Understanding the Practice of New Nurses

According to Benner’s Theory

• Novice to Expert– Novice– Advanced Beginner– Competent– Proficient– Expert

Novice

• New graduates of an RN program and are now in orientation

• Gaining knowledge and expereince in clinical and technical skills

• Under guidance of preceptor– Follows guidelines and rules learned in nursing

school and in orientation– Use objective data and seeks assistance in making

clinical decisions

Advanced Beginner• Guided by policies, procedures and standards.• Building a knowledge base through practice• Most comfortable in task-oriented environment• Describe a clinical situation from the viewpoint of

what they need to do– Not according to the context of how the patient

responds• Practice from a theoretical knowledge base while

they recognize and provide for routine patient needs

Competent• These nurses integrate theoretical knowledge

with clinical experience in the care of patients and families

• Care is delivered using a deliberate, systematic approach,

• Practice is guided by increasing awareness of patterns of patient responses in recurrent situations

• Demonstrate mastery of most technical skills• Begin to view clinical situations from the

patient’s and family’s viewpoints

Proficient

• These nurses have in-depth knowledge of nursing practice

• Perceive each situation as a whole and comprehend the significant elements based on their own previous experience

• Demonstrate ability to recognize situational changes that require unplanned interventions

• Progression from a task orientation to a holistic view of patient care

Proficient, cont.

• Develop effective relationships with other caregivers and provide leadership to the healthcare team

• Interpret the patient’s and family’s experiences from a wider perspective

• Can envision other possibilities (predict a variety of different futures)

Expert

• Expert practitioners whose intuition and skill arise from comprehensive knowledge thoroughly grounded in expereince

• Practice characterized by a flexible, innovative, and confident self-directed appraoch to patient and family care

• Operate from a deep understanding of the total situtation

Expert, cont.

• Keep personal values in perspective and are better able to encourage and support patient and family choices

• Collaborate with other caregivers• Maximize advocacy for patient and family care

and achieving the most effective outcomes.

Progression is a Process

• Nurses progress through stages in a stepwise fashion and must “spend time” in each stage to be able to progress to the next.

• Amount of time is not nearly as important as quality of time

Let’s Look at Another Activity

• It is one of the most complex everyday things we do

• It is a skill that consists of at least fifteen hundred “subskills”

• It seems so easy that we tend not to dwell on it

• It has become like breathing or an involuntary reflex

Driving

Driving/Nursing

• But for most of us it also describes nursing• We’ve been at it for a long enough time that

our thoughts and actions have become second nature

• However, these same thoughts and actions that have become commonplace and “a piece of cake” to us can seem mysterious, confusing, and even magical to new practitioners

New Drivers/New Nurses

• Missed opportunities during critical stages of skill acquisition can permanently stall progression to becoming either a better driver or a better nurse

• New drivers are “turned loose” as soon as they get a license– Must develop remaining skills on their own

because of lack of immediate feedback

New Nurses Have an Advantage

• They have a preceptor!• Performance can be evaluate on a continual

basis •

The Value of a Preceptor

• Once the new nurse is off of orientation she or he will practice in the same environment as every other nurse– ALONE and unsupervised

• Typically, the only people present during nurse/patient interactions are the nurse and the patient– The patient is not usually in a position to evaluate

the quality of care

Feedback After the Fact

• Not usually the kind we want• Ticked off fellow drivers, traffic tickets, car

crashes, action taken against our drivers license

• Unhappy patients and families, poor patient outcomes, less-that-stellare performance review, action taken against our nursing license

Concurrent Feedback is the Key

• Preceptors need to be careful not to turn their new nurses loose too soon

• Take every opportunity to evaluate and provide feedback

• Help new nurses become comfortable asking for feedback and self-identifying learning needs.

You Can’t Rush Benner!

• Six weeks of orientation will not (cannot) transform a novice nurse into a proficient nurse, or an expert nurse

• New nurses need long amounts of time in each stage to be able to progress to the next

• Take advantage of the time you have together to help the new nurse be able to gain the skills and patterns of thinking needed to progress through the stages and become the best nurse they can.

References

• Benner, P., Tanner, C., & Chesla, C. 2009. Expertise in nursing practice; Caring, clinical judgment and ethics, 2nd ed. New York: NY. Springer Publishing Company

• Haag-Heitman, B., & Kramer, A. (1998). Creating a clinical practice development model. American Journal of Nursing, 98(8), 39-43.

• Vanderbilt, T. 2008. Traffic: Why we drive the way we do and what it says about us. New York: NY. Vintage Books