Knowing That

Knowing About

Knowing How and When to Use “knowing that and knowing about.”

Knowing That and Knowing About

Knowing How and When

Patricia Benner, R.N., Ph.D., FAANUniversity of California San Francisco

Elsevier Faculty Development ConferenceJanuary 4, 2016 Las Vegas

Knowing That and Knowing About

Knowing How and When

We need new ways of thinking about teaching a practice

Without these, we will not be able to make change in nursing education

Integrating knowledge acquisition and knowledge use in practice requires choosing commonly recurring clinical problems, illnesses and public health promotion

Strengthen clinical inquiry and clinical imagination

Avoid pedagogies of cataloguing, just mapping nursing and medical diagnoses

Knowledge use is a productive way of thinking in the situation….situated thinking, situated action.

Skilled know-how in practice is based upon an intelligent grasp of the demands of the situation.

Each clinical situation requires judgment

Competencies in a professional practice have to

be situated in practice with contextual and thinking

demands, for example,

Ability to :

Recognize changing relevance in a situation

Identify the most relevant and urgent priorities in

an unstructured clinical situation

Understand particular patient in relation to the

general

FROM

Socialization and Role-taking

TO….

Formation: A Dance of Relationship and Commitment

The conscience…the person´s inner discourse of direction, what are good ways to be, good ways to act, Strong Evaluations…Charles Taylor’s Distinction: Strong Evaluation as opposed to simple choices or preferences.

Formation requires the inner discourse and desire of the learner to be the best he or she can be in order to be a good nurse, to thinkand act like a nurse.

Dance is a good Metaphor for Formation of Agency, Character Development, Situated Caring and Relational Ethic e.g. the Tango

New ways of thinking about teaching a practice:

FROMabstract theoretical classroom teaching and application of that theory

TOteaching for a sense of salience and situated knowledge use teaching an interpretive dialogical use of theory in practice

FROM

A Exclusive Emphasis on Critical Thinking

TO….

Multiple Ways of Thinking with an Emphasis on Clinical Reasoning

Clarity: Could you elaborate further? Could you give me an example? Could you illustrate what you mean?

Accuracy: How could we check on that? How could we find out if that is true? How could we verify or test that?

Precision: Could you be more specific? Could you give me more details? Could you be more exact?

Relevance: How does that relate to the problem? How does that bear on the question? How does that help us with the issue?

Depth: What factors make this a difficult problem? What are some of the complexities of this question? What are some of the difficulties we need to deal with?

Breadth: Do we need to look at this from another perspective? Do we need to consider another point of view? Do we need to look at this in other ways?

Significance: Is this the most important problem to consider? Is this the central idea to focus on? Which of these facts are most important?

Fairness: Do I have any vested interest in this issue? Am I sympathetically representing the viewpoints of others?

Problem of conflating critical thinking and clinical reasoning

Critical thinking and reflection for critique and deconstruction are essential

But nurses and physicians need a way to act and use established knowledge in rapidly changing situations

System redesign for patient safety

New patient populations with novel problems, e.g., poly trauma patients from combat in Iraq and Afghanistan ◦ Creative and critical thinking needed

Recurring clinical problems with specific patient populations

Reasoning across time about the particular through transitions in the patient’s condition and/or in the clinicians’ understanding

FROM

◦ Curricular Threads/Competencies

TO…..

Integration of the Three High-End Professional Apprenticeships: Cognitive; Practice; Formation

andIntegration of the Classroom and Clinical

Classroom:

◦ Situate science, theories, technology and ethics in practice examples, unfolding cases, case studies, clinical puzzles

Clinical, simulation and skills lab:

◦ Situate learning evidence based nursing practice in care of particular patients

Informal Learning

Participatory Culture

High-Impact Practices

Experiential Co-Curriculum

Learning to be…Learning Situated Knowledge Use…Thinking-In-Action

“Flipping the classroom” …. John Seely Brown

Common intellectual experiences

Learning communities

Writing-intensive courses

Collaborative assignments and projects

Service learning, community-based learning

Clinical practica

Diversity / global learning (study in another country

Practice change projects

Use Pat Cross’ “One Minute End of Class Questions”:

1. What, if anything, did you learn in class today?

2. What was the most significant new insight or learning?

3. What do you want to understand better, or any area of confusion today?

I want to think with you about the nature of nursing practice in the next few minutes.

Please put on your virtual nursing uniform.

Knowledge use is a productive way of thinking in the situation….situated thinking, situated action.

Skilled know-how is usually based upon an intelligent grasp of the demands of the situation.

Judging the most likely sources/causes of the current situation

Good, attuned situated knowledge use depends on understanding the nature of whole situation

Clinical imagination central to knowledge use and judgment in particular situations

Competencies in a professional practice have to

be situated in practice with contextual and

thinking demands, such as the clinician:

Recognizing changing relevance in a situation

Identifying the most relevant and urgent

priorities in an unstructured clinical situation

Particular Engaged Thinking and

Action across Time Particular Cases Required Fabrication of Patient

responses creates a problem

Singular Universal Paradigm Cases

Commonalities, Similarities and Contrasts between real whole cases

• General• Detached Snap Shot

Reasoning• Aggregated Cases Used• Fabrication of Cases Based on Averages not a Problem

• Aggregated means about objective elements.

• Comparisons of Means, and Frequency in aggregated cases.

Flipping the classroom so that students do a lot of preparatory work, reading, doing an unfolding case study, going to web-based resources, teacher’s background lecture,

EducatingNurses.com - Dr. Glenise McKenzie Video

Learning in High Stakes Environments

Confronting Suffering and Vulnerability

Expertise Depends on Relational Skills

Dealing with the Person´s Life World for Motivation, Meaning, Recovery and More…..

Skilled know how and When

Sense of salience Skill of involvement Perceptual acuity/

skill of seeing

Transitions in patient/family/ and clinicians’ concerns

Judgment for Particular Case

Knowing that and About

Medical facts related to case

Ethical Principles Legal Concerns

Hospital Policy

◦ Experiential teaching and learning

◦ Situated cognition—Thinking-in-Action (The logic of practice)

◦ Situated teaching and learning (Readiness)

◦ A community of practice learning together

◦ Reflection on particular cases and situations

Developing a Sense of Salience for what stands out as more or less important in unstructured, under-determined, open-ended clinical situations

A built-in crisis in continuing to break complex situations down into simple parts

Developing a Sense of Salience requires integrating and embodying domain-specific knowledge in particular clinical situations

Teach Students:

To recognize the nature of whole clinical situations

To use multiple frames of reference in particular clinical situations, e.g., allopathic medicine; psycho-social aspects of illness; patient concerns, recovery processes and patient well-being and more…

“Classroom and clinical content often seem disjointed from one another. Information learned in clinical does not generally appear on classroom tests. Clinical experience draws on social interaction skills not taught in class.”

Situating the Sciences in Nursing Practice: Breakout Unfolding Clinical Cases for Using Knowledge and Making Judgments in Clinical Practice

Dr. Lisa Day, Duke University

Carol Thorn, Clackamas Community College, Oregon

EducatingNurses.com