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CURRENT CONTROVERSIES IN CRITICAL CARE |
Corresponding author: Patricia Benner, RN, PhD, FAAN, Box 0612, 3333 California St, Laurel Heights 455, University of California, San Francisco, CA 94143-0612 (e-mail: Patricia.Benner{at}ucsf.edu).
The Carnegie Foundation National Study of Nursing Education has just been completed, and the book reporting the findings will be published early in 2009.1 This is the first national study of nursing education since the Lysaught report,2 published in 1970. It is dizzying to think of all the changes that have occurred in society and health care since that time: the advancement of women’s rights, the information technology revolution, the commercialization of the health care system, the changes in managed care that consolidated and closed many hospitals and down-sized a large pool of highly experienced nurses, the extreme nurse shortages (especially the shortage of nurse educators), an aging work force, growing health care disparities, a systematic and large-scale focus on improving patient safety, and more.
It is not surprising that the Carnegie study1 concludes that nurses are currently underprepared for the complex field of professional practice, given the changes just listed and the continued underfunding of nursing education, along with the failure to recognize the complexity of current nursing practice.
The Carnegie study recommends sweeping changes in the pedagogies and curricular structures of nursing education. In this short column, we focus on improving the teaching of ethical comportment and the formation of nurses’ nursing identity, skilled know-how, knowledge use, and character. In this context, formation refers to
the method by which a person is prepared for a particular task or is made capable of functioning in a particular role. One forms, as well as educates, priests, soldiers, nurses, and doctors in a process that moves beyond the knowledge content of those crafts to the moral content of the practices—the obligations entailed, the demands imposed—and thus to the moral formation of the practitioners. Moreover, it is generally the case that one is formed toward something, some telos, some ideal shape or condition.... A better metaphor [for being true to form] is dance: having and displaying integrity is more a matter of being able to move in ways that are consistent with the originating and developing themes of our lives. Teachers, guides, and practice make us better dancers because they help us listen more carefully and follow the music we hear more confidently. We learn which movements fit the rhythms and which do not.3(pp93,95)
In what follows, we focus on 4 of 6 key shifts in teaching and learning in nursing education recommended by the Carnegie study (more are recommended in the book quoted above). These shifts are needed to strengthen education for formation and ethical comportment in nursing by helping nurse educators think about and approach their teaching in new ways. The shifts include the following:
Integration
We propose that nurse educators shift from using curricular threads and competencies as the basis for curriculum design to an integration of 3 apprenticeships required for professional education: cognitive knowledge, practice know-how, and ethical comportment and formation. In our research we found many examples of curricula that were designed to teach detailed lists of competencies. These curricula were created with the idea that students must be competent in well-defined areas of knowledge. Although such an intention is laudable, this approach can breed the assumption that an exhaustive list of competencies exists, and that nursing students can somehow be checked off as having learned that list in a program of study. Or it breeds an assumption that there are distinct and separate threads of knowledge that teachers can pull out and reweave in a curriculum.
| "Patient advocacy is alive and well in the everyday ethical aspirations of student nurses."
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The Carnegie Foundation for the Advancement of Teaching National Nursing Education Study1 begins with an assumption that professional education requires 3 high-end apprenticeships. In the framework of apprenticeships used in 5 studies of professional education, we designated the first as the cognitive apprenticeship; that is, the theoretical knowledge base required for practice that occurs in all learning settings but is typically a focus in classroom teaching. In nursing, this knowledge base is broad and encompasses basic sciences, the humanities, and social sciences.
The second apprenticeship is the practical: the skilled know-how required for competent clinical practice.
The third apprenticeship is the ethical: the instantiation of the responsibilities, concerns, and commitments of the profession that show up in what we call the professional’s formation of a nursing practice identity, character, skilled know-how, and knowledge, as well as everyday "ethical comportment" as a professional nurse.
This list of separate apprenticeships can be misleading. The list does not imply that apprenticeships should be taught separately; we argue that they are best taught when they are fully integrated. Once students or teachers separate them, whether for analytical or learning purposes, it is hard to put them back together again in the ways that they are intertwined in practice.
Clinical Reasoning
"Critical thinking" has become a catch-all phrase for all forms of thinking required in nursing practice. But this use of "critical thinking" is misleading because it obscures ways that teaching and learning in nursing need to focus on multiple ways of thinking, with a much greater emphasis on clinical reasoning. Clinical reasoning is a form of practical reasoning through transitions in patients’ conditions or situations,4,5 and is defined as follows: Reasoning across time about particular situations, through changes in the patient’s condition or concerns and/or changes in the clinician’s understanding of the patient’s clinical condition or concerns.
Critical reflective thinking is essential for deconstructing situations of practice breakdown or failure of outmoded and inept theories. Critical reflection is also essential for questioning received ideas and practices that need reform or innovation. But critical reflection cannot be the only or even the primary focus in learning any professional practice.
Nurses, like physicians, lawyers, engineers, and clergy, must have some areas of solidified evidence-based knowledge upon which to understand and take action. For example, upon confronting a patient in acute respiratory distress who has low blood pressure and an extremely slow pulse, the nurse must take quick action based on a well-established scientific understanding of the functioning of the lungs, the direction of the circulatory system, causes for slow heart rate, low blood pressure, and so on. Definitive action and therapeutic interventions require evidence-based knowledge that is not up for grabs in the moment that quick action is required.
| "We suggest that nurse educators shift their approach from an exclusive emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking."
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Cynicism and excessive doubt, which often are the by-product of too much critical thinking, will not help the professional nurse, physician, or clergyperson draw on appropriate knowledge and act in particular situations. Critical thinking will not help develop perceptual acuity and clinical imagination regarding well-defined disciplinary, skilled knowhow, and practical knowledge.1 We suggest that nurse educators shift their approach from an exclusive emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking.
Unite Clinical and Classroom Teaching
We found many students and teachers alike who saw clinical and classroom teaching and learning as distinct and separate. Yet what students learn in each is necessary for practice. We suggest that they shift their thinking from separating clinical and classroom teaching and learning to integration of classroom and clinical teaching.
A shift to teaching that integrates the 3 apprenticeships in all settings can bring a much-needed reform that will unify knowledge acquisition and knowledge use. With the integration of clinical and classroom learning as a seamless whole, nurse educators can repair the fragmentation and information overload students currently experience.1
Teaching and Learning Formation and Ethical Comportment in Everyday Nursing Practice
The Carnegie Foundation study on nursing education1 found that teaching and learning of the third apprenticeship was very strong, especially when compared with other fields of professional education such as engineering, law, and medicine. However, most of the teaching about everyday ethical comportment and formation of the identity, character, and skilled capacities of nurses was confined primarily to; the clinical practice sites, and the preclinical and postclinical conferences. In the formal classrooms, ethics was typically taught as a version of the breakdown, or dilemma ethics, of bioethics.6 When we asked questions in the site visit interviews with students and faculty,1 we found that both students and faculty identified ethics as ethical rights based on the principles of autonomy, beneficence, nonmaleficence, truth telling, just allocation of scarce resources, and fairness.
Biomedical ethics is an essential standard for the nursing profession, but it is not sufficient. Bioethics has provided a critical, remedial external voice and disciplined thinking about patients’ rights and health care professionals’ duties and obligations to patients. The need for a critical voice designed to protect patients’ rights remains crucial in the current climate of market models of health care delivery and the problems of the underinsured, uninsured, and the growing inequities in health care.7 Bioethics has also focused on a critical evaluation of evolving technologies, articulating new moral questions and dilemmas created by innovative technology. Health care professionals must share the responsibility to think and decide about central questions about rights to treatments, rights to die, informed consent, new biological possibilities in reproduction and fertility, new genetic testing and therapies, and continued threats to equity in health care access. However, to be more effective and critical, bioethics must grow in its advocacy role and in its social ethics, 2 areas of central ethical concern to nurses.
Reducing the professional understanding of ethics to standards—principles designed to adjudicate ethical dilemmas—does not provide a strong enough positive agenda for formation and everyday ethical comportment. In addition to being able to deliberate on and adjudicate ethical conflicts and dilemmas, health care professionals also must learn about the notions of good practice internal to a particular health care discipline, such as nursing, medicine, social work, respiratory therapy, and so on. In the Carnegie study, we found that student nurses, particularly seniors, told of strong formative nursing experiences in which they deepened their understanding of some notion of good in nursing practice.8 When we interpreted the small-group interviews of nursing students, we found the following 6 ethical themes about formative learning experiences and the everyday ethical comportment of nurses:
The senior students in 9 excellent schools of nursing put these ethical concerns forward as key formative learning for their everyday ethical comportment. The students did not name these concerns as "ethical"; rather, they thought of them as essential lessons in learning to do good nursing practice and to be good nurses.
We conclude that these everyday ethical concerns of senior nursing students capture major notions of good internal to nursing practice. We recommend bringing these everyday ethical concerns to the center in teaching and the everyday practice of ethics for all health care professions. We are inspired by these aspirations to practice good nursing.
FINANCIAL DISCLOSURES
None reported.
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