January 2024
Patricia Benner, R.N., Ph.D., FAAN
John Benner, Doctoral Candidate University of Washington, Seattle, WA
The primary goal of clinical assignments is for students to experientially learn directly from practice what cannot be learned any other way or from any other sources. This is as much about learning how to learn from clinical experience as it is in gaining insights from particular experiences. Through skillful coaching and questioning, we can give students the habits of thought and articulation of experiential learning that will lead them to develop into expert nurses over the course of their career through ongoing and cumulative and connected experiential learning.
It is misleading to imagine that experiential learning in clinical assignments is merely learning to “apply” science and theory to clinical situations without making space for ways clinical experiences create and refine theories and create the possibility of gaining nursing expertise. We must use clinical assignments to teach nurses to create a dialogue in their practice between relevant theories, scientific knowledge and the particularites of context and the patient’s changing clinical conditions. This is what makes Alasdair MacIntyre’s definition of the nature of a practice so prescient when he claims that ‘A practice is a socially embedded form of knowledge, that is self-improving.’ It is also why Albert Borgmann (2003) points out that theory depends on practice as a source for theory development while practice as a socially-embedded form of knowledge is self-sustaining. As Joseph Dunne notes:
A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any junction only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners (Dunne, 1997, pp. 378-380)
Charles Taylor (1995; 2016) points out that practical reasoning differs from speculative reasoning which is contemplative, detached, and certain. By contrast, practical reasoning is engaged, involved, active, depends on the specifics of the situation and occurs in transitions across time in the situation. Hans Gorge Gadamer weighs in on this discussion about the nature of practice by observing:
“Theory has become a notion instrumental to the investigation of truth and the garnering of new pieces of knowledge. That is the basic situation in terms of which our question, What is practice?, is first motivated. But we are no longer aware of this, because in starting from the modern notion of science when we talk about practice, we have been forced in the direction of application of science. (p.69)
“But the knowledge that gives direction to action is essentially called for by concrete situations in which we are to choose the thing to be done; and no learned and mastered technique can spare us from the task of deliberation and decision. As a result, the practical science directed toward this practical knowledge is neither theoretical science in the style of mathematics, nor expert know-how in the sense of a knowledgeable mastery of operational procedures (poiesis) but a unique sort of science. It must arise from practice itself, and, with all the typical generalizations that it brings to explicit consciousness, be related back to practice. In fact that constitutes the specific character of Aristotelian ethics and politics. p. 92
Practice is more than “application of science,” as Gadamer points out. Clinical reasoning is a form of practical reasoning. Clinical reasoning seeks to solve evolving clinical problems with most clinical situations requiring new experiential learning for the novice, advanced beginner and competent and in novel situations, for proficient and expert levels of skill acquisition. Safe experiential learning requires situated coaching, often in the form of demonstration, and always in the form or articulating, clarifying and confirming what clinicians think they have learned in a clinical situation.
Learning any practice discipline requires learning practical reasoning which goes beyond “critical thinking” and scientific reasoning as Sullivan and Rosin point out:
…Practical reason, once central to the educational tradition that stemmed from the rhetorical and humanistic studies of the European Renaissance, has been all but eclipsed by a focus on utility, on the one side, and on analytical reasoning, on the other…For practical reason, the focus is on thinking that is oriented toward decision and action. Because of this, we take exception to the way critical thinking is currently understood and promoted.
…Teaching for practical reasoning is concerned with the formation of a particular kind of person—one who is disposed toward questioning and criticizing for the sake of more informed and responsible engagement. Such persons use critique in order to act responsibly, as it is the common search for ways to realize valuable purposes and ideals that guides their reasoning. Practical reason grounds the academy’s great achievement—critical rationality—in human purposes that are wider and deeper than criticism…In the end, practical reason values embodied responsibility as the resourceful blending of critical intelligence and moral commitment (Sullivan & Rosin, p. xvi, 2008).
Preparing students to exclusively pursue applying theory to practice, at the expense of experientially learning new knowledge directly from clinical practice through solving and learning from practical clinical problems have been the topics of two prior articles. In this article we will offer strategies for enriching and extending experiential learning based upon learning directly from caring for particular patients as their clinical condition changes across time. This post builds on the EducatingNurses.com article posted on July 16, 2023: “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” We began that article with the assertation that: “Educators in all practice disciplines have erred on the side of thinking that all knowledge is just a matter of “applying” what is conceptually and technically already known… a rational-calculation approach…”. We went on to explain:
“Theories often elucidate or enhance understanding in particular clinical situations, but it is a mistake to imagine that the direction of influence is always from theory that is applied or used in practice, rather than expecting to learn directly from practice. [Such a stance] naively [assumes] that there are, in existence, theoretical understandings or evidence-based-practices fitted to all practical situations, regardless of their context and clinical particularities. In nursing education, “putting theory into practice” is over-emphasized. Using practice as a source of new knowledge insights that may dispute or disconfirm a theory, or create revisions and enrichment of theories, is less often pointed out and [little effort is made to articulate new knowledge discovered in practice.]
The authors followed up on the July 16th, 2023 article with the September 26th article entitled: “Urgent Need for Lifelong Experiential Learning,” noting:
A dominant rational-technical view presents practice as a mere application of techniques, scientific knowledge, theories, formal concepts and guidelines to practice situations [has severe limitations in capturing actual knowledge embedded in nursing practice] (Lave & Wenger, 1991; Lave, 1996). This rational-technical view conflates and confuses the mere application of knowledge, theories, techniques to practice with the intelligent, situated use of knowledge in particular clinical situations. Situated-use of knowledge is a form of higher-order productive thinking that goes beyond mere application of knowledge…for example, a direct demonstration of “applying” specific procedures accurately, out of the context of practice [such as accurately measuring a blood pressure]. Such a rational-technical view of knowledge describes knowledge as “knowing that and about,” while failing to give accounts of “knowing how and when” and situated-thinking-in-action, the mainstay of clinical reasoning about particular patients across time [through changes in their clinical condition].
In this follow-up article, we present strategies for enriching and extending students’ experiential learning that can be expanded, adapted by faculty and students in ways useful for all clinical practice experiential learning.
Clinical Preparation for Care of Particular Patients
We recommend that students, when possible, be consecutively assigned to patients with similar and contrasting clinical conditions to foster comparisons and experiential learning. Students can help with this by identifying similar and comparable patients required for future assignments. The student’s comparisons between similar and contrasting cases allow for a deeper understanding of how the cases are similar and dissimilar, in ways not possible if the clinical conditions of past and current patients are un-related and not comparable. Past and present comparisons set up a natural dialogue between the particularities of each case in relation to the general, making it possible for the student to engage in a dialogue between particular cases, and the scientific generalizations generated by patient population statistics. This dialogue between the particular and the general is essential to good clinical practice and for experientially learning from practice.
Advanced preparation is crucial to experiential learning from practice. Studying the patient’s chart and studying the relevant clinical issues related to a particular patient’s clinical condition prior to working with the assigned patients is a key learning opportunity in itself. Coaching on what to look for, or what should stand out in a chart or clinical presentation of particular patients, provide the opportunity to focus the novice’s attention on what questions to ask, and what clinical information is relevant in the particular case.
By creating clinical assignments with comparable cases, narrative comparisons and contrasts between cases can be made by students and faculty in ways that reveal new insights and clinical understandings generated by each case. Narrative comparisons between particular cases are central to learning to make clinical judgments about a particular case in relation to similar and contrasting cases along with differences between the particular patient and statistical generalizations of the patient population. Dewey (1969) emphasized the importance of connecting to the particular learning situation and making comparisons with new learning experiences across time. Experiential learning in such comparative judgments is the backbone of developing expertise in clinical reasoning and judgments related to changing clinical conditions in patients along with patient’s responses to interventions.
All clinicians need to experientially learn to create lines of inquiry and dialogue between the clinical facts of a particular patient and knowledge gleaned from generalized population statistics and scientific knowledge about the patient’s clinical condition. The student needs to attend to the patient’s co-morbidities, and particular clinical history. This dialogue between the particular and the general creates an essential habit of thought of making continuous comparisons with past clinical understandings gained from experience and comparisons of the particular case to relevant population statistics and generalizations. This involves more than “applying theory” or “generalized statistics” to a particular case. A habit of thought and practice of making comparisons between relevant past and current cases are essential to creating cumulative, and increasingly nuanced clinical reasoning and judgment. When students learn each clinical situation as an island of isolated facts and events, they often fail to develop such comparative judgments (Rubin, 1996, 2009). When clinical reasoning is taught through the ‘snap shot reasoning,’ such as a linear reasoning approach of the Nursing Process (the scientific reasoning or rational problem-solving process) without planned comparisons between similar and contrasting cases, they often fail to notice essential qualitative distinctions, similarities and variations between past and current cases (Benner, 2022; Taylor 1995). This is why we recommend having the student develop an understanding of the practical, situated basis for clinical reasoning and judgment, which is a science-using form of practical reasoning (Taylor, 2016; 1995; Rubin, 1996, 2009 Benner, 2022). In practical reasoning, the nurse or physician starts by noticing and clarifying the nature of the particular patient’s present clinical condition in relation to their immediate past, as well as their longer clinical history. Clinical reasoning requires situated thinking in action, with constant comparisons between patient’s immediate and prior clinical conditions. Various modes of thinking and problem solving are required for clinical reasoning. For example, often the clinician engages in detective work, thinking back to the immediate past, or “modus operandi” thinking, examining the immediate past for possible clinical causes for the patient’s current clinical condition. When clinical assignments are related to one another, this kind of thinking is more accessible to the novice nurse, because the related, but distinct patient trajectories are at the forefront of the student nurse’s mind for comparison and analysis.
Clinical Care Preparation Guide
We recommend a series of clinical questions for the student to explore and consider when preparing to care and initiating care for a patient, rather than a formal nursing care plan, in order to emphasize the open-endedness, curiosity, and responsiveness to be fostered by the nurse’s lines of inquiry. This is not an exhaustive list! We encourage adding and enlarging on our suggestions:
- What is the nature of the patient’s current clinical condition. Is it in a state of rapid change, or relatively stable? What changes might be anticipated in this patient’s clinical condition in the time of your care of the patient?
- What are the immediate treatment goals and how are those goals to be accomplished by the patient treatment and management plan?
- How has the patient’s clinical condition changed across time?
- Upon meeting the patient, and establishing rapport, assess how the patient is currently feeling. Are there any recent changes? Does the patient sense they are feeling better, worse, or “about the same” since admission, since yesterday and earlier in their hospitalization? What are the patient’s/families’ major concerns about the patient’s condition and their current care?
- What are possible risks to the patient’s clinical stability? How might signs and symptoms of these risks show up?
- What are the patient’s/families’ understandings of the patient’s illness, and plans for treatment and discharge? Are there any key patient/family questions or misunderstandings of the patient’s clinical condition and treatment?
- What kinds of patient/family education might be needed for this patient?
- How might this patient’s care and clinical condition compare to prior patients with similar diagnoses and treatment plan?
- Please list any additional questions that you may have about caring for this patient.
Faculty and student can mutually plan to discuss and debrief about the care of each patient, using these clinical preparation guidelines. The student is expected to compare this patient’s care with their past similar and contrasting cases. To enhance experiential learning, students can each share, discuss and compare their learning experiences with each other, becoming an effective learning community, whose aim is to gain experiential learning insights from one another. This is a habit of thought that will enhance life-long learning from future clinicians in practice.
Post-Care Debriefing and Comparisons with Current and Prior Cases
The student is asked to narratively describe in writing their observations, assessments, and any new insights or knowledge gained in caring for this patient. What did they actually do to care for the patient? Candor, and questions about the care of the patient are encouraged. The faculty should meet with their students to debrief directly about the students’ narrative statements, and/or prepare written comments and questions on the written narrative. The student may request a faculty student consult to clarify their understanding and learning from the clinical assignment.
Articulation: Join with the student in identifying and describing new insights or knowledge experientially gained by the student in caring for this patient. By articulation, we mean: “Giving public-accessible language” to new knowledge, questions, insights gained in caring for this patient in terms of understanding the patient’s clinical condition, treatment, patient’s understanding of their illness, treatment and management plan. Often students have a sense of the situation that they cannot fully express, and asking clarifying questions and for more elaboration on the student’s observations and sense of the situation can better disclose and articulate new knowledge gained experientially is useful. Did the patient/family express specific concerns or questions? The goal of articulation is to uncover and express knowledge and understandings as they emerge from practice. This is true for existing theories, such as a nurse identifying how attachment bonds are being reinforced or undermined in Neonatal ICU care. Clear articulation of the actual situation and clinical learning are critical for fleshing out poorly articulated and under-examined knowledge, such as getting to know a patient and helping them maintain their sense of personhood in the midst of illness and hospitalization (See Benner, et. al, 2010). Such learning is enriched when well described, articulated, and developed within a clinical learning community.
One of the aims of the student’s narrative account is to better understand both the student’s formal and informal assessments of the patient and family experience and concerns. The students should be instructed that their narrative accounts should include their own observations and taken-for-granted assumptions and changes in those assumptions over the course of caring for patients, as they come to understand more of the patient’s illness and plight. For example, if the student thought that the patient seemed worried or anxious, what made the student think that? Vivid descriptions are clarifying. Questions such as: “What meanings and understandings did you gain about the patient’s statements? Demeanor? Questions? Silence? How did your understanding of the patient and the patient’s situation evolve over time?” or “What were some signals you saw in the patient that alerted you to adjust your care? Questions like these can help uncover taken-for-granted assumptions and meanings in the situation.
Other useful questions for students are:
“What insights did you gain about the most disruptive aspects of the illness on the patient’s lifeworld? What patient statements and patient observations led to your assessment of the impact of this illness on the patient’s lifeworld?”
“Describe your understanding of the patient’s responses to any attempts to educate the patient about their illness, treatment or self-care goals for the patient. If possible, capture patient’s specifically described concerns, and responses to their illness, and patient education information that you gave related to self-care.”
“How would you compare this patient’s and family situation to a patient you have care for in the past with a similar or contrasting clinical condition?”
“Describe key insights, knowledge and questions raised in the care of this patient. How do your observations and insights compare with your observations of other similar and contrasting patients?”
“Knowing what you understand now about this patient, how would you change your care for this patient, if you could start over from the beginning?”
We suggest that such advanced clinical preparation for patient care, and narrative accounts of patient care experiences that give public language to the student’s learning experiences, observations, insights and questions extending that learning into questions, insights and comparisons with whole comparable or contrasting cases extend experiential learning and make it more visible and memorable. Developing this narrative memory of learning from caring for particular patients is an essential step towards developing cumulative wisdom that leads to expertise in clinical practice.
It is this narrative ability to articulate, give evocative and clear descriptions to observations and insights learned experientially from practice that creates expertise over time. Clinical expertise is exemplified by the ability to notice early warnings and critical changes in patients’ clinical condition, or development of qualitative distinctions, such as the different bluish coloring of the skin related to low blood sugar versus cyanosis, or changes in levels of consciousness (Benner, Hooper-Kyriakidis & Stannard, 2010). Perceptual grasp of subtle clinical changes can only be learned directly from seeing, recognizing, clarifying and confirming such clinical changes and qualitative distinctions directly through observations and situated coaching. Articulating and clarifying experiential learning is facilitated when it is a shared learning experience with a community of learners. Situated coaching about recognizing qualitative distinctions and subtle early changes in patients’ clinical conditions can speed up the student’s learning, preventing costly trial and error learning. Perceptual grasp and the ability to recognize such qualitative distinctions in practice are forms of skilled know-how and must be learned experientially through direct observation, questioning, and situated coaching from others in actual practice. Students can be taught to ask clinical experts questions about how they recognize early changes in the patient, and thus facilitate situated coaching and the solicitation of comparative observations and judgments from expert clinicians. Students can be effectively coached and taught how to facilitate their own experiential clinical learning while encouraging learning about the experiential learning gained by their and nurse colleagues. This will happen only if students and faculty understand how essential it is to help students discover and articulate knowledge and skilled know-how lodged in their own and classmates’ and clinical practice and also in expert nursing practice that they observe.
References
Benner, P., (Oct.12, 2023) “Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/Families.” EducatingNurses.com.
Benner P, & Benner, J., (July 16, 2023) “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” EducatingNurses.com.
Benner, P. & Benner J., (Sept. 26,2023) “Urgent Need for Lifelong Experiential Learning,” EducatingNurses.com.
Borgmann, A. (2003) Power Failure. Grand Rapids, MI., Brazos Press.
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.
Gadamer, Hans-Georg (1981) ”What is Practice? ” In: Reason in an age of science. Translated by Federick G. Lawrence. Cambridge, Mass. The M.I.T. Press.
Rubin, J. (1996; 2009) “Chapter 7 “Impediments to the development of clinical knowledge and ethical judgment in critical care nursing,” pp.171-198. In Benner,
Tanner & Chesla, Expertise in nursing practice, Springer.
Sullivan, W. & Rosin, M. (2008) A New Agenda for Higher Education: Shaping a Life of the Mind for Practice. Stanford, CA., The Carnegie Foundation for the Advancement of Teaching.
Taylor, C. (2016) The Language Animal, the Full Shape of Human Linguistic Capacity. Cambridge, MA: The Belknap Press, Harvard University
Taylor, C. (1995) Explanation and Practical Reasoning.” In Philosophical arguments. Cambridge MA: Harvard University Press. (See pp. 51-53).