1 Facilitating Early Practice Development in Nursing Using Novice to Expert Theory Authors: Barbara Haag-Heitman, RN, MS, MA and Sara Schedler, RN, BSN April 10, 2004 © Barb Haag-Heitman – who grants permission for printing one copy for personal use. Abstract The first years of nursing practice constitute a critical period for professional practice development. Organizations are implementing programs to support nurses during this vulnerable time. This case study uses narrative accounts of practice to illustrate common concerns and characteristics of practice during these first years of development along the novice to expert trajectory.
Also presented are examples of supportive interventions and practice strategies to facilitate clinical practice. Introduction The early years of nursing practice hold unique opportunities and challenges for the individual nurse learning the art and science of nursing and for organizations to support their development. The shift from new graduate to the RN role is perhaps the most stressful and crucial part of the transition into professional practice (Godinez, Schweiger, Gruver, & Ryan, 1999).
Once off formal orientation, RNs in their first years of practice reveal a sharp decline in the support and guidance from experienced nurses (Hurst & Koplin-Baucum, 2003). New graduate nurses express concerns about staff not appreciating where they are in practice and worry that staff have unrealistic expectations of them in relation to their abilities (Evans, 2001). To ease this transition, many organizations have implemented nurse mentoring programs to support new practitioners during this transition phase (Beecroft, Kunzman, & Krozek, 2001; Hurst & Koplin-Baucum, 2003; McHugh, Duprat, & Clifford, 1996; Owens et al. , 2001; Strauss, 1997; Trevitt, Grealish, & Reaby, 2001). However, few organizations implement programs to promote life long learning and full organizational understanding and support for clinical practice development outside the preceptor/mentor relationship. The 2004 Scope and Standards for Nurse Administrators (ANA, 2004) identifies the importance of continuous learning practice development to promote sharing of expertise to subsequently facilitate positive health outcomes.
It is critical that preceptors, experienced staff, educators, managers, and nurse administrators all operate from a collective understanding of clinical practice development. Dr. Patricia Benner’s work on skill development along a novice to expert continuum (Benner, 1984, 1994; Benner, Hooper-Kyriakidis, & Stannard, 1999; Benner, Tanner, & Chelsa, 1996) integrates learning and development into one reliable research based framework that is well suited for understanding and promoting both individual and organizational learning about practice.
This paper examines personal and organizational factors that support practice development along a novice to expert trajectory. Presentation of a case study, incorporating actual clinical practice narratives, helps illustrate the progression in the development of clinical judgment and critical thinking over time. The narrative accounts from practice provide both the content and context for understanding clinical practice development while providing a mechanism for dialogue to support individual and organization learning (Benner et al. 1996; Haag-Heitman, 1999; McHugh et al. , 1996). 3 Becoming a Nurse – A Case Study S. S. began her nursing career by participating in a nurse intern program while completing her undergraduate studies. Student nurse intern programs provide opportunities for students to gain experience and skills with many of the hospital’s routines and care activities, such as dressing changes and urinary catheter management; many of which they will be expected to delegate as a RN.
These programs help bridge the gap between theory and practice and offer the opportunity for students to develop their first healthcare team professional relationships. Participation in these programs also gives students a chance to learn more about the culture of the organization and expectations for the nursing role while gaining valuable skills. Knowledge about the expected work schedule for hospital based RNs is important as the transition from school schedule to work schedule can be a source of unanticipated strife (Halfer, 2003).
S. S. reported that her experience as a Nurse Intern gave her a chance to learn many new technical skills; helped with learning time management; increased her awareness of the contribution of other hospital departments to patient care; and allowed her to explore the boundaries of the nurse/patient relationship. Following graduation, S. S. became a new graduate and novice nurse in a Neonatal Care Unit. Similar to other novice nurse, S. S. entered he professional practice world as a new graduate and through formal orientation programs, gained clinical knowledge and technical skills specific to the area of practice. During this phase, the nurse practices under the close guidance of a preceptor, and learns the hospital’s policies, procedures, and standards that guide practice. Novice nurses respond to the needs of patients and 4 families as they also develop their first professional relationships. The completion of orientation marks the beginning of nursing practice at the advanced beginner stage (Haag-Heitman, 1999). During orientation, S.
S. experienced the guidance and support of experienced nurses who practiced from a novice to expert framework and who personally understood their own developmental stage of practice through their organizational peer review process (Haag-Heitman, 1999). Following the formal orientation requirements, S. S. moved into the Advanced Beginner stage. This post orientation phase is a time of rapid learning with attention on continuing to build a practice knowledge base with a keen focus on the performance of tasks. Advanced beginners typically describe the clinical situation from what it demands from them.
Early in this stage, each aspect of clinical information and care seems to be of equal importance and significance. Using individual care planning guided by policy and procedures, advanced beginners recognize the importance of correlating theoretical knowledge with clinical information and managing clinical problems while delivering care structured by other members of the healthcare team (Haag-Heitman, 1999). Advanced beginners provide comfort and compassion to patients and families while exploring the boundaries of therapeutic relationships. They describe the clinical situation from what it demands from them.
The following narrative from S. S. as an Advanced Beginner nurse illustrates these principles. 5 Advanced Beginner Narrative I arrived on the unit one morning to find I had been assigned to care for a baby 1on 1, which was a new experience for me. I had already begun to anticipate a very busy day. As I got report, I learned that this full term infant baby, born at 0300 that morning, had been born by C-section with no heart rate and heavy meconium in the fluid. The baby was intubated immediately and thick meconium suctioned from below the cords. Chest compressions were done and epinephrine given x 4.
The first heart rate appeared at 14 minutes of life. Apgar scores of 0,0,0,3 were assigned. Umbilical lines were placed and the baby was brought to the NICU. I was surprised to learn from the RN I got report from that there had been very little warning that the baby would be so ill. This 19-year-old mom had delivered her first child by cesarean section for failure to progress and poor fetal heart tones. As I approached the bedside, I saw what appeared to be a term-sized infant girl who aside from the endotracheal tube and umbilical lines appeared to be sleeping peacefully.
As I surveyed the situation, I realized that this baby was very unstable. I assessed the infant and found her to be hypotonic with weak peripheral pulses and a mean blood pressure of 19. She was also making no effort to breathe above the set ventilator rate. I notified the physician of my findings and he ordered a 30cc fluid bolus to be given over 5 minutes. I did this and throughout the next 2 hours, this action was repeated several times because there was little to no improvement. The physician had been at the bedside throughout the morning completing his admission paperwork and keeping informed about the condition of the baby.
The father of the baby came in around 0800. Since the physician was at the bedside, he explained the ventilator and the other ‘tubes’ and gave him a thorough update on the baby’s condition. The father was very distressed and I encouraged him to touch his daughter and then took a Polaroid for him to give to the mother when she awakened. I also got the baby’s name from him and gave him the birth announcement with the baby’s footprints. He was very upset and only stayed a short time. I encouraged him to call or visit whenever he wanted. Throughout the morning, I continued to monitor the baby’s hypotension.
The physician decided to start dopamine to raise the baby’s BP. Between hanging fluids and talking to the family, I was also trying to complete admission paperwork, sponge bathe the baby to remove meconium staining, reposition infant for comfort and make a name sign for family member to be able to identify the infant. I was also observing the infant for signs of seizure activity. During the morning, the dose of dopamine was gradually increased and dobutamine started to help raise BP. Phenobarbitol was also started prophylactically for seizures.
My main priorities during the day were to maintain infant’s stability by reporting abnormal findings to MD, to keep family informed during visits and facilitate bonding with the infant and finally to keep infant comfortable. By 1900 that evening, when I was giving report, the infant’s BP had stabilized, family had been in frequently during the day and a fentanyl drip had been started due to what I felt was increasing restlessness. I felt that the infant was more stable than she had been at the beginning of my shift. I also signed up to care for her the next morning. When I arrived the next morning, it was obvious that the infant was more critical than the previous night. During the night, the RN had noticed some posturing by the infant and she needed increased ventilatory pressures. It had also been decided to give the infant plasma to try to raise mean BP. Although the MD had spoken with the family about plasma, they were very concerned. I listened to their concerns and tried to reassure them. The baby’s respiratory status was also declining and several times the RT and I had to bag ventilate the baby to raise her oxygen sats.
By mid-morning, there was a large group of family at the bedside and I was finding it difficult to help the family through this experience and complete the tasks that needed to be done. I asked another RN to help me with some tasks. The physician was at the bedside, talking to the family about switching the baby to a different ventilator. The parents were visibly upset and I was feeling like nothing I was telling them was of any help. The baby was doing poorly at this point and the MD spoke of this to the family and offered them the option of removing the baby from the ventilator.
It was at this point where I began to feel like I was not prepared to guide the family through the death of this infant. I asked the RN who had been helping me to stay and help me help the family through this. I felt very useless in the situation. We offered parents the opportunity to hold the baby and asked them if they wanted to call their minister. At this point, we stepped back to let them spend a little time with the baby. I brought some baptismal gowns so the family could choose one. The minister arrived shortly after this and led the family in a prayer.
I remember being very choked up and at this point shed some tears along with the family. The baby died slowly in her mother’s arms. I was having a very difficult time trying to control my own emotions. The RN who was helping me was very calm, honest and supportive. It was amazing for me to watch her interact with the family. It wasn’t until we laid the baby back on the warmer to remove the ET tube that I began to feel more comfortable. The other RN suggested to me that we could offer the family the chance to bather and dress the infant. I gathered supplies and stood by to provide any assistance to the grandmothers who were going to bathe her.
It was very touching to watch them clean her and I cried with them as they did it. I helped them place her back on the bed and dress her. I then took pictures of the infant with her grandmothers and by herself. After this, I took the baby into the parent room so that mom could be alone with her. At this point, I excused myself and went into the break room to cry. I really felt very helpless throughout the whole day. I don’t think that there was anything I could have said to comfort the family, but I felt that I wasn’t even entirely comfortable with the process of dying because I had no experience with it.
I felt that in light of my inexperience with death, I knew that I needed help and asked for it. Notice the validating and supportive role the experienced nurse plays in assisting S. S. in this unfamiliar clinical situation. Identifying ways for S. S to continue to be supportive to the family helped her stay engaged in the care of the family, despite having 7 no prior experience with death and dying. Also, note the description of the physician’s interactions with the family, explaining the clinical situation, which was unfamiliar to the nurse.
The supportive relationship of experienced healthcare providers standing near and providing support, versus taking over the care, helped SS feel a sense of accomplishment during this emotionally difficult situation. Supportive relationships early in practice greatly influences whether or not new nurses will become emotionally involved in the practice or withdraw and become disembodied in their care (Dreyfus, 2001) One of the most helpful factors that promoted her growth and development during this time for S. S. as the formation of a close relationship with an experienced staff nurse who helped her navigate and explore challenging clinical and social aspects of the unit. This “assisted autonomy” helped S. S. acquire knowledge and confidence to continue to expand her practice and offered her access to a broad range of therapeutic interventions. This mentoring relationship also opened up her world by “turning me towards the right path” and helped her identify alternative interventions to “steer me in the right direction”.
Transition to the Competent Stage After about a year of full time practice, the new nurse begins to move into the Competent stage. Obtaining skill and confidence in providing routine and complex patient care is one of the developmental tasks for the competent stage. Characteristics of the competent stage An increasing awareness of patterns of patient responses in recurrent situations helps guide practice at the competent stage. The nurse at this stage of development shifts their focus from task completion to managing the clinical situation. A conscious, deliberate, and systematic approach guides care planning and there is a desire to limit the unexpected by managing the environment. Competent nurses demonstrate mastery of most technical skills and begin to view clinical situation from a patient and family focus. They delegate to other care providers as a means to help manage the clinical situation. (Haag-Heitman, 1999, p. 256). Attention to practice development and learning continues to be of utmost importance at this stage as the number of potentially relevant elements and procedures that the one is able to recognize and follow can be overwhelming. To cope with this overload and to achieve competence, people learn, through instruction or experience, to devise a plan, or choose a perspective. “To avoid mistakes, the competent seeks rules and reasoning procedures to decide what plan or perspective to adopt” (Dreyfus, 2001, p. 36). Different developmental strategies from the Advanced Beginner are called for at the Competent stage. The Competent stage is a time of confrontation with the realities of the nursing role and the workplace (Benner et al. , 1996).
Increased personal expectations, coupled with demands and realities of the workplace, can create feelings of vulnerability and disillusionment. More nurses at this stage, than any other, indicate they are contemplating looking for another job or leaving nursing altogether (Benner et al. , 1996). Organizational awareness and support is critical during this stage to deal with these developmental concerns and helping the nurse stay engaged in the practice. Learning and development can arrest at this stage, leading to stagnation and remaining safe but not achieving the Expert stage. S. S. identified several learning experiences that helped her achieve confidence with the unit’s standards of care and cope with the hyper-responsibility and disillusionment common to this stage: • • becoming a member of the unit’s policy and procedure committee, completing a research utilization course and applying new findings to change practice, • • • participating in care conferences and collaboration with other healthcare workers, working closely with nursing students who rotated through the unit, and obtaining certification in Pediatric Advanced Life Support.
Involvement with the policy and procedure committee is a good strategy for late stage advanced beginner and competent stage nurses to define the steps used in their distinctive systematic and deliberate approach to patient care. Having a forum for open group discussions on practice issues helps nurses cope with their new concerns and ethical conflicts that begin to appear at this stage. As practice development continued, S. S. became “care coordinator” for patients and families, enabling her to become a consistent caregiver.
This consistency helped her integrate theoretical knowledge with actual clinical experiences leading to an increased awareness of the patterns of patient responses in recurrent situations. Her mastery of most technical of the unit’s technical skills and increasing clinical confidence accompanied a heightened responsibility to act as a patient/family advocate. About 2 years after working in the NICU, S. S. found that she was beginning to see the patient and family in new ways. “It was like I was in this accelerated learning phase.
Things began to look different for me. I was comfortable with the expected progression 10 of most of the neonatal conditions and found that I was making more suggestions for change in the care plan with physicians and other providers. Since I was with the patients over a period of time, I was recognizing subtle changes and anticipating outcomes. Many of the routines that I once used faithfully did not seem to always work for the patients and families that I cared for. I found myself challenging physicians about the care we were giving”.
Her proficient stage narrative, presented here, illustrates her changing in perspective. Narrative from the Proficient Stage I first met the parents of a little boy, born at 28 weeks by cesarean section, in the operating room just prior to the birth of their son. I went to the head of the bed and introduced myself to the mom and dad as the nurse who would take their baby to the NICU after delivery. I also let them know that the baby would need a breathing tube placed shortly after birth to help him breathe.
They expressed that they had some knowledge of what to expect and also asked if they could see the baby before going to NICU. I let them know that I would do my best to make sure they could see him, but did advise them that it might not be possible. I also asked them if they knew baby’s sex, they said that they did and that baby was a boy named James. Immediately after delivery, James was intubated. He was pink and active being hand ventilated by the respiratory therapist. The neonatologist at the resuscitation told me that he wanted us to bring the baby back to the NICU “right away” and the left the OR.
The RT helped me get James settled into the transport isolette and then noting that he was still very pink, active and in no apparent distress, we wheeled the isolette to the head of the bed so his parents could meet James for the first time. I encouraged mom and dad to take a look and touch his perfect little body. The RT continued to hand bag James while his parents touched and admired him. I continued to monitor him for signs of distress. There were none. We stayed at the head of the bed for a couple of minutes and then departed for the NICU. As we left the OR, James grandmother was waiting in the hallway.
We stopped for her to see him and I noticed that she had a camera. I asked if she would like to take a picture and rearranged his covers so that grandmother could get a better shot of her new grandson. I let her know that I would come find the family as soon as it was okay to visit in the NICU. When I returned to the NICU with James, I found a very unhappy neonatologist waiting. (This particular physician is one of our more seasoned members of the team and is very set in his ways of doing things). He was upset that I had taken so long bringing the baby back to the unit.
It had only been about 11 7 minutes since he had left the OR. I explained to him that I was carefully watching the baby during the transport and had not noted any distress. He state that I “should have come right back. ” I didn’t agree with this statement but kept quite. I felt secure having the RT with me in case anything would have happened with the endotracheal tube, which is a possibility whenever you move an intubated baby. I had caused no delay in treatment, or in the delivery of Surfactant – which is given within the first hour of life.
I had not endangered the baby in any way. If a situation like this were ever to arise again, I would do the same thing over again. I feel like these parents already had lost the opportunity to have a “normal” birth and newborn child. James will never be able to stay with his Mom in her postpartum room and the parents will experience a very different bonding process. I felt that it was important for these parents to be able to see James and to know that he was okay before we rushed him out of the room and out of sight.
James’s parents have since told me that my small gesture made a big impact on them. That made it worth it. Notice how only certain aspects of the patient’s condition show up as relevant at this stage of development. This is in sharp contrast to the detail of the patient’s condition in the first narrative. Also evident is the confident and flexible approach to patient/family care and the creation of new outcome focused possibilities, as demonstrated in the enhanced involvement of the parents and grandmother with the preterm baby.
A new perceptual grasp emerges at the Proficient stage and this changing relevancy becomes evident in narrative accounts of ethical/moral dilemmas and conflict with former ways to seeing things. Skillful attention to the unique challenges the nurse faces at this developmental juncture, especially in the area of risk taking, supports progression to the expert stage. Environments that inhibit clinically sound alternations in approaches to care at this stage of development impede individual and organizational learning and progression to the Expert stage of development.
This case study illustrates one nurse’s journey into the nursing professional practice world. The beginning of her journey is typical in many ways to her peers across the country in that there was a formal orientation period followed by informal learning from peer to peer consults and interactions. What distinguishes this from many other experiences is the supportive learning environment that this nurse experienced. Hurst & Koplin-Baucum (2003) found that failure to assimilate socially and clinically during the first year of employment contributed to increased turnover.
The following testimonial from one experienced nurse preceptor, illustrates how the use of the 12 clinical narrative promotes social integration along with individual and organizational learning: “…I feel I am a less frustrated and more understanding preceptor … as I can now clearly understand where new grads “live” in their practice and what can and cannot be expected of them. I believe with that understanding comes the ability to better guide them toward growth and development…Reading narratives has also promoted growth in my own practice.
I am constantly learning things that I am able to apply in my everyday practice…” (Haag-Heitman, 1999, p. 88) Creating Learning Environments Promoting organizational learning, using a novice to expert developmental approach and integrating clinical narratives to make the practice visible, creates an appreciative and support environment for best practice to unfold. Making the practice visible for others to see and evaluate one’s thinking processes is important to the development of critical thinking skills (Marshall, Jones, & Synder, 2001) and continual development.
Support and appreciation for each developmental stage also has a positive affect on recruitment and retention; with a lack of support during early practice development contributing to the 35% to 60% of new graduate nurses changing places of employment during the first year of practice (Delaney, 2003) or who are planning to leave the profession (Thomka, 2001). Enhanced understanding of the world of the beginning nurses has tremendous individual and organizational benefits.
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