Evidence Based Practice using Theorist Patricia Benner

Evidence Based Practice using Theorist Patricia Benner

Denise LyonCourtney MadsenDawn KooimanLynda ChaseYvonne RoblesBarb Lentz

Response to Work ComplexityThe Novice to Expert Effect

Description of nursing model/theory in research study utilizedThis study builds on the work on skill acquisition, work complexity, and nurse competency.Rationale for Use of Nursing TheoryThe environment includes frequent interruptions requiring redirection of patient care. The multiple interruptions require the nurse to redirect patient care every 6 to 7 min, and approximately half of these disruptions occur during nursepatient interventions.Practice Area of this Study5 hospitals23 RNs on cardiac/telemetry units 8 classified as advanced beginners, 8 as competent and 8 as expert nursesA purposive sample of advanced beginner, competent, and expert nurses was recruited for this study.All participants were (a) employed for at least 3 months as a registered nurse on a cardiovascular telemetry unit that was not classified as a critical care unit, (b) employed a minimum of a 0.8 full-time equivalent, (c) at least 80% of the time was spent on the unit caring for patients at the bedside, and (d) scheduled to work during the hours of 7 a.m. to 7 p.m.All participants perceived their work day as normal.

Research FindingsFour themes emerged from the data that illustrated differences in responses to the acute cares complex work environment. The themes identified were cognitive strategies, communication, integration of roles, and response to the work environment.Cognitive strategies addressed how the participants cognitively organized their work. Three subthemes were identified that described the nurses cognitive strategies: prioritization and reprioritization, anticipation, and organizational tools.Prioritization and reprioritizationThe advanced beginners prioritized in a linear manner, doing one thing at a time. They were able to prioritize based on immediate concerns, and their focus was on getting all the required care done. They relied on experienced nurses for guidance and charge nurses when encountering unfamiliar situationsCompetent nurses considered multiple factors when establishing priorities, stacking their priorities to allow shifting from one task to another, and more efficiently completing nursing care. Fewer things were viewed as interruptions and they were able to keep on task when faced with interruptions. The competent nurses had a better sense of when to delegate something and when to just do it themselves.The expert nurse focused on the patient rather than the task, with a holistic view of the patient. For instance, the nurse who had a well-known patient considered physical and psychosocial issues while caring for her. The expert nurses also had a very good sense of when to delegate, frequently providing patient care while doing assessments and giving medications AnticipationAdvanced beginner nurses anticipated immediate events such as scheduled procedures or tests. Usually reacting to a situationThe competent nurses anticipated procedures, tasks, and patient needs.The competent nurses anticipated procedures, tasks, and patient needs.Organization ToolsAll the nurses used an organizational tool such as a worksheetThe advanced beginners were less skilled in using a tool effectively as they had difficulty determining what was important to include.The competent nurses had developed a worksheet or method of using a worksheet that fit the individual nurses style and modified it to fit the assignment. They took time at the beginning of the shift to record information in a way that helped them stay organized, often coming in early to allow time for information gathering.The expert nurse used organizational tools in a very deliberate fashion. A detailed worksheet with careful organization of each patients data was created.

CommunicationThe advanced beginners oriented it to the patients immediate needs.The competent nurses were able to communicate based on anticipated problems or needs and their communication with other nurses was consultative in nature.The expert nurses communicated with everyone constantly consulting and clarifying aspects of patient care to meet all the patients needs. Using therapeutic communication.Integration of RolesThe advanced beginner limited teaching to the patients concerns and made a special trip into the room.The competent addressed immediate concerns and was more likely to include family in instruction, often while assessing the patient.The expert takes a holistic approach to teaching, often anticipating what the patient may need to know for discharge or home care.

Response to the EnvironmentThe advanced beginner experienced stress and perceived some events as crises.The competent nurse mentioned that they have days which are stressful, but have ways to avoid getting stressed outThe expert nurses simply did not discuss getting stressed out or mention experiencing crises.Research LimitationsSmall sample sizeImplications for PracticeAs the nurses progressed in expertise, they were better able to organize, more effectively deal with interruptions, anticipate patient needs, integrate varied nursing roles into their work, and communicate effectively.Critical ReflectionThe result of this research was aimed to nurse educators and administrators to examine approaches to increase the students ability to organize, prioritize and communicate. CULTURAL COMPETENCE OF NORTH CAROLINA NURSES:A Journey from Novice to Expert

Theoretical Nursing Framework for the StudyBenners stages of novice to expert were paired with the stages of the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals (IAPCC) developed by Campinha-Bacoti. IAPCC along with Benners stages were linked as follows: culturally incompetent range were novice, culturally aware range were advanced beginner, culturally competent range were competent, culturally proficient range were proficient.IAPCC scores range from 20 to 80.Culturally incompetent scores range from 20-39, culturally aware range from 40-59, culturally competent range from 60-74 and culturally proficient at 75-80.Background Variables Data Sheet (BVS) were also used to collect demographic data (age, gender, ethnicity, educational background, amount of inclusion of culture content in basic nursing program, and years of nursing experience)The BVS also requested information on any paradigm cases.

Rationale for Use of Nursing TheoryTo assess the cultural competence of students attending RN-BSN or BSN-MSN programs in North Carolina or those employed in and educational institution or a health care agency.

Research Studies SelectedCultural Competence of North Carolina Nurses

Research Findings71 participants; however only 66 were usable (93%)Majority of participants were female (97%) and white (92.4%)Highest age group participating was from age 20 to 50Least age group participating was from age 51 and upHalf of the participants had associates degrees as their highest level of educationOne third had more than 20 years of nursing experience (28.8%)58 of the participants reported that their nursing education included some cultural diversity (87%)42 participants reported getting information on cultural diversity from on the job in-services. (63.6%)IAPCC scores ranged from 39 to 72 (with a mean of 53.05) indicating that the group was at the level of cultural awareness congruent with Benners advanced beginner stage.10 scored at a level of culturally competent (Benners competent) (15.2%)Only one scored culturally incompetent (1.5%)

Critique of the Research

Small sample sizeA larger nationally represented sample would have provided a more diverse result.

Implications for PracticeThe faces of our patients, care providers and staff our changing. With our changing demographics it is essential that we are culturally competent. By becoming culturally competent we not only provide better care to our patients, we can maintain accreditation for our institutions in which we work. Providing in-services on cultural diversity will help improve quality care and patient outcomes.

Critical ReflectionIt is important to integrate research into our nursing practice because by conducting research we provide evidence for the changes made in our nursing practice. By using nursing theory in conduction of research it helps again to provide evidence for changes made in our nursing practice. As nurses we base our practice on nursing theory so what better way to integrate research with nursing practice than to have nursing theory be incorporated into the research.

Novice to Expert Model

The Clinical Practice Developmental Model: The Transition Process

Description of nursing model/theory in research study utilizedThis medical center went from a clinical advancement ladder to the Clinical Practice Developmental Model Nurses gave a narrative of their clinical practiceNarratives identified clinical practice behaviors and placement on a nursing developmental continuum (Nuccio, et. al., 1996)These narratives were compared to the model for advancement (Nuccio, et al., 1996)

Rationale for Use of Nursing TheoryNurses believed that the use of this model would make nurses contributions toward patient outcomes and organizational goals more visible and valued in terms of promotional reward and professional recognition (Nuccio, et al., 1996)Enable nurses to clearly describe nursing practice and create a framework to guide professional clinical growth (Nuccio, et al., 1996)Practice Area of this Study600 bed medical center90% of nursing areas representedResearch FindingsA possible need for changes in the organization by a shift of emphasis toward direct patient care activities and understand the shifts contributions toward patient outcomes (Nuccio, et al., 1996)Restructuring care delivery system to focus on nursing behaviors that address quality patient outcomes (Nuccio, et al., 1996)Defined nursing practicesResearch LimitationsSome of the nurse responses were anger and leaving the organizationResearch involved only medical center

Implications for PracticeHelps define the nurses roleHelps determine where the nurse is at in her/his professional developmentHelps to set appropriate professional goals

Critical ReflectionThe results of research on nursing models help hospitals with better patient outcomes, employee satisfaction/retention, and helps nurses set appropriate goals.

A Clinical Advancement Program Evaluating 10 Years of Progressive Change

Description of nursing model/theory in research study utilizedThis study shows the evolution of a clinical advancement program, UEXCEL, at a western teaching hospital and the outcomes associated with evaluation over time.Rationale for Use of Nursing TheorySustaining a clinical advancement program represents a challenge in the current healthcare environment. Critical strategies, so that progress can be achieved, are institutional commitment, staff involvement in revisions, and activities to improve professional nurse development.

Practice Area of this StudyA 23-item clinical ladder satisfaction scaleData was collected in 1993, 1994, 1996 and 1998 using standard survey methodsSubjects were registered nurses holding clinical positions at the University of Colorado HospitalPrimarily female respondent group, most on rotating shiftsMore than 55% working between 5 and 10 years at the hospitalSample nursing population was 56% BSN, 25% Associate Degree Nurse, 18% diploma 2% Masters of Science in Nursing

Research FindingsAt first there were reported low levels of satisfaction, stimulating a series of meetings to gain nurses feedback for revising the program and a to reconstruct program components.Some of the revisions are as follows:Streamlining the categories from seven to fourRewriting the standard to incorporate clearer language and defining levels of practice more specificallyOperating room nurses, consistently recorded the lowest satisfaction scoresHas the fewest number of baccalaureate-prepared nursesProved to be the most challenging group of nurse employees to engage in professional activities

Research LimitationsSmall sample size

Implications for PracticeA steady increase in nurse satisfaction with the UEXCEL program has been shown. After each revision of the program, satisfaction has improved.Sustaining a clinical advancement program represents a challenge in our healthcare environment.

Critical ReflectionThe result of this research was aimed to report the evolution of a clinical advancement program, UEXCEL. This program was initiated in 1989 to provide a professional framework for developing, evaluating, and promoting registered nurses.

HmmmExpert to Novice: Clinicians Learning New Roles as Clinical Nurse Educators

Derived from a research journal from the National League for NursingBackgroundThis article shows an evaluation of nurses that are experts in their area of nursing who become novice nurses again while taking on the role of nurse educatorsDue to the current shortage of nurses and nurse educators, a study was performed to examine how well expert clinicians could do when taking on the role of a novice teacher

Research Study Details45 participating individuals are people who met a high-level of excellence in their field of nursing and will attempt to teach/precept other non-expert nursesUtilized in this study was the Clinical Nurse Educator Academy, which was designed to give a small amount of preparation to these expert nurses before taking on their new novice roleEach person involved had four days of seminars with experienced educators Each person was to write three reflective papers describing their process of learning new skills as a clinical nurse educator (Cangelosi, et al, 2009)Each person was to answer three questions to aid in helping the authors decide if experienced nurses would do well with teaching others without extensive training in the field of educationAll participants were at the baccalaureate or masters level

Patricia Benners Theory: Novice to ExpertPatricia Benners theory was the framework of this studyShe suggested in 1984 that when nurses move from a known area of practice where they have already gained expertise to a new one, they become novices again (Cangelosi, et al, 2009)

Participants ThoughtsThe movement produced by this study created tension and anxiety, which is obvious by excerpts declared in the article by participantsWhen comparing the reflective papers turned in by the participants it was clear that in most cases they expressed enthusiasm for the roles as nurse educators, but they consistently expressed feelings of frustration at the lack of mentorship that they had receivedAfter analyzing the 135 reflective narratives, three themes were identified:

Buckle Your SeatbeltI am buckling my seatbelt to explore the educators role

Embracing the NoviceIn order to learn, one must start at a position of incompetency, which can be very uncomfortable. This is why people stop learning. They cant stand exposing the fact that they dont know something

Mentoring in the DarkWe were expected to do well since we are usually very competent in our practice. I did the best job I knew how to, but I am just muddling throughComments made by the persons partaking in the study helped to evolve the names of these themes (Cangelosi, et al, 2009

Participants Thoughts Cont.What appeared to be most difficult for people involved was that their confidence level in doing things correctly with their patients was not there with the students they now needed to teach.Feelings of incompetency aroseMany discussed the difficulties involved with leaving their safety zonesOn the other hand some stated that becoming novice in practice again, as when they began a nursing career, made them feel young again Some expert nurses believed that they had completely failed at the task at hand stating, As educators we could have made a difference for these students, but we didnt, and now we have a few less future nurses because of it (Cangelosi, et al, 2009)

ConclusionIn conclusion, the authors declared it was clear that a nurse who is proficient in clinical practice is not necessarily proficient in teaching clinical skills to others. Teaching is not a natural byproduct of clinical expertise and requires a skill set of its own (Cangelosi, et al, 2009)

ReferenceCangelosi, P.R., Crocker, S., & Sorrell, J. M. (2009). Expert to Novice: Clinicians Learning New Roles and Clinical Nurse Educators. Nursing Education Perspectives, 30(6), 367-371.Krugman, M., (2000). A Clinical Advancement Program: Evaluating 10 Years of Progressive Change. The Journal of Nursing Administration. 30(5). 215-225. ISSN: 0002-0443 Nuccio, S., Lingen, D., Burke, L., Kramer, A., Ladewig, N., Raaum, J., Shearer, B. (1996). The Clinical Practice Developmental Model: The Transition Process. The Journal of Nursing Administration 26(12), 29-37. Retrieved from CINAHL database.Lampley, TM, Little, KE, Beck-Little, R, & Xu, Yu. (2008). Cultural competence of North Carolina nurses: a journey from novice to expert. Home healthcare management & practice, 20(6), 454-461. doi: 10.1177/1084822307311946 Retrieved from http://hhc.sagepub.com/content/20/6/454Burger, J.L., Parker, K., Cason, L. Hauck, S. Kaetzel, D. ONan, C., White, A. (2010). Responses to Work Complexity: The Novice to Expert Effect. Western Journal of Nursing Research. 32(4). 497-510. doi: 10.1177/0193945909355149