can have the time and space to notice how the details of the particular case relate to the general condition and the contextual cues they are coached to examine and consider. Narratives are essential tools for honing the clinician’s perceptual grasp of clinical situations.

Narrative accounts are also essential for capturing local practical clinical knowledge demonstrated by the nurse, physician and other health care professionals in unfolding clinical situations. Local, practical clinical knowledge is socially shared in clinical practice communities (MacIntyre, 1981).

Every time a new technology is introduced, new practical experiential learning must be developed. Experientially learning how to safely use the new technology with multiple patients with different clinical problems must be systematically communicated to all the relevant patient caregivers. For example, in the accompanying video. the notions of good are explicitly expressed by the nurse caring for an acute burn patient. The burn nurse’s concerns contrast sharply with the textbook accounts of “knowledge needed for caring for the patient with new extensive burns.” The nurse was concerned with preventing the risks of sleep apnea, avoiding over-sedation that precipitated high blood levels of carbon dioxide, and to ensure that blood circulation was good at the tips of the burn patient’s fingers due to the clinical concern that circulation in the tips of the fingers (particularly on the right hand), The expert nurse identified that the patient’s circulation in the right finger tips might be diminished by the large amount of Intravenous fluids given to the patient for fluid resuscitation. So much practical knowledge and understanding, essential to excellent nursing care of this burn patient are absent in “Knowing that and about,” formal knowledge listed in textbooks and procedural manuals. Situated knowing how and when interventions that must be initiated and evaluated are left out of the textbook account of ‘required knowledge’ in caring for an acute burn patient.

Situated Coaching

Nursing students require situated clinical coaching in complex clinical situations in order to maximize their experiential learning. Often, because of the number of nursing students that the teacher is required to supervise, the nurse educator must delegate some of the situated clinical coaching about the patient’s clinical condition and interventions required to available staff nurses. Often the student is given an essential, but more peripheral role, such as taking and charting vital signs, due to their lack of clinical experience with the complex situation. Situated coaching about the meanings and clinical interventions that become imperative in the situation are essential to the student’s debriefing for maximizing experiential learning. This debriefing makes explicit the often-tacit understandings and “why’s” of skilled nurses’ clinical reasoning. Interpretation of all the clinical assessments and interventions, along with the clinical developments in the patient’s situation across time, offer essential experiential learning about rapidly changing clinical situations.

The Role of Clinical Narratives in Articulating The Content and Nature of Experiential Learning from Clinical Practice:

In clinical practice and simulation debriefing, it is essential to experiential learning to discuss and articulate the clinical insights and knowledge gained directly from clinical practice experience. This clinical debriefing should occur as close to the actual experience as possible for maximum experiential learning and maximum narrative understanding. . Experiential knowledge learned in care of particular patients requires carefully listening to and articulating the student’s narrative about what he or she has learned from caring for the particular patient. The teaching-learning goal is to uncover the understandings of what the student has learned, first-hand, from practice. This teaching-learning goal of experiential learning is essential, whether or not a theoretical account of the clinical situation exists or not. When theories do not adequately cover the practical situation, studying the meanings embedded in unusual or novel clinical situations, requires careful articulation of what is most and least salient in that clinical situation. Articulation refers to giving voice, expression to what was “accomplished, prevented, expressed, facilitated” in the situation. Articulation requires astute active listening. Articulation is challenging because it may be, first expressed orally or in writing in actions, relational qualities of caring practices that may be subtle and not immediately understood or expressed fully. Meanings and first-person, experiential learning often stem from experiential learning that the student cannot fully describe or express. For example, when, in the Carnegie National study of Nursing Education (Benner, Sutphen, Leonard-Kahn, Day, 2010) articulating the meanings found in senior nursing students’ ‘first-person-experience-near-narratives,’required careful reading and comparing of all the students’ narratives s . This careful reading by all members in the research team uncovered key meanings in the students’ experiential learning. We found that the most frequent focus of senior nursing students’ narratives had to do with “Patient Advocacy”. But articulating the various meanings of “Patient Advocacy” required multiple narrative examples, because Advocacy covered a broad range of intents and caring practices, so the broad over-arching generalizing term, “Patient Advocacy” was not descriptive enough (Benner, Sutphen, Leonard-Kahn, Day, 2010). For example, “Patient Advocacy” included nursing interventions such as, “giving the silent patient their voice;” “preventing harmful interactions between patient interventions;” “preventing the administration of drugs that the patient with allergies to the drug,” and more. A second example includes the following articulation from student narratives about “recognizing the patient as a person first.” “Recognizing the patient as a person first led to the following articulation in Educating Nurses a Call for Radical Transformation:

Recognizing the patient first as a person led the student to efforts to preserve the patient’s personhood and dignity in the face of the ravages of injuries, illness, and the influence of many medications. The students learned to highlight the person’s social and family identity as a recognition practice for the family and for the staff. They often used pictures from the patient’s life, humor, and stories outside of everyday life to help capture the person’s social identity.”( P. 193)

These examples of articulation demonstrate the thoughtful use of examples from practice. Multiple aspects of “preserving personhood and treating the patient as a person first,” in the context of the social isolation of hospitalization and suffering are described and made more visible and understandable in the narrative examples.

So, articulation is more than just categorizing the type of knowledge involved in the situation, it requires examples that illustrate the notions of good, meanings and goals of a caring practice of “preserving personhood and treating the patient as a person first.” Thorough definitions with examples and illustrations help with articulation that leads to understanding. Articulation is central to enhancing experiential learning by enabling students to carry their newly learned insights and skills forward to new situations (Dewey, 1959).

When introducing relevant theory or formal concepts into debriefings, articulation is essential in order to provide examples and illustrations of theory in different clinical contexts. The goal of this articulation of experiential learning is to enable students’to learn how theory is used in practice. The distance between naming clinical events, and understanding their clinical implications can be great. Learning how to use clinical knowledge in actual practice is a form of higher-order, productive thinking that is learned experientially directly from practice.

Summary and Conclusions:

Situated coaching and articulation of what is learned directly from practice makes experiential learning more memorable, and thus transferable to future clinical situations (Dewey, 1959). Situated Coaching and Articulation of clinical narratives about what has been demonstrated and learned directly from practice, places the student on the road to developing expertise in practice. Expertise is gained on the rough ground of practice (Dunne, 1997), complete with understanding the meaningfulness of clinical situations.

Students learn to engage in caring practices, clinical reasoning, managing rapidly changing clinical situations, through experiential learning directly from practice. Using theory in practice requires more than ‘applying theory and engaging in ‘rational calculation’ about clinical interventions. Mere “knowing that and about” and ‘applying theory” without understanding the meanings and clinical context, embedded in practical clinical situations, will not yield experiential learning from practice. Learning from practice requires situated coaching and experiential learning through identifying and articulating the meanings embedded in clinical narratives about experiential learning directly from practice.

COMPANION VIDEO

References:

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Carnegie Foundation, Stanford, CA., Jossey-Bass, San Francisco

Borgmann, A. (2003) Power Failure: Christianity in the Culture of Technology. Baker Academic & Brazos Press.

Damasio, A. (2005) Descartes’ Error: Emotion, Reason and the Human Brain. Penguin.

Dewey, J. (1969) Experience and Education. A Touchstone Book Simon and Schuster.

Dunne, J. (1997) Back To the Rough Ground: “Phronesis” and “Techne” in Modern Philosophy and in Aristotle, Notre Dame Ind., Notre Dame Press.

Dreyfus, H.L., & Taylor, C. (2015) Retrieving Realism. Harvard University Press.

Dunne, J. (1997) Back To the Rough Ground: “Phronesis” and “Techne” in Modern Philosophy and in Aristotle, Notre Dame Ind., Notre Dame Press.

MacIntyre. (1981) After Virtue: A Study in Moral Theory. University of Notre Dame Press.

Robbins P, Aydede M. (eds. 2008).The Cambridge Handbook of Situated Cognition,

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

Wittgenstein, Ludwig. (2001) [1953]. Philosophical Investigations. West Sussex: Wiley Blackwell Publishing..”

Additional Readings:

Entering A Practice: Writing Narratives about Experiential Learning in Clinical Practice.

Any practice discipline requires strategies for teaching situated thinking-in-action and practice wisdom. Formal theoretical models are the “go to” method for simplifying and rendering complex practical knowledge and action in practice situations easier to explain and manage. Formal theories are useful, especially for the first year nursing student who does not yet have sufficient clinical experience to imagine clinical actual situations. But even with the least experienced student, formal models, and theories, address “knowing that” and knowing “about,” rather than knowing how and when. They can never completely capture all that may be significant in an actual clinical situation because they systematically leave out context and history of the situation, as well as actual content and facts that may be relevant.

Formal theories and models focus on explanation rather than situated understanding. An understanding of the nature of whole complex situations is essential for all practitioners, nurses, lawyers, physicians and so on. Theory gets its reductive power by leaving out the context, but practitioners always use their knowledge in particular contexts. In philosophy, the inability to completely make explicit and formalize all aspects of practical situations is called “the limits of formalism”. First-person-experience-near narratives provide a descriptive access to practical situations including context, meanings and actions. Geertz (1977) called this a form of “thick description.” The narrator:

leaves out details of the situation that are not essential to understanding the story, (one strategy for addressing the limits of formalism) and presents a meaningful whole account of the situation that can be recognized as a singular universal or a family resemblance (Wiggenstein 2009) or a paradigm case (Benner, 2000). Students can imaginatively place themselves in a vivid, immediate narrative told by one who experienced the event in an immersed, active way.

This aspect of practical reasoning, recognizing the nature of the whole situation (Bourdieu 1980/1990) is central to expert performance, and situated thinking. And it conveniently addresses the limits of formalism. The story, as told by the first-person narrator bounds the situation. Experts telling a story for Novices or Advanced Beginners will need to explain more, give more examples, than when they are telling the story for other Experts or Masters who more readily understand nuance, timing and context (Benner, Tanner, Chesla, 2009). Such stories help inexperienced practice students develop and sense of salience and recognize the nature of whole situations. For vivid examples of how masters tell their stories see “Being in the world, The Movie, Produced and directed by Tao Raspoli (www.BeingInTheWorldMovie.com).

Narrative pedagogies are broad, and still being invented. For example the use of unfolding cases in a class, or as a classroom assignment, or an online simulated unfolding case, (Novex 2014 In Progress) retains the unfolding understanding, or narrative structure of the situation. Students can tell their immediate clinical stories in their clinical debriefing situation in order to reflect on the experience, and to enrich the understanding of the story from the diverse perspectives of the class members and faculty. In my theory classes, I always have student submit in writing first-person-experience narratives, and then with the permission of the story tellers, select 5 or 6 students to present their narratives in class, and we then proceed to reflect on their narratives in an “inside out” perspective. That is, we stay within the bounds of the story as narrated, keep the context, and articulate acceptable, understandable, meanings, skills, concerns, relational aspects, notions of good evident in the story. This is an engaged reflection on situated thinking-in-action. (See Benner, Hooper-Kyriakidis & Stannard, 2009 for more examples of narrative pedagogies.)

The following is taken verbatim from Benner, Hooper-Kyriakidis, Stannard, pp. 2012, 2nd Edit.540-544)

Guidelines for Writing Nursing Narratives

Using clinical narratives for teaching is based upon two major premises. First, there are two kinds of knowledge involved in human expertise: practical knowledge (or “knowing how”) and formal or theoretical knowledge (or “knowing that”). While these two forms of knowledge are related, the relationship is not unidirectional or linear. “Knowing how” may precede “knowing that.” Indeed, much of “knowing how” may be so contextual and situational that it does not lend itself to be captured in formal theoretical terms.

The practical world is always more complex than can ever be captured by a formal theoretical model. This does not mean that the practical world is completely random, capricious, or chaotic. Even chaotic and random events quickly become patterned due to human responses to those events. Because the practical everyday world is made up of habits, skills, practices, common meanings, cultures, and customs, there are always patterns. Human expertise is characterized by the ability to read situations and to recognize and understand patterns. Unlike formal expert systems, human experts can read fuzzy resemblances and patterns. Because there are always human variations in patients’ response patterns, good clinical reasoning will continue to be central in expert practice.

Second, when a person becomes competent in the practical world of whatever enterprise, the situation is seen as patterns full of risks and opportunities. The world becomes more differentiated. When the person becomes proficient (according to the Dreyfus Model of Skill Acquisition), situations are read in terms of past whole situations (Benner, 1984; Dreyfus & Dreyfus, 1986). Experience, as it is used in this perspective, always means a turning around of preconceptions or an adding of nuances to a former understanding of a situation; it never means the mere passing of time. Instead of understanding performance as it is often idealized (namely, cool, rational, distant, and unemotional), performance is linked to emotional investment in good outcomes and in avoiding bad outcomes. Once performers become competent, they realize that they must choose a plan or perspective and that by choosing one plan or perspective, they preclude others. Risk and opportunity are involved and the performer is invested in the outcome. Good outcomes are deeply satisfying and poor outcomes cause disappointment (Benner et al., 2009).

So, how does one capture “practical knowledge”, everyday understanding, or “know how”? It is best captured in narrative or “story” form that includes all the feelings of risk, opportunity, concerns, meaning, chronology, and changing relevance, complete with puzzles. This way “know how” can be charted, even though “knowing that” or theoretical knowledge may be incomplete or even non-existent. Thus, narratives encourage the storyteller to give a first person account of the critical incident (exemplar) that include her or his concerns, hunches, dialogue, changing understanding over time, interventions, and puzzles. The storyteller should be encouraged to give the story complete with fears, risks, opportunities, and satisfactions in order to uncover the storyteller’s practical knowledge and her or his read of the situation.

Selecting an Exemplar

Actually, in a way, the exemplar selects the storyteller or narrator. A particular situation stands out in one’s mind because it is laden with significance. It expresses important knowledge or meanings or expresses one’s notion of excellent practice or breakdown. The best exemplars will select themselves, because they are the situations the storyteller thinks of over and over again. Typically, the narrator does not remember the outstanding situations through generalizations or labels, but directly as a memorable instance, a valued time, or with a sense of pride and pleasure over outcomes. Phrases that may jog the storyteller’s memory include:

a situation that stands out as the quintessence of good nursing
a situation that taught you something new, opened up new ways of helping, new lines of inquiry, or made you notice something new
a memorable exchange or encounter that taught you something new
a situation where you clearly made a difference
a situation of breakdown, error, or moral dilemma, and the situation is memorable because of the issues and problems it raised for you as a clinician.

It is usually easier to think of particular situations rather than categories or types of situations. You can trust that a situation stands out because it was meaningful in a variety of ways and on a number of different levels.

Writing the Exemplar

The exemplar should be presented as a narrative account. The storyteller may use the typical abbreviated and condensed “clinical” voice (as in shift report) describing the clinical situation, but it should be a story with a first person reporting style. Actually, the narrator may find it helpful to “tell” her or his story first into a tape recorder and transcribe the tape and edit it, tightening it and filling in any needed details. Oral reporting of the exemplar may be helpful because the oral tradition is less linear than writing and it is more natural to include passing thoughts, and associated feelings and concerns in the oral tradition. While length of the exemplar is a consideration, it is best to tell the complete story first and then edit it down to the essential narrative account, preferably to four or five double-spaced, typewritten pages.

There are a few things the storyteller should note when editing her or his exemplar. Avoid summary statements or general phrases that do not communicate what actually occurred. For example, avoid phrases such as: “I analyzed the possible losses and took action to minimize them.” Instead, tell the reader how you recognized the possible losses, how you minimized them, and when possible, describe the actual outcomes. Another example is: “I comforted the patient.” Instead, provide details about what you did with or for the patient and how the patient responded. Include dialogue, when possible, to give the reader a first-hand account of the situation as it unfolded. Include your concerns or what you were anticipating when you took a particular action because that gives a window to your judgment. You may change the organization, hospital, department, or other identifying information to protect confidentiality. It would be helpful if the situation you chose as an exemplar could be shared publicly with others in the class or in a gathering.

Evaluating Narratives

Nursing narratives open up the possibility of demonstrating clinical inquiry in practice. For example, the faculty and students may want to do a thematic analysis of the narratives presented in a particular class. The clinical and ethical concerns that shape the story can be identified, along with the nursing knowledge, skills, and knowledge gaps evident in the story. Rich stories containing clinical knowledge that may not be well articulated in the nursing literature can be shared and reflecting on practice can be demonstrated both by the faculty and the students.

First person, experience-near narratives (written about the situation as it unfolded) require risk-taking and trust on the part of the student and the teacher. The student has a right to demand that the teacher respect the experiential learning presented by the student. Therefore, criteria for evaluating nursing narratives, either in journals or in written exemplars, include: candor; veracity; vividness of description; clarity and coherence; and good use of narrative writing style, such as dialogue and first person statements. A well told and reflective story of error and breakdown can receive an “A” based on these criteria, whereas an exemplar that points to flawless practice in a vague and non-reflective fashion should be evaluated more carefully. The goal is to encourage honest exploration.

Narrators almost always reveal more than they are aware of or intend to in the telling of a story. Consequently, students should have the opportunity to reflect on their narrative account. The student should separate the first person, experience-near narration from the reflective commentary that follows the narrative. Allowing some time to lapse between the telling and writing of the actual story and writing reflections on the story later can be helpful. A teacher must be respectful of the student’s self-revelation (“why didn’t you…” questions are typically not experienced by students as respectful) and enter into a dialogue that relates to the student’s understanding of the situation. Questions often extend the student’s reflection. (Benner, Hooper-Kyriakidis, Stannard, pp. 2012, 2nd Edit. 540-544)

References

http://vimeo.com/970665 video re-enactment of failed teamwork, Martin Bromiley

• or click to read The Airline Pilot who Lost his Wife:

http://medicalharm.org/patient-stories/martin-bromiley/

Bandura, A. (1977). Social Learning Theory. General Learning Press.

Benner, P (2000). From Novice to Expert: Promoting Excellence and Career Development in Clinical Nursing Pactice. Upper Saddle Back:NJ Prentice-Hall.,

Benner, P., Tanner, C., & Chesla, C. (2009) Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York: Springer.

Benner, P., Hooper-Kyriakides, P., Stannard, D. (2011) Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-In-Action Approach

Bourdieu P. (1980/1990) The Logic of Practice (Richard Nice, Trans.), Stanford, CA: Stanford University.

Dreyfus, H., & Dreyfus, S. E. with Athanasou, (1986). Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. New York: Free Press

Gordon, DR, (1988) “Tenacious Assumptions of Western Medicine.” In Lock, M & Gordon DR Biomedicine Examined. New York: Kluwer Academic Publ. pp. 19-46

Lingard, L.(2012) “Rethinking Competence in the Context of Teamwork” In Hodges, B.D., Lingard, L. The Question of Competence. Reconsidering Medical Education in the Twenty-First Century. thaca New York: Cornell University Press. Loc. 859-1401

Gallagher, S. (2009) “Philosophical Antecedents of Situated Cognition.” Chapter 3 in Robbins, P., Murat, A. The Cambridge Handbook of Situated Cognition. Cambridge: Cambridge Univ. Press

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

Kass, L.R. (1985) “Thinking about the Body.” The Hastings Center Report (Feb,): 20-30.

Kerdeman, D. (2004). Pulled up Short: Challenging Self-Understanding as a Focus of Teaching and Learning. In J. Dunne & P. Hogan (Eds.), Education and Practice: Upholding the Integrity of Teaching and Learning (pp. 144-158). London: Blackwell

NovEx Online simulations with illustrated Evidence Based Practice Background.

Taylor C. (1993) Explanation and practical reason. M. Nussbaum & A. Sen (eds), The Quality of Life (pp. 208-231), Oxford: Clarendon.

Wiggenstein, L. (2009) Philosophical Investigations. London: Blackwell

Teamstepps: http://www.saferpatients.com/services/teamstepps-article.htm

Additional Resources for Using Narrative in the teaching of Teamwork

Cathcart, E.B. and Greenspan, M. (2013) “The role of practical wisdom in nurse manager practice: Why experience matters”. The Journal of Nursing Management, 21(10), 964-970.

Cathcart, E.B. and Greenspan, M. (2012). “A new window on nurse manager development: Teaching for the practice”. Journal of Nursing Administration. 42(12), 557-561.

Cathcart, E.B., Greenspan, M. and Quin, M. (2010) “The making of a nurse manager: The role of experiential learning in leadership development”. The Journal of Nursing Management 18(4), 440-447

Please see the Following Educating Nurses Articles for more information on Learning Directly from Practice:

Posted on July 16, 2023 ” Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines. “

Posted on September 26, 2023 Patricia Benner, R.N., Ph.D., FAAN, John Benner, Doct. Cand. University of Washington, Seattle.

“Urgent Need: Teaching Strategies that Promote Lifelong Experiential Learning

Innovative Teaching Approaches to Help Students become Practice-Ready.”

Patricia Benner, R.N., Ph.D., FAAN, John Benner, Doct. Cand. University of Washington, Seattle.

Experiential Learning From Practice: Using Situated Coaching and Clinical Narratives