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

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 experiential learningdwhich help students
develop a deep sense of professional identity, and everyday
ethical comportment. However this done primarily in clinical
practices assignments and simulations with actual perfor-
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 clinical practice, 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 National Student 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 pedagogical implications 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: clinical reasoning 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 of an integrated practice of all
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 professional education
should be integrated in all teaching 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
practical or 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 apprenticeships work 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 of learning 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 development and 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 of information about science, dis-
coveries but little about contextualization of that 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 formal decision 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 formal decon-
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 must be 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 all the 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-member in 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 professional in 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 of the 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 of the 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 of ethical comportment and clinical imagi-
nation occurs in practices and in dispositions and actions, not just
in beliefs and decisions. Excellent nursing practice in particular
clinical situations requires experiential learning. “Situated coach-
ing” of the student in particular clinical situations 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
general education 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 for developing 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 spiritual re-
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 patient care. Tensions exist between teaching
“everything” a student needs 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 of diseases without strategies for
approach, access to patient care, or clinical imagination except
through categories. Since the student has little background un-
derstanding of nursing practice because of their lack of clinical
experience, they have no way of imagining what it would mean to
“use” a diagnosis or classification term in actual practice. 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 clinical reasoning 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 of all di-
mensions of the profession, grounded in the profession’s funda-
mental purposes. When students talk about their key clinical
learning experiences as senior students they emphasize their
ethical concerns in practice: meeting the patient as a person, pre-
serving dignity and personhood of patient, 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