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DEVELOPING CLINICAL REASONING IN
CRITICAL CARE PRACTICE
A Comprehensive Examination Presented to the Faculty
of
California State University, Stanislaus
In Partial Fulfillment
of the Requirements for the Degree
of Master of Science in Nursing
By
Marcelina Gracia-Lewis
May 2013
CERTIFICATION OF APPROVAL
DEVELOPING CLINICAL REASONING IN
CRITICAL CARE PRACTICE
By
Marcelina Gracia-Lewis
Signed Certification of Approval Page is
on file with the University Library
Dr. Carolyn Martin
Associate Professor of Nursing
Dr. Paula Le Veck
Professor of Nursing
Date
Date
© 2013
Marcelina Gracia-Lewis
ALL RIGHTS RESERVED
iv
DEDICATION
This comprehensive is dedicated to my husband Myke and my children
Melyka, Colizel, Anesia & Philomen. Without their encouragement and love; none of
this would be possible.
v
ACKNOWLEDGEMENTS
Drs. Carolyn Martin and Paula LeVeck are acknowledged for inspiring me to
seek my masters and their patience, guidance, and encouragement through the process
of completion.
My husband Myke Lewis-Tyson is acknowledged for the unwavering support,
understanding, and encouragement that he has given me through the duration of my
academic career.
vi
TABLE OF CONTENTS
PAGE
Dedication ............................................................................................................... iv
Acknowledgements ................................................................................................. v
Abstract ................................................................................................................... vii
CHAPTER
I. Clinical Reasoning in Critical Care Nursing ........................................ 1
II. Teaching and Learning Strategies ......................................................... 11
III. Building Proficiency ............................................................................. 21
IV. Critical Care Orientation Model ........................................................... 31
V. Discussion ............................................................................................. 41
References ............................................................................................................... 44
vii
ABSTRACT
In critical care, nursing knowledge and clinical skills are advancing and grow more complex
in practice. It requires registered nurses to understand complex interventions in a highly
technical environment with advanced problem solving, decision making, and clinical
reasoning. With these advancements and the growing complexity of critical care, traditional
orientation programs that continue to separate theory from practice do not promote clinical
reasoning and inadequately prepare registered nurses to practice independently. To develop
clinical reasoning and become proficient in practice, orientation programs must emphasize
and promote experiential learning in the class and clinical settings. When clinical reasoning
and proficiency are developed, registered nurses understand the global picture of individual
situations and have the ability to provide appropriate care by managing rapidly changing
situations through judgment, thinking, and action. How clinical reasoning and proficiency are
developed and nurtured will be explored through specific teaching/learning strategies, nursing
competencies, and an experiential orientation model.
1
CHAPTER I
DEVELOPING CLINICAL REASONING
The critical care environment is fast paced. A patient's condition may improve
or quickly deteriorate. Professional registered nurses (RNs) in an intensive care unit
(ICU) are faced with unpredictable situations and need to use evidence-based
knowledge to make quick decisions regarding patient care. They must be prepared to
anticipate and understand events that may threaten patient safety while preparing to
take action. Essentially, they must develop the ability to clinically reason. Clinical
reasoning is vital in critical care practice. It allows RNs to interpret new data and
changes in a patient's condition; to understand initial assessments and diagnostic
results. It allows RNs to identify a patient's changing condition and actions needed, in
order to provide safe care and to improve patient outcomes in an ICU (critical care)
environment.
Introduction
A critical care RN receives a patient from the emergency department (ED) that is
intubated, has two vasopressors infusing, normal saline (NS) at 200 milliliters (mls) per hour
and a NS bolus at 500 ml per hour. The patient’s systolic blood pressures remains low in the
80’s with the two vasopressors infusing at the maximum dose and the heart rate is accelerated
at 120-130 beats per minute. The oxygen (O2) demand and respiratory rate continues to
increase. The RN performs a complex assessment, with the primary focus on the cardiac and
respiratory status of the patient. The monitors are reassessed for accuracy and zeroed where
appropriate, medications are recalculated for accuracy and proper dosing, the ventilator is
2
assessed for any discrepancies and for possible adjustments that may be made to improve the
respiratory status and decrease the O2 demand. Adjustments on treatments are made per
ordered protocol and a further assessment is performed after treatments are adjusted but there
is no improvement. At this moment, the RN must dig deeper to resolve the current crisis that
the patient is in. What could cause the current treatments to fail? What tests and procedures
should now be taken to solve this puzzle? The RN pulls information about the unresolved
hypotension with treatment and the respiratory status together and decides to obtain an
emergent arterial blood gas (ABG) because he/she knows if the patient is in acidosis,
vasopressors may be ineffective and the respiratory status will continue to deteriorate. The
ABG results indicate that the patient has a Ph of 7.19 and a bicarbonate level of 8.0. The RN
immediately notifies the physician of the ABG results, explains the patient’s hemodynamic
status with current treatments, and requests a bicarbonate drip for treatment. A 50 milliliter
syringe of bicarbonate is given by intravenous push and a bicarbonate drip is started per
obtained orders. As the night progresses the acidosis is corrected, the vasopressors become
effective, and the respiratory status and O2 demand improves due to correcting the
bicarbonate level. To care for this critically ill patient, the RN had to grasp the clinical
situation and dig deeper than the obvious to understand and resolve the patient’s critical
status. The RN had to apply knowledge and practical skills simultaneously to solve the
problem and stabilize the patient; they had to clinically reason.
In critical care nursing, clinical reasoning goes beyond knowing and thinking;
it also involves the process of taking action and applying knowledge in clinical
practice. According to Benner (1984), nursing knowledge and clinical reasoning
consist of extending practical knowledge through scientifically based investigation
that is developed through clinical experience and practice. Without clinical reasoning,
3
RNs that transition into ICU can be dangerous. They may be a walking/talking
encyclopedia but may not have the ability to apply this knowledge in practice.
Clinical reasoning is practice-based and requires scientific and technical knowledge.
It requires the practical ability to apply knowledge in order to make clinical decisions
for each individual patient. It is the processes of thinking while taking an action and
performing skills (Himmerick, 2011; Jensen & Givens, 1999; Mattingly, 1991).
During the clinical orientation in the ICU, clinical reasoning is developed and
enhanced, preparing RNs to provide quality care to critically ill patients (Dunn,
Lawson, Robertson, Underwood, Clark, Valentine, 2000; Aari, Tarja & Helena, 2008;
Murphy & Nolan, 2006). If clinical reasoning is not further developed during the ICU
orientation, RNs can unknowingly be a danger to the patient and to self. The
development of clinical reasoning during orientation in the ICU is not a choice; it is
mandatory.
Clinical Reasoning Defined
Clinical reasoning is more than a simple application of theory; it is RNs
developing a treatment plan that addresses the medical and personal needs of each
patient. Clinical reasoning occurs when RNs move through available facts and
inferences to make a decision on the patient's plan of care (Simmons, 2009; May,
Greasley, Reeve, & Withers, 2008; Kaldjian, Weir, & Duffy, 2005). This chain
process involves the cognitive activities: judgments, decisions, and actions made
when caring for a patient.
Over time the understanding of critical thinking as it pertains to the clinical
4
setting has matured into the concept of clinical reasoning. The American
Philosophical Association (APA) Delphi Research Report defines critical thinking as:
... Purposeful, self-regulatory judgment that uses cognitive tools such
as interpretation, analysis, evaluation, and friends, and explanation of the
evidential, conceptual, methodological, criteriological, or contextual
considerations on which judgment is based (APA Delphi Report, 1990, p. 2).
Critical thinking is directed, disciplined, and monitored by self; however, it does not
address the application of knowledge and technical skills into clinical practice
(Petress, 2004; Colucciello, 1999). To critically think, RNs must assess and evaluate
data but to clinically reason, they must have the ability to take the data and apply it
theoretically and technically in nursing practice.
The development of clinical reasoning is not limited to the initial patient
assessment; it is an ongoing and changing, thinking, and decision-making process
(Himmerick, 2011). Clinical reasoning is the foundation of problem-solving. It
includes RNs self-confidence in clinical practice, ability to place events within proper
context, and the ability to adapt to new technology. Registered nurses that have fully
developed clinical reasoning analyze new information, seek out, and verify useful
discoveries that aid in caring for critically ill patients.
Most recently, a comprehensive definition of clinical reasoning was also
provided by the National League for Nursing Accreditation Commission (NLNAC):
The deliberate nonlinear process of collecting, interpreting, analyzing,
drawing conclusions about, presenting, and evaluating information that is
5
both factual and belief based. This is demonstrated in nursing by clinical
judgment, which includes ethical, diagnostic, and therapeutic dimensions and
research (NLNAC, 2002, p. 8)
The evaluation of knowledge, current practices, and research is ongoing in the
process of clinical reasoning.
Theoretical Foundation
Clinical reasoning is essential to the nursing profession. Elements that are
integral to the clinical reasoning process include deduction, analysis of data, and
efficient assimilation of data (Jensen & Givens, 1999; Mattingly, 1991; Simmons,
2009). In the end when RNs advance from novice to expert, there is no substitution
for experience (Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner, Hughes, &
Sutphen (2008) describe limitations in providing high-quality care as a lack of
experience needed to provide optimal treatment. To develop clinical reasoning it is
beneficial for RNs to care for many different patients with different medical histories
but similar diagnoses and pathology (Cohn, 1989; Himmerick, 2011). When RNs
receive patients who have common diagnoses but a difference in medical history,
they develop the ability to filter through information and gain the experience that is
needed to develop clinical reasoning.
Clinical reasoning requires multiple forms of nursing knowledge that involves
RNs ability to think, apply, and perform. Registered nurses (RNs) ability to practice
and replicate knowledge includes practical, scientific, and technical knowledge, while
the ability to reason and relate knowledge to practice includes theoretical, evidence-
6
based, and intuition. Clinical reasoning requires the practical ability to identify the
relationship between scientific and technical knowledge and to know how it applies to
individual patients in practice. It is developed and refined through experience in
actual situations (Benner et al., 2008). Applicable and theoretical knowledge
combined is known as nursing knowledge; required to develop clinical reasoning.
According to Benner, Chesla, & Tanner (1996), RNs who have developed
clinical reasoning portrays six characteristics: pattern recognition (the ability to
perceive relationships and identify patterns), similarity recognition (the ability to
recognize resemblance of patient cases past and current), common sense
understanding (the ability to see the cultural and emotional meaning of each patient),
skilled know-how (cognitive ability acquired in clinical practice), sense of salience
(the ability to differentiate important and unimportant events), and deliberate
rationality (ability to maximize judgment and consider options). Experiential and
practical knowledge is essential in the development of clinical reasoning and it is vital
in critical care. With balance, RNs are able to meet patient needs while using methods
that are impactful and lead towards positive outcomes in unique clinical situations.
Through clinical reasoning RNs are able to bring knowledge and experience into
practice and simultaneously apply them in patient care.
Developing Clinical Reasoning through Experiential Learning
Novice ICU RNs do not initially have the habits and preparation to clinically
reason as do veteran ICU nurses. It is developed through experiential learning and
initially requires clinical orientation and a conscious effort to pull book knowledge
7
and know how together when making clinical decisions. Clinical reasoning is
theoretical knowledge, clinical practice, and experience combined as one and it is
gained through a combination of multiple learning mechanisms. The mechanisms
involved in the development of theoretical knowledge and clinical repetition are case
studies, simulation, clinical orientation, and reflection.
The initial form of learning to assist in the development of clinical reasoning
is case studies. RNs learn initially through multiple written case studies, then
eventually experience that case in a clinical practice setting. This happens when RNs
pull their practical and theoretical knowledge together to make a decision. Through
case studies RNs are able to reason while in transition and evaluate the change in an
emerging situation by pulling out the "how" and "why" (Benner et al., 1999;
Grossman & O’Conner, 2010). Case studies can be the starting point in the
development of clinical reasoning in critical care.
Simulation is an artificial replication of events that may have occurred or may
occur in actual nursing practice. It allows RNs to learn in a closed and safe
environment. Simulation is a powerful teaching tool because it allows RNs to think
critically in a simple environment (Benner et al., 2008; Henneman & Cunningham,
2005). Registered nurses learn to think while in action through the evaluation of
interventions given to patients (Benner et al., 1999). This means RNs learn from a
practical application, a vital component in the development of clinical reasoning.
Simulation assists RNs in developing a strong theoretical nursing foundation and
efficient clinical skills needed to practice in ICU.
8
Clinical orientation is learning in a live setting. It is where RNs begin to
develop clinical reasoning through the processing and application of knowledge into
practice (Hicks, Merritt, & Elstein, 2003; Kreiter & Bergus, 2008; Lewis & Smith,
2001). During clinical orientation, novice RNs are mentored and guided by
experienced RNs who assist with the understanding of scientific and technical
knowledge in practice (Benner et al., 2008; Murphy & Nolan, 2006; Morris, et al.,
2007). It is through practice, experience, and guidance that RNs learn to pull nursing
knowledge together when forming a clinical decision.
The last form of learning that is beneficial in the development of clinical
reasoning is reflection which includes the processes of theoretical and clinical
learning. Through reflection the thinker examines assumptions and questions or
doubts the validity of arguments, assertions, and even facts in the case (Benner et al.,
2008; Grossman & O’Conner, 2010). Reflection contributes to the development of
clinical reasoning by teaching RNs to never assume that only one answer is correct.
The process of reflection teaches RNs to generate new ideas and endless possibilities.
They learn to think outside the box, which is a vital process in clinical reasoning and
experiential learning. With reflection, RNs are able to gather past experience, current
knowledge, and evidence-based practice together while making decisions regarding
their patient’s condition (Benner et al.,2008; Berkow, Virkstis, Stewart, Aronson, &
Donohue, 2011).
When clinical reasoning is developed through experiential learning (case
studies, simulation, clinical orientation, and reflection) it becomes second nature;
9
RNs are able to decide and act immediately with ease (Benner et al., 2008; Harjai
&Tiwari, 2009). Registered nurses know that similar symptoms have various
meanings and consequences for each patient. They are able to identify cues that
indicate system decompensation or improvement and know how to appropriately treat
the patient. The ability to clinically reason must be developed and nurtured in the
ICU.
Discussion
Clinical reasoning in nursing is a thinking process that includes theoretical
knowledge and clinical skills. With the inclusion of theory and clinical practice,
clinical reasoning is developed through experiential learning that may be obtained
through case studies, simulation, clinical orientation, and reflection. The development
of clinical reasoning occurs in a clinical setting that promotes the application of
knowledge and clinical skills simultaneously. Each form of learning promotes and
refines the use of current knowledge in order to develop a deeper understanding of
how, when, and why clinical reasoning is applied in nursing practice.
The study of clinical reasoning stresses the importance of RNs ability to apply
nursing knowledge at the bedside. Through experiential learning, RNs can gain a
significant amount of knowledge and the ability to practice safely in an ICU.
Registered nurses who have developed clinical reasoning will bring their knowledge
to a situation in which standard treatments and available resources may be insufficient
to preserve the life of the patient. When the patient’s outcome is uncertain and
consequences may be severe, critical care RNs must have the ability to clinically
10
reason and think beyond current practices to improve the patient’s outcome. When
RNs are able to combine knowledge and apply it to practice, they have developed
clinical reasoning.
11
CHAPTER II
TEACHING/LEARNING STRATEGIES FOR CLINICAL REASONING
When registered nurses (RNs) decide to transfer into critical care, they must
acquire advanced theoretical knowledge and clinical skills. Through the process of
learning, RNs eventually develop the ability to apply this new knowledge when
making clinical decisions. When RNs are able to combine in-depth knowledge and
clinical skills, they are using clinical reasoning. The purpose of this chapter is to
explore the stages of nursing development and learning strategies that will aid in the
development of clinical reasoning.
Introduction
The development of clinical reasoning is nurtured through experiential
learning (Benner, 1984). It occurs in clinical settings that may be either virtual in a
simulation lab or real in critical care orientation. Experiential learning also involves
the process of analyzing information from current and past experiences (Benner,
1984). Processing and analyzing information can be enhanced through strategies that
include case studies, simulation, clinical orientation, and reflection. By combining
hands-on practice in a clinical setting and information analysis, RNs can develop the
clinical reasoning that is imperative to provide sufficient patient care and to improve
patient outcome (Kreiter & Bergus, 2009).
To provide care to critically ill patients, RNs must assimilate technical skills,
establish priorities of care, and make clinical decisions regarding patient care (Dunn,
12
1992). With well-developed clinical reasoning, they are able to generate, apply, and
evaluate different approaches to care. Clinical reasoning develops and expands over
the course of a professional’s career, following a novice to expert path (Murphy,
2004; Morris et al., 2007). According to Benner (1984), clinical reasoning is
developed through experiential learning that occurs while RNs are in the clinical
setting. When utilized, experiential learning strategies enhance and reinforce clinical
reasoning.
Stages of Experience
Experience in critical care is obtained through an educational process that
involves the evaluation of performance and knowledge. Through experience RNs
learn to perform procedures, uncover gaps in practice, and apply treatments
recommended for specific patients (Benner, Hughes, & Sutphen, 2008). Excellence in
critical care nursing means generating more knowledge in science and technology,
through actual practice and learning strategies (Ellis & Hartley, 2009). Experience
and excellence in clinical practice are differentiated at various levels between novice
and expert (Benner, 1984). The application of RNs knowledge and skill will
determine if they have developed clinical reasoning and are able to apply it in
practice.
Each RN that transitions into critical care will enter with their own individual
skill set. This is dependent on the area of nursing from which they transition and the
length of time they have practiced as an RN in that specific area (Murphy & Nolan,
2006; Morris et al., 2007; Thomason, 2006). Benner (1984) categorizes nursing
13
experience into five levels: novice, advanced beginner, competent, proficient, and
expert. Each level has individual skill sets and levels of thinking. The initial levels of
novice and advanced beginner focus on building technical skills and tasks, whereas,
at the other levels, RNs are able to think outside the box, clinically reason, and
develop advanced skill sets (Benner, 1984). Each level of nursing requires different
teaching strategies to aid RNs in transitioning from novice to expert.
Novice.
At the beginning of a career, a person is a novice, defined as a beginner or an
inexperienced person (Webster New World Dictionary, 2003). In nursing, novices
RNs enter a clinical setting where they have no experience practicing independently
with that specific patient population. They are taught about clinical situations through
objective information such as a patient’s weight, intake, blood pressure, pulse, and
other anthropometric measure that describes measurable parameters of a patient’s
condition (Benner, 1984). When new RNs enter critical care, they are focused on
mastering tasks and skills versus analyzing the clinical situation.
Advanced Beginner.
The next category of experience is advanced beginner. As advanced
beginners, RNs new in the intensive care unit (ICU) have graduated from a focus on
technical skills and book knowledge to a stage of incorporating situations from
previous experiences. They are able to make decisions according to guidelines but
unable to differentiate aspects and attributes of a situation (Benner, 1984). Advanced
beginners need assistance in the clinical setting to set priorities and filter through
14
important data prior to making a clinical decision. They have learned from different
situations, and begin to recognize principles that will influence actions (Benner, 1984;
Fetter-Andersen, 1999; Hood & Leddy, 2003). Beginners focus on performance and
skill and remain technical and factual; they are not yet at the stage where the thinking
process involves reasoning. To transition from advanced beginner to competent, RNs
must learn to utilize past experience (personal case studies) in the process of making
clinical decisions (Benner, 1984).
Competent
Competent critical care RNs have experience in a specific critical care
specialty and are able to form a decision based on the goals of the institution and the
critical care unit which on they work in ( Hood & Leddy, 2003; Joseph, 2003).
According to Benner (1984), competent RNs have a feeling of mastery and the ability
to cope with and manage the contingencies of clinical nursing. Competent critical
care RNs eventually become proficient in their practice and continue to advance their
skills and knowledge. Registered nurses are able to filter through information, decide
what is important, and what can be ignored, but have not yet developed clinical
reasoning.
Proficient
Proficient is the stage of development in which RNs begin to blend personal
experience with factual and general realities in clinical practice (Kelly, 2008).
Proficient RNs learn from experience, what typical events to expect in a given
situation, and how plans must be modified in response to these events (Benner, 1984).
15
It is at this stage of learning that RNs begin to utilize experience with clinical and
theoretical knowledge simultaneously when making clinical decisions. Proficient RNs
learn and grow by recalling and reevaluating current and past clinical experiences.
When proficient, RNs know that there is more to clinical practice than technical skills
and objective data; they seek out other possible answers in flexible and innovative
patient plans of care. They begin to develop clinical reasoning (Benner, 1984; Dunn,
1992; Lindberg, 2006).
Expert
The stage ICU RNs must strive for is expert. As experts RNs are able to
perform duties while integrating knowledge, principles, and reflection; they are able
to clinically reason. As an expert, RNs are highly efficient because they now include
intuition in clinical situations and decisions (Benner, 1984). Their clinical experiences
guide practice. Expert RNs understand the process needed for clinical reasoning and
how it relies on theoretical knowledge and technical skills (Mattingly, 1991; Murphy,
2004). As experts, RNs are able to read situations and flexibly respond to the patient’s
changing condition and needs. Expert clinicians constantly learn and refine their
practices based on each patient’s responses, other medical professionals’ practices,
and advanced clinical practices in nursing (Benner et al., 1999; May et al., 2008).
They do not make assumptions and continue to seek out answers when they question
anything involved in patient care.
The categories of nursing levels should be assessed and reevaluated
throughout the learning and growing process of RNs. Through assessments and
16
reevaluation of RNs level of clinical reasoning and skills, an appropriate teaching and
learning plan must be developed to assist RNs progress from novice to expert. The
teaching and learning plan must promote experiential learning and utilize strategies
that promote advancing clinical skills and the development of clinical reasoning.
Learning Strategies
This section explores learning strategies that will aid in the RNs development
of clinical reasoning. To develop clinical reasoning, clinical practice is needed to
advance from novice to proficient and eventually to expert in practice (Benner, 1984;
Jensen & Givens, 1999). Experience may be gained in a live or virtual setting where
RNs utilize reflection and case studies. When one learning strategy is used alone,
learning may be difficult but when two or more of these strategies are utilized
together, it is powerful (Murphy & Nolan, 2006; Morris, et al., 2006).
Simulation and Case Studies
Simulation and case studies are learning strategies that can be utilized
together. When teaching in a virtual setting, simulation and case studies combined
create a realistic setting where RNs may experience specific clinical situations that
must be managed at a rapid rate to stabilize a patient. Through simulation, there is the
potential to improve the effectiveness, efficiency, and safety of patient care
(Henneman & Cunningham, 2005). It is a learning strategy that allows mistakes
without causing harm to a patient. To utilize simulation completely, it must be
combined with case studies. Registered nurses must learn about complex disease
processes, how to manage patients hemodynamically, and how to perform complex
17
procedures over a short period of time. By combining case studies with simulation,
the scenario becomes realistic causing RNs to feel the pressure that resembles the
critical care environment and prepares them to manage situations independently
(Rossier & Stefanski, 2009). By utilizing simulation and case studies together, RNs
have the opportunity to analyze various case studies and discuss what was missed,
what went wrong during simulation, and what could have been done differently to
improve the patient outcome (Henneman & Cunningham, 2005).
Simulation and case studies are strategies that can be utilized during the
novice and advanced beginner stages of nursing (Dunn, 1992; Murphy & Nolan,
2006; Morris et al., 2007). These two teaching mechanisms together promote the
application of knowledge and the performance of clinical skills at the bedside. They
provide the novice and advanced beginner with a safe environment when they
initially begin to develop their critical care skills and allow nurse educators or expert
nurses to critique novice RNs on what was performed and why. It assists with the
application of theory and technical skills in a clinical setting which is the first step
needed to develop clinical reasoning (Day, 2007; Rossier & Stefanski, 2009).
Clinical Orientation
Clinical orientation is a process where learners are introduced to the clinical
setting. It is during orientation RNs learn to understand patients, to interpret clinical
data, and to develop individual plans of care (Murphy & Nolan, 2006; Morris et al.,
2007). Registered nurses experience real life situations, complex disease processes,
appropriate treatments, and advanced nursing skills. One learns to filter through data
18
that contributed to a patient's acute condition. Without ICU orientation the
development of clinical reasoning would be delayed.
Clinical orientation is a vital teaching strategy needed for experiential
learning. It is through actual practice and application that RNs begin to advance from
novice to expert because they learn how to differentiate and treat multiple disease
processes within different populations. Nursing interventions are generated from
actual clinical situations, which involve physical, social, and psychological nursing
components (Benner et al., 1999; Murphy & Nolan, 2006). Clinical orientation is vital
in the development of clinical reasoning for a novice ICU nurse but clinical reasoning
remains a constant throughout a nurse’s professional career.
Preceptor
Preceptors teach; they educate (Webster New World Dictionary, 2003).
During clinical orientation preceptors will assist RNs in learning the knowledge and
skills needed to practice in critical care. Preceptors set the stage for application and
analysis of knowledge and data. They have the power to influence a preceptee’s
development of clinical reasoning and bedside skills (Murphy & Nolan, 2006; Morris
et al., 2007). Preceptors also possess expertise and are a resource for the preceptee.
They validate and identify levels of competency and clinical reasoning. At the novice
stage, preceptors influence RNs development of standards of practice, critical
thinking, and clinical competence at the bedside.
Reflection
Reflection is a learning strategy that aids in the development of clinical
19
reasoning by teaching RNs the process of examining assumptions while questioning
the validity of arguments, assertions, and facts of the case (Benner et al., 2008).
Through reflection RNs develop the ability to see beyond the numbers and details, to
learn to question data, and to know that other causes and outcomes are possible (Day,
2007). When RNs utilize reflection they are able to recall what worked, what did not
work, and why. In practice, to develop effective clinical reasoning RNs must be able
to reflect because it is a process that is needed to promote active learning, self-
awareness, and complex thinking in the ICU (Benner et al., 2008; Himmerick, 2011;
Murphy & Nolan, 2006). Through reflection, RNs learn to describe the patient's
situations and to use skills they have learned from specific experiences (Murphy,
2004). It helps the learner identify areas where reasoning must be improved
(Atkinson & Nixon-Cave, 2011; Rashotte & Thomas, 2002). Reflection and
evaluation are vital components of clinical reasoning.
Reflection is a developed over time and is used primarily by proficient and
expert RNs in practice. It is the process of recalling and recognizing change and
requires more than a simple transfer of knowledge or facts. It requires practice while
observing and thinking through changing situations (Benner et al., 1999). To become
an expert nurse and to have the ability to clinically reason, one must reflect because it
is how one learns and grows from previous experiences. It is through reflection that
RNs remain attuned with active learning, self, and complex situations.
Discussion
The development of clinical reasoning remains a crucial step in development
20
of proficiency and eventually expertise in critical care. RNs must become experts in
critical care with the ability to read situations while clinically evaluating processes
and outcomes (Benner, Hooper, & Stannard, 1999). By developing clinical reasoning,
a nurse is able to view the patient at a deeper level. Registered nurses learn to make
decisions through the inclusion of what they see and what they know may occur.
Clinical reasoning is a skill that is obtained through experience and action, trial and
error. It uses innovative and practical teaching strategies that promote thinking while
in action.
These strategies promote clinical reasoning as RNs form judgments, make
decisions, and perform actions. It can be thought of as an internal dialogue that occurs
before, during, and after patient care (Givens & Jensen, 1999). By using a
combination of the strategies RNs develop the ability to recognize change in a
patient's condition through observation and application in a changing situation; they
develop clinical reasoning (Benner et al., 1999). Reasoning that continues to develop
and grow as RNs shift from one level of experience to the next is the process that
continues through RNs career.
The building blocks of clinical reasoning involve knowledge and action,
gained through a combination of analytic and action strategies. Clinical reasoning is
developed through experience in a virtual and real clinical setting. The teaching and
learning strategies: simulation, case studies, clinical orientation, and reflection aid in
the development of clinical reasoning. Through these strategies, RNs progress from
novice to expert and develop clinical reasoning.
21
CHAPTER III
CRITICAL CARE PROFICIENCY
In critical care, building nursing proficiency means going beyond a basic skill base.
Health care providers have multiple specialties but the knowledge and skill base needed by
registered nurses (RNs) in each intensive care unit (ICU) is variable. Even with this variation
in clinical skills there are still commonalities among practice, knowledge, and competencies
in each unit. The purpose of this chapter is to discuss key nursing competencies needed to
build proficiency in critical care practice. The nursing competencies discussed are applicable
to each critical care specialty and are applied daily in practice. With the development of these
nursing competencies, RNs will be proficient and able to safely practice in an ICU.
Introduction
In critical care, RNs are expected to have a vast amount of knowledge and clinical
skills when making decisions and performing care. The knowledge and nursing competencies
that RNs need to become proficient are initially obtained through an orientation program in
the classroom and clinical settings. Once acquired, critical care knowledge is developed
through nursing competencies in clinical practice which leads to proficiency. Registered
nurses are able to provide adequate care to patients at any level of critical care.
Registered nurses are considered proficient when they acquire a sufficient amount of
knowledge and experience to safely practice. Proficiency is defined as being competent and
skilled (Webster New World Dictionary, 2003). When proficient, RNs have the ability to
apply theoretical and clinical knowledge independently into practice while holistically
assessing each situation. According to Benner (1984), proficient RNs are able to understand
situations overall. They are able to pinpoint the primary problem and resolve it while utilizing
22
standards of practice and following physician orders. Thus, RNs can provide adequate care to
patients and are less likely to have errors in practice.
Nursing competencies are defined as the overlap of knowledge with the performance
components of psychomotor skills and clinical problem solving; it is the application of
knowledge in the clinical setting (Clark, Crowder, Dunn, Herewane, Lawson, & Pubrison,
2000). According to the American Association of Critical Care Nursing (AACN, 2008)) and
the British Association of Critical Care Nursing (BACCN, 2008), standard nursing
competencies involve assessment, evaluation, education, teamwork, resource utilization, and
leadership. Each competency indicated by the AACN and the BACCN is applicable to all
ICU specialties because they build knowledge, clinical practice, and address professional
growth. Nursing competencies are applied during the development of novice RNs and
continue after proficiency is obtained in practice. These standard nursing competencies assist
RNs with the development of professional practice and clinical reasoning (Dunn et al., 2000;
Fordham, 2004). To build proficiency, nursing competencies are needed that allow RNs to
closely assess information that is present in the clinical situation (Lindberg, 2006; Walker,
2001). Competencies must be mastered for RNs to become proficient in practice. By
establishing standard nursing competencies in an ICU program RNs’ develop the skills and
knowledge necessary to become proficient when providing care to the critically ill.
Intensive Care Key Competencies
Nursing competencies in ICU are used to promote learning in order to advance
practice. They are measures that address the processes of thought and application in clinical
practice. The key nursing competencies that RNs must develop to become proficient in an
ICU include clinical reasoning, teamwork, leadership, cohesiveness, and reflection (Dunn,
1992; Thomas, 2006). By mastering each nursing competency during orientation, RNs will
23
develop the six Benner traits that define proficiency in an ICU (Benner, Hooper- Kyriakidis,
& Stannard, 1999).Once accomplished; RNs gain a holistic understanding of critical care
practice and are able to better care for the critically ill and their families (Benner, Hooper-
Kyriakidis, & Stannard, 1999).
Clinical reasoning.
The nursing competency that addresses skills that are needed to practice proficiently
at the bedside is clinical reasoning. This involves the process of assessment, diagnosis,
management of patients, and the development of treatment regimens (AACN, 2008; BACCN,
2008; Scribante, 1996). Clinicians are able to collect and evaluate information that is used to
diagnosis and manage patients’ problems (Atkinson & Nixon-Cave, 2011; Himmerick, 2011;
Harjai & Tiwari, 2009). Clinical reasoning improves RNs ability to make decisions with
fewer errors, to easily notice cues, and to take action when treatment is needed (Benner,
Hughes & Sutphen, 2008; Hicks, Merritt, & Elstein, 2003). According to Benner, Hooper-
Kyriakidis, and Stannard (1999), when this concept is developed, RNs are able to reason in
transition, utilize skilled know how, and apply clinical and ethical responses in practice
simultaneously. In critical care the traits are pulled together and used when detecting,
diagnosing, and treating patients’ conditions. Basically RNs develop the ability to holistically
provide bedside care to the patient and are able to make appropriate and safe decisions for
treatment.
Learning and reflection.
With clinical reasoning, there must be a competency that assists RNs with continuous
learning and growth. This is built through a continuous reflection on oneself and practice.
Registered nurses look at experiences, evaluate current meaning, and generate new meanings
through experiences at the clinical, emotional, and patient relationship levels. They develop
24
perceptual acuity and skills that aid them in making decisions for the patient (Benner, et al.,
1999; Rashotte & Thomas, 2002). They are able to assess practice and skills using past and
present experiences before making decisions about patient care. By reflecting on practice and
knowledge they are able to further develop clinical reasoning needed to practice proficiently
and to provide quality care at the bedside. With reflection, RNs understand the meaning of an
event and are able to become proficient and eventually an expert in ICU practice.
Teamwork and leadership
The last two competencies that RNs must develop to become proficient are
intertwined and include teamwork and leadership (Dunn et al., 2000). In the ICU, teamwork
plays a role in the development of each of the previous competencies (Dunn et al., 2000;
Nelsey & Brownie, 2012). Registered nurses are able to assist coworkers and advance their
knowledge through practice, clinical reasoning, and reflection. According to the AACN
(2008), RNs interact with peers and colleagues to enhance their own professional practice and
promote optimal patient outcomes. Teamwork and leadership make a difference in patient
outcomes because they promote cohesiveness and cause RNs to work as one to avoid
complication or possible death.
Teamwork leads to the development of leadership. Simply, leadership is defined as
the capacity to lead (Webster New World Dictionary, 2003). When further defined in nursing,
it emphasizes ethical and clinical decision-making, working relationships, respectful
communication, collaboration, delegation, and the ability to resolve conflicts with other
healthcare professionals (AACN, 2008). Through leadership at the clinical and management
level, young RNs move towards proficiency, which improves retention in the critical care
area (AACN, 2008; Alberto, Schmollgruber, & Williams, 2006). When RNs become leaders
they have the ability to assess the situation, practice in action, advocate, and make appropriate
25
clinical and ethical decisions while providing care. To develop leadership, continuous
learning must be used to advance nursing practice, improve oneself, and promote positive
patient outcomes (Nelsey & Brownie, 2012).
Clinical reasoning, reflection, teamwork and leadership are important for the
development of proficiency. When used together nursing competencies promote positive
outcomes. Teamwork, and leadership develop RNs understanding of nursing standards that
address the cooperation and understanding of coworkers, patients, and families (Scribante,
Muller, & Lipman, 1996). Without leadership and teamwork, RNs are ineffective in practice
because nursing competencies are used when advocating for needed changes in practice and
to improve patient outcomes (AACN, 2008). Clinical reasoning and reflection address how
RNs perform at the bedside. They are needed when assessing and making decisions that
address current conditions and needed treatments. They allow RNs to be able to detect subtle
changes that improve patient outcomes. Registered nurses utilize reflection to assess their
own skills in clinical practice. Each nursing competency promotes understanding of change,
personal growth, and professional accountability in practice; when the nursing competencies
are combined, proficiency is achieved (Lindberg, 2006).
A Proficient Intensive Care Registered Nurse
Registered nurses that are proficient understand how theory and clinical skills are
applied in practice. According to Benner (1984), proficient RNs understand situations
holistically and their perspectives are based on practice. When proficient in critical care, RNs
begin to have a deeper understanding of the specialty, its courses and responsibilities.
Proficient ICU RNs are able to perform efficiently at the bedside and behind the scenes. The
BACCN define proficient RNs as follows:
26
A proficient critical care nurse utilizes: advanced problem solving, decision
making, and communicative skills to provide proactive, safe, and effective
care when undertaking continuous complex monitoring and assessment,
administering, coordinating, and evaluating high intensity therapies,
responding promptly to sudden change(s) in patients’ condition, and in
providing information and emotional support to patients’ and relatives (p.11)
These ICU RNs understand their specialized nursing practice and are able to utilize multiple
thinking and clinical processes while providing care. There are specific traits that proficient
RNs must develop and master. According to Benner et al. (1999), the six specific components
needed to become proficient include 1) reasoning in transaction and thinking in action; 2)
skilled know-how; 3) response based practice; 4) agency; 5) perceptual acuity and skill of
involvement; and 6) links between clinical and ethical reasoning. When the components are
mastered, RNs become proficient because they holistically understand nursing practice.
Through proficiency RNs improve patient outcomes and family satisfaction (Dunn, 1992).
Reasoning in transition and thinking in action.
The initial nursing components in Benner’s critical care theory are known as
“reasoning in transition” and “thinking in action”. Through these components, RNs develop a
clear understanding of the current clinical situation. They are able to assess for losses or gains
in a patient’s situation and condition (Benner et al., 1999). Registered nurses evaluate and
question practice in an ongoing process through experiential learning (AACN, 2008;
BACCN, 2009). These two traits of this component assist RNs in developing an
understanding of clinical skills and how to apply skills into practice.
Skilled know-how.
27
Another component that proficient RNs have is the ability to safely perform in a
clinical setting. This component is known as “skilled know-how”; it is the performance of
intervention sets in practice that include assessments, charting, and complex clinical tasks
(Benner, Hooper-Kyriakidis, & Stannard, 1999). When RNs develop this component they are
able to make judgments, perform clinical assessments, and interpret patient data while
making a clinical decision (AACN, 2008; EFCCNA, 2004; BACCN, 2009; WFCCN, 2005).
It is more than mimicking skills; it is accomplished only after the skill becomes fluent and
second nature. By developing skilled know-how and understanding specialized skills through
theory and clinical practice RNs are able to provide a higher and more adequate level of care
for critically ill patients.
Response-based practice.
Once “skilled know-how” is developed, RNs’ begin to develop a response-based
practice; allowing them to be able to read current situations and flexibly respond to the
changing situation and patients needs (Benner et al., 1999). Registered nurses integrate
knowledge and experience when making a clinical decision. They initially choose the least
evasive treatment for patients to limit body stress and reduce patient anxiety. By developing
response-based practices, RNs become proficient because they have established the ability to
make rapid decisions, evaluate responses, and adjust treatments when appropriate (Dunn,
1992). With the development of this trait, RNs may prevent complications and improve
outcomes in the ICU.
Agency.
The next trait, which involves the ability to act for another, is known as agency.
According to Benner et al. (1999), agency is one’s ability to act upon or influence a situation.
Registered nurses become attuned with practice through experiential learning and
28
engagement in situations. When agency is developed RNs are proficient in practice because
they are able to acknowledge a change in a situation and alter previous plans to improve
outcomes (Benner et al., 2008). Proficient RNs move from task oriented care towards patient
specific care. Through agency, RNs become fully involved in their patient and the family
situations.
Perceptual acuity and skill of involvement.
Perceptual acuity and skill of involvement focuses on problem identification and is
linked to a RNs emotional engagement with the current problem and the interpersonal
relationship with the patient and family (Benner et al., 1999). When proficient in ICU, RNs
have the ability to think broadly and identify the patient’s current problem. They must have
the ability to manage the emotions of patients, families, and self when making a clinical
decision. Perceptual acuity and skill of involvement are vital in ICU nursing because when
they are underutilized, RNs are not able to see beyond basic knowledge in the clinical setting
and lack the ability to empathize with patients and their families (Benner et al., 1999) When
achieved, they have the ability to engage in the clinical and human situation. It is the skill of
involvement that requires RNs to balance clinical practice and emotions in order to be
proficient in practice.
The links between clinical and ethical reasoning.
The last trait is obtaining a link between clinical and ethical reasoning; when RNs
make clinical judgments in practice. When they clinically and ethically reason, RNs are
proficient practitioners because of their ongoing experiential learning, reflection, and
dialogue with patients and their families (Benner, Hughes, & Sutphen, 2008; Hicks, Merritt,
& Elstein, 2003). To clinically and ethically reason RNs must apply cognitive and
psychomotor skills that are based on theory and evidence as well as reflective thought
29
processes that direct change in patient situations (Atkinson and Nixon-Cave, 2011; Dunn,
1992). Registered nurses use clinical and ethical reasoning each day in practice through daily
plans of care and ongoing assessment. When RNs are able to clinically and ethically reason,
they become proficient in practice. They develop the ability to understand what the best
outcome is for the patient and their families (Benner et al., 1999). Clinical and ethical
reasoning cannot be developed overnight; it is achieved with time and through experience.
Proficiency in an ICU involves nursing theory and clinical skills that grow and
develop over time and through experiential learning. When proficient, RNs perform complex
skills fluently with quick responses to change and the knowledge to make appropriate
decisions when treating individual patients. When RNs transition into an ICU, proficiency is
accomplished when they are able to adequately assess, identify, and manage situations safely
and effectively at both the clinical and emotional level of the patient and their families
(ACCN, 2008; BACCN, 2009; Benner et al., 2008). A registered nurses development of
proficiency in ICU may determine a negative or positive outcome of a patient. Proficiency
must be obtained to improve patient outcomes in the ICU.
Discussion
Proficiency in critical care is not achieved through a single competency or clinically
based skill alone. It requires competencies that promote the processes of understanding
clinical practice and professional growth. The key nursing competencies: clinical reasoning,
reflection, teamwork and leadership are needed for RNs to become proficient (Nelsey &
Brownie, 2012). When they are used together appropriate care is provided, fewer errors
occur, and patient outcomes improve (Nelsey & Brownie, 2012; Scribante, Muller, &
Lipman, 1996). When achieved, RNs have developed Benner’s six critical care components
and are able to provide care holistically (Benner et al., 1999). They realize that nursing
30
competencies are not independent of one another and need to be used daily to solve patient
problems and improve outcomes. Ultimately, the goal is that RNs will understand critical care
practice clinically and theoretically, therefore enhancing positive patient outcomes. When
proficient, RNs value knowledge and learning; they continuously strive to become an expert
in critical care practice.
31
CHAPTER IV
CRITICAL CARE ORIENTATION
Critical care registered nurses (RNs) require advanced knowledge, clinical skills, and
clinical reasoning to effectively care for critically ill patients. Due to the growing complexity
of critical care traditional orientation programs are no longer adequate enough to build
proficiency. Current orientations programs vary in structure and in length of time spent in the
clinical setting. The structure and length of a program will determine the success rate of
orientation and improve retention of RNs in critical care (Nelsey & Brownie, 2012;
Thomason, 2006). This chapter investigates what length of orientation and program structure
are required to adequately prepare RNs to gain clinical reasoning, apply technical appropriate
skills, and communicate safely in practice.
Introduction
When RNs transition into critical care, they must obtain advanced theory and clinical
skills that are needed to care for the critically ill. These skills include advanced problem
solving, decision making, communication, complex monitoring, and high intensity therapies
(American Association of Critical Care Nursing (AACN), 2008; British Association of
Critical Care Nursing (BACCN), 2009; European Federation of Critical Care Nursing
Association (EFCNNA), 2004). Advanced theory and skills are developed initially in the
classroom setting; then, eventually, they are applied in the artificial and live clinical setting
through experiential learning. Through orientation, RNs learn how to physiologically manage
patients, assimilate and prioritize information sources, and manage patient and technology.
Knowledge and skills are learned and developed through an orientation program with the
desired outcome of transcending an RN from basic knowledge to a holistic understanding of
complex disease processes, treatments, and desired outcomes (Derham, 2007; Dunn et al.,
32
2000; Murphy & Nolan, 2006). It is during orientation that RNs will gain a true
understanding of the art of critical care.
Traditional
Traditionally, orientation in the intensive care unit (ICU) consists of two settings: the
classroom and the clinical setting. Each setting is utilized separately when educating RNs’
about critical care practice. According to Alspach (1984), traditional ICU programs are a
form of “ivory tower nursing”, which means the curriculum is based more on the theory of
the clinical practice versus the reality of it. Due to the ICU’s growing complexity, traditional
orientation programs are inadequate because they do not promote the application of
knowledge into practice (Morris et al., 2007; Murphy & Nolan, 2006; Proulx & Bourcier,
2008) According to Benner, Hooper-Kyriakidis and Stannard (1999), nurses come away from
traditional programs with mere mastery and classifying of information but that is not the
same as being able to actively think about issues and clinical situations. A greater
understanding of critical care theory and its application into practice is obtained by through
an emphasis on teaching and learning strategies that adopt a philosophy of androgogy; adult
centered learning (AACN, 2008; EFCCNA, 2004). The teaching and learning strategies of
case studies, simulation, clinical orientation, and reflection promote adult centered education
through experiential learning in the classroom and the clinical setting. When each strategy is
utilized through the duration of a critical care orientation program, the nursing competencies:
clinical reasoning, reflection, teamwork, and leadership, with the application of clinical skills,
begin to develop and carry over into phase two of the clinical orientation; preceptorship.
Preceptor Role
Nursing competencies are promoted through experiential learning that is obtained in
the clinical setting with the guidance of a preceptor, and eventually, a mentor. It is in this
33
setting that RNs transitioning into ICU will set the initial stage for learning nursing
competencies (Clough, 1982; Johantgen, 2001; Murphy & Nolan, 2006). It is through a
preceptor that RNs enhance their technical skills and clinical knowledge (Cavanaugh & Huse,
2004). When a preceptorship is complete, RNs gain independence in practice and the
preceptor becomes the mentor who will continue to assist with the development of clinical
reasoning and nursing competencies (Murphy & Nolan, 2006). Through a program that
includes a preceptorship and a mentorship, RNs transitioning into ICU will have ample time
and resources with guidance to advance from novice to proficient and eventually become an
expert in practice.
Length of Orientation
With the extensive knowledge and advanced skills needed to practice in the ICU,
there must be an adequate length of time for orientation. Orientation programs on average are
12 to 28 weeks in length and are often determined by the amount of experience RNs have had
before they begin clinical orientation (Thomason, 2006). The amount of time needed to orient
in the ICU is variable from hospital-to-hospital and person-to-person. The program should be
composed of three segments: theory, preceptorship, and mentorship. The length of
mentorship ideally should be extended for all nurses because even RNs’ practicing
independently still need an experienced RN to guide, assist, and aid them in becoming
proficient and eventually an expert.
For RNs to successfully transition into ICU, a broad amount of advanced knowledge,
clinical skills, and clinical reasoning must be developed (Scribante, Muller, & Lipman, 1996).
Success is determined by the orientation programs’ standards, structure, content, and length
of orientation (Dunn, 1992; Nelsey & Brownie, 2012). Each carries a significant weight in the
development of an ICU RNs ability to be clinically proficient. A program that is unstructured
34
and does not promote the development of critical care skills and clinical reasoning will
produce RNs that are walking, talking encyclopedias, but lack the ability to effectively care
for the critically ill.
Program Structure
The structure of a traditional critical care program consists of two components:
theory learned in the classroom and skills learned and developed in the clinical setting.
Traditional education programs were organized around a content expert. Objectives were
identified and solely based on a theoretical notion of the field of practice (Alspach, 1984). By
dividing theory and practice, traditional programs failed to begin the development of clinical
reasoning. Registered nurses would have theoretical knowledge but lack an understanding of
what they learned or how to apply it in practice. To become proficient in critical care,
experiential learning must be a piece of the program’s foundation (Derham, 2007; Walker,
2001). It must promote multiple forms of experiential learning for RNs to develop an
understanding on how theory is applied into practice and to begin to develop clinical
reasoning.
Assessment.
When transitioning into an ICU, RNs come from various specialties and have
individual levels of knowledge and nursing skills. To determine the needs of RNs prior to
beginning the orientation program, nurse educators and clinical nurse specialists assess the
knowledge and skills of RNs by giving a written examination and conducting skills
assessment in the learning lab. First, the RNs knowledge level is evaluated through the use of
a comprehensive written examination. The examination covers a variety of ICU topics:
cardiovascular, pulmonary, neurology, nephrology, endocrinology, hemodynamics, and the
significance of basic lab/diagnostic results (Morris et al., 2007; Murphy & Nolan, 2006;
35
Proulx & Bourcier, 2008). After the examination is complete, the RNs’ clinical skills are
assessed in the learning lab. While in the learning lab, nurse educators assess the RNs’ level
of technical skills, situational understanding, and clinical reasoning. Technical skills are
evaluated through RNs demonstrating the skill on a mannequin in the lab. Situational
understanding and clinical reasoning are evaluated through case scenarios that are given in a
simulation lab. During the simulation, nurse educators will evaluate the depth of RNs’ level
of clinical reasoning and ability to apply technical skills when various situations arise.
Through simulation and lab assessment, nurse educators note the RNs’ strengths and
weaknesses in clinical practice and thinking process. The assessment of knowledge and
clinical skills prior to beginning the orientation program aids in the development of
individualized learning plans for transitioning RNs and also allows the educator and
preceptor to prioritize specific needs and goals in the classroom and clinical setting (Clough,
1982, Morris et al., 2009; Proulx & Bourcier, 2008).
Classroom.
The orientation program begins in the classroom setting when theory is introduced to
the RNs and it provides a broader understanding of complex disease processes and treatment.
To be beneficial, learning must go beyond chalk and blackboard. Learning must be enhanced
by utilizing: case studies, role playing, learning labs, and learning modules (Dunn, 1992).
These methods take into consideration the various learning styles of RNs and help develop a
clearer understanding of critical care theory and how it is applied in clinical practice. By
using multiple learning mechanisms, material is presented in a manner that promotes and
encourages RNs to learn and grow (Murphy & Nolan, 2006). Once the advanced knowledge
of ICU theory is obtained, RNs begin to develop the ability to apply it in practice. This is
accomplished through experiential learning in the clinical setting.
36
Clinical orientation.
Orientation programs must provide critical care theory but place a primary emphasis
on applying theory into practice in the clinical setting (AACN, 2008; BACCN, 2008;
EFCCNA, 2004; WFCCN, 2005). Each is vital to the success of an ICU program; theory
offers what is explicit and formalized, while clinical practice is complex and provides many
more realities than can be captured in theory alone (Benner, 1984). Registered nurses are able
to practice complex skills and to develop a greater understanding of how it is applied in
critical care before performing at actual bedsides with live patients. Complex ICU skills that
are learned and practiced in a learning lab and through simulation include ventilator
management, hemodynamic monitoring, managing complex medications, and intravenous
drips, lab interpretations, and code blue scenarios. It is in the simulation lab that RNs are
exposed to multiple ICU scenarios that will assist them with the application of clinical skills
and the development of clinical reasoning (Henneman & Cunningham, 2005; Morris et al.,
2007). It is in the actual clinical setting that a majority of the RNs’ learning will occur.
Initially RNs are assigned an individual preceptor. A preceptor is defined as an
experienced staff nurse who serves as a resource and a guide to transitioning RNs as they
learn to adapt to the ICU clinical setting (Johantgen, 2001). Preceptors set the stage for
learning because they are the teacher, demonstrator, validater, and evaluator throughout the
clinical orientation. As peers they command a tremendous amount of power and influence
that encourages the preceptee to follow standards, to think critically, and to be clinically
competent at the bedside (Johantgen, 2001; Murphy & Nolan, 2006). During this level of
clinical orientation, RNs are exposed to the multiple situations, different treatments, and
outcomes. The preceptor evaluates and assesses the RNs clinical reasoning and critical care
skills by utilizing question/answer format, demonstration, and reflexion. When preceptors are
37
able to confidently state that an individual RN has developed a greater understanding of
nursing skills, critical care theory, and the application of both into practice, the RN is ready to
advance to the next level of the clinical orientation, known as mentorship.
During this phase, the preceptee transitions into mentorship. As a mentee, they are
able to function more independently with occasional guidance (Murphy & Nolan, 2006;
Proulx & Bourcier, 2008) The preceptor shifts from a parent role to the counselor and teacher
role; a mentor (Murphy & Nolan, 2006). During mentorship, the mentee is scheduled on the
same shifts and days as their mentor to maintain comfort and continuity in the
teaching/learning process. Through mentorship, more patient care responsibility, clinical
practice, and clinical reasoning are placed on the mentee and the mentor becomes less and
less involved with the patient care (Morris et al, 2007; Murphy & Nolan, 2006). In this more
independent role, the mentee is able to further develop technical skills and clinical reasoning
through experiential learning. The mentor is always available for the mentee and continues to
evaluate and assess the progression through observing the demonstration of skills, reflection
of situations, and through the use of question/answer formats. Mentorship is complete when
the mentee has proficiently demonstrated clinical reasoning, teamwork, leadership, and the
application of advanced clinical skills.
Length of Orientation Program
The initial portion of orientation occurs in the classroom and learning lab setting
where simulation and case studies are utilized. The average classroom and learning lab
segment of critical care programs is 75 hours (Dunn, 1992; Thomason, 2006). With this in
mind, the theory segment of the program would occur over the first four weeks and
simultaneously correlates theory and the learning lab. This is where the process of knowing
and applying to practice begins. It is during this transition that RNs will apply advanced
38
knowledge and practice complex skills so that when they begin clinical orientation, they will
be familiar with the equipment and the advanced tasks critical care RNs manage daily.
The clinical levels of orientation vary in length. The preceptorship segment is an
average of 12 weeks for RNs transitioning from another specialty. This segment of
orientation provides the basics of critical care practice and experience. During this time RNs
begin to master technical skills and begin to develop clinical reasoning, teamwork, and
leadership while in the ICU setting (Boyle, Butcher, & Kenney, 1998; Dunn et al., 2000). The
last level of clinical orientation would be mentorship, this segment of orientation is different
for each RN and its length is indeterminate. Mentorship further develops the skills of RNs
and their ability to utilize experiential learning by reflecting on previous experiences and
actions taken when caring for similar patients. Registered nurses transcend from knowing to
understanding when mentorship is complete.
Each RN learns in a different way while grasping ICU content and skills; some may
have a short learning curve while others may have a long learning curve. According to
Benner, Tanner, and Chesla (1996) practitioners at different levels of skill and knowledge
live in different worlds, noticing and responding to different directives for action. The length
of an ICU orientation program should not be set in stone; it must be based on the RNs
individual level of knowledge and preferred learning modalities. By individualizing RNs’
learning needs for transitioning into an ICU, nurse educators, preceptors, and mentors are
better able to determine the primary focus points and specific learning styles. When learning
needs at the clinical level are individualized, program completion and retention of RNs in
ICU may increase.
Program Outcome
39
The ICU orientation is stressful emotionally, mentally, and physically to transitioning
RNs because they may become overwhelmed with nursing theory and the need to master
critical care skills. Traditionally, when the critical care orientation is complete, RNs begin
practicing with limited resources and support. Due to this lack of support, in 2012 the
turnover rate for critical care RNs was 12.6 percent. (Nursing Solutions, 2012). Even a small
percentage of ICU turnovers make a difference in the quality of care and patient outcomes.
With this in mind, steps must be taken that will provide adequate support during and post
critical care orientation.
According to Thomason (2006), a structured program with support has shown to be
an integral component to retention in critical care. Retention is dependent on a program that
is comprehensive and supportive versus staggered with limited support. A staggered program
is composed of theory and clinical but is limited in continuity and support during and post
orientation. In a staggered program, RNs begin practice unprepared and ill equipped. In a
comprehensive program, RNs are better prepared for their new role as a critical care provider
(Thomason, 2006). If adequate orientation, resources, and support are not provided,
transitioning RNs will become frustrated and burnout causing them to leave ICU practice
(Nelsey & Brownie, 2012; Williams, Schmollgruber, & Albertson, 2006). With appropriate
support and resources, RNs transitioning into ICU have a greater chance of success because
they know that if any difficulty arises or complications occur they will not be alone or
isolated. For RNs to be successful in ICU, retention strategies must be considered with the
focus on providing a positive, supportive orientation through each segment of the program
(Nelsey & Brownie, 2011; Nursing Solutions, 2012).
The desired outcome of an orientation program is the successful development of
proficient critical care RNs that surpass knowing theory to understanding how it is applied
40
daily in ICU practice. By using the Benner’s novice to expert model, RNs will be successful
in the ICU because the program is individualized to meet RNs learning needs and
preferences. Registered nurses will move from understanding abstract principles to
understanding experiences and will have the ability to holistically understand various
situations, and transcend from observer to an involved performer (Morris et al. 2007; Murphy
& Nolan, 2006). Simply, they transcend from novice to expert.
Discussion
Intensive care unit orientation programs can no longer continue to use the traditional
model for orientation because of the need for advanced knowledge and complex skills that
RNs must have to effectively provide care to the critically ill patients. Registered Nurses must
not only have the knowledge and clinical concepts of the ICU, they must holistically
understand each patient’s individual situation. This can only be accomplished through a
program that embraces Benner’s novice to expert theory and promotes experiential learning
which is developed in a clinical orientation that moves from a preceptorship to mentorship
and eventually independence (Benner, 1984; Morris et al. 2007; Murphy & Nolan, 2006). By
utilizing Benner’s model, an orientation program produces RNs who have developed clinical
reasoning, teamwork, leadership, and advanced skills; thus becoming proficient in critical
care practice.
41
CHAPTER V
DISCUSSION
Critical care continues to grow complex as new research, technology, and treatments
add to the knowledge that registered nurses (RNs) need to acquire in order to work in these
specialty units. Registered nurses that transition into critical care must be proficient in
advanced skills to provide safe and adequate care to the critically ill. Proficiency is
accomplished when RNs are able to apply knowledge with experiences together in practice
while making a clinical decision. Clinical reasoning is holistically visualizing and adapting to
the situation, while applying treatment when appropriate (Benner, Hughes, & Sutphen, 2008).
Critical care programs develop proficient practitioners with established competencies
through experiential learning. Competencies include: clinical reasoning, teamwork,
leadership, and reflection (Dunn et al., 2000). Vital to developing established critical care
competencies are Benner’s six critical care traits: 1) reasoning in transition and thinking in
action; 2) skilled know how; 3) response based practice; 4) agency; 5) perceptual acuity and
skill of involvement; and 6) links between clinical and ethical reasoning (Benner, Hooper-
Kyriakidis, & Stannard, 1999). As competencies and traits are achieved RNs begin to
transition through developmental phases starting with novice and moving through advanced
beginner, competent, and proficient with the ultimate goal of expert. When the competencies
are mastered and the RNs display Benner’s six critical care traits, they are considered
proficient to practice alone in an Intensive Care Unit (ICU) (1999).
To achieve the competencies and acquire the six critical care components, the
orientation program is set up into four separate levels that transitioning RNs will need to
progress through in order to develop proficiency. The initial levels include learning nursing
theory in the classroom and the initial technical skills in a learning lab. Most importantly,
42
preceptorship and mentorship take place in the clinical arena and promote experiential
learning and aid in the development of competencies that are needed to be proficient in the
ICU. Each level of the program develops a deeper understanding of critical care theory and
complex skills. It moves RNs from comprehending theory alone to looking at the whole
situation. Experiential learning requires RNs to participate and interact through the
teaching/learning strategies: case studies, simulation, clinical orientation, and reflection. Each
strategy is utilized in the classroom and skills lab then carried into the clinical setting where
RNs apply acquired knowledge in practice; they gain understanding, and begin to develop
clinical reasoning, build proficiency, and achieve expert.
It is important to keep in mind that RNs travel at their own pace through this process
since each comes to the table with different levels of knowledge. They will have different
starting points and it is important to tailor the learning experience to meet individual needs.
With each learning strategy, RNs gain a deeper understanding of critical care theory and its
application in practice; they begin to grasp the competencies with the goal of eventually
progressing towards proficiency.
To develop proficient critical care RNs, orientation programs need to provide more
than theoretical knowledge and successfully passed tests; an effective program promotes the
development of clinical reasoning, leadership, teamwork, and reflection through experiential
learning. Critical care orientation programs need to promote learning in both the classroom
and clinical settings. Murphy & Nolan (2006) stated that in order to develop proficiency in
the ICU, RNs take an examination every day, every shift, with every patient and pass that
examination. In addition, they are applying and utilizing knowledge in a way that exemplifies
not only the science but also the art of critical care nursing (Murphy & Nolan, 2006).
Orientation programs for ICU settings not only need to produce RNs with book knowledge,
43
but RNs with the ability to holistically understand situations and provide safe and effective
care to critically ill patients. Strategies outlined in these chapters will accomplish this goal.
44
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