Learning outcomes
Readers will be able to:
List some of the characteristics of skill acquisition across a range of practices. Set out some of the main differences between novices and experts according to the Dreyfus, Dreyfus and Benner model.
Articulate some of the negative characteristics of expertise on the Dreyfus model: that is those things which expertise does not involve.
Define very broadly ‘tacit knowledge’ and its contrast with explicit knowledge.
Sketch a possible connection between tacit knowledge and practical know-how.
Assess some of the answers to the question of why nursing is taught both theoretically and practically and the question of whether what is taught in these two ways is fundamentally distinct or the same but under different aspects.
Summary of key points
Nursing is taught both formally in lecture halls and practically and experientially in clinical settings such as wards. This raises the question of the connection between these two modes of learning and the nature of the knowledge and skills acquired.
The five-step model from novice to expert developed by Dreyfus, Dreyfus and Benner provides one answer which privileges hands-on experiential learning for the development of expertise.
However, the Dreyfus model yields an implausibly thin account of expertise disconnected from theoretical knowledge of rules and concepts and even from thought.
An alternative account can be developed using Polanyi’s concept of tacit knowledge.
A plausible account of tacit knowledge is that it is context-dependent and practical but, like explicit or theoretical knowledge, conceptually structured. Hence theoretical and practical aspects of nursing share a common conceptual structure.
Introduction
Nursing is both a theoretical and a practical discipline.
In the UK, qualification to become a registered nurse involves a university
degree-level course or a top-up registered nurse degree apprenticeship. Other
nursing roles are available such as nursing associates. But, since 2013 all new
registered nurses have to hold a nursing degree with standards set by the
Nursing and Midwifery Council. This is a recognition of the increasing
importance of theoretical knowledge and analytic abilities to the practice of
nursing.
However, a key component of the relevant education and
training, alongside lecture-based teaching, is hands-on practical experience on
hospital wards and in other clinical settings. This raises the question of the
relation between these two ways of leaning or, perhaps, two forms of expertise.
It prompts other, subsidiary questions such as whether it is merely a
contingent matter that nursing is taught this way. Is the same knowledge taught
both theoretically and practically or are there different forms of expertise?
This chapter will look at two different approaches to
these questions via two different approaches to nursing expertise.
One is the model of expertise developed by Hubert and Stuart
Dreyfus (eg Dreyfus and Dreyfus 1980) and promoted within nursing by Patricia Benner
(Benner 1984). The other is a view of tacit knowledge, drawing on, but distinct
from, the work of Michael Polanyi. While the Dreyfus and Dreyfus model suggests
the primacy of practical, situation-specific expert judgement, developed on the
ward, the latter approach helps to show that both practical and theoretical
knowledge have a common structure. It explains more clearly how nursing
involves putting theoretical knowledge into practice and thus explains how it
can be a unified discipline requiring both formal and practical learning.
The Dreyfus and Dreyfus model of skill
acquisition: from novice to expert
In the 1970s, Hubert Dreyfus, a philosopher, and his
brother Stuart, a mathematician, developed a five-stage model of the
development of expertise. On the basis of some of their unpublished papers, Patricia
Benner, a professor of nursing, applied the model to developing nursing skills.
The Dreyfus brothers based the model on:
the skill-acquisition
process of airline pilots, chess players, automobile drivers, and adult
learners of a second language and observed a common pattern in all cases… After
we developed our five-stage description, a group of research nurses who had
amassed considerable data about the acquisition of nursing skill found our
model fitted their data very well. The results of that study may be found in
the book From Novice to Expert by Professor Patricia Benner (Benner 1984).
(Dreyfus and Dreyfus 1986: 20)
The model is thus empirically based but, as will be
described below, is also heavily influenced by Hubert Dreyfus’ philosophical
views, views that will be contested.
The five stages of the model comprise:
- Novice
- Advanced beginner
- Competent
- Proficient
- Expert
As Benner explains,
These different levels
reflect changes in three general aspects of skilled performance. One is a
movement from reliance on abstract principles to the use of past concrete
experience as paradigms. The second is a change in the learner's perception of
the demand situation, in which the situation is seen less and less as a
compilation of equally relevant bits, and more and more as a complete whole in
which only certain parts are relevant. The third is a passage from detached
observer to involved performer. The performer no longer stands outside
the situation but is now engaged in the situation. (Benner, 1984, p. 13)
In principle, if these general aspects were independent and
each had two or three possible values (as it transpires they do), this would
yield many more than five possible levels. But, according to Dreyfus and
Dreyfus, and also Benner, they are typically not independent and empirical
study yields five characteristic stages in learning skills, from novice to
expert.
For the purposes of this chapter, it will be sufficient
to characterise the model by outlining the first and last stage as this gives
the clearest contrast. The general trajectory is moving from the novice’s
explicit consultation of general and context-independent rules to the expert’s
ability to read a situation correctly and see, even without conscious decision,
what needs to be done. The gradual move from novice to expert is a move from
rule-governed deliberate behaviour to an intuitive grasp of a situation and the
actions it calls for.
Stuart Dreyfus describes the novice stage, illustrated by
the cases of learner drivers and chess players, as follows.
Normally, the instruction
process begins with the instructor decomposing the task environment into
context-free features that the beginner can recognize without the desired
skill. The beginner is then given rules for determining actions on the basis of
these features, just like a computer following a program.
The student automobile driver learns to recognize such domain-independent
features as speed (indicated by the speedometer) and is given rules such as
shift to 2nd gear when the speedometer needle points to 10. The novice chess
player learns a numerical value for each type of piece, regardless of its
position, and learns the following rule: Always exchange if the total value of
pieces captured exceeds the value of pieces lost…
But merely following rules will produce poor performance in the real world. A
car stalls if one shifts too soon on a hill or when the car is heavily loaded;
a chess player who always exchanges to gain points is sure to be the victim of
a sacrifice by the opponent who gives up valuable pieces to gain a tactical
advantage. The student needs not only the facts but also an understanding of
the context in which that information makes sense. (Dreyfus 2004: 177)
Benner gives a very similar description of novice nurses.
Beginners have had no
experience of the situations in which they are expected to perform. To give
them entry to these situations… they are taught about the situations in terms
of objective attributes such as weight, intake and output, temperature, blood
pressure, pulse, and other such objectifiable, measurable parameters of a
patient’s condition – features of the task world that can be recognised without
situational experience. (Benner 1984: 20-1)
They are also taught rules to guide their clinical practice,
which can also be understood in advance of any particular clinical experience.
This is common to the initial stages of learning any skill. A learner
driver may be taught the mantra: ‘mirror, signal, manoeuvre’ and may typically
even say this aloud when first driving. An expert driver, typically, will
not and may, in some situations, rightly disregard the rule if in some
emergency following it is more dangerous than breaching it. More generally,
they will no longer explicitly think of the rule as they drive. As Benner says,
the rule-governed behaviour of a novice is ‘extremely limited and inflexible’
(ibid: 21). Developing expertise, by contrast, is learning a more flexible
response to situations and transcending action-guiding rules.
As long as the beginner
pilot, language learner, chess player, or driver is following rules, his
performance is halting, rigid, and mediocre. But with mastery of the activity
comes the transformation of the skill which is like the transformation that occurs
when a blind person learns to use a cane. The beginner feels pressure in the
palm of the hand which can be used to detect the presence of distant objects
such as curbs. But with mastery the blind person no longer feels pressure in
the palm of the hand, but simply feels the curb. The cane has become an
extension of the body. (Dreyfus and Dreyfus 1977: 12 cited by Benner 1984: 33)
Benner suggests that an expert nurse’s use of clinical tools
and instruments is similarly transformed.
Reflection: Is
the sketch of the resources deployed early stages of skill developed accurate?
And is the charge that these resources produce poor performance plausible?
Contrasting the full expert with the stage immediately
before it – proficiency – Stuart Dreyfus describes the immediacy of an expert’s
appraisal of a situation.
The proficient performer,
immersed in the world of his or her skilful activity, sees what needs to be
done but decides how to do it. The expert [by contrast] not only sees
what needs to be achieved; thanks to his or her vast repertoire of situational
discriminations, he or she also sees immediately how to achieve this
goal. Thus, the ability to make more subtle and refined discriminations is what
distinguishes the expert from the proficient performer. Among many situations,
all seen as similar with respect to plan or perspective, the expert has learned
to distinguish those situations requiring one reaction from those demanding
another... This allows the immediate intuitive situational response that is
characteristic of expertise. (Dreyfus 2004: 179-80 italics added)
This passage exemplifies the three aspects that change as
a skill is developed, as set out by Benner earlier. There is, first, a movement
from reliance on context-free general rules to the use of past experience of
previous real clinical situations. Second, the expert sees the situation as a
whole as structured in some particular salient ways. Not every aspect of it is
equally important for a clinical intervention. Third, the expert experiences
themselves as part of the situation. Just as those familiar with the use of a
cane feel the ground beneath it rather than the handle in their hand, so the
expert driver experiences themselves not as driving a car but as driving.
They construe their actions not as the turning of a steering wheel (which has
such and such causal effects) but as changing lanes. This immediacy explains
the contrast with the merely proficient performer who sees the situation, first,
and only then decides how to respond. On the Dreyfus model of expertise,
reading the situation correctly involves knowing what has to be done
immediately.
This final characterisation corresponds to Aristotle’s
idea of ‘phronesis’, or practical wisdom, itself a concept increasingly being
applied to medical practice (Aristotle 1985; Boudreau et al 2024). Phronesis is
a kind of practical knowledge applied by Aristotle mainly to moral expertise.
The idea is that a skilled moral agent with phronesis sees the moral demands
that situations make on them, on the actions they must thus carry out, as part
of their experience of the situation itself. Their experience of the situation
is not value-free but ‘fraught with ought’ (Sellars 1991: 212). The Dreyfus
view of expertise in general is like that.
Reflection: Can
you see how expertise contrasts with novice performance across the three
aspects Benner lists? What if anything is the role of rules for expert practice
on this account?
It is tempting to think of the transition from novice to
expert as a matter of internalising rules. The learner may consult a manual of
instruction, or a memorised mantra such as ‘mirror, signal, manoeuvre’, or they
may explicitly infer such rules for themselves from taught examples, while the
expert has mastered them to such an extent that they have become subconscious. The
philosopher Mark Wrathal describes this as the ‘traditional picture’. But the
Dreyfus picture is more radical.
[O]n the traditional model,
the same rules govern the actions of the beginner and the expert alike.
Learning is thus thought of as coming to understand the rules which govern
behaviour—of beginning with an acquaintance with specific cases and learning
through experience to abstract out of those specific cases general rules which
are followed in all skilful action. But the phenomenology of skill acquisition shows
that learning in fact moves in the other direction—from abstract rules to the
recognition of particular cases. By the time one becomes an expert in a domain,
one has an intuitive ability to recognize and respond to highly particularized
situations and, unlike the beginner, is in no sense applying rules at all.
(Wrathall 2014: 6)
To assume that the rules we
once consciously followed become unconscious is like assuming that, when we
finally learn to ride a bike, the training wheels that were required for us to
be able to ride in the first place must have become invisible. (Dreyfus 2014: 111)
This rejection of the role of rules also highlights the
priority that the Dreyfus model ascribes to hands-on, on the ward, experience
over lecture-based learning, or as Benner puts it: the distinction between the
novice level ‘skilled performance that can be achieved though principles and
theory learned in a classroom and the [expert-level] context-dependent
judgements and skill that can be acquired only in real situations’ (Benner
1984: 21).
Benner provides some qualitative social science empirical
evidence that the five stage model of progress from novice to expert fits, very
well, the experiences of at least some nurses. Further, it fits the anecdotally
widespread experience of student nurses who find it difficult to value academic
lectures once they have had their first experience of placement. The latter can
seem more real and relevant. But it is worth digging a little deeper into how
Hubert Dreyfus, at least, characterises the expert stage to assess whether it
is a plausible description of expertise, after all.
Reflection:
Can you summarise the nature of expertise on the Dreyfus model? With what does
expert practice contrast? Hint: it may help to look again at the aspects Benner
lists.
What is the nature of expertise on the
Dreyfus model?
One of Hubert Dreyfus’ motivations to reject the role of
rules, even internalised rules, for expertise, is a philosophically-based
criticism – in 1999 – of the prospects of Artificial Intelligence (AI). He illustrates the general challenge for AI by
considering an apparently simple abstract task: programming a machine to select
a red square from a multicoloured array of geometrical figures. Assuming that
on an AI approach there must be a set of instructions or rules that fully
capture the expertise involved in the task, Dreyfus considers what they might
be. One might instruct a child, for example, to ‘listen to the
instructions, look toward the objects, consider the shapes, make your
selection’ (Dreyfus 1999: 175). But the AI approach requires more detailed
instructions sufficient, for example, for identifying a square rather than a
circle.
One might say: ‘Count the sides; if there are four, it
is a square.’ And what about the instructions for identifying a side? ‘Take
random points and see if they fall on a line which is the shortest distance
between the end points,’ and so on. And how does one find these points?... ‘But
you unconsciously see points and unconsciously count.’ But do you? And why do
the instructions stop here and not earlier or later? (Dreyfus 1999: 175)
The underlying
problem highlighted in this example is that of knowing which general
rule applies to a particular case. While we know that if something is a red
square then it is red and a square and if it is square then it has four equal
sides, these inferences unpack our prior mastery of the concepts. The
challenge of AI is to explain how such general concepts apply to
particular cases: cases which are all alike in being red and square but
potentially unlike in all sorts of other ways such as size, location in space
and time, orientation etc. The attempt to explicate a general rule – such as
the rule-governing ‘square’ – using further rules appears to initiate a vicious
regress. What rules guide the application of all the subsequent rules?
Dreyfus suggests that
this regress can be blocked by an appeal to situations, the same concept he applies to
human experts.
Whatever it is that enables human beings to zero in on
the relevant facts without definitively excluding others which might become
relevant is so hard to describe that it has only recently become a clearly
focused problem for philosophers. It has to do with the way man is at home in
his world, has it comfortably wrapped around him, so to speak. Human beings are
somehow already situated in such a way that what they need in order to cope
with things is distributed around them where they need it, not packed away like
a trunk full of objects… (Dreyfus 1999: 260)
Thus a philosophical objection applied to the idea of
modelling intelligence in some general formal programmable AI rules informs
Dreyfus’ rejection of the role of rules in describing human expertise. Stuart
Dreyfus summarises this view thus:
[A] beginner calculates
using rules and facts just like a heuristically programmed computer, but… with
talent and a great deal of involved experience, the beginner develops into an
expert who intuitively sees what to do without recourse to rules. The tradition
has given an accurate description of the beginner and of the expert facing an
unfamiliar situation, but normally an expert does not calculate. He or she does
not solve problems. He or she does not even think. He or she just does what
normally works and, of course, it normally works. (Dreyfus 2004: 180)
This suggests that on the Dreyfus and Dreyfus model, a expert
does not follow rules – except on occasions where unfamiliarity undermines
their expert status and they are forced to – nor do they even think. Hubert
Dreyfus makes two other striking claims: the expert does not act for reasons
nor is their action informed by concepts.
[P]hronesis shows that socialization
can produce a kind of master whose actions do not rely on habits based on
reasons to guide him. Indeed, thanks to socialization, a person’s perceptions
and actions at their best would be so responsive to the specific situation that
they could not be captured in general concepts. (Dreyfus 2014: 110
italics added)
[A]lthough many forms of
expertise pass through a stage in which one needs reasons to guide action,
after much involved experience, the learner develops a way of coping in which reasons
play no role. (Dreyfus 2014: 112 italics)
Dreyfus suggests that if, after the fact, such an expert
is asked why they did as they did, they are only able to offer a
‘retroactive rationalisation’ that draws on what they recall of the less expert
stage of being a mere ‘competent performer’. Following that reconstruction
would ‘not exhibit expertise but mere competence’ (ibid: 113). Hence expertise
does not seem compatible with what can be articulated as reasons, described as
rules or even consciously entertained as thought. The space of expert actions
is one shared by: ‘Animals, paralinguistic [ie cooing and babbling] infants,
and everyday experts’ (ibid: 118).
Such a picture of expertise emphasises a dramatic
contrast between what can be achieved through learning in the lecture theatre
or classroom and what is achieved through experience in clinical settings. It
may even appeal to those students of nursing who suspect that nothing of value
is taught in the lecture theatre! Only the latter underpins expertise
but at the cost of jettisoning what was achieved in the former. Whatever the
descriptive power of the Dreyfus and Dreyfus, and Benner, five-stage model of
acquiring nursing expertise, there is something badly wrong with its
understanding of expertise. It reduces it to the unthinking, reasonless and
thoughtless action of a babbling baby. Might there be a better account?
Tacit knowledge: Polanyi’s introduction
To recapitulate: the motivating question for this chapter
is why nursing is taught both through formal lectures and experiential
learning. The Dreyfus model suggests an answer which explains the role of the
latter in developing expertise but at the cost of playing down the role of the
former. An alternative answer, the subject of this second half, is that nursing
involves both explicit and tacit knowledge, the latter being acquired
experientially, but both forms of knowledge are unified by their conceptual
structure.
The very idea of tacit knowledge was promoted in the
second half of the twentieth century by the chemist turned philosopher Michael
Polanyi. (Polanyi himself talks of tacit knowing
rather than knowledge though that nuance will not matter here.) He gives the
following example:
We know a person’s face, and can recognize it among a
thousand, indeed among a million. Yet we usually cannot tell how we recognize a
face we know. So most of this knowledge cannot be put into words. (Polanyi
1967: 4)
This is an instance of what he takes to be a general
phenomenon. Indeed, he begins his book The
Tacit Dimension with the following bold claim:
I shall reconsider human
knowledge by starting from the fact that we
can know more than we can tell. (ibid: 4)
The broad suggestion
is that knowledge can be tacit when it is, on some understanding, ‘untellable’.
‘Tellable’ knowledge is a subset of all knowledge and excludes tacit knowledge.
But the slogan is gnomic. Does it carry, for example, a sotto voce qualification
‘at any one particular time’? Or does it mean: ever? Further, the
very idea of tacit knowledge presents a challenge: it has to be tacit and it
has to be knowledge. But it is not easy to meet both conditions. Emphasising
the tacit status, threatens the idea that there is something – some
content such as a fact – known. Articulating a knowable content, that which is
known by the possessor of tacit knowledge, risks making it explicit (since the
subject knows that…).
Reflection: Is
the idea of tacit knowledge even possible? That is, might it be a contradiction
of terms to think that there could be anything known which could not be put
into words?
There is a second strand in Polanyi’s work which helps
address this problem. At the start of his book Personal Knowledge he says:
I regard knowing as an
active comprehension of things known, an action that requires skill. (Polanyi
1958: vii)
These two features suggest a way to understand tacit
knowledge: it is cannot be made linguistically explicit and is connected to
action, the practical knowledge of a skilled agent. The latter connection
suggests a way in which tacit knowledge can have a content: as practical
knowledge of how to do something. Taking tacit knowledge to be practical suggests
one way in which it is untellable. It cannot be made explicit except in
context-dependent practical demonstrations. It is not that it is mysteriously
ineffable but that it cannot be put into words alone.
Polanyi
also compares the example of recognition (already mentioned above) to a
practical skill, likening it to bicycle riding:
I may ride a bicycle and say
nothing, or pick out my macintosh among twenty others and say nothing. Though I
cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I
don’t know it clearly), yet this will not prevent me from saying that I know
how to ride a bicycle and how to recognise my macintosh. For I know that I know
how to do such things, though I know the particulars of what I know only in an
instrumental manner and am focally quite ignorant of them. (ibid: 88)
In both cases, the ‘knowledge-how’ depends on
something which is not explicit: the details of the act of bike riding or
raincoat recognition. While one can recognise one’s own macintosh, one is,
according to Polanyi, ignorant, in some sense, of how. Thus how one recognises
it is tacit. Many of Benner’s examples of nursing expertise are also recognitional:
judging the state of health or illness of a patient.
In the passage above, Polanyi suggests that explicit recognition
of something as an instance of a type is based on the implicit recognition of
subsidiary properties of which one is ‘focally ignorant’. He explains the
distinction of focal and subsidiary awareness using the example of focusing
attention on what a pointing finger points to. In looking from the finger to
the object, the object is the focus of attention whilst the finger, though
seen, is not attended to. One attends from the proximal finger to the distal
environment.
One of the quotations from Dreyfus and Dreyfus above is similar.
The blind person who is an expert using their cane: ‘no
longer feels pressure in the palm of the hand, but simply feels the curb’. They
attend from whatever feelings there are in the hand to the state
of the ground at the other end of the cane. Polanyi argues that tacit knowledge
always has this ‘from-to’ structure.
If this were correct, all explicit knowledge would depend on
something tacit, something ‘subsidiary’. But it is not clear that this is true.
Reflection: Is
the suggestion above that Polanyi’s ‘from- to’ structure does not apply across
the board plausible? Think, again, about Polanyi’s example of recognising a
face.
Polanyi seems to assume that the question of how one recognises
something always has an informative answer and then, to cover cases where it is
not obvious what this is, he suggests it can be tacit. But, firstly, whilst it
sometimes may have an informative answer, there is no reason to think that it
always has (cf recognising that a square is red). Secondly, even in cases where
one recognises a particular as an instance of a general kind in virtue of some
further properties and cannot give an independent account of those
properties, it is not clear that one need be focally ignorant of them. It
may be, instead, that the awareness one has of the ‘subsidiary’ properties is
simply manifested in the act of recognition. One might say, “I recognise that
this is a, or perhaps my, macintosh because of how it looks here with
the interplay of sleeve, shoulder and colour” even if one could not recognise a
separated sleeve, shoulder or paint colour sample as of the same type. Whilst
it seems plausible that one might not be able to say in context-independent
terms just what it is about the sleeve that distinguishes a macintosh from any
other kind of raincoat (one may, for example, lack the vocabulary of fashion or
tailoring) that need not imply that one is focally ignorant of, or not
attending to, just those features that make a difference. Recognition may
depend on context-dependent or ‘demonstrative’ elements, such as recognising
shapes or colours for which one has no prior name. But if anything, that
suggests one has to be focally aware, not focally ignorant, of them.
Thus Polanyi’s own account of the tacit nature of
recognition faces objections. But such criticism suggests the possibility of a
more minimal account of tacit knowledge.
A minimal account of tacit knowledge
Recognition, such as recognition of a diagnostic type, is
tacit because it is a skill – for example, developed through repetition and
critical practice and demonstrated in applications in much the way that Dreyfus
emphasises – and because it can thus be articulated only in context-dependent
terms such as ‘like this!’. It cannot be explicated in words alone
independently of additional practical demonstrations in context.
This distinction between tacit and explicit knowledge is reflected
in the contrast between the ability to recognise colours and shades that most
people have and their limited general knowledge of the names for colours. For
most people, the ability to recognise, think about and recall (at least for
some period) particular shades of colour goes beyond what they can make
explicit linguistically. The ability can instead be manifested by pointing to
particular instances of colour themselves. By contrast with the fine
discriminations that can be made in the presence of actual colours and shades, context-independent
general colour vocabulary is vague.
Similarly, by contrast with the context-dependent
discriminations of skilled clinicians made in the presence of their patients,
the criteria set out in diagnostic manuals are often vague. Because they are
fully linguistic, the criteria in DSM and ICD, for example, are context-independent
or general (American Psychiatric Association 2013; World Health Organization
1992). There is an advantage in communication of a linguistic codification of
diagnosis that floats free of particular inter-personal relations. But it is
bought at the cost of precision. By contrast, the features that play a role in
diagnoses made be skilled clinicians are identified in the presence of a
particular patient’s or client’s psychological or physiological whole. Such
recognition cannot be captured in words alone.
So far, this minimal account of tacit knowledge captures
the importance that the Dreyfus bothers and Benner place on practical learning
but without reducing such expertise to a merely animal, mindless and conceptless
ability. But without going as far as they do to downplay the role of language
and reasons, this account, too, promises to show the importance of the tacit
dimension. The best way to show this is via a detour into an example that the
famous twentieth century philosopher Ludwig Wittgenstein uses. It concerns an
explicitly abstract, general, context-independent and general rule.
Wittgenstein considers teaching a pupil to continue a
mathematical series correctly who ‘judged by the usual criteria… has mastered the series of natural numbers’
and is then taught to continue series of the form 0, n, 2n, 3n, etc. for
arbitrary values of n but then goes wrong.
Then
we get the pupil to continue one series (say “+ 2”) beyond 1000 – and he writes
1000, 1004, 1008, 1012.
We say to him, “Look what you’re doing!” – He doesn’t understand. We say, “You
should have added two: look how you began the series!” – He answers,
“Yes, isn’t it right? I thought that was how I had to do it.” —– Or
suppose he pointed to the series and said, “But I did go on in the same way”. –
It would now be no use to say, “But can’t you see…?” – and go over the old
explanations and examples for him again. In such a case, we might perhaps say:
this person finds it natural, once given our explanations, to understand our
order as we would understand the order “Add 2 up to 1000, 4 up to 2000,
6 up to 3000, and so on”.
This case would have similarities to that in which it comes naturally to a
person to react to the gesture of pointing with the hand by looking in the
direction from fingertip to wrist, rather than from wrist to fingertip.
(Wittgenstein 2009: §185)
The pupil described here reacts in a divergent way (from
us) to explanations of how to continue. He appears to have acted under a
divergent interpretation of the expression of the rule. But if, to be
successful, an explanation of a rule has to be correctly interpreted, then any
expression of the interpretation might be subject to divergent understandings,
whether explicitly stated in a symbolism or by examples.
Since
any interpretation has to be specified in some way, if understanding
depends on an interpretation, no specification would be sufficient in itself.
Hence the concept of the ‘regress of interpretations’.
Reflection: Imagine a game in which one player tries to
explain with complete clarity the rule for adding 2 and the other player
has to find some way to misunderstand the instructions prompting the first
player to add more instructions. Try it!
There is, however, a more promising way to respond to
Wittgenstein’s regress argument which connects it to tacit knowledge. The moral
of the regress of interpretations according to the philosopher John McDowell is
that:
We
learn that it is disastrous to suppose there is always a conceptual gap between
an expression of a rule and performances that are up for assessment according
to whether or not they conform to the rule, a gap that is made vivid by saying
the expression of the rule stands there… We must not acquiesce in the idea that
an expression of a rule, considered in itself, does not sort behaviour into
performances that follow the rule and performances that do not. (McDowell 2009:
100-101)
This, according to McDowell, is the moral of §201 of the Philosophical
Investigations: ‘there is a way of grasping a rule which is not an
interpretation, but which, from case to case of application, is exhibited in
what we call “following the rule” and “going against it”’ (Wittgenstein 2009:
§201). For those who are party to the relevant practices, there is no gap
between the expression of the rule and being told which way to go. A signpost,
for example, not merely a signpost under an interpretation, points the way. On
this account, the regress of interpretations is stopped before it can start.
Hence, the expression of a rule is explicit in its directions.
But it is only explicit for those with the right eyes to
see, or ears to hear, an explanation: for those, in Stanley Cavell’s phrase,
who share the ‘whirl of organism’ of our form of life (Cavell 1969: 52). This
in turn grounds out in the applications of rules, which are context-dependent,
conceptually-structured and practical. The regress of interpretations argument
shows that any informative explanation of what following a rule correctly,
going on in the same way, comprises soon gives out. Any general account
of the relation of rules or conceptual generalities to particular judgements
falls prey to the regress of interpretations. What can be made explicit in
words or rules rests on the tacit because going on in each specific way simply is
accord with a rule or concept. It is also context-dependent and, since it links
conceptual generalities to particular cases in judgements, it is practical.
Because the relation of the tacit and explicit is subtle,
it is worth giving a worked example. It is possible to make a béchamel sauce by
following a recipe: to measure ingredients and to cook at a specific
temperature for a predetermined time. But it is also possible to make one ‘bi
t’rack o’ t’ee’ (by the reckoning of the eye) as it is said in Yorkshire
dialect. One judges a rough equivalence of butter and flour, sautés the
resultant roux until it looks right (so as to cook the flour) and then adds
milk gradually and intermittently while stirring continually, watching the
consistency fall to almost that of the added milk and then stiffen again.
Gradually, the rate of returning to stiffness slows. Were one to add too much
milk, it would never thicken again. Thus, the end point is fixed by a judgement
that the rate of stiffening has slowed sufficiently that a final addition of a
particular amount of milk will, combined with the residual heat energy of the
sauce, yield the right consistency by the time it is served.
Preparing a béchamel sauce is thus an expression of a conceptual
understanding of the effects of dilution, heating, stirring, thickening against
the jeopardy of adding too much milk. But the expression of the concepts
comprises demonstratives of the form ‘that degree of stiffness’ and ‘that
quantity of additional milk’. It involves the right kind of manipulation of the
sauce mixture with a spoon and the right degree of heat applied so that it
bubbles thus. Although it is possible to make a béchamel sauce following
an explicit recipe, the cook who makes it ‘by eye’ does so employing a form of
conceptually-structured, context-dependent, practical knowledge, or tacit
knowledge, on this account. Further, its expression and articulation in a
practical demonstration depends for its success on the ability of the audience
to see in the particularity of a few cases the generality of the rules
involved. They must have ‘eyes to see’. They must share the ‘whirl of organism’.
The dual challenge for an account of tacit knowledge can
be met in this way as follows. It is tacit because it cannot be codified in
context-independent and general terms – it is in that sense ‘untellable’
– while at the same time it is knowledge because it is articulated in the
application of general concepts to the particular case, grounded in practice,
which is a form of know-how. One consequence of this account is that explicit
knowledge always rests on a body of tacit knowledge.
The ward versus the lecture hall? Tacit and explicit
knowledge
On the Dreyfus, Dreyfus and Benner account, expertise is
a capacity shared with animals and prelinguistic children. It is an ability
with little to do with reasons, thought or concepts. Thus what is learnt in
practice on the ward supersedes what is learn in lecture halls. Although their
five-step model of the acquisition of skills has some empirical plausibility,
the detailed characterisation of expertise is implausible.
There is, however, a better picture. Experiential
learning teaches tacit knowledge: knowledge that cannot be put into words alone
because it is context-dependent and practical. Its demonstration requires
practical application. Further, tacit knowledge underpins explicit knowledge
even of such general and rule-governed concepts such as adding two. It remains,
nevertheless, conceptually structured. And hence there is a common structure to
tacit and explicit knowledge, to learning on the ward and in the lecture hall.
Nursing involves theoretical knowledge but also practical
skills. On a correct understanding tacit knowledge for rational agents such as
human adults is a genuine complement to explicit knowledge but also related to
it. Both are deployments of conceptual judgement, one theoretical and one
practical. The latter is a shaping of knowledgeable action. The skilled
practitioner not only knows what to do in a practical case but they also know
why, even though the reasons ground out in patient-specific judgments.
Further reading
The Heideggerian philosophical background of Hubert
Dreyfus’s views is set out here:
Dreyfus, H.L. (1991) Being-in-the-World: A Commentary on
Heidegger’s Being and Time, Division I, Cambridge,
Mass.: MIT Press
For a book length examination of the nature of tacit
knowledge see:
Gascoigne, N. and Thornton, T. 2013. Tacit knowledge.
Durham: Acumen
For a critical discussion of Hubert Dreyfus’ account of
expertise as skilled coping see:
Schear, J.K. (ed.) (2013). Mind, reason, and
being-in-the-world: the McDowell-Dreyfus debate. New York: Routledge.
Relevant web pages
The Collaborating Centre for Values-Based Practice
promotes discussion of knowledge of values in healthcare
http://valuesbasedpractice.org/
The International Network for Philosophy & Psychiatry
promotes research on the philosophy of mental healthcare more broadly
http://inpponline.com/
The Polanyi Society is dedicated to promoting Polanyi’s
views of tacit knowledge
http://www.polanyisociety.org/
References
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition (DSM-5), Washington, D.C.: American Psychiatric
Association
Aristotle (1985) Nicomachean Ethics (translated by Irwin,
T.), Indianapolis: Hackett
Benner, P. (1984) From Novice to Expert: excellence and
power in clinical nursing practice, Menlo Park, California: Addison-Wesley
Boudreau, D., Wykretowicz, H., Kinsella, E.A. et al.
(2024) Discovering clinical phronesis. Med Health Care and Philos 27,
165–179. https://doi.org/10.1007/s11019-024-10198-8
S. Cavell, (1969) Must We Mean What We Say?, Cambridge: Cambridge
University Press
Dreyfus, H.L. (1999) What Computers Still Can’t Do, Cambridge, Mass.: MIT Press
Dreyfus, H.L. (2000) Responses. In Heidegger, Coping, and Cognitive Science (eds M. Wrathall and J. Malpas), pp.
313-349 .Cambridge, Mass.: MIT Press
Dreyfus, H.L. (2014) Overcoming the Myth of the Mental:
How Philosophers Can Profit from the Phenomenology of Everyday Expertise in Dreyfus,
H. L., & Wrathall, M.A. (2014) Skillful Coping: Essays on the Phenomenology
of Everyday Perception and Action, Oxford: Oxford University Press
Dreyfus, H. L., & Dreyfus, S. E. (1977). Uses and
abuses of multi-attribute and multi-aspect model of decision making.
Unpublished manuscript, Department of Industrial Engineering and Operations
Research, University of California at Berkeley.
Dreyfus, H. L., & Dreyfus, S. E. (1986). Mind over
machine: The power of human intuition and expertise in the age of the computer.
Oxford: Basil Blackwell
Dreyfus, S. E. (2004) The Five-Stage Model of Adult Skill
Acquisition, Bulletin of Science, Technology & Society, 24: 177-181
McDowell, J. (2009) The engaged intellect. Cambridge, MA:
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Polanyi, M. 1962. Personal
knowledge. Chicago: University of Chicago Press
Polanyi, M. 1967. The tacit
dimension. Chicago: University of Chicago Press.
Sellars, W. (1991) Science, Perception and Reality.
Atascadero: Ridgeview Publishing
Wittgenstein, L.
2009. Philosophical investigations. Oxford: Blackwell
World Health Organization (1992) The ICD- 10
Classification of Mental and Behavioural Disorders: Clinical Descriptions and
Diagnostic Guidelines. Geneva: World Health Organization.
Wrathall, M.A. (2014) Introduction: Hubert Dreyfus and
the Phenomenology of Human Intelligence in Dreyfus, H. L., & Wrathall, M.A.
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