Curricular and Pedagogical Implications for the Carnegie Study, Educating Nurses: A Call for Radical Transformation

This article discusses the curricular and pedagogical implications for the Carnegie Study, Educating Nurses: A Call for Radical Transformation. Patricia Benner, RN, PhD, FAAN presents five shifts in the way we think about pedagogies in nursing education. The article focuses on the curricular and pedagogical implications of the results of the Carnegie National Nursing Education Study. The study identifies major shifts in curriculum development and ways of teaching students (pedagogies) implications of the Carnegie Study for Curriculum Development and Pedagogical Changes.

Invited Review Article
Curricular and Pedagogical Implications for the Carnegie Study,
Educating Nurses: A Call for Radical Transformation
Patricia Benner,RN, PhD, FAAN *
University of California San Francisco,School of Nursing,San Francisco 94118,USA
It is an exciting time in nursing practice and education, globally,
and particularly in Korea as nursing education moves into 4-year
college programs. I will present findings from the Carnegie National
Study of Nursing Education in the United States and hope that some
of the gaps in nursing education identified in that study can be
compared to what you know about educational programs in Korea.
Three key findings from the Carnegie Study [1] are the following:
(a) U.S.nursing programs are very effective in forming profes-
sional identity and ethical comportment.We found that
nursing education is very strong in the pedagogiesdsituated
coaching and experientiallearningdwhich help students
develop a deep sense of professional identity,and everyday
ethical comportment. However this done primarily in clinical
practices assignments and simulations with actualperfor-
mance and excellent debriefing in clinical simulation labs.
(b) Clinical practice assignments provide powerful learning ex-
periences,especially in those programs where educators
integrate clinical and classroom teaching.This means effec-
tive integration of knowing that,and about,with knowing
how, and when in actual practice situations.
(c) U.S. nursing programs are not generally effective in teaching
nursing science,natural sciences or social sciences.There is
not enough emphasis teaching the level of science for today's
health care practice, not enough prioritizing of what areas of
science are most relevant for nursing clinicalpractice,and
very little teaching of science as it is situated and used in
practice.
The Carnegie Research Team [1] conducted nine intensive site
visits, sampling schools by program type and geographical location.
Schools were also selected based upon excellent educational out-
comes and reputations.The site visits included students,faculty,
and classroom observations in all site visits.In addition to the site
visits three national surveys were completed in conjunction with
the American Association of Colleges of Nursing, the National
League of Nursing,and the NationalStudent Nurses’Association.
Both faculties and students were surveyed about educational
effectiveness,pedagogies,challenges and rewards of nursing edu-
cation, and school to work transition. Here, I will focus on the
curricular and pedagogicalimplications of the results of the Car-
negie National Nursing Education Study.
Over the last decade the Carnegie Foundation has undertaken
studies on the preparation of professionals in five fields: medicine,
clergy,engineering,law, and nursing. Each of the Carnegie studies
draws on three high-level apprenticeships required for all profes-
sional practice.
All practice professions must address the following three pro-
fessional apprenticeships:
(a) The cognitive apprenticeship: intellectual training that pro-
vides: (i) the academic and theoretical knowledge base
required for practice in the discipline;(ii) the capacity to
think in ways important to the profession.
(b) The practice apprenticeship: clinicalreasoning and clinical
practice skilled know-how that teaches students how to
think and solve problems in actual clinical situations.
Learning how to reason across time through changes in the
patient and/or changes in the clinician’s understanding of
the patient's condition and concerns
(c) Formation and ethical comportment apprenticeship:an
apprenticeship to the ethical standards,social roles,and re-
sponsibilities of the profession,through which the novice is
introduced to the meaning ofan integrated practice ofall
dimensions of the profession,grounded in the profession’s
fundamental purposes.
The word “apprenticeship” is being used metaphorically here to
describe embodied skilled know-how that must be integrated, and
usually modeled or demonstrated by a practitioner- teacher.In
other words, reading about signs and symptoms is not the same as
being able to actually recognize when these are present in patients.
Specifically,we do not mean “on the job training”. These three
apprenticeships,held in common by all professionaleducation
should be integrated in allteaching and learning settings,while
being developed for nursing domain-specific teaching and learning.
* Patricia Benner, RN, PhD, FAAN, Professor, Eemritus, University of California San
Francisco,School of Nursing,Suite 455 3300 California Street,San Francisco 94118,
USA.
E-mail address: [e-mail].
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Asian Nursing Research 9 (2015) 1e6

For example,these professional apprenticeships are taught differ-
ently for physicians, lawyers, engineers, and so on, depending upon
the nature of the practice,and relevant knowledge to be used in
practicalor clinical situations.The nursing domain-specific char-
acteristics of teaching/learning in these three apprenticeships
include first-person experiential learning,the demand for clinical
reasoning,integrated knowledge acquisition and use in clinical
situations.In addition, students need to draw upon psychosocial
and humanities knowledge and skills,and a highly developed un-
derstanding and scientific knowledge use in health promotion,
illness prevention,caring practices,and acute illness and injury.
These three apprenticeshipswork best when they are taught
together in a situated way.Integrating practice-based apprentice-
ships is broader and more discipline specific than Bloom's notion of
incorporating the cognitive,affective and sensorimotor aspects to
specific microlessons.Bloom's focus is on addressing cognitive,
affective and sensorimotor aspects oflearning in teaching any
lesson [9].
Five shifts in the way we think about pedagogies in nursing
education
The findings of the Carnegie National Nursing Education Study
in the United States identifies the following major shifts in curric-
ulum developmentand ways of teaching students (pedagogies)
implications of the Carnegie Study for Curriculum Development
and Pedagogical Changes.I present five shifts in the way we think
about pedagogies in nursing education.
First, we need to shift from superficial descriptive knowledge to
teaching our students how and when that knowledge is relevant.
Deep learning rather than superficial learning of a lot of
descriptive facts about many topics were often found in “survey
courses”.Students learn a lot ofinformation about science,dis-
coveries but little about contextualization ofthat knowledge or
how and when to use the knowledge in actual clinical situations.
Superficial approaches such as classification of nursing diagnosis,
or medical diagnosis,do not teach students how those classifica-
tions might or might not be useful in actual clinical practice.
Integrating knowledge acquisition and knowledge use
Second,we need new ways of thinking about professional
practices such as nursing,medicine,social work,teaching and so
on. Academia typically focuses on formaldecision making and
problem solving processes,explicit theories,and abstract formal
concept with little emphasis on how to use these formal theories in
actual practice.In a practice discipline,“how” to use knowledge is
equally important as the knowledge presented in formaldecon-
textualized forms.
From emphasis on critical thinking to multiple ways of thinking
This brings us to the third major shift in our thinking.From a
focus on critical thinking alone,to emphasizing multiple ways of
thinking particularly in nursing to an emphasis on clinical
reasoning across time about particular changes in the patient and/
or the clinician's understanding of the patient. Nurses, in particular,
need to be taught to use multiple frames of reference in working
with a particular patient. For example,all nurses mustbe well
educated on using medical and scientific knowledge about disease
and injuries. But the nurse also needs to understand and attend to
the nature of the patient's illness experience,the patient/family
plight, what concerns about the illness and recovery the patient
has. In caring for children and families, nurses need to understand
child development,family dynamics and more.No single formal
theory or frame of reference can cover allthe complexity of the
patient’s disease,lifeworld concerns,coping and recovery.Critical
thinking is often emphasized over other types of reasoning such as
practical reasoning, the perfect analogue to clinical reasoning over
time through changes.
Socialization and formation with a focus on an active student
participation in formation
The fourth major shift is from mere socialization and role taking,
to the student's role as a participant-memberin a profession,
becoming what they need to be in order to be a good nurse.For-
mation requires that students embody new habits of thought and
action. The notion of “formation”, as opposed to socialization, adds
an agent-centered role of the professionalin forming the habits,
skills and practices necessary for good practice.The embodied
metaphor for formation that we have in mind,is that of dance,
where situated understanding ofthe dance,the music, and the
partners are required [2].Formation allows for innovation and is
based upon the agent’s taking up the skills,habits of thought and
action,notions of good practice of nursing in ways that are com-
parable to learning to be a good dancer or clinician:
Formation refers to the method by which a person is prepared
for a particular task or is made capable of functioning in a
particular role. One forms, as well as educates, priests, soldiers,
nurses, and doctors in a process that moves beyond the
knowledge content of those crafts to the moral content of the
practicesdthe obligations entailed, the demands imposeddand
thus to the moral formation of the practitioners. Moreover, it is
generally the case that one is formed toward something,some
telos,some ideal shape or condition… A better metaphor [for
being true to form] is dance: having and displaying integrity is
more a matter of being able to move in ways that are consistent
with the originating and developing themes of our lives.
Teachers,guides,and practice make us better dancers because
they help us listen more carefully and follow the music we hear
more confidently.We learn which movements fit the rhythms
and which do not [2].
Formation fits in with the notion of deep learning where stu-
dents actually learn new ways of thinking, acting and being.
Using knowledge requires situated thinking that is productive
The fifth shift is a shift from teaching abstract formal theories
and expecting students to “apply” those theories in practice to an
emphasis on inductive,contextualized use of knowledge in prac-
tice.The model of merely “applying” fits within a narrow ration-
aletechnical framework.For example when I teach a student the
procedure and mechanics of taking a blood pressure reading for a
patient, I am teaching the application of knowledge. There is a 1:1
correlation between the teaching and performance ofthe skill.
However,when the student must interpret,contextualize and use
the blood pressure measurement to understand a particular pa-
tient’s condition.Using knowledge is a contextualized,productive
way of thinking that requires engaging in dialogue with the situ-
ation. This situated-thinking allows the student to develop a sense
of salience about what the most and least important is in a
particular clinical situation.
All five of these shifts involve a better understanding of what is
required to teach a practice such as nursing:
Teaching a practice requires experiential teaching and learning.
Students have to both acquire and use knowledge in particular
P. Benner / Asian Nursing Research 9 (2015) 1e62

clinical situation.Lave and Wagner [3] call this situated cogni-
tion, and Benner refers to engaged thinking-in-action in
particular clinical situations.
Because students must learn to act in specific clinical situations
that are ambiguous,open ended and relatively unstructured,
learning requires being coached by clinical teachers in specific
clinical situations in order to address what the most salient and
the most important is in the immediate situation.
Clinicians learn best when they focus on particular cases and
situations rather than generalized conditions, multiple patients
at once.The goal of the clinical educator is to help the student
develop a rich clinical imagination.They need to imagine how
they would take up a particular practice situation.
Finally students must develop the habits of mind and practice to
perceive and respond to particular clinical situations as an
exemplary or good nurse.This requires formation of the clini-
cian's identity, character,skilled know-hows and sense of
salience.
The development ofethical comportment and clinicalimagi-
nation occurs in practices and in dispositions and actions,not just
in beliefs and decisions.Excellent nursing practice in particular
clinical situations requires experientiallearning.“Situated coach-
ing” of the student in particular clinicalsituations is a signature
pedagogy in nursing and occurs when the teacher describes for the
novice student his or her understanding of the situation, and what
they think is the most relevant, and the most salient. In contrast to
generaleducation classes such as history,or even anatomy and
physiology, students love getting to translate their understandings
into particular clinical situations.Situated coaching addresses the
research-based finding that “situated thinking” is different from
abstract reasoning.
Another signature pedagogy in nursing is designing experiential
learning.In the US,80% of the nursing schools have nursing stu-
dents prepare on the day before they go to the clinical practicum to
take care of the patient. They must look up all about the diagnosis,
signs and symptoms, interventions, and every medication that they
might give to the patient. They develop a care plan for the patient.
The pedagogical idea behind this is that experiential learning oc-
curs best when the student's mind is well prepared in what to pay
attention to and in understanding the patient's clinical condition
and situation.At least 80% of nursing schools in the US also have
some clinical debriefing seminars after a clinical practice situation.
These clinical seminars become the occasion fordeveloping a
learning community. Students come together and share with each
other what they have learned from their patient care that day. They
also discuss how they will improve their practice the next day.
Students offer examples of what they have each learned, and even
talk about any errors,or problems that they have encountered in
their clinical practice.This strengthens the learning of all the
students.
Most clinical nursing practice requires a flexible and nuanced
ability to interpret a not-yet-defined practice situation and stu-
dents learn what is salient, what in the situation should call forth an
appropriate practitioner response.Once a clinical situation is un-
derstood or grasped by the student,the teacher then guides the
student further toward recognizing the relevant research,possible
interventions,and other inherent possibilities available in the
particular situation.The teacher must help the student nurse see
both the medical and nursing implications of a situation, since the
nursing implications always require an understanding of the
pathophysiological and diagnostic aspects of the patient's clinical
presentation and disease, as well as an understanding of how best
to strengthen the patient's own physical,social and spiritualre-
covery resources.
Teaching can be at odds with what is needed for practice:
Classes are not taught in dynamic way.They seem to be taught
in an old fashion science curriculum sort of way, when a
different approach may be more suited.Some classes were
organized around presenting diagnostic categories,signs and
symptoms with elaborate descriptions and distinctions between
the categories. (A student)
Teaching catalogues and taxonomies do not necessarily help
students to learn patientcare. Tensions existbetween teaching
“everything” a studentneeds for the transition to practice and
teaching for a lifetime of practice, or the focal practices of nursing.
“Less is more,” and deeper learning is better than presenting a lot of
materials superficially.Catalogues and taxonomies teach descrip-
tive information that points to knowledge about the topography of
practice. They are useful for organizing information and retrieving
it. They do not contain within them any problem solving,or situ-
ated understanding powers.The impact of using taxonomies,
particularly as a way to scaffold a class is that students are given
descriptions of classifications ofdiseases withoutstrategies for
approach,access to patientcare, or clinical imagination except
through categories.Since the student has little background un-
derstanding ofnursing practice because oftheir lack of clinical
experience, they have no way of imagining what it would mean to
“use” a diagnosis or classification term in actualpractice.Taxon-
omies and classifications leave out access to practical reasoning.
Knud Logstrup notes [4] that “Subsuming things under cate-
gories is not the same as productive thinking.”
Students feel overwhelmed when faculty tries to “teach every-
thing in a short period of time”.As one student stated:
So much to learn in such a short time.The most challenging
thing is all of the mountains of information that just has to be
completely committed to long-term memory.Remembering
normal lab values and drug dosages is very hard for me.(A
student)
The second apprenticeship,a skill-based apprenticeship of
practice requires learning the habits of mind required for compe-
tent practice in the profession.
This is the apprenticeship of knowing how to function in clinical
practice,think like a nurse,and engage in clinicalreasoning and
clinical imagination. In the US, nurse educators do a better job with
this apprenticeship than with the first apprenticeship, the cognitive
apprenticeship.However,our research shows that U.S.educators
need to bring the two apprenticeships together so that we help
students both acquire and use knowledge in an integrated way.
Students often do not recognize when a body of research or con-
cepts are salient in their actual practice.
The final apprenticeship is that of formation and ethical com-
portmentdan 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 ofall di-
mensions ofthe profession,grounded in the profession’s funda-
mental purposes.When students talk about their key clinical
learning experiencesas senior students they emphasize their
ethical concerns in practice: meeting the patient as a person,pre-
serving dignity and personhood ofpatient, responding to sub-
standard practice, advocating for patients, engaging fully in
learning to do “good” nursing practice
One way to teach for a clinical imagination is to use unfolding
case studies in the classroom. This integrates classroom and clinical
teaching.Excellent teachers integrate their classroom and clinical
P. Benner / Asian Nursing Research 9 (2015) 1e6 3

teaching. For example a teacher may use unfolding cases to
rehearse reactions,plans,and goals in practice.The best teachers
have a deep understanding of the practice of nursing and draw on
her own experience in an emotionally nuanced way from which
students can find a moral compass in his or her responses to actual
clinical situations and gain a moral vision of ethical comportment.
Nurse educators mustfind solutions to the important peda-
gogical riddle of how students can be ushered into the practice in a
way that enables them reliably to see salient clinical situations that
call for effective,appropriate responses from the nurse.This re-
quires attunement to the patient's concerns in their ordinary life.
Patients' concerns vary depending upon cultural background, their
family, community and work demands. Recovery requires that the
patient be able to cope with the illness and treatment, and return to
their everyday life. Most clinical nursing practice requires a flexible
and nuanced ability to interpret a not-yet-defined practice situa-
tion as an instance of something salient that should call forth an
appropriate practitioner response.Once a clinical situation is un-
derstood or grasped by the student,the teacher then guides the
student further toward recognizing the relevant research, possible
interventions,and other inherent possibilities available in the
particular situation.The teacher must help the student nurse see
the medical,nursing and human implications of a patient's situa-
tion, since the nursing implications always require an under-
standing ofthe pathophysiologicaland diagnostic aspects ofthe
patient's clinical presentation and disease,and also an under-
standing of how best to respond to the patient's concerns and
strengthen their own physical, social and spiritual recovery
resources.
Freshmen nursing students need to learn simpler aspects of
situations before moving on to understand the whole complex,
unfolding clinical situation.However,they must move on through
situated coaching, reflection, and experiential learning to recognize
the nature of whole clinical situations. This is why situated
coaching is essential for the novice, because the novice simply does
not have the deep background experientialknowledge yet to
recognize the whole clinicalsituation,nor make qualitative dis-
tinctions within a clinical situation. For example, “Is this a situation
of blood volume depletion or heart pump failure?” Or,“Is this pa-
tient obtunded and drowsy because they are tired or has their
intracranialpressure increased?” Recognizing the nature ofthe
clinical situation is at the heart of good clinical reasoning and in-
terventions. Clinical reasoning as a form of practical reasoning, that
is, situated historical reasoning through transitions in the patient's
condition, and/or the clinician's understanding [5,6].
Clinical forethoughtis presented as a habit of thought that
structures engaged thinking and action.In Clinical wisdom and
interventions in acute and critical care: a thinking in action approach
[7],we identified the following domains of practice and two com-
mon habits involved with clinicalreasoning,clinical forethought
and clinical grasp (Table 1).
The domains of practice overlap and occur simultaneously.
Taken together, these domains demonstrate how being situated in a
particular clinicalsituation in ways that guide clinicaljudgment,
thinking, and action. As Bourdieu [8] points out, recognition of the
nature of the situation is central to the logic of practice.In all the
domains of practice, reasoning-in-transition and engaged thinking-
in-action are the hallmarks of clinical judgment in practice. A loss of
understanding or sense of disquietude, puzzlement, or even
confusion prompts problem search and reasoning-in-transition,
characteristic ofethical and clinical reasoning in actualpractice.
The anticipation of likely events structures the nurse's prepared-
ness and shapes thinking-in-action.If the patient is at risk for
hemorrhage,the nurse will make sure that the patient is already
typed and cross-matched and that the blood product is available in
the lab.Clinical forethought improves over time as students learn
from prior patients with similar conditions,and from their scien-
tific knowledge of pathophysiology,therapeutic interventions,
likely complications or untoward responses to therapies.Clinical
forethought requires clinical imagination.
Nature of engaged ethical and clinical reasoning
Engaged reasoning requires skillful involvement by the clinician
in the situation.In order to grasp the nature of particular clinical
situations,inexperienced nurses experientially learn to pay atten-
tion to what the most and the least salient is in open-ended clinical
situations.In our studies of skill acquisition,we found that nurses
who were disengaged,or just saw their work as a list of tasks to
complete, did not go on to become experts. Engagementin
particular situations and having outcomes matter,are essential to
experiential learning.
Early in the Freshman year of nursing school where students are
novices,teachers must coach students so that they develop the
ability to recognize the nature of the whole situation and what the
most important and the least important is in actual situations [1].
Thinking-in-action meant the nurses' engagementin actively
discerning and problem solving the patient’s and their family's
immediate needs.
Clinical imagination and clinical forethought
Nursing practice is fast paced,because patients'responses to
medications or to their illness may occur quickly.Without clinical
forethought nurses would not be about to marshal (draw on, solicit,
gather) the appropriate resources for patients whose conditions
might change rapidly.If result of the patient's clinical manifesta-
tions in the moment require thinking-in-action,anticipation is
required for preparedness for quick responses.
Clinical forethought both shapes and is shaped by the practi-
tioner's clinical grasp,the clinician's recognition or more aptly,
their recognition of the whole clinical situation. Unlike novices, the
expert nurse because of deep background experiential learning can
recognize family resemblances between current clinical situations
and experiences they have learned in the past.Clinicians imagine
what the likely trends and trajectories oftheir patients are,and
prepare for plausible or likely eventualities. Both clinical grasp and
clinical forethought are two essential habits of nursing practice that
guide thinking-in-action.Because clinicalforethoughtis always
embedded in particular situations,over time,it becomes such a
habit of thought and patterned way of approaching clinical situa-
tions through an experientially learned set of salient contrasts.
Table 1 Habits of Thought and Action and Domains of Practice
Habits of thought and action
e Clinical grasp and clinical inquiry: problem identification and clinical
problem solving
e Clinical forethought: anticipating and preventing potential problems
Domains of practice
e Diagnosing and managing life-sustaining physiologic functions in acutely ill
and unstable patients
e The skilled know-how of managing a crisis
e Providing comfort measures for the critically and acutely ill
e Caring for patients’families
e Preventing hazards in a technological environment
e Facing death: end of life care and decision-making
e Making a case: communicating clinical assessmentsand improving
teamwork
e Patient safety: monitoring quality,preventing and managing breakdown
e The skilled know-how of clinical and moral leadership and the coaching and
mentoring of others
P. Benner / Asian Nursing Research 9 (2015) 1e64

Normal and pathophysiology must be integrated for the
nurse's iterative situated use of both
Nurses are so centrally concerned with assessing shifts from
normal to alterations from normal in their practice,that they
indeed,might be considered “practicing physiologists”,especially
in today's highly physiologically monitored patient care,charac-
terized by response-based therapies that require alteration,based
upon the patient's responses.The nurse needs an integrated
knowledge use knowledge of both normal and pathophysiological
normal and pathophysiological responses of patients.The student
nurse needs deep learning about normaland pathologicalphysi-
ology as it is manifested and used in practice, whether that practice
is in the acute care/trauma settings,community,long term care,
home care or psychiatric health settings.
Pedagogies in all settings,but particularly in the classroom,
should create an active learning climate thatengages students'
interest in the learning goals at hand.Situated learning exercises
within the class can be used to help the student use knowledge as it
is being presented.
The pedagogies of contextualizing and situating knowledge use
are particularly relevant and engaging for students.For example,
students readily engage in the presentation of patients or family
members describing their lived experience with an illness.Also
“experience-near-firstperson” narrativesof nurses at different
levels of practice are particularly evocative for student engagement
and learning.Simulation,even within a large group setting of the
classroom,can make the classroom come alive with relevanced-
creating active engagement and learning of students involved in a
classroom simulation,either online,or in person.
Pedagogies for creating clinical imagination and patient-focused
care
Literature of patient's experiences,for example,pathographies,
nurse generated literature, medical and nursing literature on their
practice,historical accounts of health care and clinical experience
can be used to expand the student’s clinical imagination for prac-
tice. For example,typically it requires the expansion ofthe stu-
dent's clinical imagination to realize that recognition practices for
the patient as a person and evidence that the patient has been
heard and understood,is usually therapeutic,and trust-building
between the patient and the nurse.Also, how the nurse listens,
attends,notices and articulates accurately the patient/family con-
cerns creates the possibility of more openness,disclosure and
possibility in the clinical situation.
Creating collaborative learning communities
In each learning setting some form of a collaborative learning
community is possible.In large class groups,it might be good to
formally organize learning communities of 6e8 members so that
they can be assigned a focus of learning, and then teach and share
with the rest of the class.For example,each learning community
could be designated and the expert consultants on respiratory care,
cardiac assessment and support, or septic shock. The goal is for the
whole class to learn these areas,for example in an acute medical-
surgical class.But the resident experts provide additionalexer-
cises, even in-service classes available in local health care settings,
engage with respiratory and physical therapists,and recommend
additional readings.Classroom presentations,power point pre-
sentation, clinical learning centers and other assignments could be
developed within the “expert consulting groups”. Students
assigned to the same clinical rotations almost always forge a
learning community in preclinicalpreparations,and postclinical
debriefings. One strong learning experience told by one student can
become a vicarious learning experience for the whole clinical
group.
Consciousness-raising: creating dialogues with the student's
life-world experience, assumptions,beliefs, coping
approaches to illness,rehabilitation, birth, death, and
suffering
Each student needs to reflect on the family coping styles deeply
ingrained in their own familial and cultural habits that will or will
not serve them well as a professional nurse. For example, extreme
discomfort with anger, conflict, helplessness,and suffering will
frequently occur in patients who are under duress due to injury or
illness.But if the student feels embarrassed,or helpless,or even
victimized by anger,they will not be able to be helpful in clinical
situations where patients or families are angry.The learning goal
for the student is to expand their understanding of the coping re-
sources of anger, and their own repertoire of responses,and
communication patterns.Pedagogies of consciousness-raising are
required for students to encounter their own background impedi-
ments to effective professional caregiving. Narrative pedagogies in
the form of journals can be extremely usefulfor this, especially
having the student uncover and reveal their areas of negative bias
and inhibitions with being with patients who are disfigured,
suffering, angry, and so on. An open, trusting and affirming
emotional learning climate is essential for consciousness raising.
Integrating in-hospital care and follow-through learning
about discharge planning and home care help students bridge
gaps between acute care,clinic care, and home care
Selected follow-through cases each semester could create more
depth and breadth in the student’s learning. Follow-up phone calls
on patients who transition to other care units, health care in-
stitutions, or home with home visits from home-care agency nurses
to find out about the patient's illness and recovery trajectory could
bridge the gaps that occur in understanding usual patient changes
in the recovery process.
Teaching for a sense of salience and grasp of the most relevant
aspects of the patient's care, now and in the immediate future
In the first year of nursing school, clinical educators will need to
frame and augment the student's grasp of the most salient aspects
of the patient's care.As the student progresses,and has more
experience with particularpatient populations,they should be
asked,guided,and coached to form the best grasp of the current
clinical situation. Situated clinical questioning is an essential
pedagogy for the ongoing development of a sense of salience in
under-determined clinicalsituations for student nurses. Devel-
oping a sense of salience becomes taken for granted: background
meanings and understandings ofwhat the most and the least
important is in immediate clinical situations. For example, different
clinical aspects are salient in caring for a patient with an acute head
trauma, a postoperative open-heart patient, and a new postpartum
mother.
Clinical evaluation for patient safety
With each patient care assignment,students should be taught
and expected to evaluate all medications for the patient for drug
dosages, patient allergies, interactions, purpose and correct dosage,
correct route,patient,and intravenous administration compatibil-
ities and contraindications ofall medications.Increasingly,such
P. Benner / Asian Nursing Research 9 (2015) 1e6 5

safety is enhanced by computer-based medicalrecord and phar-
macy systems.However the nurse is the patient’s last line of de-
fense for catching over-looked problems with patient medications.
If a patient is receiving a dosage level or a medication not usually or
clearly indicated for the patient's disease or symptom, they should
find out why the particular medication and dosage are being given.
Teaching for action and implementation steps
In most practice disciplines,and in nursing particularly,it is
essential that the student learn how to follow through in all their
clinical knowledge to practical action steps. Rapid implementation
of patient interventions becomes even more important in the rapid
pace of emergency nursing interventions (e.g.,where the external
defibrillator is located,how to access emergency power).Or for
example, in addition to knowing that a pacemaker set and internal
pacing wires may be needed during a surgery, the nurse must also
be prepared to make those pacing wires immediately available
during surgery.Likewise student nurses must learn where emer-
gency drugs are stored and how to procure them immediately
during an emergency.It is not sufficient for the student to know
about the possibility of needing an emergency medication such as
Narcan, or Atropine,but where such medications can be found for
emergency use and how the nurse can gain access to the drug.
Likewise, reconstituting and mixing drugs thatmay be used in
emergencies should be learned in advance.
Learning to make a case for a needed patient intervention,
assessment or attentiveness
Students need to communicate in their nursing reports to other
nurses,physicians and health care team.Making a case for an
intervention is part of one's advocacy and safety role whether the
case is clearly defined,or an early warning about subtly evolving
patient changes.Communicating one's assessments and rationale
for a needed intervention in clear,cogentcases is bestaccom-
plished through a clear clinicalunderstanding ofchanges in the
patient across time. Situation Background AssessmentRecom-
mendation and other standardized tools for making a case can be
useful,but they will only be as useful as the student nurse's accu-
rate grasp of the clinicalsituation and clear reasoning about the
patient's clinicalcondition. Sometimes nurses and students will
encounter a poorly understood clinicalsituation, perhaps early
changes when the patient is stillcompensating for their physio-
logical disturbances. In that case, the nurse or student needs to shift
gears and explain that the situation is ambiguous; that a clear case
for what is going on is not yet evident,and it would be helpful to
have a second opinion, or even the assessment of a rapid response
team.The less experienced nurse will more likely feel uncomfort-
able in requesting a second opinion when the clinicaldata are
unclear,but with more experience,and perhaps a failed “early
warning” the nurse willbecome more confident in requesting a
consult when the patient evidence is still unclear.
Conclusions
Modern medicine with its patient response-based therapies,
and instantaneous interventions in patient clinical changes cannot
work without expert nurses who are able to clinically reason
across time about changes in the patient and/or in changes about
their own understanding of the situation. Likewise, allopathic
medicine,with its attention primarily on diagnosis and treatment
of a subset of physiologicaland biochemicalsystems changes do
not address the human experience,nor recovery from an illness.
Human beings dwelling in lifeworlds fallill and need allopathic
diagnostic curative powers,but patients are required to undergo
treatments,to recover over time, and re-enter their lifeworlds.
Often patients' lifeworlds and embodied capacities are altered as a
result of injury and disease and therefore need situated coaching,
nurturing, encouragement, teaching and other nursing practices in
order to fully recover.Increasingly we must teach better health
care teamwork,and begin shared interdisciplinary education in
medical and nursing schools.
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