Article

Exploring clinical wisdom in nursing education

Nursing Ethics 19(2) 252–267 ª The Author(s) 2012 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733011416841 nej.sagepub.com

Andrew McKie Robert Gordon University, UK

Fiona Baguley Robert Gordon University, UK

Caitrian Guthrie Robert Gordon University, UK

Carol Jackson Robert Gordon University, UK

Pamela Kirkpatrick Robert Gordon University, UK

Adele Laing Robert Gordon University, UK

Stephen O’Brien Robert Gordon University, UK

Ruth Taylor Robert Gordon University, UK

Peter Wimpenny Robert Gordon University, UK

Abstract The recent interest in wisdom in professional health care practice is explored in this article. Key features of wisdom are identified via consideration of certain classical, ancient and modern sources. Common themes are discussed in terms of their contribution to ‘clinical wisdom’ itself and this is reviewed against the nature of contemporary nursing education. The distinctive features of wisdom (recognition of contextual factors, the place of the person and timeliness) may enable their significance for practice to be promoted in more coherent ways in nursing education. Wisdom as practical knowledge (phronesis) is offered as a complementary perspective within the educational preparation and practice of students of nursing. Certain limitations within contemporary UK nursing education are identified that may inhibit development of clinical wisdom. These are: the modularization of programmes in higher education institutions, the division of pastoral and academic support and the relationship between theory and practice. Keywords context, knowledge, phronesis, time, virtues, wisdom

Corresponding author: Andrew McKie, Lecturer, School of Nursing and Midwifery, Faculty of Health and Social Care, Robert Gordon University, Garthdee Campus, Aberdeen AB10 9QG, UK Email: [email protected]

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Introduction In recent years, there has been interest in what different conceptions of wisdom might be able to offer to the caring professions and nursing, in particular in terms of meeting each profession’s goals of service.1–3 Central to such conceptions is a recognition that rational, technical and evidence-based approaches to practice, for all their merits, may not always be sufficient to address the complexity, unpredictability and ambiguity inherent within service to context-bound human beings.4 As a concept, wisdom should be able to capture the characteristics possessed of an individual that enable the person to envisage and carry out the appropriate actions for the end(s) desired. Defining wisdom is not easy, but it may helpfully be considered in terms of ‘forms of deliberation which combine knowledge, reflection and life experience with social, emotional and ethical capabilities’.2 In this article, the role of the concept of wisdom in professional health care practice is explored, first, via consideration of different perspectives of wisdom as these have been developed historically and contemporarily and, second, by examining how a particular concept of wisdom has utility for nursing education and practice.

Concepts of wisdom For all the apparently straightforward and simple expressions of wisdom found in everyday language and in literature, a closer examination reveals that it is a complex and challenging concept. This current exploration is undertaken, however, for the purpose of encouraging practitioners to consider that ‘issues of ultimate moral meaning’5 may be of importance to the goals of nursing and to nursing practice itself. Following this, it is possible to consider several views of wisdom in the shape of ‘theoretical systematic formulations’,5 which may assist in advancing such understanding for the purpose of achieving professional and healthcare goals. In recognizing that the understanding of concepts changes over time, three such ‘formulations’ may be considered appropriate for an exploration of wisdom: philosophical, religious and psychological. While others have considered philosophical and psychological perspectives,3 explorations of religious influences on wisdom have often been absent and yet may, within western contexts particularly, have had significant impact on nursing practice and on professional cultures, in particular.

Philosophical When philosophical sources exploring and deliberating upon the nature of wisdom are sought, classical sources from Greek thought, among others, can be considered. Indeed, etymological issues themselves may be helpful here by noting that the word ‘philosophy’ itself derives from the Greek terms philo (loving) and sophia (knowledge or wisdom). Platonic and Socratic sources6 addressed wisdom, but it is Aristotle who extensively explores the subject in his Nicomachean ethics.7 In this book, wisdom is incorporated into a wider discussion of intellectual virtues. Defining a virtue as ‘a thing related to its proper function’7 as well as in goal-orientated (telos) terms of ‘purposive disposition’,7 Aristotle differentiates between moral (character) virtues and intellectual virtues. Wisdom is located within a group of intellectual virtues concerned with the pursuit of truth and is delineated into ‘five modes of thought or states of mind’7 (Figure 1). Concerning wisdom, Aristotle distinguishes between two different types of wisdom. Practical wisdom (phronesis) is concerned with particular, or contingent, actions and centres upon human actions that involve choice, options, alternatives and some deliberation as to the effects, or consequences, arising from such actions. By way of contrast, wisdom as sophia for Aristotle possesses different characteristics from its

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Science or scientific knowledge (episteme) inductive, deductive

Art or technical skill (techne) production rather than action

Prudence or practical wisdom (phronesis) d eliberations on particulars

Intelligence or intuition (nous) Apprehension of first principles of science

Wisdom (sophia) intuition and scientific knowledge Figure 1. Aristotle’s wisdom modes (Aristotle, 1983: Book Six 210–12)7

practical form (phronesis). The sophia form of wisdom is concerned with truth for its own sake, rather than being directed towards a particular (practical) end: but we regard some people as wise without qualification, not in a particular sense nor ‘wise at something else’ . . .7

Although contemporary forms of wisdom tend to relate more to Aristotle’s practical wisdom (phronesis),3 it is important not to overlook the relationship between the two virtues. Aristotle viewed practical wisdom (phronesis) as inferior to wisdom (sophia) itself,7 but the combination of both forms of wisdom was considered essential in any exploration of a person’s actions: . . . for wisdom is part of virtue as a whole, and makes a person happy by his possession and exercise of it. Again, the full performance of man’s function depends upon a combination of prudence and moral virtue; virtue ensures the correctness of the end at which we aim, and prudence that of the means towards it.8

In any attempt to answer Socrates’ question of ‘how a man should live’,8 Aristotle’s quotation suggests the need to adopt a wide framework of reference incorporating several different types of virtue concerned with addressing knowledge. This may be addressed in another view of wisdom, namely that offered by religion.

Religious The nature of wisdom, as part of a consideration of virtue, is addressed in various ways by all the ancient world religions: Judaism, Christianity, Islam, Buddhism, Hinduism and other Eastern religions.9 Wisdom, in religious terms, is often equated with the conversion of doctrine into the lives and actions of the individual. The intellectual/cognitive engagement with the Bible, Qur’an or Noble Truths, for example, may remain just that if there is no subsequent engagement and influence on daily life. While acknowledging that all religions seek to instil wisdom in its followers, we are confining our exploration of wisdom to that identified in the ‘theistic’ worldview of the Judeo-Christian tradition as this also draws on the Hellenistic influences previously discussed. In ancient Hebrew culture, wisdom was considered an intellectual virtue possessing practical dimensions of doing something well. The ultimate source of wisdom lay not within men and women, but in recognizing

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the existence of a transcendent and creative divinity. Nevertheless, the distinctive feature of wisdom was found in its links with human experience, in particular to the notion of helping people to live well. Eschewing any notion of a systematic and coherent set of teaching about life, wisdom writings were considered as guides for addressing the paradoxes and ambiguities of everyday life itself: wisdom is not necessarily about getting the right answer, but about searching for the answer through the paradox of life.10 (emphasis added)

Central to the scope of wisdom is the human desire to control the future.10 Wisdom, by way of its search, or quest, for answers, seeks to explore these uncertain futures by addressing the practicalities of present everyday living. Branick10 differentiates between ‘optimistic’ and ‘pessimistic’ genres of wisdom literature. Optimistic wisdom literature: practical living. The Book of Proverbs consists largely of pithy, everyday sayings written by men considered to ‘possess’ wisdom, such as King Solomon, Lemuel and Agur. These proverbs address a diversity of commonplace issues, as in: A wise child makes a glad father, but a foolish child is a mother’s grief. Proverbs 10: 111

Pessimistic wisdom literature: understanding life. In this type of wisdom literature, the assumptions of an orderly and successful life are challenged in language. In the Book of Ecclesiastes, its author Qoheleth (The Preacher) finds the central features of human life (the pursuit of wealth, success, labour) wanting. For Qoheleth, wisdom lies in recognizing the significance of two particular themes. The first centres upon a particular understanding of time itself. Time is not to be understood solely in linear, or sequential, terms (chronos), but also in terms of its particular appropriateness for life’s events themselves (kairos). Wisdom resides in discerning the timeliness of action itself: For everything there is a season, and a time for every matter under heaven: a time to be born, and a time to die; a time to plant, and a time to pluck up what is planted; a time to kill, and a time to heal; a time to break down, and a time to build up; Ecclesiastes 3: 1–312

The second theme, in recognizing that much of life experience might lie beyond the understanding and control of men and women, acknowledges the place of wisdom in helping people to address the future: Wisdom is as good as an inheritance, an advantage to those who see the sun. For the protection of wisdom is like the protection of money, and the advantage of knowledge is that wisdom gives life to the one who possesses it. Ecclesiastes 7: 11–1213

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The Book of Job further explores themes of ‘pessimistic’ wisdom in the context of addressing issues of illness, suffering, loss and injustice. Wisdom is presented, among others, as part of a discerning acknowledgement that many questions raised by human experience itself (e.g. suffering) may not possess straightforward ‘answers’ as such. The acceptance of such a position does not render the quest for meaning futile or pointless. Rather, the capacity of wisdom may lie in recognizing the limitations of human understanding itself in the face of life’s many complexities: But where shall wisdom be found? And where is the place of understanding? Book of Job 28: 1214

Psychological Recent work on human development locates wisdom as a ‘psychological construct’15,16 and as central to a ‘positive psychology’ reflecting various aspects of the human condition.16 Peterson and Seligman,17 in seeking to locate wisdom within a ‘science of human strengths’, attempt to classify characteristics of the ‘good life’ along the lines of recognized classifications of psychological disorders.18 Identified as a core virtue in the philosophical tradition discussed earlier, wisdom and knowledge (alongside those of courage, humanity, justice, temperance and transcendence), can be demonstrated via the practice of such human strengths as creativity, curiosity, love of learning, open-mindedness and keeping hold of perspective (the ‘big picture’).17 Csikszenentmihali and Rathunde15 outline a contemporary understanding of wisdom in terms of a reaction to the over-specialization of modern culture’s preoccupation with rationality, efficiency and analysis. Specific features of this view of wisdom include:    

the relativity of formal systems via life experience; the interrelatedness of all experiences via transformation; reflective and integrative approaches to thinking; the existence of choice via commitment to action.

Kunzmann and Baltes19 further discuss the concept of wisdom in action within traditional discourses on intelligence. This is illustrated in terms of four central characteristics derived from findings collated under the Berlin Wisdom Model (see Figure 2 below). As indicated in Figure 2, the Berlin model defines wisdom as a means (pragmatics) of addressing the problems and complexities of life itself. It can then perhaps be seen as part of the resurgence of Expertise in the fundamental pragmatics of life breadth of scope, highest form only attained by a few

Knowledge about the fundamental pragmatics of life beyond scope of individuals alone to include texts and cultural products

Orientated toward the common good intra – and interpersonal concept, relational and shared

Differs from abilities cited under conventional modes of intelligence used to address uncertain and complex life problems

Figure 2. The Berlin Wisdom Model (Kunzmann and Baltes, 2003)19

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interest in virtue ethics based on the realization that the attempt to base ethical practice on objective criteria alone does not deliver.20 However, its location goes beyond individuals themselves to include common or shared goals acknowledged by many people (ethics). This framework of wisdom-related knowledge is linked to action18 via an integrated framework that incorporates the well-being of others and a positive role for the emotions. In essence, if wisdom is concerned with addressing ‘existential problems of life meaning and conduct’,19 then it requires to acknowledge the practice of a multiple range of attitudes and actions. To summarize these three overviews, when wisdom is considered via classic, ancient and modern conceptions it remains framed in epistemological terms that do not discard theory, formulation and proposition (episteme). However, wider and deeper forms of knowledge are incorporated into a type of practical wisdom (phronesis) which may include significant ‘worldview’ dimensions of metaphysical, human, ethical and relational types. The following key messages might be taken forward and examined in the light of discussions about wisdom and clinical practice:6,17–23   

virtues related to self and care for others; knowledge-based decision making and actions; connections between cognitive and emotional worlds.

Addressing the above issues as they appear in present understandings of the place of wisdom in clinical practice may be considered an interdisciplinary concern. It is to these that attention is now given.

Clinical wisdom The recent renewed interest in wisdom within professional health care practice is noteworthy. In part, this may be linked to exploration of alternatives to the use of scientific paradigms across a diversity of areas such as spirituality,21 care,22 ethics23 and therapeutic relationships.24 In addressing the issue of wisdom as it pertains to professional health care practice, some introductory points regarding the use of terms are required to be made. Although such discussion often presupposes specific disciplinary knowledge bases (e.g. nursing, social work and medicine), many common areas of interest can also be discerned. This is reflected in the use of several terms to facilitate such explorations: e.g. ‘clinical wisdom’,3 ‘practice wisdom’1 and ‘professional wisdom’.23 O’ Sullivan explores theoretical dimensions of the nature of wisdom in social work practice and defines practice wisdom in ‘reflective judgement’ terms as: the ability to base sound judgements on deep understandings in conditions of uncertainty.1

This notion of ‘reflective judgement’ exercised within the context of uncertainty may be explained by considering knowledge processes characterized by distinctiveness, explicit reasoning, credibility, value and effectiveness.1 Such dimensions of practice wisdom could be acquired, maintained and fostered in practitioners by communities of professional education, both in university and practice contexts. These notions of reflection find parallels in other current approaches to professional practice involving a balance between knowing and doing, and seeking to understand the use of skills in contexts characterized by complexity and uncertainty.25 In addition, it includes seeing the bigger picture and being able to articulate strategies for action that can incorporate risk or change to achieve more realistic outcomes. Tsang26 similarly addresses knowledge issues in practice wisdom within social work. Focusing on practice wisdom in terms of Aristotle’s practical knowledge (phronesis), emphasis is placed on the: neglected element of time in the deliberation of practice wisdom.26

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Tsang also contrasts linear time (chronos) with ‘soul satisfying time’ (kairos). The value of practice wisdom lies in recognizing the significance of the latter and, in particular, the timeliness of actions as they are perceived within professional practice. Although the parallel working of both time perspectives within the therapeutic relationship is recognized, the value of practice wisdom may centre upon looking for, and assessing the effects of, the ‘soul satisfying time’ (kairos) moment in ways that take full account of the particularities of time and place. This may be comparable to the contextualized nature of wisdom identified in the Judeo-Christian ‘worldview’ with an understanding of ‘time as quality’27 in which highly specific actions are characterized by their timeliness. Thus, for Tsang wisdom: has to do with the social worker’s ability to identify the right moment to do the right thing at the right place.26

It is possible to identify several other features of practice wisdom. Litchfield28 locates practice wisdom as part of the ‘turn of attention to the nature of practice’ initiated by the advent of the postmodernist reaction against theory and ‘grand narratives’.29 Practice wisdom then refers to the significant dynamic of reflexivity on the part of the practitioner practising within local and particular contexts and emphasizing change, contingency, uniqueness and participation.30 Such approaches may come to erode traditional distinctions between values, beliefs and knowledge within professions (ontology and epistemology).28,31 Similarly, Krill32 notes the ‘growing’, rather than attainment, of wisdom in terms of practitioner integration of theory, philosophy and subjective experience. Another aspect of this exploration of clinical wisdom may lie in its relation to current considerations of professionalism in nursing. Crigger and Godfrey33 locate professionalism within an Aristotelian virtue ethics framework incorporating the ‘end of a goal-directed process’ as discussed earlier under ‘Philosophical’ sources of conceptions of wisdom. This framework is outlined in Figure 3 below. This then may move beyond objective transactions to the potential transformation of both person and situation. In addition, by emphasizing the contingent aspect of practical wisdom, no premium is put upon the perfect attainment of desired ‘ends’ (e.g. flourishing). Instead, practical wisdom recognizes that the attainment of certain ‘ends’ may turn out to be wrong or ill-advised (mistakes). This emphasis on practice is given sharper focus by a study of the practice of proficient nurses in Denmark.34 Drawing upon Benner’s work on the deportment of nursing skills acquisition, Uhrenfeldt and Hall34 identify the presence of clinical wisdom in ‘proficient’ nurses in the areas of ethical discernment, action and responsibility. Significantly, while clinical wisdom is identified in these qualities of practising nurses, contextual issues (e.g. poor caring conditions) may act as ‘barriers’ and thus contribute to a lack, or decline, of clinical wisdom. This practice focus may be highlighted further by considering two particular models of practice wisdom. In the first model, Edmondson and Pearce2 locate wisdom within important processes of judgement and reasoning in professional health care practice. In noting the multiple features of wisdom, the particular ‘problem’ of locating the person within contemporary knowledge frameworks in health care is summarized as: the philosophy of scientific reasoning most widely accepted among natural scientists assumes that the type of person someone is should not make a difference to one’s professional decisions.2 (emphasis added)

This exclusion of the person is challenged across a wide range of health care practice, e.g. mental health practice,21 ethics23 and professional practice and performance itself.35 Edmondson and Pearce2 describe a ‘trifoliate model of wisdom’ which incorporates within any practice setting attention to capacities of the self, the other and the problem. Using the metaphor of three leaves overlapping adjacent to each other, these capacities may be considered to intertwine with each other within very specific practice contexts (Figure 4). On a contemporary note, it is often suggested that rationalist views of evidence-based practice consider the characteristics of the practitioner or the patient/family as unimportant and that evidence will take prime

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Moral Agenda

Practical Wisdom (Phronesis)

Outcomes (Telos)

Social codes, standards, traditions, rules, norms

deliberation making fitting choices acting on these practice

Social results of actions response of others

Individual past experiences virtues, knowledge, affective issues, preferences, perceptions

Individual flourishing − moving toward the ideal slips or mistakes − moving away from the ideal

Figure 3. A framework for nurse professionals (Crigger and Godfrey, 2011)33

Capacities of the self practice, reasoning professional knowledge moral characteristics

The ‘problem’ Capacities of the other

technical issues contextual factors: social, cultural and motional

personhood f lexibility to perceived needs

Figure 4. A trifoliate model of wisdom; adapted from Edmondson and Pearce (2007)2

position and be implemented irrespective of these.36 However, this perspective was not envisaged by those originally involved in the Evidence-Based Practice (EBP) movement37 who clearly identified that evidence formed only one corner of a ‘triangle’ with the patient and context (including practitioner characteristics)

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forming the other two. Far from being an ‘individual’ use of ‘objective’ evidence, recognizing the influence of contextual factors may indicate the extent to which practice is shared and communal.4 Clinical wisdom may, then, come to involve the judicious and appropriate application of available ‘best’ evidence that takes account of all these factors. Don Berwick, the Chief Executive of the Institute for Health Improvement, echoes this in a presentation available on the IHI website (‘Eating Soup with a Fork’).38 In a second model, Haggerty and Grace,3 provide a different, but related, framework for clinical wisdom consisting of three key features:   

balancing the good for another with the common good; recognizing the balance between affect and intellect; acknowledging the role of tacit knowledge in wise clinical practice.

Two other examples add support to the place of wisdom in clinical practice. First, the giving of spiritual care is often viewed with considerable uncertainty and misgiving by many nurses.21,39 In this area, Leathard and Cook40 draw from inter-disciplinary sources in practical theology to locate practical wisdom (phronesis) within holistic nursing care of the patient. In this approach, such features of practical wisdom as ‘empathic presence’ and ‘relationality’ may enable a nurse to explore with a patient significant features of spirituality such as meaning, value and purpose. Second, this discussion on practical wisdom can also be linked to the issue of clinical leadership in nursing.41 Cook and Leathard,42 in a research study on clinical leadership utilising a grounded theory methodology, identify the ways in which practical wisdom can demonstrate contextualized learning in ways that complement, rather than compartmentalize, the insights to be derived from both theory and practice. Five attributes of practical wisdom (creativity, highlighting, influencing, respecting and supporting) are discussed within the context of nursing knowledge and practice aspects of the administration and prescription of medicine.40 These two examples may be linked to features of a ‘professional wisdom’ outlined by Banks and Gallagher.23 Drawing upon Aristotle’s concept of practical wisdom (phronesis) as an intellectual virtue (see Figure 1), practical wisdom may be considered as the virtue that keeps the others on the ‘ethical rails’23 and is located within a ‘professional artistry’43 that recognizes the complexities and challenges of everyday practice. This may be compared with the scientific (or ‘technical-rational’) approach so often lauded in theoretical approaches to professional practice.44 Instead, ‘professional wisdom’, in its links to action, can be encouraged via such approaches as engagement with the humanities (e.g. through reading literature), selfscrutiny, reflection in/on practice and in a focus upon ethical decision-making.23

Wisdom and nursing education The above discussion brings us to the crux of the article. How can the concepts of wisdom highlighted across a number of ‘traditional’ views and related practice focused perspectives be incorporated into nursing education? If we distil the work so far, it may be considered that clinical/practice/professional wisdom is an important feature of nursing practice. Moreover, this wisdom may acknowledge that practice requires an engagement where both emotional and cognitive awareness are essential in order to address the complex and uncertain nature of care itself. Haggerty and Grace3 state that ‘clinical wisdom can be cultivated but not taught’. They highlight the need for education staff to facilitate and mentor through: 1. 2. 3.

informed questioning about practice; exploring ethics in context; make visible ‘being present’ with patients;

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exemplifying balance in care; encouraging self-reflection in practice.

In a similar way, Edmundson and Pearce2 acknowledge that the development of wisdom in nurses might best be approached via the adoption of ‘growth’ metaphors (e.g. cultivation) rather than through didactic teaching approaches. Such approaches, in fostering skills of recognizing context (e.g. tacit knowledge), questioning assumptions, incorporating the end or aim of an action (telos) within wider frameworks and encouraging reflexive practice, may give due recognition to cognitive and emotional dimensions. Our reflections suggest that, within much of higher education in the UK, there is conflict in achieving the above. Three distinct areas seem to negate the potential for wisdom development in nursing: first, the hegemony of ‘common’ course architecture in most higher educational institutions; second, the schism between academic and pastoral support and, third, the ever- present dichotomy between theory and practice.

Course architecture and clinical wisdom It is possible to see the contextualized and experiential dimensions of wisdom as offering certain critiques of, as well as alternatives to, current forms of curricular organization in nursing education. In discussing the move of professional nursing education into higher education (university) in the late 1990s, Standlich45 summarizes this context in terms of adherence to a ‘technical rationality’. In this schema, the educational preparation of nurses is shaped by course architectural values that are scientific, planned and systematic by the inclusion of such organizational features as modularization, learning outcomes and competencies, the use of information technology and the use of wider aspects of performance indicators (e.g. pass rates) and quality control. In terms of dividing a course into distinct modules, Gass et al.46 show that course design divided into discrete modular units of learning may present constraints on a subject (in this case, mental health) philosophy espousing student-centred learning and flexibility in terms of a ‘negotiated curriculum’. Teachers may adhere to the ‘formal’ curriculum while attempting to nurture different (‘hidden curriculum’) values in teaching students. The overall result may be ambiguity and confusion in the overall student experience. In the assessment of student learning, the use of rationalistic objective-based learning outcomes may delimit, or ignore, other potentially vital sources for learning. This may be seen in the area of ethics education. Reliance upon cognitivist and external sources such as ‘ethical principles’ (e.g. autonomy, beneficence, non-maleficence and justice) and codes of professional conduct may underestimate the insights to be derived from engaged and embodied perspectives. These may include considering the patient’s experience and student understanding gained from reflexive practice and critical thinking.47 In similar terms, Duchscher48 argues that adherence to such narrowly rationalist objectives in learning may socialize student nurses into inadvertently accepting different, and even questionable, modes of practice in care settings (e.g. professional relationships based upon hierarchy and control). While recognizing the place of the ‘scientific-rationalist’ model in contemporary higher education for nursing, it is possible to see ways in which clinical wisdom might be developed more positively within the curriculum. This may be considered in two distinctive ways. First, the ‘growth’ metaphors derived from wisdom (e.g. cultivation and nurture) may be enhanced by considering the merits of ‘liberal education’ within the professional preparation of nurses. By promoting student learning from a variety of knowledge bases (theoretical, practical, experiential and philosophical), students may be nurtured in a type of learning characterized by breadth and depth. Such learning may be life-long and help to address the ‘terrors of life’ that all nurses will experience both personally and professionally throughout their careers.49

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Second, the tenets of wisdom may be able to assist teachers in addressing, on the one hand, the pressures and tyranny of the ‘additive curriculum’ and the constant demands of course rationalization, on the other.50 By addressing such goals as the ‘negotiated curriculum’, teachers can, where possible, through such strategies as smaller class sizes, encourage in students habits of critical thinking, participation, discussion and recognition of the importance of values in personal and professional practice.50

Academic and pastoral The critical perspectives that wisdom can shed upon the curriculum can be considered further in the areas of academic and pastoral support. Where curriculum organization is characterized by ‘technical rationality’,44 a tendency may exist to segment, or compartmentalize, important dimensions of the student learning experience. As one example of this, an organizational separation between academic and pastoral support for students may result in tendencies towards student learning and personal support in classroom contexts characterized by dullness, superficiality, uniformity and impersonality.51 A wisdom-orientated perspective may be able to contribute towards an ‘ethical education’51 where student learning is experienced in terms of teacher attention to enhancing the student experience via respect, dignity and promotion of learning in creative and innovative ways. Although certain constraints (e.g. class size) may make such aims difficult to achieve, the use of innovative and flexible teaching strategies may be able to promote this. One example of this is the use of ‘narrative pedagogies’52 where learning is shaped around narratives of patients and nurses inviting both student and teacher engagement, participation and recognition of wisdom-based contextual factors. A further dimension of the potential contribution of wisdom to the academic and pastoral dimensions of the student experience lies in notions of ‘graduateness’. Where student nurse participation in wider university campus life has been low for many reasons,53 recent attention to ‘graduate’ attributes that might potentially be attained via student participation in wider social, cultural and environmental arenas may be another significant way of promoting wisdom within the curriculum.54

Theory and practice If, as indicated above, wisdom cannot be taught but can be cultivated, it raises the question of its importance in the schema of knowledge that student nurses are expected to attain. In addition, to what extent can wisdom be expected to be an identified outcome of the educational process? Might it be absorbed through, for example, engagement with practice? If it is an identified product of the educational process, we can find little of where it might be incorporated explicitly into the structures and processes of present day educational programmes. Similarly, in practice, current focus on competency-based outcomes may negate the interplay between knowledge, practice and personal characteristics. These sorts of questions and debates about the nature of knowledge are not new. In Plato’s Republic,55 knowledge is more than just knowing facts but denotes a ‘deeper knowing’, which enables, for example, the knower to fit things together, use exemplars and what we might now call critical thinking and, in addition, relate these to ethical principles such as beneficence or justice. Philosophers since then have been seeking to explain epistemology in ways that seek to examine the relationship between knowledge and human existence and endeavour. Many nursing writers have also sought to explain the interplay between knowledge and practice, and the extent to which one may lead or be subordinated. Interest in reflective practice49 and personal, or tacit, knowing56 have featured heavily in nursing education by way of considering that knowledge of facts is not enough. The same arguments are seen in relation to clinical wisdom (‘cannot be taught’) where ideas of student-centred learning have been introduced to seek influence on the person and to create an environment

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where there is transformation of the person alongside, and in conjunction with, the ‘facts’. However, we have no idea if such approaches are working and often, somewhat like the Summerhill project57 in general education (AS Neil56 and RF Mackenzie58), there is a perceived view that they are less effective in a world that prizes facts and objective knowledge (‘technical-rationalist’ perspectives). Knowing how and when to be ‘present’ or to deal with uncertainty (possible aspects of wisdom) are less tangible and may not lend themselves to learning in outcome/objective/competency-based programmes for undergraduate nursing education. We may, of course, take the view that educational programmes will have no impact on the development of clinical wisdom, although it may be possible to identify the antecedents for instilling wisdom through nursing education. First, we need to consider the nature of nursing knowledge, through, for example, the use of a framework such as that described over 30 years ago by Carper59 where empirical, aesthetic, ethical and personal knowledge have to be combined into an ‘experienced whole’. Second, how might we incorporate practice into these ‘patterns of knowing’ so that wisdom may be one that has clinical or practice application? Third, to what extent might we consider the curriculum itself to be ‘student-centred’ to ensure the potential for perspective transformation or the ‘cultivation’ of wisdom?60 Historically, nursing education was constructed around divisions between education (characterized by the classroom) and clinical practice where the student nurse was seen as: . . . a scientific student whose education and instruction must not be allowed to conflict with the practical nursing work on the wards.61

However, such divisions became viewed as antithetical to the development of nurses and connectivity between education and practice were pursued. The extent to which division, or interconnectedness, enhances clinical wisdom is unknown and, while we might see the interconnectedness as being more likely to enhance wisdom, it may only serve to foster a primacy of empirical knowledge as it is applied in practice and against which practice is to be judged. If we also consider that the inclusion of ethical, aesthetic and personal knowledge, for example, is essential, then we may also consider that wisdom is cultivated in the combination. However, at present there is emphasis on singular, modular-based, subject knowledge rather than the experienced whole, which may cultivate the requisite foundations for clinical wisdom. There is also the key component of practice by nursing students and how this might influence clinical wisdom. Johnson and Ratner62 identify practical wisdom, which is subtitled ‘insights about what should be done’, as a distinctive feature of practical, subjective knowledge. It is considered distinct from other aspects of practical, subjective knowledge, namely prudence, clinical judgement, ethical comportment, manual skill, body knowledge and aesthetics. In addition, it is also distinct from speculative, subjective knowledge in consisting of intuition (insight about what is happening), pattern recognition and personal knowledge. Johnson and Ratner62 do not give any indication how practical wisdom differs from these other elements of knowledge other than to highlight the situational nature of practice and the individualized responses from nurses. This, for us, presents a further challenge because we had been assuming that practical wisdom would incorporate much of the areas of subjective knowledge identified. However, possible unconscious pre-reflective responses and actions of nurses are highlighted62 and it may be the case that, until a student can reach such a position, then wisdom cannot be said to be present. Wisdom may thus be something that only exists in a later state of practice and what may be important are the potential insights to be derived from the rehearsal of practice that experience can bring. Such an observation may be supported in the developmental learning that students can derive from programmes of preceptorship or mentorship support. Myrick et al.63 argue that the current preoccupation with developing critical thinking skills in students requires to be balanced by an emphasis on responsible action and

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competent practice. By locating practical wisdom (phronesis) in the role modelling dynamic of preceptorship support, such features as ‘doing good in the moment’ and ‘being sensitive to the unspoken’ can be cultivated as key aspects of the student’s learning experience. Finally, in this section we require to consider the possibility that a student-centred curriculum may be more likely to lead to clinical or practical wisdom. Within higher education it is likely that curriculum development will remain a predominantly teacher-based practice with relevant professional rules and regulations predetermining areas of content; for example, in the UK the Nursing and Midwifery Council (NMC) and European Union (EU). To suggest that there has been a shift in power towards the student may misrepresent the unequal relationships of such situations. While there is much that is presently, and could be further, built in to nursing education programmes to enhance the student experience (e.g. features of liberal education discussed earlier), these programmes remain largely controlled and are not designed to empower students through raising consciousness in the dialogical way advocated by, for example, Friere.64 As Kelly65 highlights: a curriculum planned not as a vehicle for the transmission of subject-content but as a device for supporting individual development could support the potential for developing clinical wisdom in students, rather than the present position which appears to prize knowledge of facts above other forms of knowledge.

Conclusion This article has sought to outline a number of complex and challenging features inherent within the current interest in utilising wisdom within professional health care practice and in nursing education. The revived interest in wisdom draws upon classical, ancient and modern sources and its nuanced and distinctive features have begun to be considered by professional health care practitioners as part of their reflection on, and consideration of, contemporary practice. These deliberations upon wisdom highlight a need to give greater recognition to different approaches to curriculum planning and incorporation of greater complementary knowledge within professional health care education and practice. In this way, the insights of wisdom may be seen as a central thread in educational programmes that could, we would argue, contribute to enhancements in clinical practice. Although the notion of the ‘wise nurse’ may not find universal acceptance, consideration of the welfare of the patient may permit the ends or goals (telos) of nursing actions to be more widely accepted in ‘human flourishing’ terms of, for example, promotion of care or comfort.66 This, as Crigger and Godfrey33 in Figure 3 illustrate, is, however, not seeking an unattainable ‘end’: acknowledgement of the possible shortcomings and mistakes that can occur in practice is made. Wisdom, as phronesis, may then realistically be seen as integral to practice itself rather than simply being considered as an interesting, but ultimately expendable, option in compliance with higher educational structures and processes. The place of a curriculum informed by the perspectives of wisdom may be a real challenge to nurse educationalists faced with multiple agendas and constant demands on valuable teaching ‘space’. The recognition, however, of the need to provide an integrated learning experience for student nurses that addresses issues derived from a variety of knowledge bases may provide added impetus to the promotion of wisdom within the curriculum itself. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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