Problem solving skills versus knowledge acquisition: the historical dispute that split problem-based learning into two camps

  • Reflections
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  • Published: 30 May 2018
  • Volume 24 , pages 619–635, ( 2019 )

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clinical problem solving skills acquisition

  • Virginie F. C. Servant-Miklos   ORCID: orcid.org/0000-0003-1987-531X 1 , 2  

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This paper sheds light on an intellectual dispute on the purpose of problem-based learning that took place in the 1970s between two major figures in the history of PBL: Howard S Barrows from McMaster University and Henk Schmidt from Maastricht University. Using historical evidence from archive materials, oral history accounts and contemporary publications, the paper shows that at the core of the dispute was their divergent understanding of cognitive psychology. On the one hand, Barrows espoused hypothetico-deduction, and on the other, Henk Schmidt was a proponent of constructivism. The paper shows how the dispute played out both in the scientific literature and in the divergent practice of PBL at McMaster and Maastricht and continues to affect the way PBL is done today.

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Introduction

In 2009, Schmidt et al. ( 2009 ) acknowledged that there was not one but several types of problem-based learning curricula being used by medical schools in North America and beyond. Primarily, they distinguished between what they called Type 1 curricula, in which students are asked to generate a “mental model” of phenomena underlying a problem, and a Type 2, in which students “play doctor”, focusing on problem-solving and clinical reasoning skills. For the sake of simplicity, we shall refer to the former as the Knowledge Acquisition model, and the latter as the Problem-Solving Skills model. What Schmidt and colleagues did not explain is how, issued from a single source, namely McMaster University Medical School’s 1969 pioneering programme, the world of PBL came to be divided along this fault-line. The beginnings of PBL were recently the subject of extensive research and shall not be covered in detail here (Servant 2016 ). The story can be summarised as follows: in the period after the second World War, higher education experienced an unparalleled growth around the western world, which, combined with bountiful financial resources and a rising tide of anti-authoritarianism, contributed to the birth and development of many innovative higher education programmes in various disciplines. In Germany and Denmark, problem-oriented education grounded in critical theory emerged in social sciences and humanities, and later engineering, as a challenge to mainstream didactics (Servant-Miklos and Spliid 2017 ); in business education, the Harvard Case Method gained international traction (Garvin 2003 ); in medical education, Western Reserve University pioneered an organ systems-based approach, a direct ancestor to PBL (Williams 1980 ). Between 1966 and 1972 a group of creative Canadian medical educators assembled around McMaster Medical School’s founding Dean Dr. John Evans with the mission to start a new undergraduate medical education programme. They took the medical education world by storm when instead of opening a traditional school, they decided to develop a small-group, self-directed, problem-based learning curriculum (Spaulding 1991 ). Their students began their learning with biomedical problems under the guidance of a tutor who acted as a process guide rather than a lecturer, leaving students to do most of the studying in their own time (Spaulding 1968 ). By the time of Schmidt’s article, over 500 medical schools were using some form of PBL (Moust et al. 2007 ), the majority using the Problem-Solving Skills version, and a substantial minority the Knowledge Acquisition version. This division is interesting considering the substantial support that the latter position has gained in the scientific literature, often at the expense of the former—a support that this paper will surely reinforce. How did these two iterations emerge from the McMaster experiment? What is the difference between these two versions, and how does this play out in terms of the way PBL is conducted? Why does this difference matter for medical education? Using historical data from oral history interviews, archives from McMaster University and Maastricht University and contemporary publications, this paper will try to answer these questions and shed light on a little known but highly significant divide in medical education.

The research for this paper was done using an inductive and hermeneutic approach to historical data in provenance from three types of primary sources that were triangulated to make sense of the historical events and the meanings ascribed to them by those who experienced them. These three sources were oral history accounts from primary witnesses, who were interviewed in English on site at McMaster and Maastricht Universities; archival records from McMaster University, Maastricht University, the Rijksarchief in Limburg and the private collections of former teachers, students and managers and both institutions, and contemporary publications and out-of-print books and journals that were acquired via the second-hand market or directly from the authors. Events, their meanings and interpretations were given weight according to how many independent sources could support the interpretation. Where a conflict emerged between the recollections of a witness in an oral history account and a written record, the written record was given precedence unless there was overwhelming oral historical evidence to the contrary. In writing this paper, the focus was on interpreting and analysing an important historical development rather than on providing a descriptive history of what happened at McMaster and Maastricht.

Why did two iterations of PBL emerge from the original McMaster model?

To understand how two different interpretation of PBL emerged from the original experiment at McMaster, it is important to understand that the 1969 McMaster programme was not designed as a realisation of educational theory principles, as has often been claimed. The five founding fathers of PBL at McMaster University were pioneers and innovators, but not education theorists. In 1966, Dr. John Evans drafted a one-page bullet-pointed list of ideas which became the founding principles of PBL, but he never wrote anything significant to justify his choice of items for the list (Evans 1966 ). The list read as follows:

“The Following is an outline of the objectives for the McMaster M.D. Programme as expressed in terms of knowledge, abilities and attitudes that McMaster would like a graduate of the programme to have acquired or developed:

The ability to identify and define health problems, and search for information to resolve or manage these problems.

Given a health problem, to examine the underlying physical or behavioural mechanisms. […]

The ability to recognize, maintain and develop personal characteristics and attitudes required for professional life […]

The clinical skills and methods required to define and manage health problems of patients, including their physical, emotional and social aspects.

The ability to become a self-directed learner, recognizing personal education needs, selecting appropriate learning resources and evaluating progress.

To assess professional activity, both personal and that of other health professionals

To function as a productive member of a small group, which is engaged in learning, research or healthcare.

To be aware of and able to work in a variety of health care settings.”

As far as we know, his main source of inspiration was the Flexner report (McAuley 1979 ), but extracting from this anything more than general statements about the outdatedness of lecture-based medical education would be a stretch. Evans’ right-hand man Bill Spaulding occasionally mused about the 16th Century humanist Johannes Comenius (Spaulding 1968 ), but Spaulding’s role as the Chair of McMaster’s Education Committee was more that of a nuts-and-bolt planner than an education philosopher. Jim Anderson, possibly the most creative of the founding fathers, may have been inspired by humanistic principles, but he was really an inspired anatomist, not an education psychologist (Barrows 1996a , b ). Neither of the final two members of the Education Committee—Fraser Mustard and Bill Walsh—had read much beyond what was widely circulating in higher education circles at the time; namely Mager’s Behaviour Objectives (Mager 1962 ) and the work of Knowles on self-directed learning (Knowles 1975 ). The lack of strong and coherent theoretical underpinnings for the programme meant that the McMaster experiment was more of a trial-and-error process in constant development than an application of cleverly crafted educational ideas. The fact that the term “problem-based learning” wasn’t coined in print until 1974 (Neufeld and Barrows 1974 ), and not by any of the founding fathers, goes to show just how uninterested the latter were in making grand jargonistic statements about what they were doing. A review of contemporary journal publications (Campbell 1973 ; Neufeld and Spaulding 1973 ; Spaulding and Neufeld 1973 ; Spaulding 1969 ) shows three things: firstly, that very little was published about PBL in its early years; secondly, that what was written tended to be by faculty who were not part of the original education committee; and thirdly, that the articles that were published tended to be descriptive rather than analytic. This meant that there was no definitive statement of what PBL was or what it was for, and when the founding fathers left the Education Committee—beginning with John Evans who resigned as Dean in 1972—the concept of PBL took on a life of its own under the pen of later prophets who filled the theoretical void with their own, often conflicting interpretations of what PBL was about.

The dispute at the heart of the division between the Problem-Solving Skills and the Knowledge Acquisition Approach is precisely the product of the theoretical chasm left by McMaster’s founders. This dispute played out in the late 1970s and 1980s between two of PBL’s most prolific theorists: Dr. Howard Barrows, a neurologist originally from California who came to McMaster on sabbatical in 1968 and joined the faculty roster from 1971 until 1981; and Henk Schmidt, a Dutch psychologist who was hired at the start of Maastricht University’s PBL programme in 1974 as part of the Department of Education Research and Development. The Maastricht programme was adapted from McMaster but sported some notable differences, such as the inclusion of systematic tutor and student training (Schmidt 1977a , b ), the development of a “skills lab” for clinical skills training (Bartholomeus 1977 ), the codification of the PBL method into seven steps (Schmidt et al. 1979 ), the use of biomedical problems rather than (only) patient cases (Schmidt et al. 1979 ), and the allocation of research funds for a Department of Educational Research and Development (Rijksuniversiteit Limburg 1972 ). Although this department was officially run by the psychologist and assessment specialist Dr. Wynand Wijnen, in practice most of the early research on PBL was done by Henk Schmidt and his colleague Peter Bouhuijs. Howard Barrows was an occasional visitor and advisor to Maastricht, and Schmidt an occasional guest at McMaster, but their divergence of perspective on PBL played out mostly on paper. Both authors wrote their first major book on PBL in 1980 (Barrows and Tamblyn 1980 ; Schmidt and Bouhuijs 1980 ), and by that time their academic differences had already crystallised into an unbridgeable epistemological gulf. This means that Barrows and Schmidt’s understanding of what knowledge is, how it is constructed and how it is used in problem-solving was not only different, but fundamentally contradictory, such that the two positions could not be reconciled in the middle—one cannot take both positions at once, as the next section will explain.

What is the difference between the problem-solving skills and the knowledge acquisition approach?

The crux of the intellectual dispute behind the two versions of PBL lies in two differing interpretations of what happens to the learner who is engaged in problem-based learning. On the one hand, some, led by Barrows, believed that the learners in PBL were honing “clinical reasoning skills” (Barrows and Tamblyn 1980 ) through a process called “hypothetico-deduction” (Elstein et al. 1978 ). We refer to this as the Problem-Solving Skills approach to PBL. Others, led by Schmidt, believed that learners in PBL were triggered by context-bound problems to understand the phenomena underlying the situation described in therein. We refer to this as the Knowledge Acquisition approach to PBL.

Both approaches are the product of the Cognitive Revolution in psychology, which began in 1956. The ‘50s were the heyday of behaviourism, but at an MIT symposium which brought together figures such as Jerome Bruner, Allen Newell, Herbert Simon and Noam Chomsky, a new interpretation of psychology was born that was based not on the study of behaviours and conditioning, but of mental processes instead (Miller 2003 ). While Bruner and Millers’ early work on cognition proceeded in relative isolation, the straw that broke the behaviourist camel’s back was Chomsky’s 1956 paper on linguistics (Chomsky 1956 , 1967 ); it demolished the behaviourist understanding of language acquisition by showing that a purely behavioural account could not explain grammar acquisition. Chomsky’s pioneering paper paved the way for what some regard as one of the first works of cognitive psychology: A Study of Thinking by Bruner, Goodnow and Austin, from 1956 (Bechtel et al. 2001 ; Bruner et al. 1956 ).

And yet, the very people who broke the hold of behaviourism on American psychology in 1956 were also the authors of a schism that divided cognitive psychology from its very beginnings until the 1990s. On the one hand, at the dawn of computer science, inspired by the workings of computer operating systems and refusing to believe that human problem-solving could be understood simply as trial-and-error, the two young computer scientists Newell and Simon ( 1972 ) produced a version of cognitive psychology that thought of people as general problem-solvers whose problem-solving skills were independent of their content knowledge; it became known as information-processing psychology (IPP). On the other hand, inspired by the Swiss psychologist Jean Piaget and his Schema Theory (Piaget 2003 ), authors initially rallying under Jerome Bruner’s banner developed a branch of cognitive psychology concerned with the role of the activation of existing knowledge in knowledge acquisition; this became known as constructivist psychology (Hergenhahn 2001 ). The division of the Cognitive Psychology movement into these two irreconcilable halves paved the way for the disagreement between Barrows and Schmidt.

Howard Barrows and the problem-solving skills approach to PBL

Although he may not have known it, Barrows owed the inspiration for his approach to PBL to the IPP school of thought. IPP was born in 1955, when Newell and Simon began their work in cognitive psychology from the premise that like computers, the human mind acts as a general problem-solving device (Newell et al. 1958 ). They believed that the process of solving a problem consisted in a collection of heuristic pathways that together formed a problem space and should be considered independently of the content of the problem. Newell and Simon’s research objective was to identify the invariant characteristics within the “Human Processing System” (Newell and Simon 1972 ).

While IPP was all the rage in the 1970s, by the 1980s it had hit an impasse. Firstly, from a methodological perspective, Newell and Simon’s trademark strategy for measuring the elusive “general problem-solving” capability was deeply flawed (Ohlsson 2012 ). It consisted in getting participants to voice their cognitive strategies out-loud while confronted with a sample problem. The experimenters recorded these verbal protocols, and then built computer programmes that mimicked the temporal order of the protocols in order to uncover the cognitive heuristics used by the human in this problem situation. However, there was a major problem with this approach: the verbal protocol was actually problem-specific rather than general—so much for their General Problem Solver . Secondly, from a theoretical perspective, the attempt to produce a general theory of problem solving didn’t work. Newell and Simon posited the existence of a problem-solving strategy that was context-free, but it became rapidly apparent that humans don’t generally engage in means-end analysis but use other cognitive strategies such as analogies, forward search etc., all of which are context-bound. And yet, perhaps because of psychology’s fascination with computers, the IPP model survived for decades longer than evidence should have allowed it to. Indeed, it survived long enough to spawn a model of medical problem-solving that ricocheted into the problem-based learning literature via Barrows: the hypothetico-deductive model.

The IPP methods were picked up by Arthur Elstein and Lee Shulman, working out of Michigan State University (Anderson 2003 ). In 1978, they attempted to demonstrate the existence of content-independent heuristics of medical problem-solving (Elstein et al. 1978 ). Clinicians, they conjectured, went through a process of hypothetico-deduction when faced with a medical problem. This meant that they would engage in the formulation of hypotheses for potential diagnoses, which would be either confirmed or disproved by new data from medical tests on the patient until the most likely hypothesis was left standing. The authors’ initial contention was that expert clinicians would fare better at hypothetico-deduction than novices, but their research found no evidence that expert clinicians were indeed better at generating hypotheses than novices. Instead, they were forced to acknowledge that the expert’s prior medical knowledge in the particular domain of the problem made a substantial difference in the expert clinicians’ ability to solve that problem, as compared with the novice. This indicated that the expertise was not one of deductive ability, but of content knowledge. However, the influence of IPP was such that they were not able to surrender the idea of the existence of content-independent heuristic processes. Instead of seeking a content-driven alternative explanation for the fact that some people appear to be better at problem-solving than others, they sought to explain this with the idea that some heuristics require extensive training.

The influence of the hypothetico-deductive model was then channelled into problem-based learning by Howard Barrows, particularly through his input into the McMaster curriculum in the 1970s and his 1980 book. Barrows began his research on hypothetico-deduction in the early 1970s, but his most developed argument in favour of content-independent reasoning processes can be found in Problem - based Learning: An Approach to Medical Education , the highly popular book on PBL which he co-authored with Robyn Tamblyn in 1980. In this book, the authors dismissed the idea that a physician’s clinical reasoning process was a mysterious intuitive “art”, and instead argued that these cognitive skills could and should be taught in medical education. The solution for this was to confront students with patient, health delivery, or research problems, since “by working with an unknown problem, the student is forced to develop problem-solving, diagnostic, or clinical reasoning skills” (p. 13).

Barrows argued that increased medical knowledge could even be detrimental to problem-solving skills as more precise knowledge might encourage students to tunnel-vision around what they had learned rather than consider a wider range of hypotheses. The distinction between content and process knowledge was cemented in Barrows’ call for process evaluations that are “concerned with the student’s ability to observe data, solve problems or show aspects of the clinical reasoning process, make clinical decisions and therapeutic decisions, and the like” (p. 113). Such aspects of the clinical reasoning process were made to include data perception and representation, problem formulation, hypothesis generation, inquiry strategy, diagnostic decisions, therapeutic decisions, time, cost, sequential management, and, finally, the medical information acquired. Therefore, while it would be unfair to claim that Barrows dismissed the importance of prior knowledge in problem-solving as Newell and Simon had, it is clear that the emphasis of his work was on the process of problem-solving via hypothesis generation. He believed that this process could be isolated enough from the specific problem content in which it was practiced to produce some general and teachable mechanisms by which medical problems should be approached; a trait which places Barrows squarely within the information-processing tradition.

This had some deep consequences for McMaster’s PBL curriculum. Beginning in 1977, calls were being issued by faculty and students to reform the 1969 curriculum (Roy 1978 ), and the process of change was taken over by Victor Neufeld, supported by Barrows. The new curriculum, progressively rolled out between 1977 and 1984, did away with the strong biomedical nature of the first curriculum and instead focused on priority healthcare problems management (MacDonald et al. 1989 ). Evidence of this change can be seen through the year-by-year evolution of the education materials found in the McMaster archives between 1975 and 1982, and in the notes of the Education Committee meetings (Ali 1977 ; Neufeld 1977 ) In the new curriculum, the students mainly dealt with long descriptions of patient cases compiled on the basis of lists of most commonly experienced medical issues, with a focus on solving the medical problem at hand. The objectives of the Faculty of Medicine were thus revised to read in top position: “to identify and define health problems at both an individual and a community level and to search for information to resolve or manage these problems” (Educational Programme Committee 1978 ). In addition, the development of clinical skills became a central feature of the reform efforts. Under the influence of Barrows and Tamblyn, the McMaster clinical skills training programme was constructed to train the students’ skills in encounters with simulated patients (Sutton 1977 ). This curriculum lasted until 1993, when, in the face of the high student failure rates in the national medical exam, McMaster abandoned the IPP approach and adopted a curriculum with many content-oriented features resembling those of Maastricht University (Norman et al. 2010 ).

Henk Schmidt and the knowledge acquisition approach to PBL

The Knowledge Acquisition position owes a lot to the early works of Jean Piaget and Lev Vygotsky. Although Schmidt was most strongly influenced by the renaissance of constructivist ideas in the wake of the cognitive revolution, that renaissance would not have been possible without the groundwork laid out by Piaget’s Schema Theory (Piaget 1952 , 1959 , 2003 ). Piaget was the first to propose that knowledge is not stored as raw data but “constructed” through particular mental structuring processes called “schemas”. Schema Theory fell out of favour with the dominance of behaviourism in the 1960s, but by the late 1970s, a growing number of experimental psychologists, such as Andrew Ortony, Rand Spiro and David Ausubel, were looking into information encoding and retrieval in an attempt to explain the way knowledge is stored and reconstructed for recall. Even though they seldom explicitly referred to Piaget, they expanded on his notion of the schema by providing it with the scientific specificity that the Swiss psychologist was lacking. Under their pen, schemas were understood as mental “frames” or “scripts” that contained “slots” or “placeholders” that could be “instantiated” by elements in a situation (Anderson et al. 1978 ). Although all of these names made their way into Schmidt’s research on PBL in the late 1970s and early 1980s, the work of Richard Anderson returned with more consistency and force than the others. Schmidt recalled:

What (PBL) students were doing while discussing a problem was activating prior-knowledge in order to make sense of that problem. If the problem was sufficiently complex (but adapted to their level of knowledge) the need for new knowledge would arise and self-directed learning would satisfy that need. Since relevant prior knowledge was already activated, the new information would be more easily integrated. That this indeed leads to better learning is what I have shown in my PhD-thesis published in 1982 (personal communication).

In 1977, Anderson expanded on the concepts of “assimilation” and “accommodation” in Schema Theory (Anderson 1977 ). He posited that schemas could not be a simple aggregation of response components, perceptual features, semantic features, functional attributes and the like – instead, schemas could only be understood in terms of their emergent properties. This insight enabled Anderson to hypothesise how schemas are used (assimilation) and change (accommodation). He argued that accommodation happens as a gradual process whereby incongruent elements increasingly challenge an existing schema and make assimilation more and more difficult. Although people are extremely reluctant to accommodate their schemas, they also attempt to preserve cognitive consistency, and when the latter tendency wins over and a schema change is engaged, the acquisition of knowledge truthfully begins. Thus, Anderson saw accommodation as a sine - qua - non condition of learning:

I suspect that large-scale accommodation may be a dialectical process which entails a confrontation with difficulties in one’s current schema and coming to appreciate the power of an alternative (p. 429).

Anderson’s explanation paved the way for Schmidt’s idea that problems, by offering realistic situations for students to work with, could activate students’ existing schemas and thus provide the basis for sense-making that is essential to learning (Schmidt 1983a , b ). The development of this theory was a slow process that began shortly after the opening of Maastricht Faculty of Medicine and ripened until 1983. We can see from archival evidence that the research efforts began in earnest in 1977, although at the time the education research group’s ideas on learning in PBL were a little haphazard. A note in the tutor training manual Het Tutorensysteem indicates that the researchers believed that the strength of PBL lay in the promotion of knowledge retention and transfer, but without further specification (Bouhuijs et al. 1977 ). In fact, the text indicates that the authors, including Schmidt and his colleague Peter Bouhuijs, were aware of the limitations of contemporary research in the field. By 1979, Schmidt had developed more precise ideas on this. He elaborated on his previous work with a paper entitled Leren met Problemen ( 1979 ) and for the first time referred to the activation of prior knowledge and Ausubel’s take on Schema Theory. At this point, Schmidt’s work was fully aligned with the constructivist credo that people do not passively ingest the outside world but instead constantly attempt to give meaning to it through personal interpretations of what their senses tell them. In a paper from 1983, he offered three connected explanations of the learning process that takes place in PBL: the activation of prior knowledge; encoding specificity (the similarity between the situation in which knowledge is learned and the situation is which it is applied); and elaboration of knowledge (Schmidt 1983a , b ). By this stage, his research had expanded well beyond the work of Anderson and Ausubel and was aggregating reports from all over the blooming field of cognitive psychology. Schmidt’s later article on the foundations of problem-based learning provided some elaborations of these three ideas, but the central themes remain the same to this day (Schmidt 1993 ).

How the dispute played out at Maastricht University

The story takes root in the early 1970s, when Howard Barrows took it upon himself to demonstrate that educational aids could be used to improve “clinical reasoning skills”, “problem-solving skills”, “diagnostic skills” and other variations thereof. The first apparent results of this research appeared in 1972, under the title The diagnostic (problem - solving) skill of the neurologist , in which it was claimed that hypothetico-deduction could be equated to a “cognitive hat rack” for organising the information acquired during the patient interview (Barrows and Bennett 1972 ). Barrows worked closely with Vic Neufeld on this research—neither of them having a prominent role in the curriculum development at McMaster at that time. Neufeld studied medical education at Michigan State University, where Elstein and Shulman were doing their work and according to their research assistant Geoffrey Norman, the Barrows-Neufeld duo “had a close relation” with the Elstein–Shulman team (personal communication). It is therefore unsurprising that Barrows borrowed so heavily from the theory of hypothetico-deduction to support his ideas. This research culminated in a paper written in 1977, in which not only was the “hat rack” idea alive and well, but prior knowledge was relegated to a secondary relevance (Feightner et al. 1977 ). They developed a model of medical problem solving which would be of crucial importance in the later debates on PBL (Fig.  1 ).

figure 1

The hypothetico-deductive model of Feightner et al. ( 1977 )

The McMaster team boldly concluded: “Family physicians do have identifiable legitimate problem solving skills which they can teach. We feel that the model outlined above can help student to develop their clinical problem solving skills” (p. 71). These are the ideas with which Barrows and Neufeld travelled to Maastricht to act as educational consultants to the new Faculty of Medicine. There is ample evidence from written correspondence between them that throughout the 1970s and 1980s, Schmidt held both Barrows and Neufeld in very high esteem (Schmidt 1983a , b ). In Schmidt’s eyes, Barrows was one of the founders of PBL and therefore warranted listening to. It is therefore not surprising to find Barrows and Neufeld’s model of hypothetico-deduction in Schmidt’s early work. How did Schmidt move from one paradigm to the other? A comparison of his two major contributions between 1977 and 1979 may provide answers to this question. In 1977, Schmidt wrote Probleemgeoriënteerd onderwijs , a booklet designed to be used internally at the Faculty (Schmidt 1977a , b ). In it, he wrote down for the first time his ideas on the cognitive mechanisms underlying learning through PBL. This manuscript was published 1 year later in the Dutch journal Metamedica (Schmidt 1978 ), and 1 year later re-written in a substantially amended format as Leren met Problemen (Schmidt 1979 ). The key lies in the changes made between the 1977 paper (and its identical reprint in 1978) and the 1979 paper. The table below indicates the most significant of these changes. It may seem strange that Schmidt offered argument from both paradigms in his work, even though they are not epistemologically compatible—but this incompatibility was not generally understood at the time, even among cognitive scientists (Table  1 ).

We see in the 1977 paper an extensive explanation of PBL in terms of Barrows, Elstein and Shulman’s hypothetico-deductive model, with diagrams that closely resemble those published by Barrows in his own work from 1977. And yet, already in 1977, Schmidt was intrigued by the experiments of a Dutch psychologist, De Groot ( 1965 ), on chess players. De Groot had tested chess players’ ability to solve a checkers problem, and found that chess masters made mediocre checkers players—indicating the absence of a general problem-solving ability among chess masters. The plausible explanation was that chess masters had a great prior knowledge of possible chess combinations to draw from when solving chess problems, that was of no use to them when solving a checkers problem. Schmidt concluded, as Elstein also did later, that prior knowledge must be a major factor in performance on problem-solving tasks. But these ideas could only be considered hunches at the time: aside from a passing mention of Bruner, in 1977, Schmidt’s reference list is remarkably devoid of constructivist literature. This was very much amended in the 1979 paper, which is replete with notes on Ausubel, Kelly, De Groot, as well as digressions on Bruner and Miller. Although Schmidt had used the term “prior knowledge” before, this was the first time that he framed it strongly in terms of the “activation of prior knowledge”—and therefore PBL as a learning method that could be used precisely for that purpose. By 1979, gone were the references to hypothetico-deduction, absent the diagrams of Barrows–Schmidt now saw hypothesis generation as an automatic process of the human cognitive architecture which therefore cannot not be trained, and he therefore saw little point in expending energy researching it.

Incompatible approaches to PBL

Barrows and Schmidt were in regular contact during the 1980s as consultants from McMaster flew to Maastricht and vice versa. In particular, in 1983, Schmidt organised a symposium on PBL for which he invited Barrows as a speaker. A series of letter exchanges leading up to this event sheds some light on their academic relationship. For instance, a letter written by Barrows to Schmidt in July 1982 indicates that the former believed PBL to be the acquisition of basic sciences knowledge and “medical problem solving as a cognitive skill” in equal measure (Barrows 1982 ). In response, Schmidt returned a letter to Barrows in January 1983, in which he voiced in the clearest way possible the rift between their approaches to PBL:

I think that the difference between your work and mine is more a difference of problem-solving in terms of encoding, storage and retrieval of knowledge for use in problem-solving situations (and, most important, in terms of the organization of knowledge in memory), while you focus on the process of problem-solving itself. My main interest lies in the role PBL plays in knowledge acquisition - that is why I refer with emphasis to theories of learning (role of knowledge, inference production, organization of knowledge, retrieval cues etc.) - while you are particularly interested in how the students use the knowledge acquired in clinical problem-solving situations (and therefore refer to theory and research in that area). In fact, I think that our approaches are complementary. We would make a good team! When you are in Maastricht, we certainly should sit down to discuss these matters and others (Schmidt 1983a , b ).

In fact, it seems that the approaches were not so much complimentary as mutually exclusive as they relied on opposing understandings of the role of knowledge in problem-solving. The version of PBL supported by Barrows posited the primacy of heuristics and associations in medical problem-solving. That of Schmidt relied on problem-solving anchored in prior knowledge and experience. But problem-solving cannot be both content-independent and content-dependent—these two positions are therefore epistemologically incompatible with one another. Therefore either Barrows or Schmidt was right about PBL, but they could not both be. This incompatibility is not a matter of a historical clash of personalities: by all accounts, Schmidt and Barrows actually held each other in high regard. This is really a question of two interpretations of PBL, the underlying epistemological constructs of which are irreconcilable, and produced a very different type of problem in PBL. Whereas a PBL problem for Barrows could be “a written case, case vignette, standardized (also called simulated patient), computer simulation, video tape” (Barrows and Tamblyn 1980 , p. 5), for Schmidt, a problem could also look like a description of a biomedical phenomenon with no “solution”. Schmidt’s problems required instead that the underlying phenomena or theory be understood by the students (Schmidt 1993 ). While this sort of problem could be and was translated to almost any academic discipline, problems based on the management of healthcare problems could not be. Perhaps this serves to explain the profusion of PBL programmes in the Netherlands in all manner of academic disciplines ranging from psychology to liberal arts.

Luckily, History has provided us with some answers as to which of the two versions of PBL fared the best in terms of helping students to solve medical problems; by the mid-1980s, IPP was beginning to crumble as a psychological paradigm. In 1985, Christine McGuire lamented resilience of the idea of content-independent cognitive skills and abilities:

Professional evaluators (…) wanted to believe in the existence of some generalized kind of cognitive achievement – a related set of skills or developed abilities – that individuals could bring to bear in managing patient problems. They have been pursuing that chimera ever since, despite a mind-numbing torrent of studies that continue monotonously to report the same findings (McGuire, 1985 ).

McGuire also stated that she did not believe that the doctors reported in Barrows’ studies were actually engaging in hypothetico-deduction:

Doubts that these diagnostic labels are genuine hypotheses are considerably exacerbated if, as Barrows and Tamblyn say, they literally ‘pop’ into the clinician’s head within moments of the initial encounter. Such a process appears to be more akin to the act of pattern-matching or to the procedure involved in comparing group phenomena with various templates and selecting best fit (McGuire, 1985 ).

In what should have been a death blow to the Problem-Solving Skills approach to PBL, in 2002, Elstein became his own harshest critic when he acknowledged that the theory that medical problem-solving was based on hypothetico-deduction processes was in large part erroneous (Elstein and Schwarz 2002 ). Most problems, he realised, were actually resolved on the basis of pattern recognition or the construction of a mental model of the problem. Both of these processes were based on the extent of the clinician’s knowledge rather than the mastery of heuristics. This, he acknowledged, has such strong implications for problem-based learning that it led him to a re-evaluation of the purpose of the method:

The finding of case specificity showed the limits of teaching a general problem solving strategy. Expertise in problem solving can be separated from content analytically, but not in practice. This realisation shifted the emphasis towards helping students acquire a functional organisation of content with clinically usable schemas. This goal became the new rationale for problem based learning (p. 731).

This is not quite a full embrace of the constructivist paradigm, as Elstein struggled to let go of his embrace of IPP “analytically”. Yet ironically, “in practice”, Elstein turned to the alternative approach to PBL: constructivism and the Knowledge Acquisition approach championed by Henk Schmidt. And yet, despite these strong criticisms including from within the school of thought of hypothetico-deduction, Barrows refused to re-evaluate his approach to PBL. In the light of this, the divergence with Schmidt that had begun in the late 70s turned into a dispute in the late 1980s, culminating in an open confrontation during a review of the PBL curriculum of Sherbrooke University in Canada in 1992, as Schmidt recalls:

Howard Barrows, George Bordage, Charles Boelen (of the World Health Organization), and I were invited around 1992 to assess the then five-year old problem-based medical curriculum of the University of Sherbrooke in Canada. I had been one of this school’s consultants, had visited many times in the previous years, and had conducted teacher training workshops emphasizing PBL as a method to acquire knowledge and its embedding in cognitive constructivism. Barrows (perhaps not aware of my previous role) was highly critical about what had been accomplished, because the curriculum “was not a problem-solving curriculum”. Much more emphasis should be put on students acquiring the process of clinical reasoning, otherwise it was not really problem-based. I felt it necessary to object and eventually ended up in a heated argument with him (personal communication).

When asked, Georges Bordage and Charles Boelen could not remember the specifics of this particular event, but both agreed that Barrows, on different occasions, “was not too enthusiastic about knowledge-based PBL- too much about knowledge and not enough about the process of clinical reasoning, same issue” (Bordage, personal communication). Boelen recalled:

On another occasion at UNM in Albuquerque, I think in 1993, as we were considering with a dozen of colleagues PBL applied to public health problems, I remember him exposing very strongly the same arguments and the conversation became so heated that our friend Charles Engel [a PBL pioneer in Australia] who dared to argue was shocked and about to weep (personal communication).

If any doubt persists within the reader, an analysis of the later works of Barrows clearly show that he espoused information-processing to some degree until the end of his academic career, a claim also confirmed by his former research assistant Norman (personal communication). In 1996, Barrows produced a paper summarising his view of PBL in which he re-iterated the importance of clinical problem-solving skills, but also the importance of the acquisition of a medical knowledge-base that would be integrated, centred around the cues of patient problems, and enmeshed with the problem-solving process (Barrows 1996a , b ).

Until the end, Barrows and Schmidt retained two different understandings of the role of problems in PBL. Even though this debate was settled at Maastricht, it remains a major source of debate in PBL education and research around the world. As reported by Schmidt and colleagues, there are still many PBL curricula that follow the information-processing approach to PBL (Schmidt et al. 2009 ). In these curricula, PBL is still seen as a method for developing problem-solving skills rather than as a vehicle for understanding the underlying principles or mechanisms that produce these phenomena. These two interpretations are at such odds with one another that calling both of them “problem-based learning” tends to deprive PBL of its psychological and philosophical underpinnings and may leave only a methodological shell behind, devoid of theoretical support. From a historical perspective, declaring a victor in the dispute for the interpretation of PBL is a difficult matter. In terms of scientific consensus, the constructivist Maastricht interpretation of PBL, as the more theoretically-grounded approach can be awarded a clear academic victory: information-processing has largely been erased from the psychology of learning. But in terms of educational practice, educators from all over the world continue to preach the teaching of general problem-solving skills, so the turf-war for the interpretation of PBL is far from over.

Whilst as a historian, one would not purport to prescribe the application of historical lessons to the present day, one may very well encourage present day educators to seriously and extensively question the rationale behind their PBL curriculum: is it primarily grounded in information-processing or in constructivism, and is there a full and open understanding of the educational consequences that this implies?

This research was limited in scope to McMaster and Maastricht in the field of medical education, but there may be other disciplines and areas where the debate between IPP and constructivism played out. This may be worthwhile investigating. This being a historical paper, it has not investigated the present situation with regards to Problem-solving and Knowledge Acquisition curricula, including at McMaster and Maastricht; this may be an interesting exercise for follow-up research.

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Servant-Miklos, V.F.C. Problem solving skills versus knowledge acquisition: the historical dispute that split problem-based learning into two camps. Adv in Health Sci Educ 24 , 619–635 (2019). https://doi.org/10.1007/s10459-018-9835-0

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The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective.

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Medical Education Online , 14 Jun 2010 , 15 https://doi.org/10.3402/meo.v15i0.4846   PMID: 20563279  PMCID: PMC2887319

Abstract 

Conclusions, free full text , the dreyfus model of clinical problem-solving skills acquisition: a critical perspective, adolfo peña.

1 VA National Quality Scholars (VAQS) Fellowship Program

2 Birmingham VA Medical Center

3 University of Alabama at Birmingham

4 Center for Surgical, Medical Acute Care Research and Transitions (C-SMART)

The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the ‘acquisition’ of clinical skills.

This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus' main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims.

Although the Dreyfus model may partially explain the ‘acquisition’ of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain ‘acquisition’ of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully.

Models are conceptual constructs that aspire to represent real things or processes that to a large extent are hidden for the senses and to the ordinary experience. Models have a role to describe, represent, explain, and ‘translate’ the world. Some good examples are the Feynman diagrams of electrodynamic processes, the fluid mosaic membrane, and the DNA double helix. Although models are partial and just approximations to the truth, they are not fictional or conventional at all. They try to represent their referents in a truthful and objective way with the hope to constantly improve or replace them with better approximations or more precise explanations ( 1 ).

Dreyfus and Dreyfus ( 2 , 3 ) have offered a model of professional expertise that plots an individual's progression through a series of five levels: novice, advanced beginner, competent, proficient, and expert. In the novice stage a person follows rules that are context-free and feels no responsibility for anything other than following the rules. Competence develops after having considerable experience. Proficiency is shown in individuals who use intuition in decision making and develop their own rules to formulate plans. Expertise is characterized by a fluid performance that happens unconsciously, automatically, and no longer depends on explicit knowledge. Thus, the progression is envisaged as a gradual transition from a rigid adherence to taught rules and procedures through to a largely intuitive mode of operation that relies heavily on deep, implicit knowledge but accepts that sometimes at expert level analytical approaches are still likely to be used when an intuitive approach fails initially.

This model, a product of philosophical deliberation and phenomenological research, was initially adapted by Benner and other nursing educators to explain the development of nursing skills ( 4 ). However, this was not without debate, which still remains. Hargreaves and Lane criticized Benner's model, a linear model of skill acquisition that cannot sufficiently explain the everyday experiences of learning ( 5 ). Thompson ( 6 ), Purkis ( 7 ), and Rudge ( 8 ) criticized Benner's and Dreyfus' models because of their apparent absence of social structure or social knowledge. English pointed out that Benner's and Dreyfus' models fail to identify expert nurses because they neglect to specify objective qualifications for expertise ( 9 ). For Effken, the terms ‘expertise’ and ‘intuition’ do not have operational definitions: ‘structured measurement has been elusive because of the complexity of the domain and the degree to which skill is embedded in a particular situation’ ( 10 ). Gobet and Chassy, in contraposition to Dreyfus' and Benner's phenomenological philosophy, suggest an alternative conceptual framework to understand the role of intuition in expertise ( 11 ).

Assuming that nurses’ and physicians’ skills are of the same nature, physician educators have ‘translated’ and adjusted such a model to explain clinical skills not only in terms of simple routine tasks but also in terms of the most symbolic skills, i.e., clinical problem-solving skills ( 12 ). Many authors express their support for this. For Daaleman, Dreyfus provides a model of knowledge and skill acquisition that is relevant to the training of physicians in practical wisdom ( 13 ). Batalden, Holmboe and Hawkins recommend assuming Dreyfus' ideas as a framework to understand medical competencies [ 14 , 15 ]. The Accreditation Council for Graduate Medical Education (ACGME) recommends this model for curriculum-planning for residency training programs ( 16 ).

Contrary to the debate raised in academic nursing fields, judging by medical publications and recommendations from academic organizations, the current form of Dreyfus' model ( 2 , 3 , 17 – 19 ) is being accepted almost without explicit criticism from physicians. Thus, although there may be some debate among clinicians and educators, such a debate is not evident in published papers. The Dreyfus model is reaching out to the educative arena and thus plays an important role in modeling how physicians acquire clinical skills. This may generate important consequences for our education. As was mentioned in this introduction, even models that are born from science are not complete explanations or perfect approximations to the truth, and they might be erroneous. Different from those, the Dreyfus model comes from philosophical fields; this fact makes even more urgent a critical analysis and debate. This paper tries to stimulate both.

  • A brief inventory of the Dreyfus model

A very important requirement for any model is its referent, i.e., the object or process referred to by the model or that which the latter is about ( 20 ). The Dreyfus model postulates that when individuals acquire a skill through external instruction, they normally pass through several stages. It is undeniable that such a process implies the acquiring of some knowledge. This psychological result of perception, learning, and reasoning constitutes the Dreyfus model's primary referent. Because the acquisition of knowledge does not happen in a vacuum but in a very complex organ (the brain), it is desirable that any hypothetical construct that attempts to explain learning is defined not only psychologically but also neurologically ( 21 ). Unfortunately, neurological terms appear in the model only when Dreyfus gestures toward artificial neural networks to demonstrate that phenomenology can reveal objective structures of bodily praxis ( 18 , 22 ). Therefore, we may say that the brain is a secondary or spurious referent of such a model.

Postulates and propositions

The Dreyfus model has been proposed in prose style. Because it is easier to analyze a model when its content is structured in clear and unambiguous sentences (propositions) capable of being evaluated as true or false to some degree, two lists have been created and are presented in Boxes 1 and 2 . They were prepared after a careful review of Dreyfus' original works and summarize the model ( 2 , 3 , 17 – 19 , 23 – 25 ). To contrast Dreyfus' ideas, the author proposes some statements (listed to the right of the boxes) that were produced after reviewing various psychological, neuroscientific, and philosophical works ( 1 , 20 , 21 , 28 – 30 , 34 – 66 , 68 – 79 ).

Dreyfus's postulates versus alternative propositions

Dreyfus' postulates versus alternative propositions, history and scientific evidence.

Some historical facts may be also interesting. The original model was not published immediately for public scrutiny. Four prior reports exist from the US Air Force ( 2 , 23 – 25 ), where some observations carried out on the instruction of jet pilots are described by Dreyfus. In those reports, few original scientific studies were cited and standardized protocols were not utilized. The only recent change in the model is the addition of two stages (‘master’ and ‘practical wisdom’) ( 17 ) to the five originally proposed ( 2 ).

All models have philosophical roots; Dreyfus' ideas are based on phenomenology ( 18 ), a philosophical doctrine proposed by Edmund Husserl based on the study of personal experience in which considerations of objective reality are not taken into account. This view opposes scientific realism; for Husserl, the world of things ‘is only a presumptive reality,’ whereas the subject is the absolute reality ( 26 ). The world is also ‘an infinite idea, a complete synthesis of possible experiences’ ( 27 ). Thus, the reality is subject-dependent because a thing is a complex of sensations. Moreover, according to Husserl, introspection through ordinary experience rather than through experiment, analysis, and modeling can yield deep knowledge of the world ( 28 ). For Martin Heidegger, another key proponent of phenomenology, ‘the word is the abode of being’ ( 29 , p. 280), and ‘things become and are only in the word, in language’ ( 30 ). In other words, reality is constituted in and through discourse. We smell this philosophy in Dreyfus' original work on the model of skill acquisition ( 2 ) and we discover his explicit adherence to phenomenology, especially to Heidegger's existential phenomenology, in one of the most authoritative texts on these matters: ‘Being in the world: a commentary on Heidegger's “being and time”’ ( 31 ).

Adaptation to clinical medicine

For the medical field, the model has been adapted with minor changes. For example, Dreyfus' main postulates are that the ‘immediate intuitive situational response is the characteristic of expertise’ ( 17 , p. 42), and that most expert performance is ongoing and non-reflective: ‘fluid performance happens unconsciously, automatically, naturally’ ( 3 , p. 32), and ‘the expert driver generally knows how to perform the act without evaluating and comparing alternatives’ ( 3 , p. 33). Medical educators have proposed a hybrid model where masters are highly intuitive as well as reflective: ‘the master is the practitioner who self-assesses and self-regulates and reflects in, on and for action’ ( 12 ). This current statement contradicts the original model. Frequently, it is also stated by physicians that the model postulates that experts use intuition where empirical and propositional knowledge does not yet exist. Actually, the original model was proposed the other way around: experts work intuitively on every problem and only use other types of knowledge in a few cases when intuition fails.

The following paragraphs will discuss the most controversial aspects the Dreyfus model proposes. The main body of this paper will go further about the referents and basically will clarify what kind of knowledge the model is about and will review its coherence with problem-solving skills; some relevant scientific evidence from cognitive science, psychology, and neuroscience will also be reviewed. The central idea of intuition as a major definition of expertise will be discussed in some detail. This is also a good time to advise that this manuscript does not have any intention to be ‘ecumenical.’ Readers interested in favorable opinions and sympathetic papers of the Dreyfus model are urged to read several of the publications included in the references ( 4 , 12 – 15 , 32 , 33 ).

  • Types of knowledge and the Dreyfus model

Because one of the most important referents of the model is knowledge, it would be of some benefit to review that concept. There are many kinds of knowledge and several ways of grouping these kinds into large categories ( 34 ). A division of knowledge that is relevant when analyzing Dreyfus model is into know-that and know-how. Traditionally, explicit knowledge or ‘knowing that’ has been understood as expressible in some languages; it can be attained easily from any codified information ( 35 ). By contrast, ‘knowing how,’ tacit or implicit knowledge, as it was proposed by philosopher Michael Polanyi, is not expressible in some languages. It is considered intuitive – acquired through practical experience – and as such, is subjective and contextual, and cannot be readily made explicit or formalized ( 36 ). Polanyi also suggested the supremacy of such implicit knowledge: ‘While tacit knowledge can be possessed by itself, explicit knowledge must rely on being tacitly understood and applied. Hence all knowledge is either tacit or rooted in tacit knowledge’ ( 37 ).

In psychology, the knowledge gained in implicit learning is defined by using several criteria ( 38 ). It is not fully accessible to consciousness. The learner cannot provide a full verbal account of what he has learned. Implicit knowledge does not involve processes of conscious hypothesis testing. In addition, implicit knowledge is preserved in cases of amnesia; thus, implicit learning relies on neuronal mechanisms other than the hippocampal memory system ( 39 ). Implicit knowledge is stored as abstract – and possibly instantiated – representations rather than aggregate or verbatim representations. This knowledge may also be inflexible because of its non-hippocampal base ( 40 ).

Knowledge that represents its content, attitude, and its holder explicitly is on the higher-order thought theory, conscious, and is considered explicit. Explicit mental representation is required to refer in verbal communication and thus a link emerges between explicitness and consciousness ( 41 ). The explicit processing of knowledge includes perceptual, cognitive, and motor processes, such as stimulus selection and search, attention focusing and maintenance, memorization, computation, decision making, response selection, and execution ( 42 ).

Recently, neuroscientists have proposed the Competition between Verbal and Implicit Systems (COVIS) model to explain the brain functional specialization and localization for the processing of these two types of knowledge ( 43 ). The verbal (explicit) system is mediated by frontal brain areas, such as the anterior cingulate, prefrontal cortex, and the head of the caudate nucleus. The implicit system is mainly mediated by the tail of the caudate nucleus and a dopamine-mediated reward signal ( 44 , 45 ). The role of the basal ganglia in implicit learning and knowledge has been investigated through the study of people with Huntington's or Parkinson's disease ( 46 , 47 ). Besides the COVIS model, there is evidence that the frontal lobes appear to be involved in the evaluation of implicit knowledge in making conceptual fluency judgments ( 38 ). Hippocampus-dependent memory systems subserve explicit memory formation ( 40 ).

There is considerable evidence in favor of this ‘specialization’ and division of knowledge ( 38 , 41 , 48 , 49 ). However, there is not any evidence that sophisticated skills are performed either without a rich connection of both neuronal subsystems or without a rich interplay of both domains of knowledge. Galanter and Smith observed that even in subjects who are not engaging in conscious hypothesis testing, they can still notice that there is a pattern and can develop explicit knowledge of it ( 50 ). Individual learners, during motor skill practice, can discover the correct solution to a movement problem using either their implicit, explicit or a combination of both domains of knowledge; each approach leads to motor skill learning ( 51 ). The serial reaction time task, a classical example of ‘implicit’ knowledge acquired during sequence learning, is available for intentional control and is, in this sense, explicit ( 52 ). Automatic and intentional forms of processing can be brought under intentional control ( 53 ). Besides, explicit knowledge is an important and active variable that influences problem-solving processes, especially problem representation. Individuals who have accumulated considerable explicit knowledge in a domain represent problems more efficiently than individuals without extensive knowledge bases ( 54 ). In the face of strongly held explicit beliefs, knowledge gained through implicit learning is disregarded ( 55 ). Hence, in normal humans, it is difficult to develop a pure task that allows only implicit or explicit knowledge to contribute to performance. In particular, sophisticated skills are fueled by explicit knowledge.

Although the Dreyfus brothers recognize this division of knowledge, they believe that skills are exclusive instances of know-how or implicit knowledge: ‘you can ride a bicycle because you possess something called “know-how,” which you acquired from practice and sometimes painful experience’ ( 3 , p. 16). The Dreyfus brothers assert that when we perform a skill, we basically execute implicit knowledge without a connection to explicit knowledge. They believe that skills are automatic dispositions that cannot be readily made explicit ( 2 , 3 ). They go further and propose that the net effect of learning is intuition and define it in terms of implicit knowledge: ‘when we speak of intuition or know-how, we are referring to the understanding that effortlessly occurs upon seeing similarities with previous experiences. We shall use intuition and know-how as synonyms’ ( 3 , p. 28). In summary, Dreyfus and Dreyfus define skills at expert level almost exclusively in terms of implicit knowledge.

A critical point is to accept whether or not clinical problem-solving skills are implicit in nature or if they are predominantly dependent upon implicit knowledge. As we reviewed above, it is difficult to develop a task exclusively in terms of implicit knowledge. Even more importantly, clinical problem-solving skills are also instances of explicit knowledge. The clearest cases of explicit knowledge of a fact are representations of one's own attitude of knowing that fact. Knowledge capable of such fully explicit representation provides the necessary and sufficient conditions for conscious knowledge ( 41 ). This is the case when a physician evaluates a patient. Although he is not aware of all of the cognitive steps needed to make a diagnosis, he needs to be conscious of at least of the following events: characterization of a patient's symptom, valuation of a patient's sign, and solicitation of a diagnostic test. Furthermore, physicians explicitly provide a representation (diagnosis) and express the degree of accuracy or inaccuracy and can judge their representations to be true, false or undecided. Hence, it is reasonable to accept that making a diagnosis also subsumes an explicit dimension of knowledge. Therefore, a model that does not respect the complex and rich interaction between both domains of knowledge will have difficulty explaining skills that are not just routines but instead very complex tasks, i.e., finding solutions to problems.

  • Inverse problems and clinical problem-solving skills

Well-defined and direct problems have a clear path to a solution. The problem may be solved by using a set of recursive operations or algorithms ( 57 , 58 ). In contrast, the cognitive processes involved in the solution of ill-defined problems are far more complicated and still ill-understood. In the case of ill-defined problems, all aspects of problem formulation are challenging. Most are fuzzy problems, often difficult to delineate and even harder to represent in a way that makes them solvable ( 59 ). In addition, inverse problems imply a novelty for each case, and expertise should reflect an ability to react to situations that experts have never encountered before. In this context, problems cannot be solved ‘automatically’ or only ‘intuitively.’

The Dreyfus model has been derived from observation of the performance of experts, such as jet pilots and dancers, experts who are used to tackling direct problems. Is it correct to use this model also to explain the performances of experts who are used to tackling inverse problems? It is plausible that often the skills involved in solving direct problems are not the same as those involved in solving inverse problems. Think about the skills needed to solve this short list of inverse problems: to ‘guess’ the intention of a person from his/her behavior, to discover the authors of a crime knowing the crime scene, to ‘imagine’ an internal body part from the attenuation in intensity of an X-ray beam, to guess the premises of an argument from some of its conclusions, or to diagnose a sickness on the strength of its symptoms. The investigation of those problems does not proceed downstream, from premises to conclusions or from causes to effects. Working on all those problems involves reversing the logical or causal stream. In medicine, physicians face inverse problems all of the time. In fact, the typical diagnosis problem is not the direct problem of inferring syndrome from disease, but the inverse problem of guessing disease from symptoms ( 60 ). Anyone who wants to propose a model to explain how we develop clinical problem-solving skills must recognize carefully that the skills used to solve inverse problems are of a different nature than the skills used to solve direct problems. A model should be specific for skills of different natures; the Dreyfus model is not specific enough.

  • Rules and context

In the Dreyfus model, a novice should memorize rules and should not feel responsible for other things: ‘to improve, the novice needs monitoring, either by self-observation or instructional feedback, so as to bring his behavior more and more completely into conformity with the rule.’ ( 2 , p. 7). Besides, the Dreyfus model supports the idea that at proficient and competent levels, performers should have developed ‘personal guidelines and maxims’ in order to be able to deal successfully with tasks and problems ( 2 , 3 ). Why do we have to assume that these Dreyfus propositions are right? Is that the way we learn skills of explicit or even of tacit nature? Is it a good idea to memorize rules at novice stages? Do proficient and competent physicians solve diagnostic problems using just a set of ‘personal’ rules and maxims?

Early problem-solving research proposed the ‘general problem solver model.’ In this model the solution of a problem is conceptualized as a movement between two states: a starting state, named ‘problem space,’ and a final state named ‘goal state’ ( 58 ). There are ‘rules of transition’ which refer to those functions that move the system from one state to another, and there are also heuristics tools, rules that determine which moves are to be made in the problem space. Although this model gives great value to the use of rules, it should be recognized that these components are well suited for solving well-defined and direct problems, where the space and transitions between states are unambiguous ( 59 ). However, the model offers no solution whatsoever for dealing with inverse problems, for which there do not exist simple rules to solve them.

In medicine, although there are clinical guidelines and algorithms available that can help physicians deal with some problems, physicians acknowledge that these ‘rules’ are just general recommendations. Besides, physicians use ‘guidelines’ after they have transformed an inverse problem into a direct one. This is after diagnostic hypotheses have been generated. However, there is not a recipe to generate hypotheses. Furthermore, physicians use heuristic rules, such as Occam's razor regarding parsimony, but these ‘rules’ are general recommendations. They are explicit (not personal), and still it is not well known what impact they have on clinical problem-solving skills ( 61 ).

Rules are instructions for doing something, and even when they may be constructed as a mapping of possible actions (algorithms), they do not describe or explain any particular event or thing because they prescribe what to do. If we accept that knowledge has a transferable content that has been encoded and externalized in cultural artifacts, such as a book, then we should recognize that rules are not the sole element of that content, because knowledge consists of thousands of concepts, propositions, and theories. This knowledge allows us to grasp the nature of disease; understanding is a pre-requisite to learning. The development of clinical reasoning skills for medical students is dependent on basic science achievements ( 62 , 63 ). Novices, who rely on biomedical knowledge, solve complicated diagnostic problems with more success ( 64 ).

Believing that students should only memorize rules has a dark side and can cause deleterious consequences. When rules are available for everything, novices can spare the effort of imagining a different way to solve an inverse problem. Hence, they would tend to proceed to solve problems in a rather mindless way. We should reflect on the fact that to learn, students need all kinds of stimuli, such as propositional from books and experience. But they also need freedom to develop the talent to produce diagnostic hypotheses by spotting, inventing, and sometimes guessing.

Other elements to analyze are Dreyfus ideas that learners at pre-competent stages have a complete ignorance of the ‘context,’ and that the education at this level should be decontextualized: ‘normally, the instruction process begins by decomposing the task environment into context-free features which the beginner can recognize without benefit of experience’ ( 2 , p. 7). Contrary to such an idea, we should acknowledge that everything in our world, including concepts, is interrelated. Learning, as any other event, happens under specific conditions and should not be detached from the real experience. Medical students always face the context. Of course, at the beginning, there is not enough insight into every detail. However, students’ minds are not like computers following a program; they have some ideas, some approaches, and some knowledge of the context. For example, medical students can generate numerous diagnostic inferences, even without considerable clinical experience ( 65 , 66 ). How can they do that if novices like them ‘ignore’ the context? Accumulating experience is not a passive recording. Learning is creative in the sense that it is new and not automatic to the individual. Even at the pre-beginner stage, learners gain experience and understanding of the context. Information, context, and experience cannot be separated.

The Dreyfus brothers propose that intuition is the endpoint of learning and a key characteristic of expertise: ‘the expert pilot, having finally reached this non-analytical stage of performance, responds intuitively and appropriately to his current situation’ ( 2 , p. 12). Hubert Dreyfus describes a master as one with a lot of experience who produces almost instantaneously appropriate perspectives, who thinks intuitively, not analytically, and who ceases to pay conscious attention to his performance turning it unconsciously: ‘the expert, like masters in the “long Zen tradition” or Luke Skywalker when responding to Obi Wan Kenobi's advice to use the force “transcends” “trying” or “efforting” and “just responds”’ ( 67 , p. 22).

Adults often learn to drive a car, type, play chess, ski, etc. In most cases we perform such skills intuitively, quickly, unconsciously, and ‘just respond.’ These everyday skills are relatively easy to acquire, at least to an acceptable level. It is plausible that some steps required to perform a simple task are so fast that we consider them on an unconscious level even though we are alert and oriented. Neuroscience tries to explain that there are two kinds of neuronal aggregations in the brain's organization: one is constituted of heavily interconnected neurons with long-range axons (named workspaces) and the others are system sets of specialized neuronal processors (perceptual, motor, memory, evaluative, and attentional) with short axons ( 68 ). The latter ones are not enough to perform tasks that require great effort, so the workspace neurons are activated, making the effort conscious. This mobilization is greater with complex cognitive tasks ( 68 , 69 ).

However, the popular conception that some simple everyday skills are performed fast and ‘unconsciously’ can explain neither the performance of difficult tasks nor the acquisition of sophisticated skills ( 70 ). In the case of problem-solving skills, empirical studies have demonstrated a distinction between expert and novice problem representation in terms of the time spent on various stages of the problem-solving process. Contrary to the idea that experts dedicate less time than novices, Lesgold ( 71 ) found that experts spent more time than novices determining an appropriate representation of the problem. Experts spent more time comparing their knowledge to the information they needed to discover in order to best represent the problem.

Even skilled rapid motor production, as in typing, is not simple nor is completely automatic. Studies showed that expert typists look ahead to prepare for what comes next. They acquire complex representations and skills to anticipate future actions ( 72 ). Something similar happens in music, where the mark of expert performance is the ability to control one's performance and its results; there is not such a thing as an automatic and immediate response. Expert music performance requires several different representations: ‘imagined music experience’ (desired performance goal), ‘playing a piece of music’ (how to execute the performance), and ‘listening to the played music’ (hearing one's performance) ( 73 ). The resulting music performance should not be seen as a fixed and automated sequence of motor actions. It should be viewed as a flexible, controllable outcome based on these representations ( 70 ).

Consequently, it is hard to believe that the whole clinical problem-solving process is intuitive in the sense that it is unconscious, effortless, and automated. Although the use of ‘pattern recognitions’ and ‘illness scripts’ can happen in an automatic way, especially when data or a prior experience triggers a possible diagnosis, this explains only one state of the whole problem-solving process. Good physicians, although esteeming intellectual intuition because of its suggestive power, know that it can be dangerous: first, because intuition does not have demonstrative force, and second, because intuition is never fine enough. Intuition, as a very fast and almost instant inference, consists of showing rather than demonstrating; in proving in a brief and imperfect way, and in rendering plausible the hypothesis that has been invented. It is a kind of rudimentary reasoning that uses incomplete evidence, visual images, and analogies (prior experiences) rather than complete data, refined concepts, and detailed inferences ( 74 ). A diagnosis formulated in an intuitive way will have to be worked out in a rational way and then tested by the usual procedures. This is because the suspicion generated by the illness scripts and pattern recognitions are not proof of a diagnosis. Further, this is why we use a lot of auxiliary tests and image studies. Expert clinicians intentionally avoid any tendency toward automatization as they often lose control of many relevant aspects of a clinical encounter. Ericson called this ‘deliberate practice’ ( 70 ).

There is evidence that experts use two modes of thinking: analytic (hypothetic–deductive) and non-analytic (pattern recognition), even in perceptual specialties ( 75 – 78 ). Both modes of thinking are part of a continuous process. Expert physicians do not use analytic reasoning only after a failed attempt with non-analytic reasoning or the other way around. Clinical medicine is one of the more complicated and challenging professions; it is very simplistic to explain problem-solving processes starting and ending with intuition. Many diagnostic errors are due to overconfidence and heuristic availability, and some errors occur during non-analytic reasoning ( 79 ). Intuition, because it is brief and readily accomplished and grasped, must be expanded to be validated.

  • Implications and conclusions

Any model is a representation of a thing, and in this representation two elements play important roles: the represented and the representing things. With this pair of elements we can make diverse kinds of representations: factual–factual (a scale model), factual–conceptual (a theoretical model), factual–semiotic (a scientific text), and semiotic–factual (a text illustration) ( 1 ). The acquisition of skills is a learning process and is obviously factual. Hence the Dreyfus model attempts to be a factual–conceptual model, a theory or at least an outlook of how we acquire diverse skills. Any fact–concept correspondence is of course difficult and not of the one-to-one type. However, because it tries to be truthful, a theory must attempt to be coherent and related to the facts.

Although the Dreyfus model is not taken strictly as a ‘prescription,’ it is plausible that its descriptive face is influencing us to generate a worldview, a general outlook of how we learn and teach medicine. Every worldview has an effect on our actions and policies. And here is the point of major implication, because this model can influence educative policies, recommendations, and guidelines. This model can also generate unhappy contradictions. For example, it has been said that the Dreyfus model provides us with a framework for consistency within the evaluation system ( 80 ). How can this model help us to ground our evaluation system if the model suggests explaining physicians’ performance in terms of implicit knowledge and intuition? By definition, if implicit knowledge is not expressible in some language, then it is inaccessible to evaluate. Certainly we need more debates and we need to evaluate this model not only in light of philosophical but also of scientific considerations.

Although the Dreyfus model could partially explain the ‘acquisition’ of some skills, it is another matter as to whether it can explain the acquisition of clinical skills. The occurrence of inverse problems and the rich interplay between the implicit and explicit domains of knowledge must be taken into consideration when we want to explain ‘acquisition’ of clinical skills. The idea that the net effect of education and training in medicine is that we start developing intuition about what we are doing must be revised and evaluated carefully.

Using this model in a prescriptive way must elicit a more critical eye to see if novices must receive an education where rules are the only important things to learn in a decontextualized environment. Finally, we must acknowledge the complexity of all the processes implied in learning. We cannot merely accept the temptation to oversimplify these complex processes, and ignore intentionally or not information from science, in particular from cognition, psychology, and neuroscience.

  • Acknowledgements

The author would like to offer special thanks to Dr Mario Bunge, Frothingham chair of Logic and Metaphysics at McGill University; Dr Gustavo Heudebert, Director of the UAB Internal Medicine Residency Program; and the anonymous reviewers for helpful comments and suggestions on an earlier draft of his article.

  • Conflict of interest and funding

This paper was prepared while the author was a VAQS fellow at the VA Birmingham Medical Center and the Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), these institutions covered the publication costs for this paper.

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Integrating Clinical Reasoning Skills in a Pre-professional Undergraduate Human Anatomy Course

Affiliations.

  • 1 Department of Academic Technology, University of Wisconsin, Madison, Wisconsin.
  • 2 Department of Kinesiology, University of Wisconsin, Madison, Wisconsin.
  • 3 Doctoral Program in Educational Leadership Policy Studies, School of Education, Edgewood College, Madison, Wisconsin.
  • PMID: 33387378
  • DOI: 10.1002/ase.2050

Clinically integrated curricula in health science education has been shown to promote the development of problem-solving schema and positively impact knowledge acquisition. Despite its' purported benefits, this type of curricula can impose a high cognitive load, which may negatively impact novice learners' knowledge acquisition and problem-solving schema development. Introducing explicit clinical reasoning instruction within pre-professional undergraduate basic science courses may limit factors that increase cognitive load, enhance knowledge acquisition, and foster developing clinical problem-solving skills. This study, conducted over the Fall and Spring semesters of the 2018-2019 school year, sought to evaluate whether the implementation of a clinical reasoning instructional intervention within a clinically integrated pre-professional undergraduate general human anatomy course influenced students' acquisition of anatomical knowledge and development of clinical problem-solving skills. Results of the study were mixed regarding the acquisition of anatomical knowledge. Both the intervention and comparison groups performed similarly on multiple choice examinations of anatomical knowledge. However, the clinical reasoning intervention positively impacted students' ability to apply clinical reasoning skills to anatomically based clinical case studies. Results from M\mixed between-within subjects analysis of variance comparing scores on Written Clinical Reasoning Assessments revealed a significant interaction between time and group affiliation, with the groups receiving the interventions outperforming the comparison groups: Fall, P < 0.001; Spring, P < 0.001. The results of this study may imply that explicit clinical reasoning instruction within a clinically integrated undergraduate Human Anatomy course could hold potential for fostering students' early clinical reasoning skills.

Keywords: clinical reasoning instruction; clinically integrated curriculum; human anatomy education; undergraduate anatomy education.

© 2021 American Association for Anatomy.

  • Anatomy* / education
  • Clinical Competence
  • Clinical Reasoning
  • Education, Medical, Undergraduate* / methods
  • Students, Medical* / psychology
  • Open access
  • Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

  • Jacqueline Maria Dias 1 ,
  • Muhammad Arsyad Subu 1 ,
  • Nabeel Al-Yateem 1 ,
  • Fatma Refaat Ahmed 1 ,
  • Syed Azizur Rahman 1 , 2 ,
  • Mini Sara Abraham 1 ,
  • Sareh Mirza Forootan 1 ,
  • Farzaneh Ahmad Sarkhosh 1 &
  • Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

  • Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).
Course work or ethical experiences should provide the graduate with the knowledge and skills to:
  • Use nursing and other appropriate theories and models, and an appropriate ethical framework;
  • Apply research-based knowledge from nursing and the sciences as the basis for practice;
  • Use clinical judgment and decision-making skills;
  • Engage in self-reflective and collegial dialogue about professional practice;
  • Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
  • Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As 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 juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

  • Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

  • Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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  • Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. [Nurse Educ Today. 2016] Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Lee J, Lee YJ, Bae J, Seo M. Nurse Educ Today. 2016 Nov; 46:75-80. Epub 2016 Aug 15.
  • Combining the arts: an applied critical thinking approach in the skills laboratory. [Nursingconnections. 2000] Combining the arts: an applied critical thinking approach in the skills laboratory. Peterson MJ, Bechtel GA. Nursingconnections. 2000 Summer; 13(2):43-9.
  • Review About critical thinking. [Dynamics. 2004] Review About critical thinking. Hynes P, Bennett J. Dynamics. 2004 Fall; 15(3):26-9.
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  1. The Dreyfus model of clinical problem-solving skills acquisition: a

    The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain 'acquisition' of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully.

  2. The Dreyfus model of clinical problem-solving skills acquisition: a

    Conclusions: Although the Dreyfus model may partially explain the 'acquisition' of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to ...

  3. The Dreyfus model of clinical problem-solving skills acquisition: a

    The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted ...

  4. Problem solving skills versus knowledge acquisition: the historical

    In 1996, Barrows produced a paper summarising his view of PBL in which he re-iterated the importance of clinical problem-solving skills, but also the importance of the acquisition of a medical knowledge-base that would be integrated, centred around the cues of patient problems, and enmeshed with the problem-solving process (Barrows 1996a, b).

  5. Understanding the Dreyfus model of skill acquisition to improve

    The Dreyfus model of skill acquisition. The Dreyfus model, first proposed in 1980, breaks down the process of practical skill acquisition into five distinct stages. 4 The original model was subsequently adapted to the learning of clinical skills and the five stages widened to include a sixth. These stages are novice, advanced beginner, competent, proficient, expert and master. 5 The original ...

  6. Understanding the Dreyfus model of skill acquisition to improve

    From the educational bench to the clinical bedside: translating the Dreyfus Developmental Model to the learning of clinical skills. Acad Med 2008; ... The Dreyfus Model of Clinical Problem-Solving Skills Acquisition: A Critical Perspective. Medical Education Online 2010;15:4846. Coaction Publishing [online].

  7. Comparative Theories in Clinical Decision Making and their Application

    The phrase 'Clinical Decision Making' is used synonymously with terms such as 'Clinical Judgement', 'Problem Solving' and 'Critical Thinking' implying that it is a cognitive process concerned with problem recognition through ... The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Medical ...

  8. The Dreyfus model of clinical problem-solving skills acquisition: a

    Assuming that nurses' and physicians' skills are of the same nature, physician educators have 'translated' and adjusted such a model to explain clinical skills not only in terms of simple routine tasks but also in terms of the most symbolic skills, i.e., clinical problem-solving skills (12). Many authors express their support for this. For

  9. Multidimensional factors determine skill acquisition development in

    INTRODUCTION. Globally, person-centred care (PCC) is acknowledged as an essential aspect of quality in health care [].Guided Self-Determination (GSD) is a person-centred method developed in nursing more than 20 years ago [2-4].The purpose of GSD is to support the patient's development of life skills such as, for example problem-solving and self-management [2, 3].

  10. Clinical Problem Analysis (CPA): A Systematic Approach to Te ...

    Clinical problem analysis is an explicitly analytic and systematic approach to clinical problem solving in the sense that it makes optimal use of content-independent (methodical) aspects of medical problem solving. ... Mental models of physical mechanisms and their acquisition. In: Anderson JR (ed). Cognitive Skills and Their Acquisition ...

  11. The Dreyfus model of clinical problem-solving skills acquisition: a

    Conclusions: Although the Dreyfus model may partially explain the 'acquisition' of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want ...

  12. Understanding the Dreyfus model of skill acquisition to improve

    From the educational bench to the clinical bedside: translating the Dreyfus Developmental Model to the learning of clinical skills. Acad Med 2008; 83: 761-7. Crossref. PubMed. ISI. ... The Dreyfus Model of Clinical Problem-Solving Skills Acquisition: A Critical Perspective. Medical Education Online 2010;15:4846. Coaction Publishing [online].

  13. Problem solving in nursing practice: application, process, skill

    This paper analyses the role of problem solving in nursing practice including the process, acquisition and measurement of problem-solving skills It is argued that while problem-solving ability is acknowledged as critical if today's nurse practitioner is to maintain effective clinical practice, to date it retains a marginal place in nurse education curricula Further, it has attracted limited ...

  14. Problem solving skills versus knowledge acquisition: the historical

    In 1996, Barrows produced a paper summarising his view of PBL in which he re-iterated the importance of clinical problem-solving skills, but also the importance of the acquisition of a medical knowledge-base that would be integrated, centred around the cues of patient problems, and enmeshed with the problem-solving process (Barrows 1996a, b).

  15. The Dreyfus model of clinical problem-solving skills acquisition: a

    The acquisition of skill is viewed as a learning process in two ways: suddenly and gradually. All kind of stimuli is necessary to facilitate the trainee's learning, aside from rigidly following rules. 12. A high degree of performance is attained when the individual works intuitively.

  16. Moving from Novice to Expertise and Its Implications for Instruction

    The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Med Educ Online. 2010; 15:1-11. [PMC free article] [Google Scholar] 42. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008; 15 (11):988-994.

  17. Integrating Clinical Reasoning Skills in a Pre-professional

    Introducing explicit clinical reasoning instruction within pre-professional undergraduate basic science courses may limit factors that increase cognitive load, enhance knowledge acquisition, and foster developing clinical problem-solving skills. This study, conducted over the Fall and Spring semesters of the 2018-2019 school year, sought to ...

  18. Nursing students' stressors and coping strategies during their first

    Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses' sources of stress and coping styles ...

  19. Teaching Strategies for Developing Clinical Reasoning Skills in Nursing

    Critical thinking and clinical judgement involve reflective and logical thinking skills and play a vital role in the decision-making and problem-solving processes . The first search was conducted between March and September 2022, and an additional search was conducted during October 2023, adding the new articles published between September 2022 ...

  20. The Clinical Problem Solvers

    The Clinical Problem Solvers Democratizing clinical reasoning education Podcast Morning Report RLR CPSolvers Frameworks - Scripts Get Involved!

  21. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and

    Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses' continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.