assignment to share 2 - Benner -from novice to expert

 1.0      Introduction

The successful nurse will go through various phases of experiences in their work until the end of their nursing career. Based on my experience as a nurse, the first day in the clinical area is an unforgettable memory for conquering fear, stress and self-excited. Godinez, Schweiger, Gruver, & Ryan (1999), cited by Barbara (2004), also said that the shift from new graduate to the registered nurse  role is perhaps the most stressful and crucial part of the transition into professional practice. After few years later, I have become efficient and confident in the operating and managing of patients and ward. I have been able to see patients in a holistic manner and understand what patients needs based on their illness.

 If all nurses through the same experiences, this phases can be described scientifically in Benner's theoretical model and illustrated in Figure 1. Before the scientific formulas develop, Benner stated that knowledge development in a practice discipline  consist of extending practical knowledge (know-how) through theory-based scientific investigations and through the charting of the existence ‘know-how’ developed through clinical experience in the practice of that discipline.

Benner (1982) patterned her work on the Dreyfus Model of Skill Acquisition (1980) and found that model can be generalized to nursing. In the acquisition and the development of a skill, a profesional passes through 5 levels of proficiency which are novice, advance beginner, competent, proficient and expert. The performance level can be determined only by consensual validation of expert judges and the assessment of outcomes of the situation. The Benner Model has been used intensively as rationale for career development and continuing education in nursing. Areas specifically cited for utilization include nursing management, career development, clinical specialization, staff development programs, staffing, clinical internships, and precepting students and novice nurses (Benner, 2001).

Novice - New qualified nurse was ready to face new tasks in the clinical  and need close supervision

 

Beginner - Beginner nurse  with her nurse supervisor during preparing medication

 

Competence – Competence nurse examine the patient and do nursing plan  with her own judgment

  

Proficient – The  nurse give full responsibility for her own work

Expert –  Expert nurse give holistic care, health education, do referral, and suggestion to the patient regarding their medical illness.

   nursing activities in accordance with the Benner’s theoretical Model 

B. Adaptation of Novice To Expert in clinical area

Table 1 : Novice to Expert scale

From the profesional standards for conservation, Institute of Conversation (London) 2003. Based on the Dreyfus model of skill acquisition

Does nursing experience matter in relation to outcomes and patient satisfaction? Intuitively, most nurses and nurse leaders would say yes. One important factor that contributes to nursing quality is the nurse's years of experience in nursing (Aiken, Havens, & Sloane, 2009; Dunton, 2007). Tacit (skill) knowledge, better known as 'the how to' knowledge, in contrast to theoretical knowledge, is acquired primarily through experience, including observational experiences, preceptorship learning opportunities, and working with mentors (Evans et al., 2006).

 The National Database of Nursing Quality Indicators (NDNQI) was established by the American Nurses Association in 1998 to identify and promote nursing's role in quality outcomes (Dunton & Montalvo, 2009) and from their data base on a study of  “Keeping Patient Safe” indicated that for every increase of one year in average Registered Nurse experience, the fall rate was lowered by 1% lower.

Benner observed that profesional advancement along a hierarchy of thinking, judgment, behavior, and experience differentiates one level of practice from another. Differentiation among the levels is  determined by the nurse’s experience and theoretical knowledge (Waldger & Olson, 2007).

Level one is novice. According to Benner (2001), novice define as a beginner with no experience in to practice. The nurses in this stage describe as one has no background experience of the situation in which one is involved, so that context-free rules and objectives attributes are required for safe entry and performance in the situation. It is unusual for a graduate nurse to be a novice, but it is possible. For example, an expert nurse in renal would be a novice in a neonatal intensive care unit. Many first-year nursing students will begin at the novice stage (Benner, 2001). Novice focus on the immediate needs for action for a clinical situation based on rules, protocols and practice structures such as flow sheets or structured documentation (Benner et al. 1992). The focus of their practice is the organization and prioritization of their tasks. In this case, novice nurse always ask the senior nurse “what to do to now, what to do next?”. Daley (1999) has reported that novice nurses tend to learn through formal training, such as review of policies and procedures and attendance at educational offerings. In contrast expert practitioners supplement formal learning with a mature knowledge base that they have developed over a period of years.

Example situation : A novice nurse is faced with the request of the husband of intubated patient in intensive care to bring his 5 years old children to see his wife, even though it is against  hospital protocol to allow children enter in critical ward. The novice is very uncomfortable wih the request because it against the rules. The novice denies the request, citing the hospital rules.

Level two is Advance Beginner. Advance Beginner define as the one who can demonstrate marginally acceptable performance. They can base their actions on both theory and principles but tend to experience difficulty formulating priority. The advance beginner nurse who has coped with enough real situations to note, or to have pointed out by a mentor, recurring meaningful situational components. The advanced beginner has enough background experience to recognize aspects of a situation (Benner, 2001). Nurses functioning at this level are rule-guided and task-completion orientated and have difficulty grasping the current patient situation in term of the larger perspective.. Benner places most newly graduated nurse at this level.

Example situation : When faced with the same situation as the novice nurse and the husband of intubated patient in critical care, advanced beginner is still likely to deny the patient husband request, but the nurse also has an understanding the feeling of the patient husband and his 5 years old children to the patient. The nurse understand that the important of the  psychological support from the relatives to the patient. The advance beginner suggest that the husband wait until the patient look more stable then maybe can allow the young visitor after discus with the senior and doctors.

Level three is competent. According to Benner (2001), competent nurse usually have 2 to 3 years experience in a setting. As a result, they feel competent, organized and efficient most of the time.  Competent nurses focus on organization of tasks and care plans. The competent nurse begins to recognize the limitations of protocols and practice structures. These feeling of mastery are  a result of planning and goal-setting skill and the ability to think abstractly and analytically. The competent nurse spends a few moments at the start of his or her shift, examining the needs of each patient and start planning fundamental care. At this stage, the competent nurse understand that situations changed quickly and that planning is the best way to ensure that care gets implement even when emergencies or unexpected events arise.

Example situation : When faced with the same situation as the novice nurse and the husband of intubated patient in critical care, this nurse may or may not allow the husband to bring his 5 years old children to visit the patient, however the nurse will examine the needs of everyone carefully, for example the effect in psychology.

Level four is Proficient. Proficient nurse usually have three to five years experience in the same practice. These nurses are able to see patient holistically. Proficient nurses are better able to see changing relevance in clinical situations. This ability to read the clinical situation quicker allows the proficient nurse to establish situation-specific priorities (Benner et al. 1992 cited in Basavanthappa, 2007). They can focus on long-term goals and desire outcomes. These experienced nurses are likely to be leaders on their Units, having a wealth of experience and commitment to nursing. The nurses concern with the patient outcomes rather than institutional rules.

Example situation : When faced with the same situation as the novice nurse and the husband of intubated patient in critical care and their needs to be close as well as patients at critical moments. This nurse is likely to allow the “rules” to be broken in difference to the needs of the family.

The fifth level is expert. Benner described the expert nurse as having an intuitive grasp of the situation and as being able to identify the region of the problem without wasting consideration on a range of alternative diagnoses and solution. The expert nurse has his ability of pattern recognition based on deep experiential background. For the expert nurse, meeting the patient’s actual concerns and needs is of utmost importance, even if it means planning and negotiating for change in the pelan of case (Basavanthappa, 2007). There is almost a transparent view of the self (Tomey & Alligood, 2002).

Example situation: The expert nurse will give the permission to the husband to bring his daughter  in Intensive care. The expert nurse have clear objectives that patients should receive holistic care that include   physical as well as psychological support. The expert nurse also emphasize on the advantages and disadvantages of taking the child in the hospital area, but always use discretion approach in dealing with the situation.

Management of novice to expert nurses in University Kebangsaan Malaysia Medical Centre (UKMMC)

UKMMC is one center of excellence. UKMMC mission is:

“UKM Medical Centre is dedicated to providing excellent service and quality education and to conducting research within modern, advanced and cost effective medical facilities”.

As a major component in PPUKM, the UKM has prepared plans for nursing to achieve its mission of excellence through Nursing Department. In general, the plan of excellence emphasize  in the advancement of knowledge and skills from novice to expert.

Nursing management action plan by the Department of Nursing

Department of Nursing is responsible for managing all nurses in clinical areas, from novice nurses to nurse expert. For new nurses (novice), an orientation program will be implemented. The purpose of the orientation program is to introduce the novice nurses about the organization at UKMMC especially nursing organization. They will also be exposed to information about the rules of the organization, pay scheme and other facilities. This information is necessary to attract and motivate new nurses into the working environment. Upon completion of orientation week, new nurses will be placed in clinical areas where there head nurse and clinical nurse specialist has been prepared as a mentor. Professional 'apprenticeships' and nurse residency programs have also been proposed to speed the progression of new nursing graduates along the experience trajectory (Pine & Tart, 2007). Orsolini-Hain and Malone (2007) have encouraged long-term mentorships

As a mentor, new nurses will be explore one by one on the clinical area, the management of patients, how to interact with the patient and family members, colleagues and other professional groups such as doctors and other support staff such as dietitians, pharmacists and others. They will be shown all of the files of rules and guidelines and patient care wards. Mentor always with the new nurses in performing tasks and demonstrate the proper treatment procedures such as giving medication procedures. For example, if patient requires a new intravena line to be started, the mentor should informed the novice nurse that this is to be done and then review the steps required to start new line using the evidence-based clinical practice standard followed on the unit. This allow the novice nurse to ask question and obtain guidance. This enhance the like hood that the task will be performed correctly the first time, improving the patient satisfaction and self confidence to the novice. An experienced nurse may assess the same patient as an inexperienced nurse but respond differently based subtle changes that serve as a forewarning of significant, underlying issues. Multiple experiences of observing cues, and recognizing patterns related to patient status that need to be acted on in specific ways, lead to higher levels of clinical performance (Burritt & Steckel, 2009).

As a profesional nurse grows in leadership readiness, the mentor should shift to a coaching style where staff are rewarded with increased relationship behavior, that is, positive reinforcement and socio emotional support. Then, when individuals reach the higher levels of leadership readiness, as a proficient or expert nurse, the mentor moves first to participatory, supportive style characterized by a high quality working relationship with proficient staff and a lower need to give task direction. The mentor moves to a style of more complete delegation, communicating a sense of confidence and trust. Motivation will be given to stimulate the spirit of new nurses. As a mentor, staff development will be recorded on the development of staff  chart. Examples of evaluation staff development charts are shown in Table 1. Notes on development of new employees is important to see the development of individual knowledge and skills and to plan further action.

KNOWLEDGE	Evaluation of Staff Development in Ward
	3 MONTH	6 MONTH	1 YEARS
Skill

               Table 1 : An Evaluation of staff Development Chart in Ward, UKMMC

Throughout the process from novice to expert nurse, the nursing department plan and encourage the nurse for higher education such as Post Basic, Bachelor and Master. Technical courses are also planned to enhance technical skills. Although nurses have reached the level of competent, proficient and expert, the role of mentor are still needed. Mentor serves as a reference, motivation and a place to talk about things that lead to the betterment of the organization.

Annual assessment of staff is one of how to evaluate employee performance. Only mentors who can assess the level of staff development as a source closest to the staff. Performance appraisal can have a profound effect on levels of employee motivation and satisfaction and for better as well as for worse. Performance appraisal provides employees with recognition for their work efforts.

Through this method, the nurse from novice to expert will compete to be the best and get update with  latest knowledge to be assessed by the assessor. To nurse expert level, performance appraisal is necessary for the purpose of promotion. For advance beginner nurses, if performance appraisal is good, they will be entrusted with the responsibility as shift team leader. For the competent and proficient nurses, a good performance appraisal can be considered for the trust as a clinical preceptor. The nurses maybe competent, proficient or even expert practitioners in a particular area of practice and becoming a preceptor may result in the registered nurse being classified as a novice in the relation of the new role as described by Benner (1984). Now, nursing college was given the responsibility to shape and guide the preceptor from novice to expert.

Nursing college (Nursing Faculty) preceptor development plan

Hospital and nursing school are incorporating simulation-based training. Students using patient simulation learn by participation, observation, and debriefing. This process stands in contrast to the lecture methodology, which involve passive learning. (Billings & Halstead, 2005).  Additionally, simulated learning experiences are now offered as an alternative to traditional measures of developing competency (Benner, Sutphen, Leonard, & Day, 2010). The Banner model is applicable to training faculty members in simulation because they will start at the novice stage when learning how to teach with high-fidelity human (HPS) patient simulation.

The goals is to train the expert clinicians and the plan is built on the novice-to-expert  model (Figure 1).

FIGURE 1 : Example of Faculty Development Plan, UKMMC simulation

In Level 1, novice trainee will be explore more on basic knowledge of simulation. The second level, intermediate trainee will be explored to the simulation concepts and allows the trainee to participate in writing scenarios, running simulations and debriefing a simulation and includes basic technological training of simulation. At Level 3, trainee will explore on specialized training such as  debriefing and advance technical skills. Finally, level 4, solidifies the trainers through a competency program, experience, willingness to serve, and commitment to teach in simulation (Waxman, 2009).

D.        Conclusion

Theoretical framework Patricia Benner has provided essential understanding of how knowledge and skills are acquired and directly applied to nursing practice, education, research and administration. Specifically, her work indicates a growing concern with the development of explanatory frameworks for understanding the nature of nursing practice and the development of nursing expertise.

In UKMMC, an adaptation of model has helped in the retention of new nurses and prevent the migration of nurses to other places other than a successful strategy to realize the mission UKMMC.

(Total words : 2790)

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