ADEA CCI Liaison Ledger

A Conversation with Dr. Patricia E. Benner, Lead Author of Educating Nurses:A Call for Radical Transformation

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By Nicole Fauteux

"Most people use critical thinking to mean our best thinking," says Dr. Patricia E. Benner, Professor Emerita, Department of Social and Behavioral Sciences at the University of California, San Francisco. "That's not a bad thing," she adds. "They usually mean being sharp and not just making snap judgments or acting in a rote way."

Nevertheless, she believes that critical thinking is just one of several modes of thinking that skilled clinicians need. She would add formal reasoning, diagnostic reasoning, clinical reasoning, creative thinking, and deliberative rationality to the list. She draws precise distinctions between these different modes of thought.

"Does it help to be this picky and philosophical in the education process?" she asks rhetorically. "I think it does help," she replies. "I think clarifying all these things is very helpful to students and sharpens their thinking."

Having spent decades as a professor of nursing, Dr. Benner has given considerable thought to what's involved in teaching clinicians how to think. Her experience is reflected in Educating Nurses: A Call for Radical Transformation, part of the Preparation for the Professions series commissioned by the Carnegie Foundation for the Advancement of Teaching. The report recommends four fundamental shifts in how nursing is taught, including a shift "[f]rom an emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking."

As lead author of the report, Dr. Benner took responsibility for developing the rationale for this recommendation. It reads:

Critical thinking alone cannot develop students' perceptual acuity or clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking. Nurses need multiple ways of thinking, including clinical reasoning-the ability to reason as a clinical situation changes, taking into account the context and concerns of the patient and family-helping nurses to capture a patient's trends and trajectories. Clinical imagination, which requires students to grasp the nature of patients' needs as they change over time, is also needed, as well as critical, creative, and scientific reasoning.

"In the Carnegie study, we looked at how people were teaching critical thinking," Dr. Benner recalls. "We found they were really very fuzzy about the language."

Not so Dr. Benner, who defines critical thinking as "the main mode of thought in the scientific and enlightenment traditions-to question the received view, to deconstruct what is given to you, and rethink it and create something new."

This type of thinking can be invaluable, she points out, in novel situations when the clinician encounters something that he or she has never seen before or where the treatments applied are giving substandard results. "Then you have to step back and rethink the whole situation and engage in a very broad search of what this could be," Dr. Benner explains. "You have to consciously leave behind your usual assumptions. That's a really good use of critical thinking."

She also sees a place for critical thinking in evidence-based practice, stressing its utility in helping students assess the value of scientific research. Yet despite its importance, Dr. Benner argues that critical thinking is not the mode of thinking clinicians use regularly in their day-to-day practice.

"The real crux of all of this is that critical reasoning demands a kind of stepping back from the situation and considering all the elements and deconstructing what's going on," she says. "Well, that's a bit of a problem in practice. You really need situated thinking and engagement with the situation so you're very present and aware."

Dr. Benner advocates achieving situated thinking by placing more emphasis on clinical reasoning in health professions curricula. She defines this mode of thinking as "reasoning across time about changes in the patient's condition or in the clinician's understanding of the patient's condition."

She says that nursing education, like dental education, has room to grow in drawing these distinctions and effectively training students to engage in these various modes of thought. That said, she reports that the Carnegie study has prompted discussion of these issues among her colleagues. "They're working on it," she says, "and they're beginning to see distinctions."

She is especially excited about the new curriculum in place at the University of Pennsylvania School of Nursing. The curriculum emphasizes situated learning, meaning learning that occurs in the context (or the simulated context) in which it will be applied. For example, students are given unfolding case studies that call on their knowledge of science and engage them in the clinical reasoning over time that they will use every day in practice.

"The agenda in higher education has been critical thinking, questioning, sometimes to the point of cynicism," Dr. Benner concludes. She hopes that soon the kind of situated contextual thinking students need to develop as clinicians will be given equal-if not more-time.


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