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
Patricia Benner, R.N., Ph.D. FAAN
John Benner, Doctoral Candidate at University of Washington, Seattle, WA
Experiential learning directly from practice is central to all practice disciplines. Practice situations are filled with particularity, nuances, complexities of the particular patient’s clinical conditions such as, co-morbidities, sensitivities, past illnesses, and chronic illnesses that require experiential learning on the part of students and all practicing nurses. Because nursing practice is changing and advancing, and contextual and patient particularities will always exist, the need for clinical experiential learning never goes away. The clinical environment itself is always changing. Health care teams and institutions have their own particular resources and availability of specialists depending on the time of day and what current patients need to be examined and treated. In addition, all technologies require experiential learning and adaptation in general and in relation to particular patients. Learning to use technologies in multiple contexts always requires first-hand experiential learning. The need for specific kinds of experiential learning by nurses and students are not always recognized and well-articulated. For example, for nursing students, and newly graduated nurses, facilitating experiential learning requires assisting the student to articulate and understand what they are learning and need to learn in caring for specific patients. Experiential learning is defined by Gadamer (2013) as a turning around of mistaken pre-understandings or preconceptions of a situation or adding nuances to one’s understanding or perceptual grasp of a clinical situation. New insights to the meanings and significance of a clinical situation as it unfolds and changes across time also requires experiential learning. No one can be beyond experiential learning; clinicians must experience many unfolding clinical situations and connect them to similar and different situations in order to learn how to clinically reason in particular unfolding clinical cases.
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 applied or used in practice, rather to expect to learn directly from practice, or to naively believe 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, and using practice as a source of new knowledge insights, that may dispute or disconfirm a theory, or create revisions and enriching of theories, is less often pointed out and utilized to articulate knowledge gained from practice.
John Dewey (1969) points out that experiential learning requires connection, i.e., engagement, openness, responsiveness, and curiosity in the practical situation, and continuity, that is, an ongoing dialogue and inquiry from past to the current experiential learning. In a practice discipline such as nursing, this ongoing dialogue between what one has learned experientially from past clinical experiences and is then enriched or better understood in future clinical experiences is typical and common. Dewey’s (1969) two central tenets of experiential learning of connection and continuity require a historical, biographical narrative by the learner that creates a dialogue of continuous links between past and current experiential learning. A narrative understanding of learning from clinical practice over time requires that the clinician compares past with current clinical learning. This requires that the clinical learner stay open and curious about extending and enriching experiential clinical learning across time. In safe clinical practice (Benner, Tanner & Chesla, 2009) experiential learning must be related and have continuity with past learning experiences. This is how one develops experience-based expertise (Benner, 2021; Benner, Tanner & Chesla, 2009).
We propose that students develop a habit of creating a first-person-experience-near narrative accounts of experiential learning in clinical practice situations that include their concerns, questions, puzzles, insights and comparisons with other past similar and contrasting past clinical situations from engaging in patient care and clinical reasoning across time about particular patients (Geertz, C. (1973). We claim, with Charles Taylor (2016) that the nature of narrative understanding is unsubstitutable for an adequate account of experiential learning in practice. As Taylor (2016) states in his chapter “How Narrative Makes Meaning” narrative is essential and not substitutable for practical reasoning and experiential learning:
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, P.292.)
Clinical reasoning across time about clinical situations through changes in the patient and/or changes in the clinician’s understanding of the patient’s clinical situation is a science-using form of practical reasoning (Benner 2022, Oct. 12; Benner, Hooper-Kyriakidis, & Stannard, 2011) It requires narrative understanding and accounts (a chronological story of an unfolding clinical history) to capture changes in a patient’s clinical condition and any changes in the clinicians’ understanding of that clinical condition across time. A narrative account can depict the specific nature of a patient’ clinical changes as they become clearer with the patient’s evolving clinical condition, and the accruing clinical evidence of changing vital signs, laboratory and diagnostic data that become available about the patient’s clinical condition.
Too often accounts of experiential learning are couched only in terms of conceptual or theoretical knowledge removed from context. These decontextualized theories or concepts may not capture all the nuances of change in understanding of the situation, significance of changes in the patient along with the significance of context in the clinical situation that shape the clinician’s insights about the nature of the patient’s clinical condition across time and the appropriate steps to take along the way.
Expert nurse clinicians do not just engage in mere “application of knowledge (or rational calculation) they use appropriate knowledge in specific clinical situations which is a higher form of productive thinking than mere application of knowledge (See Blooms’ Revised Taxonomy, 2001). For example, a return demonstration of measuring a blood pressure is mere application of knowledge, whereas interpreting the meaning of blood pressure changes or trends in a particular patient, indicates a situated of use of clinical knowledge. Expert nurses, and astute experiential clinical learners develop new clinical understandings, an astute perceptual grasp of the nature of a clinical situation. They develop a new sense of meaningfulness of the whole situation (called “sense of salience”), where the relative importance of situations are perceived and understood without having to figure out what is most and least significant, (e.g. in a situation of respiratory arrest for clinicians familiar with respiratory arrest). Observant attentive clinicians develop new clinical knowledge that allow for nuanced distinctions like the recognition of a particular shade of blue unlike cyanosis that is associated with very low blood sugars (A different shade of blue is described and confirmed by clinical colleagues ( Benner, EducatingNurses.Com Feb. 6, 2022).
A practice such as nursing or medicine, is not a mere carrying out of an interiorized formal theory; rather, it is a dynamic dialogue in which understanding is refined, refuted, changed, enhanced, and at the very least filled with nuances and qualitative distinctions that are not fully captured in abstract theoretical terms, or even generalizations from population statistics that may not fit a particular clinical situation (Benner, P. 2001 p. 308). Examples of experiential learning directly from practice may be, for example: Directly observed, perceived changes in the patient’s color, demeanor, feel of skin color, turgor, level of anxiety as well as contextual and relational changes. It is impossible to interpret or use theory in actual clinical situations where one does not have experience-based understandings that fit the current clinical situation. Practice-based experiential learning points to what the student learns directly from practice which may include tacit knowledge, perceptual and situational awareness, a vast amount of perceptual grasp of changes in patients’ clinical condition across time, as well as relational aspects of patients’ coping with their illness, dependencies and receiving care.
Learning directly from practice can be enhanced by theoretical understandings of psychological aspects of suffering and coping, pathophysiology, nursing theories related to stress and coping, and social and illness transitions. However, the ground for theory-use in practice is based upon gaining an experience-based first-hand understanding of manifestations of illness, patient concerns, clinical reasoning across time as the patient’s clinical condition changes, perceptual grasp of those changes, a sense of salience about what is most and least important in a changing clinical situation. Note these aspects of situated clinical reasoning requires more than an abstract application of theory and/or use of generalizations without creating a dialogue between and understanding of the particular situation and the generalizations from research and theory.
The attentive curious nurse gains new insights and understandings directly through experiential learning in practice. Learning how and when as well as learning a sense of salience. A sense of salience is having experience-based perception of some things standing out as more or less urgent or more or less significant without having to figure out which things are meaningful…why they stand out.) Having a sense of salience is a higher order productive kind of thinking because it requires situated thinking in context. “Knowing that and about” clinical knowledge, is important but not sufficient. Knowing how, when and why in context of actual unfolding clinical situations are also necessary for accurate clinical reasoning, and appropriate situated use of knowledge. “Knowing that and about” can be apprehended, learned from books, but situated knowing how can only be learned experientially in practice. Educators in all practice disciplines have erred on the side of thinking that all knowledge use is just a matter of “applying” what is conceptually and technically already known, a rational-calculation approach. However, the “application” model of knowledge (a form of rational calculation) is too narrow to capture situated understanding of contextual issues, clinical changes across time, meanings and qualitative distinctions in the clinical situation and situated thinking-in-action. Thus, mere 1:1 application of knowledge is seldom sufficient, nor is it the only approach to clinical learning and understanding required in clinical practice. Prescribed return demonstrations of skills with no clinical context or meanings of a patients’ clinical condition are too decontextualized, and consequently stop short of clinical understanding and knowledge, because they lack the necessary situated use of knowledge. Using knowledge in actual situations requires understanding the nature of the whole situation, what is most and least important in the particular clinical situation (an accurate sense of salience).
A sense of salience, i.e., what is of highest priority and greatest threat to the patient’s well-being, along with understanding the most relevant causes of a patient’s current clinical condition, including the effects of therapeutic interventions are central aspects required for good clinical reasoning. All clinicians must engage in understanding patient changes across time and be able to explain the most likely causes and effects of the patient’s current clinical condition. The most accurate terms for this thinking capacity are clinical reasoning and situated cognition (Benner, 2022 Oct. 12; Benner, Hooper-Kyriakidis, Stannard, 2011; Lave and Wenger, 1991; Lave, 1995; Lave, 1996). Clinical Reasoning is a science-using form of practice-based knowledge embodied, socially embedded and extended through direct experiential learning from practice. Current embodied, socially and contextually embedded views of the mind, learning and knowledge-use have implications for all practice disciplines. Current neuro-science and cognitive views of the mind include situated, embodied intelligence, skilled-know-how in context, and social embeddedness of the thinker/knower (a socially extended, embodied, and contextually, emotionally imbued interactive mind (Merleau-Ponty, 1962; Robbins P. and Ayede, M. 2009; Collins, 1985; Benner & Wrubel, 1989; Lave & Wenger, 1991; Damasio, 1999; Lakoff & Johnson, 1999; Noe, 2010; Gallagher & Zahavi, 2021; Benner, 2022). This embodied, emotionally imbued perceptual grasp, and socially extended view of the mind refutes a Cartesian representational mind that is falsely imagined to reside within the head…a mind separated from the body in the world (Gallagher, 2009; Noe, A.2009; Benner, 2022; Benner, In Press). The current neurocognitive science view of the mind is that the mind is interactional and extended out into an environment replete with embedded meanings and embodied and skillful responses to actual practical situations. The embodied, contextually embedded skillful, experienced person develops a sense of salience about what is important and unimportant in familiar situations. The extended mind is made possible by the embodied, and contextually embedded mind. A common pedagogical error in teaching experienced learners is to teach as if teaching to a novice, decontextualizing (objectifying) thought apart from the person’s situated experience-based participation in the world (Noe, 2009; Dreyfus 1997; Dreyfus and Taylor, 2015; Benner, Tanner & Chesla, 2009). The Cartesian view of the representational inner mind and the older computational models of the brain in Old Fashioned Artificial Intelligence, fit the behaviors and thoughts of an inexperienced novice, but fail to account for the neurological evidence of how the experienced or practiced mind embodied, embedded and extended in already meaningful environments and social interactions, actually thinks, and learns (Dreyfus & Taylor, 2015; Tayor, 2016).
First-person-experience-near narrative accounts of the situated thinking-in-action of clinical reasoning support learning clinical reasoning directly from clinical situations when they:
Describe situations as they unfold,
Include the contextual and timing issues,
Articulate the learner’s thinking and concerns about in the situation.
Students’ best preparation for learning from clinical experience, is a mind expecting to learn not only what is anticipated, but also the ability to notice the unexpected and unanticipated.
The professional disposition of curiosity and openness to learning from practice are essential to becoming an expert nurse (Benner, Tanner & Chesla, 2009; Benner, 2021; Benner, P. (2022). Such experiential learning is facilitated by encouraging the student to both tell and write about their experiential learning and then reflect on what they have learned, giving it accessible and understandable public language. Such articulation of the meanings and insights of experiential learning creates a biographical narrative of learning across time which in turn, further extends and facilitates clinical learning.
As Louis Pasteur noted, chance favors the prepared mind. Students’ best preparation for learning from clinical experience, is a mind expecting to learn not only what is anticipated, but also the ability to notice the unexpected and unanticipated. Their clinical imagination must not be shrunk down to only “applying theory” or “putting theory into practice” because when the student is curious, attentive, and responsive to the situation, they can discover new knowledge in clinical experiences not yet articulated and not yet theorized about, not yet fully understood or explained.
References
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