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From Novice to Expert

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LADANA BADGER

on 1 May 2013

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Transcript of From Novice to Expert

by LaDana Badger FROM NOVICE to NOVICE EXPERT Beginner
No experience
Knowledge is limited to textbook, not practice
Requires close supervision, i.e.- nursing student
Cannot deal with complex issues
Actions tend to be isolated

(WordPress, 2011) ADVANCED
BEGINNER Good working and background knowledge in area of practice
Practices based on purpose
Able to achieve most tasks with own judgement
Uses analysis and planning to handle complex situations
Focuses on goals of outcome instead of holistic care


(WordPress, 2011) COMPETENT Depth of understanding of discipline and area of practice
Routinely achieves fully acceptable standard
Accountable for own work and actions, sometime other's actions when necessary
Can see overall picture and intervene in complex situations holistically
Confident in decision making

(WordPress, 2011) PROFICIENT Deep understanding in area of practice
Can achieve Excellence with ease
Goes above and beyond the expectation with ease
Uses intuition and knowledge to handle complex situations holistically
Comprehends the big picture and searches for alternative approaches

(WordPress, 2011) Can complete straight forward tasks
Actions begin to become guided based on working experience
Can complete straightforward tasks at an acceptable level
Supervision needed for majority of tasks, but can complete some independently
Likes complex situations, but can realistically handle parts of it
Sees actions as a chain of steps
(WordPress, 2011) Metaparadigm in Nursing Environment Health Person Nursing Patricia Benner described nursing as an “enabling condition of connection and concern”. She elaborated by describing how “Nursing is viewed as a caring practice, whose science is guided by the moral art and ethics of care and responsibility”



(Alligood & Tomey, 2010, p. 148) Benner stated that a “self-interpreting being, that is, the person does not come into the world predefined but gets defined in the course of living a life. A person also has…an effortless and non-reflective understanding of the self in the world. The person is viewed as a participant in common meanings.”




(Alligood & Tomey, 2010, p. 148) Patricia Benner focused “on the lived experience of being healthy and ill”. She defined health as what can be assessed, while well-being is the human experience of health or wholeness.




(Nursing Theories, 2013) Instead of using the term environment, Benner used the term SITUATION, because it suggests a social environment with social definition and meaning. She used the phenomenological terms of being situated and situated meaning, which are defined by the person’s engaged interaction, interpretation, an understanding of the situation.




(Nursing Theories, 2013) Patricia Benner -Focus is on skills acquisition/ clinical judgement and applying them to nursing practice

-Developed 5 levels of capability amongst nurse
“Skill attainment requires an ordinal progression through these stages, and discrete capabilities reflect the stage of development reached. This incremental development is dependent on a combination of depth and range of clinical experience, which is positively correlated with the length of time spent nursing.”
(English, 1993, p. 387) Movement from reliance on abstract principles and rules to the use of past, concrete experiences




(Benner, Tanner, & Chesla, 1992) Passage from a detached observer, standing outside the situation, to one of a position of involvement, fully engaged in the situation




Benner, Tanner, & Chesla, 1992 Shift from reliance on analytical, rule-based thinking to intuition





Benner, Tanner, & Chesla, 1992 Change in the learner’s perception of the situation from viewing it as a compilation of equally relevant bits to viewing it as an increasingly complex whole, in which certain parts stand out as more or less relevant



Benner, Tanner, & Chesla, 1992 “Never become so much of an expert that you stop gaining expertise. View life as a continuous learning experience”
Denis Waitley (Nursetopia, 2011) Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th ed.). Maryland Heights, MO: Mosby Elsevier

Benner, P., Tanner, C., & Chesla, C. (1992). From beginner to expert: Gaining a differentiated clinical world in critical care nursing. ANS Advances in Nursing Science, 87(1), 23-31.

English, I. (1993). Intuition as a function of the expert nurse: A critique of Benner’s novice to expert model. Journal of Advanced Nursing,18, 387-393.

Nursetopia. (2011). ‘Star Wars’ flavor to Dr. Patricia Benner’s ‘Novice to Expert’. Retrieved from http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/

Nursing Theories (2013). Patricia Benner: Metaparadigm in nursing. Retrieved from http://nursingtheories.info/patricia-benner-metaparadigm-in-nursing/

Waitley, D. (n.d.) Personal statement. Retrieved from http://www.wisdomquotes.com/quote/denis- waitley-2.html

WordPress.com. (2011). Integrating theory and practice. Retrieved from http://apologyfornonsymmetry.wordpress.com/2012/01/04/integrating-theory-and-practice-8/ Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th ed.). Maryland Heights,
MO: Mosby Elsevier

Benner, P., Tanner, C., & Chesla, C. (1992). From beginner to expert: Gaining a differentiated clinical
world in critical care nursing. ANS Advances in Nursing Science, 87(1), 23-31.

English, I. (1993). Intuition as a function of the expert nurse: A critique of Benner’s novice to expert
model. Journal of Advanced Nursing,18, 387-393.

Nursetopia. (2011). ‘Star Wars’ flavor to Dr. Patricia Benner’s ‘Novice to Expert’. Retrieved from
http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/

Nursing Theories (2013). Patricia Benner: Metaparadigm in nursing. Retrieved from
http://nursingtheories.info/patricia-benner-metaparadigm-in-nursing/

Waitley, D. (n.d.) Personal statement. Retrieved from http://www.wisdomquotes.com/quote/denis-
waitley-2.html

WordPress.com. (2011). Integrating theory and practice. Retrieved from
http://apologyfornonsymmetry.wordpress.com/2012/01/04/integrating-theory-and-practice-8/ MY PREVIOUS EXPERIENCE Benner's levels of skills acquisition are of great value to nursing because it can be used as a guidelines to grow expert nurses. I was not 'thrown to the wolves' after my internship, but I would have greatly benefited it we had followed Benner's definitions of what to expect from a novice, beginner, competent, proficient, and expert nurse. Like I previously mentioned, most of night shift staff tends to be the least experienced nurses. I became great at what I do because I learned from my mistakes, not from someone else's expertise.
When I was in the competent stage,I felt too confident with my knowledge and skill level. My patient told me that with her other 2 children that she is typically ready to deliver as soon as she feels pain. I heard her, but I did not take heed to what she was saying. A few hours later, she calls out in pain. So routinely, I check her cervix and give her pain medicine and expect her to go back to sleep (like everyone else). Needless to say, I delivered her baby 15 minutes later in the hallway by myself. She did not get her epidural that she wanted and her husband was not present for the birth of his child.
Now that I am an expert in the OB field, I know that I did not know enough at the time to be confident. Each patient's situation is unique and I should not have handled this as a routine matter. I should have listened to my patient and I should have listened to my intuition. Now, I understand instinct and intuition so much better as Benner describes it as a mark of an expert. I learned from my mistake and have never made that mistake again.
I had to go through each step just by learning from experience. Many mistakes would have been avoided if these stages had been identified in each nurse and we were guided through the various stages. As a Women’s Center nurse educator and part of upper management, I could use Benner’s levels of skills acquisition to guide preceptorships.

1.Seek out expert preceptors
Each nurse should rate his/herself based on Benner's definitions of novice, beginner, competent, proficient, and expert. During skills day, set up a simulation lab. As a part of the nurses' annual competency, check off each nurse and grade them from novice to expert based on Benner’s skills acquisition. This helps identify the nurses that would serve as the greatest resource to the interns.

2.Train the proficient and expert nurses
In an preceptor class, we would train the preceptors on how to teach each intern depending on the level the interns may be at. The interns are expected to be at a novice level, but there may be some experienced nurses that are new to the OB setting. The preceptor class will focus on how to properly teach the novice and beginner levels.

3.After the internship, staff based on the various levels
Most interns get placed on night shift. So the night shift tends to be the most inexperienced nurses. When staffing, make sure that there is an even mixture between novice to expert nurses. There is no good example for a novice nurse if there is only novice and beginner nurses on the shift. The key is to make sure that there is always a proficient and/or expert nurse available. This will help progress the least experienced nurses through the different stages. APPLICATION TO EDUCATION APPLICATION TO OBSTETRICS Novice Nurse Expert Nurse Competent Nurse Proficient Nurse Beginner Nurse Allow the novice to shadow the preceptor all shift

Provide consistency for the novice

Set clear, detailed expectations that are task oriented, i.e.- by the end of the shift, you will have placed 2 patients on the fetal monitors

Remind the novice nurse to focus on care of the patient, not just completing the skill

Organize tasks for the novice

Provide a checklist on how to properly set up a room for a scheduled induction

Provide tools that help memorization, i.e.- VEAL CHOP for memorization of decelerations and their causes

Variables Cord Compression
Early Head Compression
Accelerations OK
Late Placental insufficiency

Care plans- have the novice nurse to write out a care plan for preterm labor

Recognize that students need to gain confidence- give tasks that they can be successful at, i.e.-placing a patient on the fetal monitor, doing a blood sugar Serve as a continual resource for nurses that have not reached expert level

Continue to gain knowledge

Seek out learning opportunities, and look for CE opportunities, i.e. - attend AWHONN and ACOG conferences, learn new drugs or new research studies.

Be aware that:

An expert can still be a novice when dealing with new information, i.e.-new evidence based practice, new drug, new technique.

An expert is not perfect; mistakes can still be made. So do not get complacent.

Take on a leadership role within the unit, i.e.- management, supervisor, OB council No longer on an internship, but will be supervised by a charge nurse

Encourage independence.
Not necessary to shadow a competent nurse. Allow them to act autonomously and remain available as a resource.

Suggest alternatives. Allow the nurse to make decisions on his/her own, but suggest other methods.

The competent nurse may challenge other’s decision making and alternatives, especially prioritization.

Be aware that this is a normal part of the process.

After the situation is over, discuss rationale with the competent nurse and allow them to reflect and how it could have been done more efficiently

Promote teaching on OB related topics.

Have the competent nurse to teach a class, i.e. - class during skills day, NRP or charge can listen in on a detailed breastfeeding education or discharge teaching. You learn so much more through teaching. Have the beginner to explain specific diagnosis in their own words.

Help with psychomotor skills.

Allow them to do the skill on their own, but shadow them during skills, such as IV starts, vaginal exams, monitor positioning.

In spare time, practice skills

Connect interventions with rationale. The beginner is dependent on the skilled nurse’s knowledge.

Allow them to complete skills, but help with the rationale for the skill.

Allow time for simulation

Quiz the beginner on interventions, i.e.- If the patients starts having contractions, what are is your priority intervention?

Allow them to attempt to prioritize patient load based on report.

Who should you see first? Why?

Teach based on examples that they are familiar with, i.e.- based on their current patient load

Provide learning opportunities. Allow students to make decisions on their own, good or bad. We all learn from what we do wrong, more so than what we do right. (of course not at the risk of the patient) Continue to promote independence.

Allow them to act autonomously and remain available as a resource.

Has a tendency to become complacent.

Assign more complex patients. Consult on complex situations to promote critical thinking.

Encourage the proficient nurse to be a role model for newer nurses.

Take a preceptor class and become a preceptor.

Promote professional advancement.

Moving up the clinical ladder or achieving RNC. Martin Heidegger
(the concept of self) Richard Lazarus
(stress & coping) Jane Rubin
(scholarship, teaching, colleagueship) Stuart & Hubert Dreyfus
(model of skill acquisition) Virginia Henderson
(thinking in nursing) Influences & Origins of Thought Patricia Benner’s Work Benner herself said, “I’m awfully glad this is a ‘Living Legend’ award, because I’m not finished yet” (Austin, 2012). 2011 – American Academy of Nursing
“Living Legend Award” 2010 – President’s Award for Creativity and
Innovation in Nursing Education 2008 – Retired from full-time teaching 2007 – UCFS Nursing Centennial Wall of Fame 2004 - American Association of Colleges Nursing
Pioneering Spirit Award Leadership Award 2003 – Institute for Nursing Healthcare 2002 – Award for outstanding contributions, NCSBN Wisdom in Critical Care: A Thinking-in-Action Approach) 1999 – AJN Book of the Year (Clinical Clinical Judgment, and Ethics) (Expertise in Nursing Practice: Caring, 1996 – AJN Book of the Year Lecture Award 1995 – Helen Nahm Research Stress and Coping in Health and Illness 1989 – AJN Book of the Year (The Primacy of Caring Leadership in Education 1989 – Linda Richards Award for of Nurses 1985 – Inducted American Academy Clinical Nursing Practice) (From Novice to Expert: Excellence and Power in 1984 – AJN Book of the Year 1984 – Dissertation published Berkley (emphasis Stress, Coping, & Health) 1982 – Ph.D. University of California 1979 – Teaching & Research UCSF 1970 – MSN Nursing UCSF
(emphasis Medical Surgical Nursing) 1964 – BSN Nursing Pasadena College Born Hampton, VA; raised in California
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