Evidence Based Practice using Theorist Patricia Benner

1. Evidence Based Practice using Theorist Patricia Benner Denise Lyon Courtney Madsen Dawn Kooiman Lynda Chase Yvonne Robles Barb Lentz

2. Response to Work ComplexityThe Novice to Expert Effect

3. Description of nursing model/theory in research study utilized This study builds on the work on skill acquisition, work complexity, and nurse competency. Rationale for Use of Nursing Theory The 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 nurse–patient interventions.

4. Practice Area of this Study 5 hospitals 23 RNs on cardiac/telemetry units – 8 classified as advanced beginners, 8 as competent and 8 as expert nurses A 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.

5. Research Findings Four themes emerged from the data that illustrated differences in responses to the acute care’s 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 reprioritization The 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 situations Competent 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

6. Anticipation Advanced beginner nurses anticipated immediate events such as scheduled procedures or tests. Usually reacting to a situation The competent nurses anticipated procedures, tasks, and patient needs. The competent nurses anticipated procedures, tasks, and patient needs. Organization Tools All the nurses used an organizational tool such as a worksheet The 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 nurse’s 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 patient’s data was created.

7. Communication • The advanced beginners oriented it to the patient’s 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 patient’s needs. Using therapeutic communication. Integration of Roles The advanced beginner limited teaching to the patient’s 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.

8. Response to the Environment The 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 out The expert nurses simply did not discuss getting stressed out or mention experiencing crises. Research Limitations Small sample size Implications for Practice As 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 Reflection The result of this research was aimed to nurse educators and administrators to examine approaches to increase the student’s ability to organize, prioritize and communicate.

9. CULTURAL COMPETENCE OF NORTH CAROLINA NURSES: A Journey from Novice to Expert

10. Theoretical Nursing Framework for the Study • Benner’s 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 Benner’s 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”.

11. Rationale for Use of Nursing Theory • To 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 Selected • Cultural Competence of North Carolina Nurses

12. Research Findings • 71 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 50 • Least age group participating was from age 51 and up • Half of the participants had associates degrees as their highest level of education • One 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 Benner’s advanced beginner stage. • 10 scored at a level of “culturally competent” (Benner’s competent) (15.2%) • Only one scored “culturally incompetent (1.5%)

13. Critique of the Research • Small sample size • A larger nationally represented sample would have provided a more diverse result.

14. Implications for Practice The 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.

15. Critical Reflection It 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.

16. Novice to Expert Model The Clinical Practice Developmental Model: The Transition Process

17. Description of nursing model/theory in research study utilized • This medical center went from a clinical advancement ladder to the Clinical Practice Developmental Model • Nurses gave a narrative of their clinical practice • Narratives 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)

18. Rationale for Use of Nursing Theory • Nurses 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)

19. Practice Area of this Study • 600 bed medical center • 90% of nursing areas represented Research Findings • A possible need for changes in the organization by a shift of emphasis toward direct patient care activities and understand the shift’s 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 practices Research Limitations • Some of the nurse responses were anger and leaving the organization • Research involved only medical center

20. Implications for Practice • Helps define the nurses role • Helps determine where the nurse is at in her/his professional development • Helps to set appropriate professional goals

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

22. A Clinical Advancement Program • Evaluating 10 Years of Progressive Change

23. Description of nursing model/theory in research study utilized This 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 Theory Sustaining 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.

24. Practice Area of this Study A 23-item clinical ladder satisfaction scale Data was collected in 1993, 1994, 1996 and 1998 using standard survey methods Subjects were registered nurses holding clinical positions at the University of Colorado Hospital Primarily female respondent group, most on rotating shifts More than 55% working between 5 and 10 years at the hospital Sample nursing population was 56% BSN, 25% Associate Degree Nurse, 18% diploma 2% Masters of Science in Nursing

25. Research Findings At 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 four Rewriting the standard to incorporate clearer language and defining levels of practice more specifically Operating room nurses, consistently recorded the lowest satisfaction scores Has the fewest number of baccalaureate-prepared nurses Proved to be the most challenging group of nurse employees to engage in professional activities

26. Research Limitations Small sample size

27. Implications for Practice A 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.

28. Critical Reflection The 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. Hmmm

29. Expert to Novice: Clinicians Learning New Roles as Clinical Nurse Educators

30. Derived from a research journal from the National League for Nursing Background • This 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 educators • Due 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

31. Research Study Details • 45 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 nurses • Utilized 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 role • Each 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 education • All participants were at the baccalaureate or masters level

32. Patricia Benner’s Theory: Novice to Expert • Patricia Benner’s theory was the framework of this study • She 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)

33. Participant’s Thoughts • The movement produced by this study created tension and anxiety, which is obvious by excerpts declared in the article by participants • When 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 received • After analyzing the 135 reflective narratives, three themes were identified:

34. Buckle Your Seatbelt • “I am buckling my seatbelt to explore the educator’s role”

35. Embracing the Novice • “In order to learn, one must start at a position of incompetency, which can be very uncomfortable. This is why people stop learning. They can’t stand exposing the fact that they don’t know something”

36. Mentoring in the Dark • “We 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 through” • Comments made by the persons partaking in the study helped to evolve the names of these themes (Cangelosi, et al, 2009

37. Participant’s 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 arose • Many discussed the difficulties involved with leaving their safety zones • On 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 didn’t, and now we have a few less future nurses because of it”(Cangelosi, et al, 2009)

38. Conclusion • In 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)

39. Reference Cangelosi, 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/20/6/454 Burger, J.L., Parker, K., Cason, L. Hauck, S. Kaetzel, D. O’Nan, 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