Abstract
In this midrange theory analysis, Patricia Benner’s Theory, From Novice to Expert, will be explored in relation to the transition from a new graduate to an expert nurse in the various roles and skills they must possess. This paper will explore and define Benner’s theory and how it relates to the current state of emergency room nursing practice. Many factors affect positive patient outcomes in a world where nursing practice changes daily based on new science, medicine, and technology. The competence of the nurse providing clinical care in the emergency room is the one factor that should not be wavering. Not only is an emergency room nurse faced with multiple roles within the department, they encounter numerous patient diagnoses, and must be skilled in recognizing urgency versus emergency.
Keywords: Competence, critical thinking, managing situations, competency, transitions in the Emergency room, Benner, novice, expert
An Evaluation of the Taxonomy of Competency of Nurses in the Emergency Room
Purpose. The intrinsic environment of the emergency room in the United States today constantly experiences rapid changes in health care delivery. Emergency room nurses have one of the greatest turnover rates in comparison to other specialties while the societal demands on the healthcare industry are greater than ever. These nurses are also faced with patients with various acuities of illness. They must be skilled in caring for minor illnesses such as common colds and viruses, and then quickly be able to care for a patient with a myriad of diagnoses who need critical care and attention. Despite these trends the competency of nurses continues to be challenged. “Patricia Benner studies clinical nursing practice in an attempt to discover and describe the knowledge embedded in nursing practice” (Alligood, 2014, p. 121.) She believes that experience accumulates with time, in relation to clinical practice and theory-based knowledge, and reflection back upon those experiences is what drives best practice. The purpose of her theory, From Novice to Expert, was to thoroughly document the transitions of nurse learning in order to better understand “the uniqueness and richness of the knowledge embedded in expert clinical practice” (Benner, 1983, p. 36). Benner’s goal is to have nurses survey a situation and record their clinical learning in order to guide theory, further perpetuating clinical practice.
Benner is able to apply the Dreyfus Model of Skill Acquisition to her studies on the transitions From Novice to Expert. This model is based on observations made from skilled chess players and pilots during times of high stress situations. Dreyfus’ Model provides a way to assess how a student learns through the progression of skills. This can be applied to a practitioner in a clinical aspect as well. If we are able to properly assess a nurse’s skill level we can also make sure we are assigning appropriate roles. One could also deduct the competency of a nurse, allowing them to correctly use learning methods that would be most appropriate to the learner. The theory is useful in an emergency room setting because it allows a charge nurse to allocate appropriate assignments based on education and skill level of the nurse in association to acuity of the patient. Benner’s model is describing five levels of skill acquisition and development: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, (5) and expert (Alligood, 2014). This model is based on a person’s movement and understanding through a situation, while also accounting for their educational background, allowing the nurse to blend educational and theoretical knowledge into one.
Application and Rationale to Practice. According to The Institute of Medicine Committee on Quality of Health Care in America, preventable adverse hospital events are now killing more people than breast cancer, AIDS, or motor vehicle accidents and is averaged to cost healthcare consumers $17 to $29 billon dollars yearly (Kohn, 2000.) Today’s world of bedside nursing in the emergency room is ever changing with new technology, higher acuity of patients, and a multitude of roles that are appropriated. In particular, Benner’s midrange theory, From Novice to Expert, can be applied directly to the emergency room setting. This theory describes the transition in skill level as a nurse gains more experience. Utilizing this information can ensure the proper assignment of patients based on experience of the nurse and acuity of the patient. Staff are stretched to the limits with higher acuity of patients, less support staff availability, and patient ratios that leave the nurse unable to give adequate care. Novice nurses are being introduced to the workforce and are expected to care for these patients as expert caregivers while also taking on other roles. These roles include classes such as triage training, emergency communication registered nurse training (ECRN), and charge nurse training to name a few. Registered nurses in the emergency room could be fatigued, underprepared, and emotionally drained after a typical shift, especially if they feel unqualified for their daily tasks. Care of high acuity patients without a degree of expertise can potentially place patients in harm’s way.
According to Kani-Pak, Aiken, Sloan, and Paghoysan (2008):
“As the patient population is aging and presenting with more comorbidities and nursing budgets are tightening, professional RN managers and staff are finding it necessary to examine quality of care more closely. For these reasons, more attention is being given to efficiency of staff and quality of care in the current health care environment. If appropriate assignments are not made, patients suffer from increased mistakes of nurses with inadequate judgment. More adverse events such as higher mortality rates occur and a lower efficiency of assignments may result if nursing assignments aren’t based on nursing education, experience, and patient acuity.”
Patricia Benner’s Levels of Competence exposes the different stages of proficiency a nurse surpasses in order to acquire a level of expertise. The theory bases skill level on years of service and knowledge achieved with proper utilization in application to real patient experiences. This transition occurs as the beginner moves from rule governed practice to more intuitive behavior later in practice.
Major Concept Definitions. The first level of competence as described by Benner is the novice. Merriam-Webster dictionary defines a novice as a person with no previous experience with something. This nurse has no actual experience in patient care situations and therefore must be monitored by a preceptor in order to have verbal cues on what tasks to complete. These practitioners are taught rules and are able to apply them to situations universally. This stage is more observational with no real analysis of any situation because they lack judgement and experience to draw from. In the emergency room this would be illustrated by either a new graduate nurse or a nurse new to the floor with no past emergency room experience. Typically, they are given a preceptor for a period of 8-12 weeks depending on where their experience lies. The preceptor can than gauge how much more learning a “student” must have prior to being off orientation.
The second stage of competence is known as the advanced beginner. This nurse has had time to learn certain basic skill sets and is able to accomplish them with minimal support from a more experienced team members. This stage has a continual growth of knowledge and application because the nurse begins to see her role as more of a process rather than task oriented based on previous experiences. This person has coped with enough real-life situations that this experience is the driving force in daily care of patients. In the emergency room, this would be a nurse in the middle of orientation. This nurse is able to perform basic tasks independently but still needs help in setting priorities and deciding what is a priority from a more experienced preceptor.
The third stage of nursing advancement is known as a competent. A competent nurse has been in similar roles for about 2-3 years and feels fairly confident in the tasks she or he performs daily. This person purposefully plans for their patients and is able to intervene efficiently. Organization and prioritization is based on deliberate planning because they concentrate more on outcomes rather than task orientation. The emergency room nurse at this level would be an independent practitioner that comfortably provides care but does not yet have the efficiency and flexibility of a more experienced practitioner. Most institutions aim their in-service guides at a practitioner of this experience level. This nurse gains the most from having simulations that help them to manage multiple complex patient care needs at once so they have a basis for actual patient experiences.
The fourth stage of nursing growth is the proficient nurse. This nurse is able to view the patient and situation as a whole in order to plan for long term goals treating the patient in a holistic view. This nurse pulls from past experiences to understand abnormal outcomes and intervenes when necessary. They are able to differentiate the difference between mundane versus important aspects of patient presentation after about four to five years of service. This emergency room nurse can question orders based on looking at the situation and planning ahead, utilizing similar experiences. They are able to see a situation and pick out what is the normal versus abnormal. Decision making is less difficult to this nurse because they are able to recognize what is the most pertinent aspect of the situation and prioritize accordingly.
The final stage of competence is the expert nurse. This is a nurse with multiple years of experience in a similar setting. This person is able to problem solve without wasting any time on unnecessary patient information. They are able to perform tasks fluidly and proficiently while also analytically breaking down patient situations they may have never come across before. They are able to intervene prior to unexpected outcomes based on the deep understanding of past experiences. During this time, a nurse is able to hone in on their intuition more to help guide their practice. These emergency room nurses are those that are frequently utilized by other staff for questions about nursing care or policy. They are able to look at a patient and though the nurse may not be able to verbalize ques that a patient is declining, they intuitively interact and intercept prior to patient deterioration (Benner, 1983).
These levels of the theory are able to overlap at incremental levels of expertise and background knowledge. The stages of competency occur in a linear fashion from one to the next. There is not a clearly defined passage from novice to advanced beginner and so on and so forth. Practitioners are exposed to varying patient experiences and are able to pull from this in order to propagate them into the next skill level. This is depicted in the images below.
“The other central concepts of Benner’s Model are those of competence, skill acquisition, experience, and clinical knowledge” (McEwen &Wills, 2014, p.223). Church comments that the World Health Organization (WHO) accredits deleterious patient outcomes when coupled with a deficiency in the competence of the nurse (2016). Competence is described by Church as “understanding of the disciplines knowledge, mastery of discipline specific skills, ability to use sound judgement, adherence to professional standards, and situational application of skills and knowledge.” Skill acquisition can be defined as the science that illustrates the movement of learning and implementation of that learned knowledge. Experience is also known as clinical practice and a development of knowledge based on those encounters (Arbon, 2004). Clinical knowledge is best described by Benner. She believes that clinical knowledge is gained from experience of practice, but it is shaped by the values and culture of nursing (1984).
ASSUMPTIONS. A few things must be understood when applying Benner’s theory of competence to clinical practice according to Alligood. The first assumption is that there are no interpretation free data. This means that all information gained is open to analysis from the one who is obtaining the information. For example, individual nurses may perceive information on the same patient differently. A novice nurse may interpret information completely different from an expert nurse. This is because people enter into situations with their own opinions and understandings. Another assumption that Benner has is that data cannot be nonreactive. This is because the nurses being studied are aware of it. When this happens, it cannot be guaranteed that their actions would be different or more “natural” if they were in a more relaxed, unobserved state. A third assumption discussed is the existence of meaning that is imbedded in the skill and intentions practiced by the nurse. Because this tends to be a smooth process this is not always recognized as knowledge. The fourth assumption of Benner’s theory is that those with a shared language and cultural base tend to find similar meanings behind concepts. Therefore, the meaning and understanding of the information gathered can then be validated with those of similar cultural background and language, however that does not mean that there cannot be differences in interpretation of the data. A fifth assumption of From Novice to Expert is that every situation can be more inherently complicated and detailed than any theory predicts. This means that no matter how many abstract guidelines one follows to guide practice, eventually extenuating circumstances will play a role in the decision making of the provider. For example, a patient can present in the emergency room with complaints of being exposed to a known allergy. A patient who comes in awake, alert, and talking can quickly deteriorate to an anaphylactic response requiring intubation. Different medications and treatments could be employed prior to the patient needing intubation, but the quickness of the practitioner at recognizing the need and actually retrieving and administering the medications is also a key component. The last assumption addressed is that expertise is domain specific (Mchugh, 2010). This means that if a nurse is an expert in labor and delivery, when she transitions to another department such as the emergency room she may be considered less competent. This is because she may understand the basic concepts of patient care but the direct care provided to this population would be much different than that she was considered expert
Evaluation of the Theory.
Clarity. Patricia Benner’s theory, From Novice to Expert, is clearly broken down in language that providers can understand and relate to. However, while the major concepts are defined they do not have clear time frames of passage from one level to the next. The theory also does not describe independent variables that affect the learning process. For example, an advanced beginner may need more guidance than another advanced beginner who has past experience as either a certified nursing assistant or emergency room technician. Being around similar patients and equipment prior to being a nurse in that field would make one more knowledgeable with these patients and supplies. Furthermore, Benner does not discuss if there are varying levels of expertise within each stage. Are there varying levels of competence for a novice prior to them transitioning to advanced beginner? One must ask how, in a clinical setting with the variables of experience, intelligence, confidence, workplace variability and educational background, that Benner can even attempt to quantify and qualify what it means to be an expert (English, 1993). Additionally, Benner does not discuss if every nurse reaches expert level. It should be stated that just because someone has thirty years of nursing experience that does not necessarily make them an expert based on individual factors. However, the way the theory is depicted logically makes sense for the flow of growth in terms of experience and skill level over a general timeframe. It allows for a universal framework that can be applied using its ideas and beliefs.
Plausibility. Benner’s theory can be utilized in numerous clinical settings. It helps to lay a framework that management, educators, and preceptors can utilize when training new staff and evaluating their performance. The theory can be applied specifically in the emergency room setting by evaluating level of competence of the nurse and matching acuity level of the patient as well. Learning that utilizes a simulation lab allows for an insightful learning experience that helps in preparation of connecting the practical knowledge to the theoretical knowledge. Utilization of the theory helps guide education, practice, and research.
Usefulness. Benner’s theory, From Novice to Expert, has been adopted by many schools as a foundation for providing education for nurses at different skill levels, as noted by English (1993). It has already been put into practice by multiple hospital administrations in the way of their orientation of nurse new hires, staff development, and recognition programs (Nelson and McGillion 2004). Understanding nurses’ varying levels of competence, simulation programs can be geared at laying a theoretical framework of actual patient situations and outcomes. It is also useful in education to help direct preceptor parameters. It helps a preceptor understand where a new hire should be performing, and allows management to set objectives suitably. Management and educators are more aware of the staff educational disparities and are able to develop competencies based on these requirements. Overall this is extremely useful when initiating staff development. Nursing is constantly changing and this midrange theory helps novice nurses to see that becoming an expert nurse is eventually attainable with further education and experience.
Testability and Empirical Evidence. According to Alligood, Patricia Benner collected empirical evidence to support her theory over the course of her career. She was able to compile questionnaires and interviews gathering interpretive information that helped to describe the differences in characteristics from the novice to the expert when faced with the same clinical picture (2014). From this research, Benner was able to describe multiple domains of the nursing role and function. These competencies can then be adjusted by individual hospitals to help guide nursing practice through the nature of clinical knowledge. Benner further conducted other studies which focused on gathering information regarding how nurses encounter a problem and their methods of problem solving. She deducted that more clinical experience one has the greater the skill of involvement appeared to be.
A Cumulative Index of Nursing and Allied Health Literature (CINAHL) search covering a period between 1986 through 2015 revealed over 700 English language listing of articles in nursing journals citing Benner’s model. For example, in 2008, Lyneham, Parkinson, and Denholm conducted an analytical study exploring the expert level of the nursing process in relation to practice development. In that same year Rischel, Larsen, and Jackson (2008) catalogued nurses’ competence in relation to their admission assessment.
In general, it appears as though the majority of the studies conducted using Benner’s model use qualitative methods. These are similar to the same methods Benner herself used when first conducting research. Benner felt that interpretive data best described nursing practice. “Nurses descriptions of patient care situations in which they made a positive difference present the uniqueness of nursing as a discipline and an art (Benner, 1984, p. 26). It remains difficult to test hypotheses related to Benner’s theory because clinical situations are inherently different and more complicated than proposed scenarios and it bases its framework on individual experiences rather something that can be measured or valued.
Application to Practice Setting.
Overview of Relation to Current Practice. Currently many emergency rooms require an orientation period that involves introduction to the hospital, policies, and unit as well as an orientation period of clinical practice at the bedside. This period can range from 12-24 weeks for a new graduate, or as little as 6-8 weeks for a more experienced practitioner (Kingsnorth-Hinrichs, 2009). In order to apply Benner’s theory in a practical way, one must start from the understanding of classifying novice from expert. A preceptor should be those ranked at an appropriate level of expertise. Nurses at this level of skill should be able to educate new staff about proper evidence based techniques of providing care as well as the knowhow of what a new nurse should be adept in assessing in order to prevent poor patient outcomes. Executing a training model based on Benner’s model helps to guide the structure for training and competency programs. While some hospitals have a class nurses must take in order to precept others do not. This could also be helpful in coaching preceptors to know at what level of performance the new nurse should be at and what skills they need to be accomplishing.
Nurses are also introduced to other roles while they are in the emergency department. For example, a triage nurse is the greeter who essentially assigns a level of acuity for who needs to be seen immediately versus those who are deemed safe to wait to see a provider while in the waiting room (Ebrahimi, Mirhaghi, Mazlom, Heydari, Nassehi, & Jafari, 2016). The responsibility of this person is of utmost importance. Their assessment skills of the verbal, nonverbal, and physical must be very keen so that they get the whole picture in a limited amount of time and transmit that information back to the charge nurse or physician. It is obvious to see why a novice nurse would not be appropriate in this position. The expert nurse is able to make rapid, accurate, and complex decisions. In order to ensure suitable staff are placed in this role, management can ensure that novice through competent nurses have at least one to two years’ experience prior to being placed in this function. Not only that, usually staff must complete a triage class and test, but it would be important for ongoing education, assessment, and verification of adequate triage assessment skills to ensure patient safety.
Another role nurses are faced with in the emergency room is the charge nurse. This nurse does not have a particular assignment, although she oversees the placement of patients as well as the operations of the entire floor (Ohio Nurses Association, 2016). It is pertinent that this nurse supervises what is going on in the individual rooms to make sure the staff are managing their patients. The charge nurse must have a strong background of clinical knowledge and skills on which to make sound judgements, manage nursing responsibilities, and zealous interpersonal skills to help expedite communications. Without a doubt, this nurse should be an expert in their field. They must be a resource for every other nurse on the floor, manage the acuities of the sickest patient, serve as a liaison between physicians and other staff, as well as processing the patients from the waiting room, to ambulances, and directly from clinics. This nurse must also be keen on when one of the staff is struggling with their patient load; the main goal is to ensure appropriate and optimal nursing care through proper nursing assignments.
A third role an emergency room nurse faces is called an emergency communications registered nurse (ECRN). This nurse is able to answer incoming calls from paramedics and other emergency medical services giving them directives on medications and treatment to initiate while still in the field. When reviewing policies for different hospitals it appears that hospitals generally request that a nurse has finished hospital orientation, has an advanced cardiac life support certification, and is skilled in reading electrocardiograms. Again, this would be best suited for a competent nurse or higher skill level. This nurse must be comfortable in communicating with prehospital emergency services and delegating tasks and redirecting them to more appropriate facilities. This nurse must also have experience with different situations in order to be competent in the types of medications and treatments and their side effects if they are to safely direct prehospital staff.
McHugh states that “organizations that facilitate a professional nursing practice environment foster clinical autonomy, support the continued education and advancement of nurses, increase the opportunity for shared experience and knowledge with physician colleagues, and provide support for professional decision making and action (2010). This is an extremely important concept for hospitals to practice because it promotes the best patient outcomes, reduces hospital costs by increasing nurse satisfaction and retention rate, as well as intervening prior to patient deterioration – potentially saving even more hundreds of thousands of dollars per year. It has been shown in studies that there is a link between the length of time a nurse has been practicing compared to the quality of care they are providing. (Blegan, Vaughn, & Goode 2001) One study found that the more experienced nurses had patients with lower mortality rates once discharged from hospitals within a thirty-day period (Tourangeua, 2006). This study further claims that every additional year of nursing experience lead to four to six few deaths per 1000 patients. Unfortunately, most studies regarding patient outcomes to nurse experience is related to education level more so than experience level in practice.
After reviewing numerous articles and studies utilizing Benner’s theory training of new staff might be more practical for nurses to be trained by a range experience levels depending on what stage of orientation they are in. One particular article, written by Kingsnorth-Hinrichs, detailed a plan set out by an emergency department for training new graduates. They found that their methods generated competent nurses, retained a more satisfied staff, while maintaining a conscientious orientation budget. Their method involved five stages which included a formal orientation to the main emergency department, a front-end assessment, resuscitation, precepting, and triage. Formal orientation was geared towards socialization, rules, clinical tasks, and assessment skills. These nurses were trained by other nurses in the competent stage of learning. This was because a competent nurse is thought to be able to relate to a new nurse’s fear and intimidation on the floor but will still be able to provide the socialization and proper modeling of patient care. The expert nurse may have a more difficult time trying to explain how they came to conclusions based on “intuition.” That being said, the proficient or expert nurse may be better suited to train a charge nurse or triage nurse of the proper techniques required of this role. The second part of orientation involved the front-end assessment. Nurses would pass to this stage after successfully meeting objectives in their formal orientation. During this stage, these nurses would be trained to do a more thorough assessment after a patient checked in at triage. From here the nurse could upgrade or downgrade a patient’s acuity level. The learner would get experience in these two areas for another six months. From this stage, they would be oriented to the resuscitation roles. This stage would discuss medications, equipment, and skills used during the resuscitation of a patient. The learner would then have to apply this information and present an assignment based on a real-life situation they were involved in utilizing the information they learned. The orientee works closely with the charge nurse to make sure they are given an opportunity to be assigned a patient in cardiac arrest while still in orientation to get this much-needed experience while still under the direction of a competent preceptor. The fourth phase of this training utilized these new graduates as preceptors for an incoming set of new hires. This is thought to enhance the learner’s knowledge by now encouraging them to teach new graduates the same skills, management, and roles they recently acquired. The last stage in this orientation program was learning the triage role. By this time, the new hire should be able to quickly decipher urgency versus emergency. This nurse should have had enough emergency experiences to base their decisions on.
Discussion.
In order to utilize Patricia Benner’s, From Novice to Expert, the discretion of management and educators must be factored. The theory does not have a defined beginning or end to any of the skill levels. Due to this, a nurse will respond to experiences and information in various ways. Someone with twenty years’ experience in the emergency room may not necessarily be as equipped with newer technology and advancements as someone coming from nursing school or a more modern facility who has recently learned newer techniques and equipment. Patricia Benner’s theory, From Novice to Expert, is general enough that it can be applied to many settings without changing the structure of the theory or making many modifications. Many factors must be considered when accounting for orientation of new hires, as well as the appropriate roles that nurses are being placed base on their past experience. It is vital for management and educators to know their staff in order to gage their strengths and weaknesses, promoting and developing their knowledge base in order to get to the expert level. Doing so will foster a caring environment which promotes nurse retention rats and encourages an inviting environment for staff to work in.