Different Brains, Same Goal

What Clinical Educators Need to Know About Neurodivergent Learners in Clinical Settings

How to tell a disengaged learner from a differently wired one — and why it matters for patient safety.

The clinical unit is one of the most demanding learning environments a nursing student will ever encounter. It is also one of the most common places where neurodivergent behavior gets misread as a character flaw. What looks like distraction may be a different brain doing exactly what it needs to do to function in a high-stimulation environment. And when that misread becomes a written evaluation, it does not stay there.

Scenario: The Midterm Evaluation

A clinical instructor completes a midterm clinical evaluation. Under Clinical Performance, they wrote: “Learner demonstrates knowledge in post-conference but cannot apply it in real time. Freezes when priorities shift. Requires repeated redirection to stay on task. Concerned about independent practice readiness.”

The evaluation is submitted. The learner receives a meeting request from the clinical coordinator.

Three weeks later, the learner discloses a diagnosis of ADHD. The clinical instructor revisits their notes. The learner’s written care plans were among the strongest in the cohort. Their reasoning in post-conference was organized and precise. But standing at the bedside, managing a change in patient status while an aide asked a question and the charge nurse called across the room, they went still. Not because they did not know what to do. Because their brain could not sequence it all in that moment, in that environment.

What the clinical instructor documented as a safety concern was a learner’s executive function failing under load. Not under normal conditions. Under the specific conditions of a high-stimulation, unpredictable clinical floor.

This scenario is not rare. And it does not require malice. It requires only a clinical evaluation that mistakes performance under pressure for performance overall.

What Gets Misread on the Clinical Floor

The clinical unit is a sensory environment unlike almost anything else: cardiac monitor alarms, overhead paging, fluorescent lighting, simultaneous conversations at the nurses’ station, the smell of antiseptic and everything a clinical floor carries. For a neurotypical learner, this is stimulating. For a learner with sensory processing differences, it can be neurologically overwhelming.

Research by Sharfi and colleagues (2022) found that learners managing high levels of sensory input have measurably fewer cognitive resources available for task sequencing, working memory, and verbal response. The learner is not working on the wrong things. They are filtering the environment so they can access the right ones. That filtering has a cognitive cost, and the cost comes out of the same budget as clinical reasoning.

The learner who is not making eye contact during report may be listening more carefully than the one who is.

Eye contact is the other commonly misread behavior in clinical. Research by Adolph and West (2022) found that eye contact avoidance is not a reliable indicator of engagement, motivation, or competence in everyday interaction. For many neurodivergent learners, looking away during a complex verbal exchange is a focus strategy, not a sign of disconnection.

These are mechanisms, not excuses. And knowing the mechanism changes what the behavior means.

When Evaluation Becomes Assumption

A scoping review in Medical Science Educator (Mavis et al., 2022) found that implicit bias in health professions education is malleable, but awareness alone does not shift it. What drives change is critical self-reflection and recognizing that our internal template of what a “good” learner looks like is almost never examined.

That template is built on pattern recognition. The clinical educator who has a feeling that something is off about a learner is often responding to a mismatch: the learner’s behavior does not match what they have internalized as the professional norm. That norm is rarely articulated. And it is almost always neurotypical.

When that mismatch results in a written evaluation, the consequences follow the learner. A clinical evaluation is not a private impression. It becomes part of their educational record, potentially shapes future placement decisions, and may influence how the next preceptor receives them before they have said a word.

Is this about clinical competence, or communication style?

Three Strategies for Clinical Instructors and Preceptors

Lead with curiosity before you write a conclusion.

Before the evaluation is written, ask. “I noticed you tend to look away during handoff. Can you help me understand what’s going on for you in that moment?” That single question can change the dynamic. The learner moves from being assessed to being seen. The instructor gains information instead of a misread. And the relationship shifts from evaluator to educator, which is the relationship that actually produces learning.

Behavior is communication. That is a clinical principle. The instructor who treats unexplained behavior as data to be curious about, rather than a problem to be labeled, is practicing better clinical education.

Build certainty into the shift.

David Rock’s SCARF model (2008) identifies Certainty as a domain the nervous system treats with the same urgency as physical safety. For a neurodivergent learner, the clinical environment is already saturated with uncertainty: new patients, new routines, unpredictable events, a preceptor they have not worked with before.

A brief start-of-shift check-in costs nothing and returns a significant amount. “Here is how today is structured. Here are the two things I want you to focus on.” Written expectations alongside verbal ones give the learner’s brain something to hold onto. When the structure is clear, cognitive resources go toward clinical reasoning instead of managing the unknown.

Allow more than one way to demonstrate competence.

If the learning objective is to manage care for a patient whose status has just changed, a learner who uses a structured checklist to sequence their priorities is meeting the objective, even if it looks different from how their peers approach it. The format is not the competence. If a learner struggles to retain auditory-only instructions, offer a written backup. If they need a few more seconds before responding, give it when the situation allows.

The standard is clinical competence. The pathway to demonstrating it can be flexible.

Why This Matters

A learner whose sense of safety is under threat cannot access the part of their brain required for clinical reasoning. The clinical educator who labels without asking is not just making a fairness error. They are creating a patient safety risk. A learner whose cognitive resources are consumed by a belonging threat has fewer available for medication safety, clinical assessment, and critical thinking.

A diverse nursing workforce requires neurodivergent nurses. That workforce starts here, in this preceptor relationship, on this shift. The evaluation that penalizes a neurotype rather than measuring clinical competence is a barrier to that workforce, not a standard.

These learners are not asking to be exempt from expectations. They are asking to be seen clearly enough that the right expectations get applied.

3 Key Takeaways for Clinical Educators

1. The most misread behaviors in clinical are often sensory, not motivational. Eye contact avoidance, fidgeting, processing delays, and slow verbal responses are frequently how a different neurotype manages a high-stimulation environment. Before writing the observation, ask what the brain might be managing. That question changes what you see.

2. Implicit bias lives in the evaluation form. “Lacks engagement.” “Appears distracted.” “Slow to respond.” These phrases describe behavioral style, not clinical competence. Every evaluation that uses behavioral style as a proxy for competence risks penalizing a neurotype rather than measuring a nurse. For every behavioral observation, ask: is this about what they know, or how they move through the room?

3. Structure is the simplest intervention available. A brief start-of-shift check-in, written expectations alongside verbal ones, one question asked before assuming. These are low-cost, high-return shifts. They reduce cognitive load for neurodivergent learners and improve clarity for everyone. The clinical educator who provides structure is not accommodating a deficit. They are doing better clinical teaching.

Conclusion

Go back to the instructor at their desk, revising that midterm evaluation after the disclosure.

They are troubled, to their credit. They did not intend to write an evaluation that penalized a neurotype. They wrote what they saw, through the lens they had, without the language to see it differently.

That is where this work begins. Not with the intention to exclude, but with the moment before the evaluation is written, when there is still time to ask instead of assume.

One question. One check-in at the start of the shift. One format offered alongside another.

That is what different looks like in practice.

References

Adolph, K. E., & West, K. L. (2022). Autism: The face value of eye contact. Current Biology, 32(12), R577–R580.

Mavis, S. C., Caruso, C. G., Dyess, N. F., Carr, C. B., Gerberi, D., & Dadiz, R. (2022). Implicit bias training in health professions education: A scoping review. Medical Science Educator, 32(6), 1541–1552.

Rock, D. (2008). SCARF: A brain-based model for collaborating with and influencing others. NeuroLeadership Journal, 1, 44–52.

Sharfi, K., Rosenblum, S., & Meyer, S. (2022). Relationships between executive functions and sensory patterns among adults with specific learning disabilities as reflected in their daily functioning. PLOS One, 17(4), Article e0266385.