Nursing knowledge may often go unnoticed. As Liaschenko (1998) points out nursing knowledge is often only expressed amongst nurses and whilst some of this knowledge is highly visible within the culture of nursing (and therefore is accorded legitimacy and authority); large portions remain invisible and silenced. She goes on to explain that in medicine knowledge can be represented and made visible to the public eye and is therefore recognised by contemporary society; consequently society only acknowledges that which can be represented as knowledge, therefore that which is not represented does not count as knowledge and is readily dismissed, ignored or not seen. According to Liaschenko this has particular significance to nursing as a mainly female dominated profession because the knowledge which women have about the world and how it works is obtained from local practices and oral traditions; and is largely discounted as knowledge. This is because
women do not speak from what she terms as the dominant discourse of scientific knowledge and their knowledge may lack authority as a result. Four kinds of knowledge are identified, each of which involves witnessing and telling: knowledge of therapeutic effectiveness, knowledge of how to get things done, knowledge of patient experience and knowledge of the limits of medicine (Liaschenko 1998). Knowledge is viewed from the framework of testimony reinforcing her notions of oral traditions. Testimony is carefully defined as involving bearing witness as the means of access to knowledge as well as the telling of that knowledge; “to give testimony is to speak the truth of some phenomena” (p12) to an audience. This is similar to the notions of exploratory talk suggested by Slavin (1996).
Professional learning
Eraut (1994) and Schon (1987) suggest that professional practitioners have a specific and unique way of learning. Eraut postulates that professionals learn on the job by deliberating on specific events, termed case specific learning. However, he acknowledges that cases have to be viewed as special rather than routine and time must be set aside to deliberate their significance in order for learning to take place (Eraut 1994). Schon (1987) suggests that the knowledge on which professionals draw is broad, deep and multi faceted; moreover, the problems which professionals face are complex and messy. Schon describes this as a topography of high, hard ground overlooking a swamp. On the high ground problems may be solved by the application of research based theory and technique; whereas problems in the swampy lowlands are confusing and defy technical solution. He goes on to say that ironically problems of the “high ground” nature tend to be relatively unimportant to individuals and society in general; but in the swamp lay the problems of greatest human concern. Professional practitioners can not solve problems solely by applying theories of techniques derived from the body of professional knowledge; there is more to it than that. For Schon the messy
problems present practitioners with indeterminate zones of practice where professional use a core of professional artistry.
“Artistry is an exercise of intelligence, a kind of knowing, though different in crucial respects from our standard model of professional knowledge. It is not inherently mysterious; it is rigorous in its own terms; and we can learn a great deal about it…by carefully studying the performance of unusually competent performers” (Schon 1987. p13).
In order to learn professional artistry, a learning environment which encourages learning by doing should be created this means an environment which is low in risk. Schon argues that there are two kinds of practice situation, each requiring the practitioner to use a different form of knowing. The first is the familiar situation where problems are solved by routine application of facts, rules and procedures derived from the body of professional knowledge. Secondly, there are unfamiliar situations where the problem is not initially clear and there is no obvious fit between the characteristics of the situation and the available body of existing knowledge. Learning for practice is said to take place in one of three ways. The practitioner may learn the practice on his own, although Schon acknowledges that this is rare. Learning alone has the advantage of freedom to experiment without the constraints of received views. However, the disadvantage is that each student is required to reinvent the wheel, gaining little or nothing from the accumulated experience of others. Secondly, the learner may become an apprentice to a more senior practitioner offering direct exposure to the real conditions of practice and patterns of work. Importantly, Schon points out that most offices, firms, factories and clinics are not set up for the demanding tasks of initiation and education because pressures for performance tend to be high; time is at a premium and mistakes costly. Also senior professionals have learned to expect apprentices to come equipped with rudimentary practice skills (Schon 1987). Thirdly, the student may enter a practicum: a setting designed for the purpose of learning a practice, in a context that approximates a practice world. Here students learn by doing. However Schon does not offer any specific examples of low risk practice settings. The notion
of creating a learning practicum suggests that the practice setting is malleable according to the learners’ ability, which of course is not the case. Conversely, high risk practice settings may produce practitioners who are more able to learn by doing; which may not always be true.
Eraut suggests that there are different kinds of professional knowledge which can often be found on examination of training courses or curricula. Knowledge is likely to be labelled and packaged according to traditional assumptions about how and where it will be acquired. Eraut explains that mapping out knowledge in this way is problematic. Firstly, because large areas of know how are omitted from training, and where common knowledge exists it is structured, labelled and perceived differently. Secondly, much professional know how is implicit, posing the question: how much know how is essentially implicit, and how much is capable with appropriate time and attention of being described and explained? (Eraut 1994).
Eraut (1994) identifies six types of knowledge:
1. Situational knowledge i.e. the way people conceptualise situations, think about them and “read” them. This knowledge is acquired as people learn about situations through personal experience of them, rather than studying them from afar. Such knowledge may be built up through both purposive and accidental means, purposive because much discussion and deliberation is required; and accidental because intuitive assumptions are used.
2. Knowledge of people and the basis on which one gets to know and make judgements about people.
3. Knowledge of practice which includes not just simple factual information but also knowledge of possible solutions or actions which might be implemented in any given situation. This is said to be a vital component of effective decision making and inherent within problem solving.
4. Conceptual knowledge, including formal and informal theories which guide much of our behaviour but may, again be tacit. When concepts are learned in an academic context they may be under critical control but are not necessarily
5. Process knowledge or how to do things or get things done.
6. Control knowledge. Controlling ones’ self, having self awareness of personal performance, self assessment and management.
Eraut argues that knowledge can be used in four ways: replication, application, interpretation and association. He suggests that interpretation and association are more typical of the way a practitioner uses their knowledge base. It is not clear whether all six categories of knowledge hold equal weighting in terms of professional practice. Those learning professional practice may not necessarily posses all six types of knowledge.
However, in more recent work Eraut acknowledges that his ideas regarding knowledge in a professional context have developed. In 2000 he provides two parallel definitions of knowledge; namely codified knowledge and personal knowledge. Codified knowledge is subject to quality control by peer review, debate and editors; furthermore it is given status through incorporation into curricula. This type of knowledge includes propositions about skilled behaviour but not skills or ‘knowing how’. Personal knowledge is described as the cognitive resource which a person brings to a situation, enabling both thought and performance. Eraut goes on to outline a typology of informal
learning which distinguishes between implicit learning, reactive on the spot learning and deliberative learning.
It seems there is little literature which attempts to explain the mechanisms by which student nurses learn in the clinical setting. Further more it seems that there is a paucity of literature from the student perspective.
Dialogue between student nurses and more experienced practitioners has been highlighted as a useful mechanism to support student learning. Spouse (1998) suggests that a mediator is necessary to help students to translate general (formalised) knowledge into practice settings. In a longitudinal study investigating professional development of pre registration nursing students Spouse (1998) indicates the importance of sponsorship by a clinical member of staff and participation in what she refers to as legitimate peripheral activities. However, Spouse does not go on to specify what such activities might be. One strategy which mediators employ is purported to be scaffolding (Spouse 1998). Scaffolding is said to take place within sponsored nursing activities; in other words when the mediator and student are working together; and builds on the important concept of Vygotsky’s work on the Zone of Proximal Development (ZPD), where speech becomes a tool to facilitate learning and development. Scaffolded activity does not always have to be supervised but Spouse acknowledges that it should be planned in order to help the learner see the relevance of their knowledge in waiting. Being verbally guided through a whole process (clinical activity) ensures that learning is structured by being encouraged to think aloud. This type of dialogue Spouse refers to as proleptic instruction or coaching which helps knowledge in waiting become knowledge in use. By guiding students through activities using proleptic instruction the learner extends their perceived level of skill and so the learner is more able to fulfil their potential (Spouse 1998). However the notion of appropriateness to steer student nurses through dialogue remains unconsidered. Whilst qualified nurses may be engaged in proleptic instruction with students Spouse does not say whether others may act in this capacity. It may be possible for other students who are more
advanced in the programme to verbally guide more junior students through clinical activities.
Similarly, in later work Spouse (2001a) expounds the notion of purposeful dialogue and suggests that work placed learning must include opportunities for challenge and resolution through discussion. It is suggested that the key element is the collaborative nature of the interaction between practitioner and student. The dialogue that takes place between mentor and student relies on the mentors’ ability to think aloud; the learner then internalises the dialogue, identifies questions that promote recognition of significant earlier learning or to seek new information that explains their experiences (Spouse 2001a). Spouse (2001a) employed a phenomenological longitudinal study to investigate factors influencing the development eight pre-registration nursing degree students during their practice experience. Although the findings discuss the students’ experiences in clinical practice, the study was conducted within the researcher’s academic institution. Whilst qualified staff acting as mentors may be influential in helping students to learn other members of the clinical team may also act in this capacity. Other student nurses in particular may have a role in collaborative interaction. However, Spouse does not consider this point.
Drawing on earlier work, Spouse (2003) utilises a flexible research method based on two essential approaches: ethnography and phenomenology to examine student nurses in naturalistic settings in a longitudinal study. The focus of the work examines the clinical learning activities of a small group (n = 6) of student nurses undertaking a pre registration degree course. Each case study is presented as an exemplar of students’ professional development. A number of factors important to student nurses’ clinical learning are outlined (some of which are reported elsewhere; for example: Spouse 1998, 2001a). However, here my comments are related to specific findings describing peer support and peer learning. Spouse appears to tentatively propose that peer support is more important to some students than to others and suggests that reliance on peer support may be age related as the younger students
participating in the study demonstrated an increase in the amount and type of support gained from peers. However, Spouse does not elaborate on this point in discussion of the findings as different themes are presented for each case study (in order to reflect the individuals and their journeys to becoming nurses), but this does not help to explain the initial suggestion. Specific perspectives of older students are described, whereby older students, particularly those who did not live in student accommodation, found that they did not have the same contact with their peers. One student felt alienated by her peer group because she was several years older than most of her fellow students, having little in common with them. Similarly on clinical placements mentors (who were the same age) were separated by their status within the organisation. Spouse does not expound on this concept to fully discuss the implications of how students are, or should be, grouped together in terms of age in order to promote peer learning.
Non formal learning
Eraut (2000) suggests that informal learning is often treated as a residual category to describe any kind of learning which does not take place within, or follow from, a formally organised learning programme or event. However, Eraut argues that this definition belies the importance of informal learning because informal learning covers a continuum from implicit to deliberative learning. Implicit learning is said to happen when there is no intention to learn and no awareness of learning at the time it takes place. Between implicit and deliberative learning a middle category of reactive learning is suggested. Reactive learning is explained as being near spontaneous in nature and unplanned, the learner is aware of it but the level of intentionality is debatable and varies. This learning is also difficult to articulate explicitly without setting aside more time for reflection. However, this then makes the learning more deliberative. Planned non formal learning is deliberative (Eraut 2000).
Eraut (2000) clearly links implicit learning to tacit knowledge. Our lived experiences are stored within long term memory, although this may not be a conscious or deliberate process. We link several memories and accumulated experiences of several episodes together to help us in future action. However, there is no conscious awareness of this happening (Eraut 2000). This notion would seem to imply that reflection which uses past events involves memory in a similar way. It also suggests that reflection in order to learn is not a single or linear process.
Episodic memory may be used for specific, personally experienced events whereas semantic memory is for generalised knowledge that goes beyond the specific episode. Importantly, Eraut (2000) suggests that there is traffic between the two forms of memory. He argues the same episode may contribute to performance both implicitly (within episodic memory from direct experience) and explicitly (within episodic and / or semantic memory). For example: episodic memory may be used to recognise a new but comparable practice encounter where a previously used decision option is used; the individual may realise that the match between the practice encounters may not be exact and that therefore a repeat of the decision option may not be the best action. Here tacit knowledge would be used. Eraut goes on to say that when public, prepositional knowledge is fed into semantic memory and subsequently called upon for performance; this kind of knowledge is useful for clarifying the meaning of events; but further deliberation is necessary, otherwise the knowledge is too abstract to be used. Tacit knowledge is used when situations demand rapid action or are too complex to be fully analysed. However, in this explanation Eraut assumes that these practice encounters have to be personally experienced. At no time does he consider whether learning from another’s experiences is possible or if such vicarious experiences could be used within memory in a similar fashion.
Experiential learning in nursing
The work of Benner (1984) is well known within nursing as individuals develop from novices to experts. Throughout the five stages outlined by Benner the perspective of the individual alters; the expert having a library of experiences on which to draw. Experts are said to have total mastery and this is demonstrated by the speed and flexibility of their actions; they are able to zero in on a problem straight away. Learning through and from experience is enhanced by reflection (Benner 1984). However, Benner’s work is not without critics as the thinking processes by which nurses decide on the most appropriate care for patients may not be adequately described by the reflective practitioner concept. Lauder (1994) considers whether the process of deliberation is in fact more complex than simply reflective activity; and argues that the reflective moment separates thought and behaviour. A nurse’s practical wisdom being characterised by a complex combination of doing and thinking, which in clinical situations can not be separated into theoretical and practice components. Indeed, Lauder suggests that to do so reduces and fragments the unity of clinical experience.
Similarly, Arbon (2004) comments on Benner’s work and says that she implies that the journey to expertise is a linear process, cumulative in nature, temporal and dependent on the interaction that seems to occur between exposure to clinical forms of experience and learning. He goes on to say that this concept of expert practice does not seem to adequately explain the experience of nurses as they interact with patients in different settings in different circumstances. Arbon suggests that nurses bring to practice understandings about people and situations that they use in their work; these are grounded in the understandings about the lived world that they have developed in all its forms. He also points out that the nursing literature to date, has largely failed to capture the influence of other (non-clinical) experience(s). Over recent years there has been a shift in emphasis from learning psychomotor skills through development and subsequent application of scientific forms of knowledge towards the application of nursing
knowledge to practice. Alongside this shift there is a contemporary focus on producing skilled graduates; effective decision makers who take appropriate action in clinical situations. In short there has been an overriding concern with safe practice.
Arbon argues for a broader understanding of experience. His study explored the role of meaning and understanding drawn from experience in all its forms