Thirty years ago Pat Benner’s seminal work “From Novice to Expert” offered a theoretical perspective on the development of expertise in nursing practice. This book has found its way on to most, if not all, pre-registration nursing curriculum reading lists. Benner’s “expert nurse” is able to execute complex decision-making, rapidly sifting through a wide range of contingencies in their subconscious, eliminating irrelevant stimulus material and selecting salient material in order to come to a decision. We have all witnessed the wisdom of these expert nurses in clinical practice, and nursing scholars have mused for decades about how to facilitate the learning of this clinical fluency.
This mode of processing thought (let us call it the Automatic thinking system) is rapid and unconscious. We use this continuously, to filter out sensory stimuli, to work out the difference between what is threatening and non-threatening, pleasant or unpleasant. We are often unaware of how we arrive at decisions using this system, as we have all experienced when we arrive at our destination without conscious memory of the journey.
Some tasks lend themselves naturally to automatic thinking. Driving is a often-quoted example; if we break down the task of driving into its constituent elements and every one of these elements became conscious it would become a difficult (and potentially dangerous) activity. We would have greatly reduced capacity for distractions such as traffic, music, and conversations with passengers. In healthcare practice we see appropriate use of the Automatic system as well. Benner observed nurses pressing the crash button moments before a patient experiences a cardiopulmonary arrest, who are subsequently unable to accurately explain how they recognised the deterioration in the patient. Being unconscious, this system demands little in the way of higher cognitive resources, and as such it is possible to engage in automatic and unconscious behaviour whilst carrying out a number of tasks.
Uniquely among the animal kingdom, humans also possess a second thought-processing system, let us call it the Reflective thinking system. This system involves meta-cognition; that is, awareness of self. In contrast to our automatic thinking, this type of thinking is slower, requires conscious deliberation and decision-making, and may lead to the development of new ideas. Both these systems are thought to work together in a complex dual processing relationship. Newly qualified nurses often report feeling frustrated at how slowly they find themselves completing tasks which seem effortless to those with more experience. A large part of this slowness is that they are engaging in this form of thought-processing. The task is requiring conscious, rather than unconscious processing. This feature is also what has enabled humanity to give birth to such amazing achievements as music, art, technology, organised society, politics and philosophy, as it enables the conscious consideration of a range of alternative options, which is fundamental to the creative process. It is also the thought-processing system that is required when one establishes a meaningful connection with another human being; this cannot be done automatically.
In nursing, a range of tasks are required at any one time. The nurse requires awareness of the ward routine, and to prioritise scheduled tasks as well as responding to changing patient needs. In a busy ward environment, using the Reflective thinking system is more taxing than using the Automatic thinking system. It requires attention, emotional presence, openness to new and unfamiliar situations, and slow and deliberate consideration of a range of stimuli, including those which may be unfamiliar and perhaps threatening. This might partly explain how and why nurses often prioritise automaticity, routines and task-focused practice.
If conversations with the dying are expected to also be conducted with the “expertise” described by Benner, we would imagine a great deal of the processing to occur subconsciously. The nurse may recognise patterns from other patients and use highly complex systems in order to select the most appropriate response in the situation. But what if the situation is new, or unfamiliar, or threatening? What if the nurses’ threat awareness systems are activated because of subconscious thoughts of death, disgust, blame, or guilt? These emotions may never enter consciousness but they will doubtless inform responses within the conversation. A nurse using Automatic thinking may recognise patterns from previous experiences and draw on one of a range of “appropriate” responses to the situation, but is able to do this without authentic conscious connection with the patient. So automatic reassurance or prioritising one element of what is said whilst ignoring or blocking others do not necessarily indicate a lack of compassion. A nurse who is experiencing such a high demand on cognitive resources (through perceived threat, stress or competing tasks) may well engage in a higher proportion of Automatic thinking, but a conversation with a dying patient will never follow the same course twice (although there may be patterns and familiarity). The connection of that patient with that particular nurse will also never be replicated with another staff member, since the relationship exists in the unique space between them.
I am not arguing against the importance of experts. Expert clinical practice is what frees up cognitive load in the advanced practitioner enabling them to engage additional resources for use of the second, more conscious process. But I believe we also have a lot to learn from non-experts. When a student asks “why?” it is because the situation is unfamiliar. Explanation of reasoning requires conscious thinking, and the easier Automatic response often leads to the resigned “because we’ve always done it that way” that students so often report to me.
The non-expert shines a light on to all aspects of a situation, indiscriminately. They require guidance as to what is clinical or interpersonally significant, which requires the person giving the guidance to become aware of things which they had previously processed automatically, rapidly and unconsciously. This can be challenging for mentors and teachers. Applied to some aspects of practice, it might be that Automatic thinking is detrimental to the quality and authenticity of care, and Reflective thinking should be consciously brought to the surface. Zen Buddhists describe a state known as “beginners mind”, in which they extol the benefits of the open, curious and non-discriminatory nature of the new meditation initiate. They suggest that beginners mind is one to be aspired to by all, no matter how experienced. Using this curiousity, all aspects of experience are equally open to examination, including the nurses’ own emotional responses to the situation.
Reflective practice is one means of facilitating awareness of the wider context of events in order to minimise routinised and automatic practice. The theory behind this is that the unconscious becomes conscious through the deliberate focusing of attention on to aspects of the experience, sometimes prompted by a framework or clinical supervisor. This is not the only way to increase the proportion of Reflective thinking, but it is a profoundly important aspect of becoming a true expert.
Next week I’ll be writing about the sorts of things which might influence the balance of automatic and reflective thinking in humans in general, and healthcare professionals in particular.