clinical problem solving skills acquisition

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

The idea that experts work from intuition, not from reason, should be evaluated carefully.

intuition, implicit knowledge does not always work for experts, in which case they fall back to analytical approaches.

(The model seems to have been extended to include “master” and “practical wisdom” stages.)

The only recent change in the model is the addition of two stages (‘master’ and ‘practical wisdom’) (17) to the five originally proposed (2).

Dreyfus and Dreyfus define expert level skill almost exclusively in terms of implicit knowledge. (Ignoring explicit knowledge.) → Dreyfus model does not take into account explicit knowledge

Dreyfus model does not respect complex and rich interaction between implicit/explicit knowledge domain and has difficulty explaining very complex tasks (not just routines) — e.g., finding solutions to problems

Forward/inverse problems: → Forward/reverse problems

Direct or forward: given C (causes) → E (effects), find E (effects)

Inverse: given effects, find cause

inverse problems are also ill-defined: a simple solution might not exist, there may be more than one solution, or a small change in the problem leads to a big change in the solution

Dreyfus model has been derived from observations of jet pilots and dancers, who tackle forward problems → Forward/reverse problems

(How well does Dreyfus model apply to knowledge work?)

Diagnosis that has been formulated in the intuitive way, needs to be worked out in a rational way and then tested by the usual procedures. → Intuitive solutions have to be rationalized

“Expert clinicians intentionally avoid any tendency toward automatization as they often lose control of many relevant aspects of a clinical encounter.” → re: Deliberate Practice

📝 Intuitive solutions have to be rationalized
📝 Forward/reverse problems
📝 Dreyfus model does not explain reverse problems solving
📝 Dreyfus model does not take into account explicit knowledge
📝 Dreyfus model
📝 How to use Dreyfus model in teaching

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> Journals
> British Journal of Anaesthetic & Recovery Nursing
> Volume 13 Issue 3-4
> Comparative Theories in Clinical Decision Making and...

Article contents

Introduction, literature review, comparative theories in clinical decision making and their application to practice: a reflective case study.

Published online by Cambridge University Press: 06 December 2012

Within this article the author critically reviews the theories surrounding clinical decision making and judgement while discussing a clinical incident, and his experiences of decision making within his own practice setting. Exploring the works of Elstein and Schwarz, Benner, Hammond and Hamm, the author discusses how aspects from each of their theories relate to his practice and clinical reasoning before concluding on the clinical decision-making process and factors that can influence their successful application.

The author's experience of clinical decision making details the diagnosis of an acute myocardial infarction and the decision-making process taken to reach this. To maintain confidentiality, the identity of the patient, hospital and other healthcare professionals have been anonymised in accordance with the Nursing and Midwifery Council's (NMC) Guidelines on confidentiality [NMC, 2008 ].

Although walking through the post-operative care ward, the author noticed a patient lying in bed who appeared unwell with shallow ‘disorganised’ breathing. On closer examination the gentleman appeared cold and clammy with a grey pallor and a blue cyanotic tinge to his lips. The author attempted to speak to the gentleman; however, he was confused and anxious and talking incoherently. The author immediately undertook an Airway, Breathing and Circulation (ABC) assessment, checked his airway, placed him on 15 L of oxygen via a Hudson non-rebreathe mask and checked his vital signs. The gentleman's pulse rate was 120 beats per minute and regular; he had unrecordable oxygen saturations and his systolic blood pressure was 89 mmHg. The author immediately tilted the base of the patient's bed and set up an IV infusion of plasma expander (colloid) to raise his blood pressure.

Working in post-operative rehabilitation it is often common to encounter patients who suffer with orthostatic hypotension and syncope secondary to hypovolaemic shock. However, the author was concerned that the patient was not responding to the usual treatment provided and contacted the duty doctor on call. He was informed that the gentleman had been reviewed some 10 min earlier and there was no cause for concern as the patient appeared comfortable and was sleeping. It was explained that the patient was acutely unwell and the doctor responded that he would re-review the patient shortly. As the author was convinced that the gentleman's condition was deteriorating, he undertook an electrocardiogram (ECG), which upon examination indicated a myocardial infarction.

Concerned that he was not getting the appropriate response from the duty doctor the author called the clinical lead down from the Post-Anaesthetic Care Unit to help assess the patient again. On examination of the ECG, a posterior myocardial infarction was identified and the gentleman was immediately transferred to a High Dependency Care bed in her unit. The gentleman was promptly started on the Acute Coronary Syndrome protocol of care and further diagnostic tests revealed an extensive myocardial infarction.

Decision making forms the foundation of all nursing care and associated interventions from the administration of medicines to assistance with activities of living and rehabilitation. Over the past 40 years considerable emphasis has been placed on the need for knowledge and evidence to support practice and guide the decisions healthcare professionals make. Policies and directives issued by the Government and Department of Health [Department of Health, 2010 ; House of Commons, 2011 ] stipulate a need for high quality care underpinned by research and clear evidence.

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 identification of cues and clinical features, data gathering, integration, analysis, evaluation and choice to produce an informed decision [Clack, Reference Clack 2009 ]. Standing [ Reference Standing 2010 ] suggests that decision making is a complex process that involves observation, information processing, critical thinking and clinical judgement to select the best course of action in promoting and maintaining a patient's health. While Elstein and Schwarz [ Reference Elstein and Schwarz 2002 ] assert that clinical decision making involves a rational process of ‘hypothetico-deductive reasoning’ based on information processing.

Within clinical decision-making theory, ‘hypothetico-deductive reasoning’ is considered the most dominant approach in health care with practice based on rationality and empirical precision [Jefford et al , Reference Jefford, Fahy and Sundin 2011 ]. A hermeneutic examination of figures, text, verbal and non-verbal cues forms the foundation from which a hypothesis is generated and subsequent treatment is based. This diagnostic ‘paradigm’ is formed of four stages that assist the assessor in identifying and interpreting cues and constructing and evaluating a hypothesis (primary diagnosis).

These four stages are:

1. Cue acquisition – primary data and sensory stimuli that steers the nurse towards a particular thought process through specific cues.

2. Hypothesis generation – development of a provisional and differential diagnosis based on cues and baseline data.

3. Interpretation of Cues – re-exploration and interpretation of cues to support or dismiss hypothesis with further data collection to aid interpretation.

4. Evaluation of Hypothesis – the cues are then evaluated and applied to an overall hypothesis that directs the decision made and subsequent intervention/action taken.

Relating the author's clinical experience to the hypothetico-deductive approach, cue acquisition involved the collation of information from previous baseline observations and past medical history with new data that included visual cues and vital signs. From this information an initial hypothesis was formed that suggested the patient was having a heart attack. Further interpretation of cues included the use of electrocardiography that revealed a posterior myocardial infarction leading the author to evaluate and determine his hypothesis as correct.

As detailed above, the hypothetico-deductive model of clinical problem solving relates to the way a nurse or healthcare professional processes patient-relevant information [Norman, Reference Norman 2005 ]. This scientific method to problem solving and analysis is considered beneficial due to the linear approach and prescriptive manner in which practitioners address a given situation; hypothesis generation is considered rational and structured, and related to the directionality of interpretation [Banning, Reference Banning 2007 ]. This assertion is supported by Botti and Reeve [ Reference Botti and Reeve 2003 ] who define the generation of a hypothesis through data acquisition and interpretation as ‘forward reasoning’, and claim that clinical experts use such an approach in clinical decision making and diagnosis.

However, this mode of decision making is not infallible and a number of researchers have questioned whether such a simplistic approach to assessment can facilitate safe, accurate diagnosis and subsequent treatment [Patel and Groen, Reference Patel and Groen 1986 ; Kennedy, Reference Kennedy 2002 ; Priddy, Reference Priddy 2004 ; Banning, Reference Banning 2007 ].

Hypothetico-deductive reasoning is dependent on the hypothesis generated. That is, application of an inaccurate hypothesis can lead to a misdiagnosis and an inaccurate result. An example of this is the hypothesis generated in the author's scenario in which he diagnosed a heart attack based on the symptoms presented and associated cues. Symptoms of extreme anxiety, cold clammy pallor, a positive ‘Portsmouth Sign’, unrecordable oxygen saturations and peripheral shutdown are also associated with late signs of septic shock [Woodrow, Reference Woodrow 2000 ]. Thus, it can be suggested that the author could have erroneously interpreted the cues leading to misdiagnosis and ineffective treatment. This assertion is supported by Rozeboom [ Reference Rozeboom 1990 ] who is particularly scathing in his criticism of this approach, claiming that the ‘epistemic fecklessness’ of hypothetico-deductive reasoning wrongly implies a simple rational process to decision making without acknowledging context, affect, emotions and intuition.

While hypothetico-deductivism provides a linear and scientific structure to the decision-making process, it fails to acknowledge intuition and experiential learning, both of which influence the approach taken. This notion is supported by Cioffi [ Reference Cioffi 1997 ] who claims that intuition is a legitimate and essential component of clinical judgement and decision making. Yet up until the past 25 years, and until the seminal work of Dreyfus and Dreyfus and Benner, the notion of experience and intuition in decision making was not considered legitimate due to ambiguity and a lack of ‘hard-data’ [Mallick, Reference Mallick 1981 ].

In a study of decision-making behaviour among US Air Force pilots, brothers Stuart and Hubert Dreyfus developed a model of skill acquisition based on situated performance and experiential knowledge [Dreyfus and Dreyfus, Reference Dreyfus and Dreyfus 1980 ]. Developing previous research undertaken by Johnson-Laird and Wason (1977, cited in Dreyfus and Dreyfus, Reference Dreyfus and Dreyfus 1980 , pp. 4–5), the authors determined a subject's task performance improved significantly if related to previous experience. Further research identified a direct correlation between the levels of skill acquisition in relation to concrete experience. As professionals gain experience in their specific line of work, they move through a developmental continuum progressing from a novice to an expert. Dreyfus and Dreyfus, [ Reference Dreyfus and Dreyfus 1980 ] assert that workers move through five stages of career development that they categorized as: novice, advanced beginner, competent, proficient and expert. With each stage of ‘skill’ acquisition comes an increase in knowledge and ability. At the beginning, the ‘novice’ acts according to rules that determine a specific action; in the later stages of this paradigm, the ‘expert’ is able to make intuitive decisions based on previous experience, operating outside guidelines and scientific principles [Blum, Reference Blum 2010 ].

In her book ‘From Novice to Expert’, Benner [ Reference Benner 2001 ] applies the principles of Dreyfus and Dreyfus’ model to nursing practice and clinical decision making. Employing the five stages of novice to expert, Benner suggests that novices undertake clinical decision making guided by rules and policies. Novices have little experience in clinical decision making and critical analysis and rely on guidelines and rules for direction. Decision making and associated actions are often based on rudimentary ‘primary’ concept formation influenced by fear, mistakes and the need for acceptance from one's peers [Daley, Reference Daley 1999 ]. As the nurse moves through the stages of skill acquisition and gains experience, ‘secondary’ concept formation occurs and new and pre-existing knowledge is assimilated in a process referred to as ‘subsumption’ [Vacek, Reference Vacek 2009 ]. The expert is able to make decisions based on both abstract and concrete information, which has been obtained through individual experience and skill acquisition. This notion is supported by Benner, who states that ‘at the heart of good clinical judgement and clinical wisdom lies experiential learning from particular cases’, before going on to state that nursing practice requires both techné (craftsmanship) and phronesis (wisdom) [Benner et al , Reference Benner, Tanner and Chesla 2009 , p. XV (introduction)].

What is clear from the work of both Dreyfus and Dreyfus and Benner is that practice is guided by experiential knowledge and that intuition can only take place in the presence of this. However, one significant criticism of the notion of novice to expert is the lack of any clear definition as to what an ‘expert’ actually is [Peña, Reference Peña 2010 ]. Lyneham et al [ Reference Lyneham, Parkinson and Denholm 2008 ] asserted that Benner's theory fails to explicate the final stage of the expert practitioner and it therefore remains open to debate. The authors go on to provide their own definition based on Benner's principles suggesting that the expert practitioner uses ‘embodied intuition; taking what action is appropriate at the time, doing so freely, without conscious thought and practising within both cognitive and embodied intuitive paradigms’ [Lyneham et al , Reference Lyneham, Parkinson and Denholm 2008 , p. 384].

Referring to the author's scenario it is hard to consider his actions as that of an ‘expert’. What occurred with the identified patient was not part of the author's usual working practice and was a predominantly medical (cardiac) problem. Yet despite this, the author instinctively undertook what he considered was the most appropriate action based on a pre-existing knowledge and experience of cardiac arrest and resuscitation. The use of ‘heuristics’ based on previous experience provided a ‘cognitive shortcut’ in the decision-making process and allowed the author to develop a rapid response to a difficult situation.

Based on Simon's theory of bounded rationality [ Reference Simon 1991 ], Tversky and Kahneman [ Reference Tversky and Kahneman 1974 ] transformed academic research and theories on judgement with their ideas on ‘heuristics’ and rationality. The authors assert that when faced with complex decisions individuals often make use of experience-based problem solving techniques using a three-tier process:

1. Availability – assessing probability of actions based on previous phenomena and recalling previous occurrences.

2. Representativeness – comparing representation of data with that from previous experiences. Estimating the probability that patient A is having the same problems as patient B through the comparison of cues and data.

3. Anchoring/adjustment – Developing an initial hypothesis (anchor) based on availability and representativeness, and then adjusting this based on additional information.

This heuristic framework was employed when the author undertook his decision making in the incident detailed above, with the recollection of previous incidents involving a cardiac arrest guiding the author's actions. The patient presented with symptoms commensurate with previous experience and the author was able to undertake a representative comparison of the cues presented in both. Having developed a hypothesis based on ‘rough pattern recognition’ the author then ‘anchored’ this with the use of additional diagnostics that confirmed this.

However, despite this cognitive approach being successful it can be suggested that the author's actions were based on ‘trial and error’ rather than structured assessment. Thompson and Dowding [ Reference Thompson and Dowding 2009 ] claim that the use of heuristics generates predictable systematic biases and errors due to the subjective nature of the decision-making process. Tversky and Kahneman suggest that when recalling previous experience, individuals will often only recall those incidents where interventions or decisions were positive and had ‘favourable’ outcomes; thus rendering the decision-making process biased and unrealistic. Reflecting on the two approaches detailed above, it is apparent that intuition and analysis are at separate ends of the decision-making spectrum. Yet, it can be asserted that decision making is seldom entirely intuitive or analytical but a combination of both.

Based on Brunswik's Lens Model [see Thompson et al , Reference Thompson, Cullum, McCaughan, Sheldon and Raynor 2004 ], Hammond's Cognitive Continuum Theory (CCT) focuses not only on the decision maker, but also on the environmental factors that influence cognition and the decision-making process, taking into account both analytical and intuitive strategies [Hammond, Reference Hammond 1996 ]. Hammond's theory rejects a dichotomous view of intuition and analysis, instead detailing six modes of cognitive inquiry that places intuition and analysis at opposing ends of the continuum [Dunwoody et al , Reference Dunwoody, Haarbauer, Mahan, Marino and Tang 2000 ]:

1. Physical science experiment

2. Control group experiment

3. Quasi-experiment

4. Computer modelling

5. Expert judgement

6. Unrestricted judgement.

In his theory, Hammond argues that different decision-making tasks require different approaches according to the situation and task complexity [Hammond, Reference Hammond 1996 ]. The cognitive continuum places tasks along a vertical axis in accordance with the decision-making approach taken. Along the horizontal axis, is the cognitive approach taken with the decision-making process beginning with ‘pure intuition’ and moving across to ‘pure analysis’. In addition to the two axis, Hammond subdivides the cognitive continuum into six modes that detail the divergent intuitive and analytical methods associated with different tasks and the structure of the decision-making process [Thompson et al , Reference Thompson, Cullum, McCaughan, Sheldon and Raynor 2004 ]. The scientific/analytical modes of 1–3 enable the decision maker to apply explicit theoretical knowledge supported with evidence-based practice and associated research. The intuitive/experimental modes of 4–6 allows the decision maker to undertake tasks supported by tacit knowledge and trial and error [Standing, Reference Standing 2010 ]. Thus, the CCT focuses on the relationship between the concepts of tasks and modes of cognition with Hammond asserting that the more structured a task is, the more analytically induced the decision-making process will be. In contrast, an ill-structured decision-making task is likely to be intuition-induced with little analysis involved [Cader et al , Reference Cader, Campbell and Watson 2004 ].

Hamm [ Reference Hamm 1988 ] later revised Hammond's theory to explore doctors’ understanding of decision making and clinical judgement; amending the terminology used in the six modes of inquiry to allow for better association of tasks:

1. Scientific experiment

2. Controlled trial

4. System-aided judgement

5. Peer-aided judgement

6. Intuitive judgement.

Hamm also determined that the quality of the task structure was in direct proportion to the amount of time taken along with the potential for judgement bias and visibility of the task process.

In his study, Hamm identified that decision making among doctors fell between the 5th and 6th modes of the cognitive continuum, whereby mainly intuitive and peer-aided judgement was used [Standing, Reference Standing 2010 ]. Thompson [ Reference Thompson 1999 ] asserts that employing the cognitive continuum in nursing practice can help provide the ‘middle ground’ in decision making that allows for the use of both analytical and intuitive cognition. By sitting firmly between Elstein's hypothetico-deductive model [Elstein and Schwarz, Reference Elstein and Schwarz 2002 ] and the notion of intuition and tacit knowledge derived from the work of Dreyfus and Dreyfus [ Reference Dreyfus and Dreyfus 1980 ] and Benner [ Reference Benner 2001 ], the cognitive continuum allows for the synthesis of both theories allowing for more comprehensive decision making. Reviewing Thompson's work, Harbison [ Reference Harbison 2001 ] endorses his notion of the usefulness of the cognitive continuum in nursing asserting that Hammond's paradigm helps to instill quality in the decision-making process and subsequent care provision by supporting the need for evidence-based practice and a sound knowledge base. However, Harbison is keen to point out that there needs to be further investigation to determine what constitutes ‘quality’ in nursing judgement and decision making. It can be suggested that like Benner's theory of expertise, the notion of quality is enigmatic and subjective, which is open to mixed interpretation and a multitude of conflicting descriptions.

Like Hamm [ Reference Hamm 1988 ], Standing [ Reference Standing 2008 ] further revised Hammond's Cognitive Continuum in an attempt to make it more applicable to the nursing profession. Standing asserts that the definitions used in both Hammond and Hamm's versions of the continuum are ambiguous with the typology used for task structure confusing. Moreover, Standing states that decision making in nursing not only involves peer-aided judgement, but involvement from the patient too. In revising Hammond's theory, Standing changes the terminology used and adds a further three ‘modes of practice’ within the cognitive continuum that she feels underpins decision making in nursing. Standing's ‘revised cognitive continuum’ [Standing, Reference Standing 2008 ] identifies the benefits of reflective practice and replaces the quasi-rational and experimental modes of cognition with more specific categories that include action, experiential, qualitative, survey and experimental research.

In removing quasi-rationality from the cognitive modes, Standing acknowledges that, unlike the medical model of care, decision making in nursing does not take a predominantly ‘scientific’ stance. The nursing profession prefers a ‘holistic’ approach that encompasses reflection on and in action, patient involvement and evidence-based practice. This notion is supported by Harbison [ Reference Harbison 2001 ] who claims that nurses are reluctant to adopt medical frameworks and theories due to a need for ‘professional identity’ coupled with the fact that decision making in nursing is fundamentally different from the technical/rational approach taken in medicine.

Furthermore, Standing's revised theory removes the numerical sequencing from 1–6 as she asserts that decision making should not be seen as a ‘linear’ activity, but a ‘flexible continuum oscillating in either direction along the continuum in response to continually changing judgement tasks’ [Standing, Reference Standing 2008 , p. 130].

Standing's revised continuum provides a rational and structured approach that promotes the ethical and professional aspects of decision making in nursing. Recognising that the modes of practice are not sequential, by removing the didactic numerical scale to each mode signifies the personal nature of decision making and the need for an objective multi-modal approach.

Referring to the author's clinical incident, it can be suggested that his actions and the approach taken were positioned across a number of modes in Standing's revised continuum, encompassing elements of intuitive, reflective and peer-aided judgement. Furthermore, having made a clinical decision and undertaken the associated actions, the author returned to the continuum to review this with the use of reflective judgement and critical reflection to evaluate the patient outcome.

In conclusion, it can be suggested that the theoretical principles of the CCT and associated paradigms developed by Hammond [ Reference Hammond 1996 ], Standing [ Reference Standing 2008 ], Dreyfus and Dreyfus [ Reference Dreyfus and Dreyfus 1980 ] and Benner [ Reference Benner 2001 ] all provide the conceptual framework and insight from which clinical decisions are formed. The ideas and methods identified are well supported by research that identifies the many different approaches the nurse can take in clinical judgement and decision making. However, it can be suggested that in reality, as patients’ needs change and care provision constantly evolves, these theoretical models will soon become obsolete, forcing the nursing profession to reassess their approach to clinical decision-making theory and practice. Moreover, as demonstrated by Benner [ Reference Benner 2001 ] and Elstein et al [ Reference Elstein, Shulma and Sprafka 1978 ], no decision-making model is completely infallible; environmental factors associated with socio-economic instability and changes to the way in which care is provided have the potential to ‘shift the goalposts’ and make the decision-making process more difficult even for the ‘experts’.

It is appreciated that the theories discussed within this article have not been explored as fully as the author would have liked due to the constraints of this assignment. However, it is hoped that the link between theory and practice is evident. Although the author takes a more pragmatic approach to the issues raised in this assignment, it is evident that the theories have applications.

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DOI: https://doi.org/10.1017/S1742645612000435

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DOI: 10.3402/meo.v15i0.4846
Corpus ID: 17048237

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

Adolfo Peña
Published in Medical Education Online 1 January 2010
Philosophy, Medicine, Psychology

146 Citations

Critical thinking in health sciences and how it pertains to sonography education: a review of the literature, a theory of mental frameworks, developing skills in intra-workplace rehabilitation education: i, sandbox of competence: a conceptual model for assessing professional competence, experiences from leading parental education groups: perceived difficulties and rewards as an indication of skill acquisition, teaching clinical judgment: a review with consideration of applications for health professions, the effects of simulation-based training on critical thinking.

Highly Influenced

Experiential Learning in Clinical Ethics Consultation

Dreyfus and dreyfus and indicators of behavioral performance: a study of measurement convergence, the utility and development of the competencies of professional psychology rating scales (coppr), 91 references, from the educational bench to the clinical bedside: translating the dreyfus developmental model to the learning of clinical skills., dreyfus on expertise: the limits of phenomenological analysis, tacit knowledge and visual expertise in medical diagnostic reasoning: implications for medical education, informational basis for expert intuition., qualitative differences in knowledge structure are associated with diagnostic performance in medical students, medical students' clinical reasoning skills as a function of basic science achievement and clinical competency measures: a structural equation model, towards an alternative to benner's theory of expert intuition in nursing: a discussion paper., the medical home: locus of physician formation, intelligence without representation: merleau-ponty''s critique of mental representation, intuition as a function of the expert nurse: a critique of benner's novice to expert model., related papers.

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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.

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

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

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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 ).

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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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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7 Phases of Skill Acquisition: How Someone Develops Skills to Mastery and Beyond

Dr Raman K Attri
November 11, 2017

Multiple views on Dreyfus & Dreyfus’s (1986) model explain the characteristics of 7 phases of development any newbie experiences to become a domain expert and beyond.

The process of skill development that could explain how a novice develops mastery in certain specific skills, has attracted a great research focus for a long while. To demystify this, in an earlier post, “ 7 Phases of Skill Acquisition: Mastery and Beyond on Dreyfus’s Model” I expanded the definitions and characteristics of the 7 stages specified by Dreyfus & Dreyfus (1986, 2001, 2008) model by combining perspectives and explanations from various thought leaders and researchers. Among those 7 stages, most commonly the five stages have become widespread in the academic and professional literature. These stages are – Novice, Advanced Beginners, Competent, Proficient, and Expert. Some researchers nomenclature these stages slightly differently but fundamentally with similar essence. Some of them also combined expert and master together as a pinnacle stage in skill acquisition. In another post, “ 7 Models That Explain How Novice Develops into an Expert” , I explained 7 different models that explain novice to expert transition, though all of those models reported different stages and described those characteristics differently. Among all those models, four models hold particular academic significance and business appeal. These models are – Dreyfus & Dreyfus (1986, 2001, 2008), Hoffman (1998) Journeyman model, Alexandar (2003) Model of Acclimation of Proficiency Development and from business literature Rosenberg (2012) Beyond Competency Model.

Developing newbie employees in any organization is a prime business goal. In a previous post, “ 7 Models That Explain How Novice Develops into an Expert “, I explained some famous models that attempt to explain this progression of a novice towards mastery. Among the other models, one of the most recognized works in specifying stages of expertise was proposed by Dreyfus and Dreyfus (1986). This model holds particular academic and professional significance due to the amount of research that has been done on this model. However, I came across so many different variations of the model. This post is an attempt to combine various perspectives into one. At this moment I will stick to the word ‘stage’ or ‘phase’ interchangeably to denote various states through which skill development happens.

The Dreyfus model is based on the basic notion that the acquisition of skill is a continuous process and skill is transformed by experience and mastery, and this then brings about a change in performance. As a novice progresses, he acquires more and more situational understanding and is able to exert his intuition in several situations. According to this model during skill acquisition, competence, proficient and expert are points in the continuum of performance whereby the novice is on one side of the scale while the expert is on another end of the scale and the individual demonstrates a different type of performance at each level. According to Dreyfus and Dreyfus (1986, p. 35), the most important difference between the levels of expertise is the gradual shift from analysis to intuition and the grade of involvement. Dreyfus and Dreyfus changed the nomenclature of the levels from their original 1980 proposal to new ones as Novice, Advanced Beginner, Competence, Proficiency, and Expertise (Dreyfus & Dreyfus, 1986). In the original model, they did not have “advanced beginners”. Over the years this has remained the most simplistic and most commonly used model of stages of skill progression due to its implication in the professional and training world.

Over the years including Dreyfus (1986, 2001, 2008) several other researchers like Burns (2012), Gunderman (2009), Berner (1984), Eraut (1990), Khan and Ramachandran (2012), Stan Lester (2010), Steve Flowers (2012) have significantly added more perspectives to the definition of each of the levels. I am compiling those thoughts into one post here.

FIRST PHASE – NOVICE

This is the first stage where a novice works to gain a better understanding of skills mostly through formal training. Novice continues to be unaware of the particular skills or knowledge that must be applied by the practitioner in real-world situations; learners indicate an interest and willingness to develop the necessary skills and knowledge. During this phase, the novice learns to recognize various facts and figures pertaining to the skill as well as rules for deciding how to act on it. Novice takes these facts and figures context-free. They are trained to adhere to rules rigidly and apply them in any situation. From that perspective, they will not have much situational perception or discretionary judgment on whether or not to apply a given rule in a given situation.

Novice (Hoffman, 1998): Literally, someone who is new – a probationary member. There has been some minimal exposure to the domain. Hoffman called another level ‘Initiate’ to indicate a novice who has been through an initiation ceremony and has begun introductory instruction.

Novice (Rosenberg, 2012) . A novice (or apprentice) is, by definition, new to a job. Novices know little or nothing about the work, certainly too little to be able to perform to any acceptable standard. Novices must be taught (or shown) the basics of what is to be done before they can have any chance of being productive. The learning strategy here is overwhelmingly instructional. “Show me (teach me) how to do my job,” they ask.

Other views

Beginners, because they have no experience with the situations in which they are expected to perform, must depend on rules to guide their actions. Following rules, however, has its limits. No rule can tell novices which tasks are most relevant in real-life situations. The novice will usually ask to be shown or told what to do (Patricia Benner, 1984, pp 13-34).
Rigid adherence to taught rules or plans. Little situational perception. No discretionary judgment (Eraut Michael, 1994).
Minimal, or ‘textbook’ knowledge without connecting it to practice. Unlikely to be satisfactory unless closely supervised. Needs close supervision or instruction. Little or no conception of dealing with complexity. Tends to see actions in isolation (Institute of Conservation, London, 2003).
Novices are beginners who lack any previous experience with a task. The novice learns basic rules for necessary actions but lacks the understanding to deviate from a prescribed performance. Therefore, novices can perform an action only by applying rules they have learned to use in a specific context (Gunderman, 2009).
At the novice level knowledge is treated Without reference to context but no recognition of relevance. Context is assessed analytically. While decision-making is rational (Stan Lester, 2010)
A novice is just learning the basics of a subject, unable to exercise discretionary judgment, and has rigid adherence to taught rules or plans (Steve Flowers, 2012).
Rules (protocol)-based performance Direct supervision is needed at all times. Unable to deal with complexity. The task is seen in isolation (Khan & Ramachandran, 2012)
Operate by using context-free features and rules; Do not understand that rules are contextually based; context-free rules need to occasionally be violated given the context or situation presented; Do not assume responsibility for the consequences. Thus the desire to create a protocol or a set of concrete rules results; Follows rules (Rebecca West Burns, 2012).

SECOND PHASE – ADVANCED BEGINNER

Advanced Beginner (Dreyfus, 1986): As the novice attains some experience in real situations, his performance starts improving to a marginally acceptable level (DiBello, Lehman, Missldine, 2011). Learners in this stage develop the comprehension of objective facts, initial concepts, and specific rules and are able to apply them within a discipline or in structured settings but may struggle to apply them to real-world situations ( Piantanida, n.d; Noreen. 1975). As novice gains more practical and concrete experience, he starts comparing the new situations with previously experienced situations but still applies the earlier learned rules. This enables him to deal with unrecognized facts and elements. At this stage, the learner learns to apply more sophisticated rules to both context-free and situational factors. These rules make it possible for advanced beginners to shape the experience so that it is possible to learn from experience but situational perception is still limited. Learners may be comfortable solving routine well-defined problems but may be ineffective and inefficient in manipulating knowledge in unfamiliar settings or in solving ill-defined problems.

Apprentice (Hoffman, 1998): Literally, one who is learning – a student undergoing a program of instruction beyond the introductory level. Traditionally, the apprentice is immersed in the domain by living with and assisting someone at a higher level. The length of an apprenticeship depends on the domain, ranging from about one to 12 years in the Craft Guilds.

Acclimation (Alexander, 2003): Learners have limited or fragmented domain and topic knowledge. Challenging tasks prompt to use of surface-level strategic processing. Reliance on situational interest to maintain learner focus and performance.

An advanced beginner is one who has coped with enough real situations to note (or to have them pointed out by a mentor) the recurrent meaningful aspects of situations. An advanced beginner needs help setting priorities since she/he operates on general guidelines and is only beginning to perceive recurrent meaningful patterns. The advanced beginner cannot reliably sort out what is most important in complex situations and will need help to prioritize (Patricia Benner, 1984, pp 13-34).
Guidelines for action based on attributes or aspects (aspects are global characteristics of situations recognizable only after some prior experience); Situational perception is still limited; All attributes and aspects are treated separately and given equal importance (Eraut Michael, 1994).
Working knowledge of key aspects of practice; Straightforward tasks likely to be completed to an acceptable standard; Able to achieve some steps using own judgment, but supervision needed for the overall task; Appreciates complex situations but only able to achieve partial resolution; Sees actions as a series of steps (Institute of Conservation, London, 2003)
Advanced beginners have developed the ability to distinguish between more and less characteristic features of a situation, although they still tend to rely on checklists (Gunderman, 2009).
At the advanced beginner level, knowledge is treated in context but no recognition of relevance; Context is assessed analytically; While decision-making is rational (Stan Lester, 2010)
Guidelines-based performance; Able to achieve partial resolution of complex tasks; Task is seen as a series of steps; Able to perform routine tasks under indirect supervision; Direct supervision needed for complex tasks only (Khan & Ramachandran, 2012)
The advanced beginner is beginning to connect relevant contexts to the rules and facts they are learning. Folks at this level may have no sense of practical priority. All aspects of work may be treated separately and will likely have equal importance (Steve Flowers, 2012).
Achieved after considerable experience; More sophisticated rules that are situational; Develops the idea that the idea of developing skill is a much larger conception “Through practical experience in concrete situations with meaningful elements, which neither an instructor nor the learner can define in terms of objectively recognizable context-free features, the advanced beginner starts to recognize those elements when they are present (p.22).” The advanced beginner begins to ask the question – how? How does one (fill in the blank)?; Can set goals but can’t set them reasonably (Rebecca West Burns, 2012)

THIRD PHASE – COMPETENT

Competent (Dreyfus 1980, 1986): With experience, the learner begins to recognize more and more context-free and situational elements. At this point, the learner is able to organize the situation and then concentrate on important elements. He is able to assess the situation, set the goal, and then choose the best course of action. He may or may not apply rules. He may or may not be successful but that constitutes an important element of future expertise.

Journeyman (Hoffman 1998) : Literally, a person who can perform a day’s labor unsupervised, although working under orders. An experienced and reliable worker, or one who has achieved a level of competence. Despite high levels of motivation, it is possible to remain at this proficiency level for life.

Competence (Alexander, 2003): In terms of Knowledge (domain/topic), learners demonstrate a foundation body of knowledge. In terms of strategic processing, learners at this level use surface-level strategies and develop deep-processing strategies to acquire knowledge. Learners’ individual interest increases and reduced reliance on situational interest.

Competent (Rosenberg, 2012): Competent (or journeyman) workers can perform jobs and tasks to basic standards. They’ve had their basic training and now look for more coaching and practice to get better at what they do. “Help me do it better,” is their primary request.

Coping with crowdedness; Now sees actions at least partially in terms of longer-term goals; Conscious, deliberate planning; Standardized and routinized procedures ( Eraut Michael, 1994)
Good working and background knowledge of the area of practice; Fit for purpose, though may lack refinement; Able to achieve most tasks using own judgment; Copes with complex situations through deliberate analysis and planning; Sees actions at least partly in terms of longer-term goals (Institute of Conservation, London, 2003)
When learners achieve competence, they can think conceptually and develop strategic approaches in terms of long-term goals. Yet, in many situations, their approaches remain highly standardized and rule-based (Gunderman, 2009).
At the competent level, knowledge is treated in context and also there is recognition of relevance; Context is assessed analytically; While decision-making is rational (Stan Lester, 2010)
A competent performer is able to select rules or perspectives appropriate to the situation, taking responsibility for the approach (Steve Flowers, 2012).
At the competent level, performance not solely based on rules and guidelines but also on previous experience; Able to perform routine complex tasks; Able to deal with complexity with analysis and planning; Task is seen as one construct; Training and supervision are needed for non-routine complex tasks (Khan & Ramachandran, 2012)
More experience; Possess a sense of importance and is able to prioritize behaviors based on levels of importance. Behavior is determined by importance and not by context-free rules or merely situational rules; Possesses a hierarchical procedure for making decisions; Requires organization and the creation of a plan; Accepts responsibility for choices because they recognize they made choices; they are emotionally invested in their decision-making “The competent performer, on the other hand, after wrestling with the question of the choice of a plan, feels responsible for, and thus emotionally involved in, the product of his choice (p. 26).” Problem-solving indicates competence; Slow and detached reasoning (problem-solving); Makes decisions (Rebecca West Burns, 2012)

FOURTH PHASE – PROFICIENT

Proficient (Dreyfus & Dreyfus, 1981, 1984, 1986): At this level, the learner is deeply involved in the task. He is capable of identifying the important part of the tasks and paying requisite attention. A proficient person sees situations holistically in terms of various elements. As the situation changes, his deliberation, plan, and assessment may change. With changing situations, he is able to see new patterns which deviate from the normal. Decision-making is very quick and fluid because of the experience in a similar situation in past. However proficient learners will use maxims to guide their decision-making. Consistency in performance distinguishes this phase from the previous phase.

Proficiency / Expertise (Alexander, 2003): Combines proficiency and expertise stages into one. Broad and deep topic/domain knowledge base. Use deep processing strategies almost exclusively. High individual interest and engagement

Experienced (Rosenberg, 2012): This is where it gets really interesting. Experienced workers are beyond merely competent. They can vary their performance based on unique situations. Because they encounter a variable and often unpredictable set of work problems and challenges, they need access to knowledge and performance resources on demand, and the ability to search those resources in ways that are flexible and customizable by them, depending on the situation. “Help me find what I need,” they ask, as they search for information, from sophisticated online systems to the coworkers around them.

A Proficient is someone who perceives a situation as a whole rather than in terms of parts. With holistic understanding, decision-making is less labored since the professional has a perspective on which of the many attributes and aspects present are the important ones. The proficient performer considers fewer options and hones in on the accurate region of the problem (Patricia Benner, 1984, pp 13-34).
A proficient person sees situations holistically rather than in terms of aspects; Sees what is most important in a situation; Perceives deviations from the normal pattern; Decision-making less labored; Uses maxims for guidance, whose meanings vary according to the situation (Eraut Michael, 1994).
Depth of understanding of discipline and area of practice; Fully acceptable standard achieved routinely; Able to take full responsibility for own work (and that of others where applicable); Deals with complex situations holistically; decision-making more confidence; Sees overall ‘picture’ and how individual actions fit within it (Institute of Conservation, London, 2003)
Proficient learners can distinguish between typical and atypical features of a case and tailor their approach to the particular features at hand (Gunderman, 2009).
Knowledge is treated in context and also there is recognition of relevance; Context is assessed holistically; While decision-making is still rational (Stan Lester, 2010)
A proficient performer has experience making situational discriminations that enables the recognition of problems and the best approaches for solving the problems. At this stage, intuitive reactions replace reasoned responses (Steve Flowers, 2012).
At proficient level, performance mostly is based on experience; Able to perform on acceptable standards routinely; Able to deal with complexity analytically; Related options are also seen beyond the given task; Still needing supervision for non-routine complex tasks; Able to train and supervise others performing routine complex tasks (Khan & Ramachandran, 2012)
A proficient person uses intuition based on enough past experience; Intuition is “…the product of deep situational involvement and recognition of similarity (p. 29).” Intuitive-based cognition coupled with detached decision-making. The proficient person recognizes intuitively but responds by more calculative decisions. Being proficient means attributing success to the calculative aspects of the success and ignoring the even more brilliant intuition that occurred first (Rebecca West Burns, 2012).

FIFTH PHASE – EXPERT

Expert (Dreyfus & Dreyfus, 1981, 1984, 1986) : Experts don’t apply rules, or use any maxims or guidelines. He rather has an intuitive grasp of situations based on his deep tacit understanding. One key aspect of this level is that individuals rely on intuition and the analytical approach is used only in new situations or unrecognized problems not earlier experienced. Experience-based deep understanding provides him with a very fluid performance. At this stage, skills become automatic that even an expert is not aware of it. Based on prior experience, they can even come up with a solution for new, never-experienced-before situations (DiBello, Lehman, Missldine, 2011). “Experts” adopt a contextual approach to problem-solving and understand the relative, non-absolute nature of knowledge. This ability distinguishes the “expert” from the “proficient” practitioner ( D’Youville College, n.d.). Reflection comes naturally and experts solve problems almost unconsciously.

Expert (Hoffman, 1998): The distinguished or brilliant journeyman, highly regarded by peers, whose judgments are uncommonly accurate and reliable, whose performance shows consummate skill and economy of effort, and who can deal effectively with certain types of rare or “tough” cases. Also, an expert is one who has special skills or knowledge derived from extensive experience with subdomains.

Master/Expert (Rosenberg, 2012): Rosenberg defines it as one single stage rather than two different stages. Masters and experts create new knowledge. They invent new and better ways to do a job, and they can teach others how to do it. They are truly unique individuals and seek to learn in unique and personal ways, primarily through collaboration, research, and problem-solving. “I’ll create my own learning,” they say.

The expert professional is one who no longer relies on an analytical principle (rule, guideline, maxim) to connect an understanding of the situation to appropriate action. With an extensive background of experience, the expert has an intuitive grasp of the situation and focuses on the accurate region of the problem without wasteful consideration of a larger range of unfruitful possibilities (Patricia Benner, 1984, pp 13-34).
Expert no longer relies on rules, guidelines, or maxims; an Intuitive grasp of situations based on deep tacit understanding; Analytic approaches used only in novel situations or when problems occur; Vision of what is possible (Eraut Michael, 1994).
An expert is someone who has authoritative knowledge of the discipline and a deep tacit understanding across areas of practice; Excellence achieved with relative ease; Able to take responsibility for going beyond existing standards and creating own interpretations; Holistic grasp of complex situations moves between intuitive and analytical approaches with ease; Sees overall ‘picture’ and alternative approaches; a vision of what may be possible (Institute of Conservation, London, 2003).
At proficiency and expertise level, the learner possesses a broad and deep topic/domain knowledge base; Use deep processing strategies almost exclusively; High individual interest and engagement (P.A. Alexander, 2003)
Expert learners do not use rules and guidelines. Their problem-solving is based on an intuitive grasp of relevant features and a conceptual understanding of underlying principles (Gunderma, 2009).
At the expert level, knowledge is treated in context and also there is recognition of relevance; Context is assessed holistically; While decision-making is now intuitive (Stan Lester, 2010)
The expert performer is able to see what needs to be achieved and how to achieve it. This level of the performer is able to make more refined and subtle discriminations than a proficient performer, tailoring the approach and method to each situation based on this level of skill (Steve Flowers, 2012).
At the expert level, performance is based on experience and intuition; Achieves excellent performance in complex situations and moves easily between analytical and intuitive solutions; All options related to the given task are considered; Able to train and supervise others performing routine and non-routine complex tasks (Khan& Ramachandran, 2012).
Expert functions or responses as a result of “mature and practiced understanding”, Loss of awareness of intuition and decision-making – operates simply because he does; knowledge becomes tacit; “When things are proceeding normally, experts don’t solve problems and don’t make decisions; they do what normally works (pp. 30-31).” Experts “see” but sometimes don’t recognize that they “see”; Experts perform without reflecting on every behavior, but experts do reflect and will consider alternatives when presented with time and critical outcomes. When experts reflect, they engage in critical reflection of their own assumptions; They possess: “An immense library of distinguishable situations is built upon the basis of experience (p. 32).” Actions are unconscious operating out of intuition and tacit knowledge; performance is fluid; “But when time permits and much is at stake, the detached deliberative rationality of the type described can enhance the performance of even the intuitive expert (p. 40).” (Rebecca West Burns, 2012).

SIXTH PHASE – MASTERY

Mastery (Dreyfus & Dreyfus, 2001, 2008): A subsequent work by Dreyfus and Dreyfus (2001) includes the sixth stage of “Mastery” beyond expertise in their model stating mastery as “A very different sort of deliberation from that of a rule-using competent performer or of a deliberating expert characterizes the master”. An important difference between an expert and a master is explained by Dreyfus (2001) as: When an expert learns, she must either create a new perspective in a situation when a learned perspective has failed, or improve the action guided by a particular intuitive perspective when the intuitive action proves inadequate. A master will not only continue to do this but will also, in situations where she is already capable of what is considered adequate expert performance, be open to a new intuitive perspective and accompanying action that will lead to performance that exceeds conventional expertise (p 44).

Master (Hoffman, 1998): Traditionally, a master is any journeyman or expert who is also qualified to teach those at a lower level. Traditionally, a master is one of an elite group of experts whose judgments set the regulations, standards, or ideals. Also, a master can be that expert who is regarded by the other experts as being “the” expert, or the “real” expert, especially with regard to sub-domain knowledge.

In contrast to experts, masters have developed recognizable personal styles of practice, like the style of a great artist or composer. They welcome novelty as an opportunity to reexamine their assumptions and explore new ways of thinking (Gunderman, 2009).
The mastery performer has developed their own style, extending expertise within a domain with their own synthesis of tools and methods (Steve Flowers, 2012).
At mastery level, performance becomes a reflex in most common situations; Sets new standards of performance; Mostly deals with complex situations intuitively; Has a unique vision of what may be possible related to the given task; Able to train other experts at national or international level (Khan & Ramachandran, 2012).

SEVENTH PHASE – PRACTICAL WISDOM

Dreyfus (2008) added the seventh stage of ‘practical wisdom’ in the original Dreyfus model of skill acquisition. Steve Flowers (2012) summarizes this stage as “This describes the assimilation of the master’s creations within the culture of a work unit or organization. In my interpretation, this is the closure of the cycle and describes the giving back from the master to the domain, enhancing the domain body of knowledge itself.

My own view is that practical wisdom is the ultimate goal of the human race and every time we learn a new skill, we don’t necessarily look to reach this stage. Several times acquiring a new skill is driven by survival needs rather than intellectual thirst. From a training standpoint, I don’t think this stage has any implication or application. Mastery level is still a goal of some high-end skill acquisition such as sports, martial arts, chess, or other world-class performances.

SPECIALIST – BETWEEN PROFICIENT & EXPERT?

There could be a debate on what should be an organizational training goal. Though the expertise and mastery stage looks appealing, one needs to be conscious of the time it takes to reach expertise or mastery.

On the side of expertise , let’s be realistic. How many organizations really want each and every employee they have to operate at an expert level? Probably not many. Designing training and learning to accelerate the acquisition of expertise is still in its fancy. Though there is a lot of research, most of those are in closed domains like sports and music or similar. Applying expertise theories in an organizational context requires not only organizational energy but also a great amount of personal commitment from employees.
On the side of mastery , producing masters is probably not going to be the goal of training in the organization. Attaining mastery requires a different game plan and it might actually be difficult to keep moving toward mastery in an ever-changing dynamic world of business. Further definitions and measurements of mastery in the professional world are something that has not even seen the daylight.

Therefore I asserted in one post that most organizations need to make the ‘proficiency’ stage a goal of their organization training. However, as my thinking is evolving, I am of the opinion that organizations very soon would need higher-level training goals than proficiency. I am proposing that there should be another stage of ‘Specialist’ between Proficient and Expert. In my research, it looks like ‘specialization’ makes the path to expertise shorter. Given that expertise takes a very long, it makes sense to add a ‘specialist’ level that is measurable and verifiable against organizational standards. Going beyond proficiency level could be a more realizable goal in developing employees into specialists who operate “like” experts but may not be true experts yet. I have written a preliminary post from personal expertise angle earlier, but I will come back with an expanded post based on my research so far in regards to my view of the ‘Specialist’ stage in the skill acquisition model.

Guidelines for designers and strategists

According to Dreyfus and Dreyfus (1986: 35), the most important difference between the levels of expertise is the gradual shift from analysis to intuition and the grade of involvement.

One issue which I noticed with this model is that it is derived from observation of the performance of experts, such as jet pilots and dancers, experts who are used to tackling direct problems. Its applicability to complex problem-solving is questionable (Pena, 2010). It is believed that skills used to solve inverse problems are of a different nature than the skills used to solve direct problems. Dreyfus’s model does not directly deal with complex skills. However, it does refer to handling the ability to solve complex problems as progressive levels toward expertise. Also, progression from competence, proficiency, expertise, and mastery indicates a kind of confidence and an increase in intuition. However, in terms of behavioral components, it does not offer any demarcation. For a particular skill, the model does not specify milestones that clearly indicate the attainment of a given stage.

Though there are a few flaws in Dreyfus’s model and there were some arguments in regards to the concept of stages in this model, the applicability in general to skill progression and relevance to training design cannot be designed. One key thing that stands out in this model is how proficiency and expertise are drastically different from other stages.

Organizations these days are aiming for the “Proficiency” stage as their organizational training goals. The main reason is the quality of performance exhibited by a proficient employee which is characterized by “reproducibility”, “consistency” and “reliability” in the performance”. That’s what is needed in today’s changing business world. I will be writing about training design challenges when proficiency becomes the organizational goal. Stay tuned for that.

On the other hand, the expertise stage though looks appealing, it does take a long time to attain expertise. In an organizational context, attaining expertise is even more difficult given changing business needs, frequent changes in roles, dynamic environments, and the short shelf life of skills. Making an individual a specialist is probably a more appropriate and feasible goal for organizations by honing the skills of an individual in a relatively defined context or role.

Nevertheless, when you design your training – the first question to ask is – what level of performance is expected from the individual at the end of a training program?

Some questions to reflect upon:

What is your definition of competent, proficient, expert, and master?

How do you view mastery differently from expertise in an organizational context?

Do you see there should be a ‘specialist level’ between proficient and expert?

SUGGESTED CITATION

Attri, RK (2018), ‘7 Phases of Skill Acquisition: A Novice’s Journey To Expertise And Beyond’, [Blog post], Speed To Proficiency Research: S2PRo©, Available online at < https://get-there-faster.com/blog/development-of-newbie-to-expert-and-beyond/ >.

Benner, P. (1984): “From novice to expert – Excellence and Power in Clinical Nursing Practice”, Addison-Wesley Publishing
Benner, P. E. (2004). Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education. Bulletin of Science, Technology and Society, 24(3), 188–199. doi:10.1177/0270467604265061
Burns, R.W (2012) Five Stages of Acquiring Expertise Novice to expert. Available at http://www.rebeccawestburns.com/index.php?option=com_k2&view=item&id=57:five-stages-of-acquiring-expertise-novice-to-expert&Itemid=187
Dreyfus SE and Dreyfus HL (1980) A Five-Stage Model of the Acquisition of the Mental Activities Involved in Directed Skill Acquisition. AFSC: USAF (contract F49620-79-c-0063). University of California: Berkeley. available at http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA084551&Location=U2&doc=GetTRDoc.pdf
Dreyfus, H.L., Dreyfus, S.E., (1986). Mind over machine: The power of human intuition and expertise in the era of the computer. New York, NY: The Free Press.
Dreyfus, H. L. and Dreyfus, S. E. (1986a). Why skills cannot be represented by Rules. In. Sharley, Elis, Hardwood, and Chichester, Advances in cognitive science. pp.315-335.
Dreyfus, H. (2007). Design conference on the learning environment: keynote address from novice to expert. Dreyfus, H. L. (2004). A Phenomenology of Skill Acquisition as the basis for a Merleau-Pontian Nonrepresentationalist Cognitive Science. Berkeley, CA: University of California, Department of Philosophy. Online version :http://www.irafs.org/irafs_1/cd_irafs02/texts/dreyfus.pdfACGME Bull April 2007: 6-8.
Dreyfus, H. L. & Dreyfus, S. E. (2008). Beyond Expertise: some preliminary thoughts on mastery. In Klaus Nielsen, K. et al. (eds) A Qualitative Stance: Essays in honor of Steiner Kvale. pp 113-124. Aarhus University Press. Available at: www.ieor.berkeley.edu/People/Faculty/dreyfus-pubs/mastery.doc‎
Dreyfus, H.L., (2008). On the Internet. 2nd edn. London: Routledge.
Eraut, Michael (1994). Developing Professional Knowledge and Competence.London: Falmer Press. p. 124.
Flowers, Steve (2012) Defining Competence, Proficiency, Expertise, and Mastery. Androidgogy Blog. Available at https://androidgogy.com/2012/09/16/skill-proficiency-expertise-and-shuhari/
Flyvbjerg, B. (1990) Rationalitet, intuition og krop I menneskets læreproces: Fortolkning og evaluering af Hubert og Stuart Dreyfus’ model for indlæring af færdigheder (Rationality, Intuition, and Body in Human Learning: An Interpretation and Evaluation of the Hubert and Stuart Dreyfus Skill Acquisition Model). Aalborg: Department of Development and Planning, Aalborg University.
Flyvbjerg, B. (1991). Sustaining Non-Rationalized Practices: Body-Mind, Power, and Situational Ethics. An Interview with Hubert and Stuart Dreyfus. Praxis International, 11 (1), . 93-113.
Gunderman R. Achieving excellence in medical education. New York, NY: Springer, 2006.
Gunderman, R. (2009) Competency-based Training: Conformity and the Pursuit of Educational Excellence Radiology: Volume 252: Number 2. doi: 10.1148/radiol.2522082183
Hoffman, R. R. (1998). How can expertise be defined?: Implications of research from cognitive psychology. In R. Williams, W. Faulkner, & J. Fleck (Eds.), Exploring expertise (pp. 81–100). New York: Macmillan.
Institute of Conservation (2003). Professional standards for conservation based on the Dreyfus model of skill acquisition.Cited by Stan Lester (2010). Available at https://saspd.wikispaces.com/file/view/dreyfusmodel.pdf
Khan, K., & Ramachandran, S. (2012). Conceptual framework for performance assessment: Competency, competence and performance in the context of assessments in healthcare – Deciphering the terminology, Medical Teacher, 1 (9) Early Online, DOI: 10.3109/0142159X.2012.722707Pena, A. (2010). The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Med Educ Online, 15. doi: 10.3402/meo.v15i0.4846
Lester, Stan (2010) Novice to Expert: the Dreyfus Model of skill acquisition. Stan Lester Developments. Available at https://saspd.wikispaces.com/file/view/dreyfusmodel.pdf
Rosenberg, M. J. (2012) Beyond Competence: It’s the Journey to Mastery the Counts, Learning Solution Magazine available at: https://www.learningsolutionsmag.com/

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Clinical Sales Specialist [Mitek Sports Medicine – Philadelphia, PA] – DePuy Synthes

Job Title Clinical Sales Specialist [Mitek Sports Medicine – Philadelphia, PA] – DePuy Synthes
Function MedTech Sales
Sub Function Inside Sales & MedTech (No Commission)
Category Analyst, Inside Sales & MedTech (No Commission) (P4 & E23)
Location Philadelphia, Pennsylvania, United States; Delaware, United States
Date Posted Jul 02 2024
Requisition Number 2406190842W

Description

Johnson & Johnson is recruiting for Clinical Sales Specialist for Depuy located in Philadelphia, PA.

At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions today to deliver the breakthroughs of tomorrow, and profoundly impact health for humanity. Learn more at https://www.jnj.com/ . 

DePuy Synthes, part of the Johnson & Johnson Medical Devices Companies, provides one of the most comprehensive orthopedics portfolios in the world. DePuy Synthes solutions, in specialties including joint reconstruction, trauma, craniomaxillofacial, spinal surgery and sports medicine, are designed to advance patient care while delivering clinical and economic value to health care systems worldwide. For more information, visit  www.depuysynthes.com .    

Mitek Sports Medicine: At Mitek Sports Medicine, we are passionate about getting patients back to their passion. As a global leader in orthopaedic sports medicine, we develop minimally invasive devices and non-surgical products used in the treatment of joint injuries related to sports and physical activity, as well as degenerative tissue conditions.    

The overall responsibilities of the Clinical Sales Specialist position include advancing the Company’s sales of orthopedic surgical products by providing clinical and logistical expertise in hospitals and operating rooms - such as independent coverage of surgical cases, management of billing/purchase orders, logistics, and asset management. Works under close supervision by management and in close partnership with Sales Consultants.

Key Responsibilities:

Independently guide and assist surgeons in the operating room by providing clinical and technical support of orthopedic surgical cases.
Advance DPS sales by serving as sole Company representative to provide direct customer support by attending surgeries and assuring that the proper equipment is available and functioning.
Troubleshoot and apply independent judgment to respond to physician needs; address customer requests; effectively handle hospital billing, build / close purchase orders.
Share key customer, procedural and marketplace insights with other sales, clinical, marketing, and strategic account teams to improve on solutions / service levels and support sales growth. Prepare sales reports and documents as the need arises.
Provide Operating Room and Sterile Processing Department consultation.
Maintenance, tracking, and deployment of equipment and assets throughout assigned area ensuring product availability.
Ensure all promotional materials are maintained in a presentable manner. Ensure DePuy Synthes Services and offerings meet the highest quality standards.
Provide logistical support by moving instruments, implants, and equipment between sales representatives and hospitals.

Qualifications

Education & Experience:

Bachelor’s Degree or
Associate Degree or Medical Certification (CST, PT, etc.) + minimum of 2 years of professional experience or
Minimum of 4 years of professional experience or
Recently transitioned from Active Military Duty

Other:

The ability to work in a lab/operating room environment.
A valid driver's license issued in the United States
The ability to travel, which may include weekend and/or overnight travel.
Residence in or ability to relocate to the assigned territory.
Strong interpersonal communication, influencing, critical thinking, and problem-solving skills required.
Experienced in data analysis and data insight skills
Results orientation/Prioritization
Ability to work independently and autonomously
Ability to work in a complex organization and team structure
High level of accuracy and attention to detail.
Demonstrated ability to understand, interpret, communicate, and work in a complex environment
Functional knowledge of human anatomy and physiology, basic knowledge of surgery
Strong technical product knowledge of surgical instruments, procedures, protocols, and solutions preferred

Johnson & Johnson is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

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应聘者知情同意函 Job Applicant Consent Letter

鉴于强生全球集团业务的全球化经营性质，当您向强生中国 [1] 应聘职位时，强生中国会按照《应聘者隐私政策》所述情形，向境外接收方及其经授权的第三方提供您的个人信息，包括但不限于：

Due to the global nature of the operation of Johnson & Johnson Family of Companies, in the course of processing your application with J&J China, J&J China may provide your personal information to the overseas recipient and authorized third parties in accordance with J&J’s Careers Privacy Policy, including but not limited to:

基本信息：姓名、生日、民族、性别、国籍、照片； Basic Information: Name, Birthday, Ethnicity, Gender, Nationality, Headshot;
联系信息：住址、电话号码、电子邮件地址； Contact Information: Address, Phone Number, Email;
教育工作信息：职业、职位、工作单位、工作经验、教育背景、学历、学位、培训记录。 Academic & Professional Information: Occupation, Position, Employer, Work Experience, Educational Background, Degree, Training Records.

除强生中国或法律特别要求外，请您避免在您的申请中提交可能会被视为敏感个人信息的信息，即生物识别、宗教信仰、特定身份、医疗健康、金融账户、行踪轨迹，以及不满十四周岁未成年人的信息等一旦遭遇泄露或非法使用，容易导致人格尊严受到侵害或者人身、财产安全受到危害的个人信息。

Except as specifically requested by J&J China or legally required, please avoid submitting information in your application which may be deemed as sensitive personal information, which includes biometrics, religious belief, specific identity, medical health, financial accounts, whereabouts, as well as information of minors under the age of fourteen (14), and other information that the breach or illegal use of which may easily lead to the infringement of an individual’s personal dignity or harm to personal or property safety.

前述境外接收方为：美国强生公司（Johnson & Johnson Services, Inc.），其联系方式为：美国新泽西州新不伦瑞克市强生广场一号。

The overseas recipient is Johnson & Johnson Services, Inc., which can be contacted at One Johnson & Johnson Plaza, New Brunswick, New Jersey 08933, U.S.

境外接收方将按照如下目的和方式处理您的个人信息。

The overseas recipient will process your personal information in accordance with the following purpose and method:

处理目的：根据强生全球集团“统一人力资源（One HR）”原则，对人才招募进行全球统一管理，具体请参见《应聘者隐私政策》中“我们收集此类个人信息的原因”部分。

Processing Purpose: Conduct talent acquisition management globally following the One HR principle of the Johnson & Johnson Family of Companies, as described in the “Reasons We Collect This Information” section of J&J’s Careers Privacy Policy.

处理方式：通过统一流程和全球互联应用实现对人才招募的统一管理，涉及存储、使用、加工、传输、删除已出境个人信息。境外接收方将采取适当的管理和技术措施保障出境个人信息的机密性、完整性和可用性，并将在完成上述目的最小必要范围内保存出境个人信息。

Processing Method: Conduct talent acquisition management through the unified process and globally connected applications, including storage, use, handling, transmission, and deletion of provided personal information. Overseas recipients will apply appropriate managerial and technical measures to ensure the confidentiality, integrity, and availability of the provided personal information and shall store such personal information to the minimum extent necessary to complete the above purposes.

您可以通过[email protected]联系强生中国公司的个人信息保护官以向境外接收方行使您享有的相关权利，包括要求访问、更正、复制或删除您的个人信息。

You may contact the Personal Information Protection Officer of the J&J China at [email protected] to exercise your relevant rights to the overseas recipient, including access, correct, copy, or delete your personal information.

鉴于强生全球集团业务的全球化经营性质，当您向强生中国应聘职位时，强生中国会向境外接收方及其经授权的第三方提供您的个人信息。具体而言：

	美国强生公司（Johnson & Johnson Services, Inc.）联系方式：1-800-458-1653
	根据强生全球集团“统一人力资源（One HR）”原则，对人才招募进行全球统一管理，具体请参见《应聘者隐私政策》中“我们收集此类个人信息的原因”部分。
	通过统一流程和全球互联应用实现对人才招募的统一管理，涉及存储、使用、加工、传输、删除已出境个人信息。境外接收方将采取适当的管理和技术措施保障出境个人信息的机密性、完整性和可用性，并将在完成上述目的最小必要范围内保存出境个人信息。
	：姓名、生日、民族、性别、国籍、照片；：住址、电话号码、电子邮件地址；：职业、职位、工作单位、工作经验、教育背景、学历、学位、培训记录。
	您可以通过[email protected]联系强生中国公司的个人信息保护官以向境外接收方行使您享有的相关权利，包括要求访问、更正、复制或删除您的个人信息。

除强生中国或法律特别要求外，请您避免在您的申请中提交可能会被视为敏感个人信息的信息，即物识别、宗教信仰、特定身份、医疗健康、金融账户、行踪轨迹，以及不满十四周岁未成年人的信息等一旦遭遇泄露或非法使用，容易导致人格尊严受到侵害或者人身、财产安全受到危害的个人信息。

Due to the global nature of the operation of the Johnson & Johnson Family of Companies, in the course of processing your application with J&J China, J&J China may provide your personal information to the overseas recipient and authorized third parties. Specifically:

	Johnson & Johnson Services, Inc. Contact Information: 1-800-458-1653
	Conduct talent acquisition management globally following the One HR principle of the Johnson & Johnson Family of Companies, as described in the “Reasons We Collect This Information” section of J&J’s Careers Privacy Policy.
	Conduct talent acquisition management through the unified process and globally connected applications, including storage, use, handling, transmission, and deletion of provided personal information. Overseas recipients will apply appropriate managerial and technical measures to ensure the confidentiality, integrity, and availability of the provided personal information and shall store such personal information to the minimum extent necessary to complete the above purposes.
	: Name, Birthday, Ethnicity, Gender, Nationality, Headshot; : Address, Phone Number, Email; : Occupation, Position, Employer, Work Experience, Educational Background, Degree, Training Records.
	You may contact the Personal Information Protection Officer of the J&J China at [email protected] to exercise your relevant rights to the overseas recipient, including access, correct, copy, or delete your personal information.

[1] 在本个人信息出境同意函中，“强生中国”是指与您申请的职位所属的强生全球集团内具体公司。强生全球集团指美国强生公司（Johnson & Johnson Services, Inc.）以及其在世界范围内的关联公司，包括强生中国。

In this Employee Consent Letter, “J&J China” means the company in the Johnson & Johnson Family of Companies which you applied for, and “Johnson & Johnson Family of Companies” means Johnson & Johnson Services, Inc. and its worldwide affiliates, including J&J China.

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IMAGES

(PDF) The Dreyfus model of clinical problem-solving skills acquisition
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Clinical Skills Assessment in the Twenty-First Century
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clinical problem solving process

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COMMENTS

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.
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 ...
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 ...
The Dreyfus model of clinical problem-solving skills acquisition: a
📖 The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. February 6, 2021 . permalink. authors Pena, Adolfo year 2010 url ... are also ill-defined: a simple solution might not exist, there may be more than one solution, or a small change in the problem leads to a big change in the solution.
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 ...
A Clinical Problem-Solving Model for Identifying and Addressing
skill-acquisition services, not all types of skill-acquisition goals are commonly taught with this procedure (e.g., activities of daily living, social skills). Furthermore, the problem-solving model proposed by Ferraioli et al. did not include data on the application of the model to client barriers to learning.
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).
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
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 ...
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].
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 ...
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 ...
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].
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 ...
Assessing Student Performance Using a Novel Rubric ...
The use of the Dreyfus model is not without controversy because some authors have been critical in placing the complexity of clinical learning into a linear model that may not fully explain the acquisition of clinical skills and the complex interplay between analytical thinking and intuition. 2, 18 Although this study had not set out to seek ...
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.
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).
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.
7 Phases of Skill Acquisition: How Someone Develops Skills to Mastery
Their problem-solving is based on an intuitive grasp of relevant features and a conceptual understanding of underlying ... The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Med Educ Online, 15. doi: 10.3402/meo.v15i0.4846; Lester, Stan (2010) Novice to Expert: the Dreyfus Model of skill acquisition. Stan ...
problem-solving skills acquisition: Topics by Science.gov
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. PMID:20563279
Clinical Sales Specialist [Mitek Sports Medicine
Johnson & Johnson is recruiting for Clinical Sales Specialist for Depuy located in Philadelphia, PA. At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in ...