Author's Note: This article is dedicated in loving memory of Sheryl Jenkins-Bates, BSN (LaSalle University, Class of 2006)-A great friend, classmate and nurse.
According to Merriam-Webster's New American Dictionary, a novice is defined as someone who is "inexperienced or untrained" and an expert is "highly skilled or knowledgeable." Nursing is a very noble profession and those who carry the title of RN must understand that they can influence change in the world by choosing to practice safely, competently and compassionately. With this in mind, how does a novice nurse acquire the essential experience, training, skills and knowledge that will enable him or her to become an expert?
The process begins with learning the fundamental skills of nursing care while also learning to apply sound principles of nursing, evidenced by research and exemplified through proficient patient care. Another important part of the process is learning to apply critical thinking skills to find solutions to complex situations or problems. Before nurses are capable of excelling in their chosen field, they must be willing to absorb information, have a positive attitude towards learning, be able to accept constructive criticism and adapt to new environments and cultures.
For the newly graduated nurse, learning to make the transition from theory to practice by gaining hands-on patient care experience is an important step. The subjects taught in nursing school in theory enable students to think critically through both didactic and clinical work. But until he or she has had the opportunity to apply the principles from the foundation courses to "real world" situations on a daily basis, the novice is not yet fully prepared to practice with competence.
As the new nurse gains hands-on, direct care experience, the learning curve increases over time. It's important to keep in mind that the length of time it takes to master new skills often varies from person to person. That is why a number of health care facilities offer flexibility in their preceptor and mentorship programs, to help assist the novice nurse through training and skill development. These programs were developed to support quality care initiatives and are tailored towards each preceptee/mentee's individual style of learning.
Nursing educator, researcher and author Patricia Benner, PhD, RN, FAAN, FRCN, provides in-depth insight into how the terms "novice" and "expert" are applied in clinical nursing practice in her 1984 model, Benner's Stages of Clinical Competence. It is based on the Dreyfus Model of Skill Acquisition, developed by educationalists Stuart and Hubert Dreyfus, which examined the skills-learning process in airline pilots, chess players, automobile drivers and other adult learners. Benner's nursing-specific novice-to-expert model consists of five stages:
Stage 1: Novice
Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them perform. The rules are context-free and independent of specific cases; therefore, they tend to be applied universally. A novice has no "life experience" in the application of rules.
Stage 2: Advanced Beginner
Advanced beginners are those who can demonstrate marginally acceptable performance, and who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components. Principles to guide actions begin to be formulated. The principles are based on experience.
Stage 3: Competent
Competence, typified by the nurse who has been on the job in the same or similar situations for two or three years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware. For the competent nurse, a plan establishes perspective, and the plan is based on considerable conscious, abstract and analytic contemplation of the problem. However, the competent person does not yet have enough experience to recognize a situation in terms of an overall picture or in terms of which aspects are most important.
Stage 4: Proficient
The proficient performer perceives situations as wholes rather than in terms of chopped-up parts or aspects. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient nurse can now recognize when the expected normal picture does not materialize.
Stage 5: Expert
The expert performer no longer relies on an analytic principle to connect his or her understanding of the situation to an appropriate action. The expert nurse has an enormous background of experience and an intuitive grasp of each situation. In addition, the expert operates from a deep understanding of the total situation.
In a recent article published in American Journal of Critical Care, Kathleen Dracup, DNSc, RN, and Christopher W. Bryan-Brown, MD, discuss specific examples that clearly illustrate how Benner's model works. "Instead of seeing patient care as bits of unrelated information and a series of tasks, the expert is able to integrate various aspects of patient care into a meaningful whole," they write. "For example, to the novice focusing on mastering the technical aspects of care, an unstable, critically ill postoperative cardiac surgery patient is an urgent to-do list. The vital signs must be noted every 15 minutes, the cardiac rhythm assessed, intravenous drips titrated to keep the blood pressure within a certain range, the lungs auscultated, chest tubes checked routinely, and intake and output recorded.
"An expert nurse caring for the same patient would complete the same tasks but not be caught up in the technical details. The expert integrates knowledge of cardiovascular physiology and pathophysiology to assess symptoms and guide patient care. For example, the skin is a little cooler than it should be, the patient is harder to arouse than he was an hour ago, the pulse oximeter shows a decrease in arterial oxygen saturation and the cardiac monitor shows an irregular heart rhythm. The expert integrates such information and determines that the irregularity is new onset atrial fibrillation and that the cardiac output has probably dropped as a result. The expert knows to watch for emboli, adjust intravenous medications to maintain blood pressure, monitor for other signs and symptoms of reduced cardiac output and notify the physician about the patient's change in status. The expert has gone beyond the tasks to read and respond to the whole picture. A potential catastrophe ('failure to rescue' in the lingo of patient safety) is averted."
Mentoring and precepting can play a crucial role in assisting new nurses and fostering their growth so they can become experts in their practice. According to Dracup and Bryan-Brown, "Preceptors help new nurses deal with the uncertainty of the clinical setting that is inherent in gaining proficiency. Ultimately, both nursing and medicine are taught in an apprenticeship system and the role of the 'guide at the side' is critical to moving from novice to expert."
In researching this article, I conducted conversations with some of my fellow nurses, in specialty areas ranging from critical care to public health, and asked them what advice they would give to a novice nurse. Here are some of their recommendations.Receiving this kind of guidance from a more experienced nurse is important, because starting your first job as a newly graduated RN can be a confusing and stressful experience. As a beginner, the stress level is high because everything around you is new and different. You might be worried about how to fit in or where to find equipment in an urgent situation.
Charlene, BSN, RN, who works on a bariatric care unit in an urban health care setting, suggests that the novice should "celebrate life every day and practice with a smile, regardless of how the day is going. You will meet people from different backgrounds with different sets of issues. You, as the RN, will need to remember that patients are people and what you learned in school is a safe way to practice.
"I have learned to be more patient during my first year as an RN," she adds. "I stop and talk with my patients, listen to them and help them adjust to their situation, even [helping them adjust spiritually] at times. I think that nurses are in the business of healing, touching the lives of others and supporting each other as a team."
Leslie, BSN, RN, who works in a critical care unit at a community hospital, encourages novice nurses to "go into nursing with an open mind. Be willing to learn a lot in a short period of time, [and recognize] that the growth and learning curve will be accomplished over a lifetime if you are willing to learn. In order to be effective, a novice must take on difficult patients, those with the most comorbidities. During your orientation period, take the opportunity to learn with a mentor or other expert nurses on the unit. Lastly, the most important thing to know is to be honest and supportive of your skills. I've been an RN for over a year and I [still] have a lot to learn. Every day is a new experience."
In conclusion, a novice nurse should always plan for the future. Once the novice has obtained pertinent skills, he or she can identify areas of strength and areas requiring further improvement. You can document in a journal or notebook the areas in which you wish to improve, share the information with your preceptor or mentor and then map out resources and information you will need to enhance your learning.
Everyone has a different learning style—for example, it can be hands-on, verbal, written or a combination of all three. Novice nurses should read scholarly journals, conduct informational interviews with experts, take time to shadow, and follow up when they receive a constructive evaluation of their skills in the clinical setting.
Nursing is a dynamic, constantly evolving profession. We are always looking to improve our patient care and find creative solutions to complex problems, both clinical and non-clinical. It is imperative that nurses work as a team, keeping in mind that both novices and experts are important parts of the team. Novice nurses and experienced nurses can work together to meet common goals. We can all learn from one another. Eventually the novice will become an expert and it will be only a matter of time before he or she begins to give back and help other new nurses become proficient and skilled.
Shonta D. Collins, BSN, RN, MPA, graduated in December 2007 from the BSN program at LaSalle University School of Nursing and Health Sciences in Philadelphia. She is a critical care nurse at Penn Presbyterian Medical Center and the founder of the nonprofit organization Explorers Sans Frontières.