Clinical wisdom among proficient nurses

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Special Article

The Development of Nurses’ Individualized Care Perceptions and Practices: Benner’s Novice to Expert Model Perspective

Nur Guven Ozdemir, BSc, MSc Research Assistant, Zonguldak Bulent Ecevit University, Health Science Faculty, Department of Fundemantal of Nursing, Kozlu, Zonguldak, Turkey

Correspondence: Nur Guven Ozdemir, BSc., MSc., Research Assistant, Zonguldak Bulent Ecevit University, Health Science Faculty, Department Of Fundemantal Of Nursing. Office Address: İbn-I Sina Campus, Esenkoy, Kozlu, Zonguldak, Turkey E- Mail: Nur.Guven1988@Gmail.Com

Abstract

Individualized nursing care, which is a significant indicator for quality of nursing care, should be integrated into nursing education and practice. Benner’s Novice to Expert Model guides nurses in care practices by providing the theoretical framework.This article aims to create awareness that the Benner’s Novice to Expert Model could provide nurses with a valuable strategy to develop their individualized care perceptions and practices and to help enlighten the nursing discipline-specific studies.

Keywords: individualized care perceptions, nursing practices, nursing model

Introduction

Individualized nursing care is considered as indicator for the quality of care due to enhance positive patient outcomes (Acaroglu & Sendir, 2012; Papastavrou et al., 2015). Therefore, the importance of individuality in nursing education and patient careare emphasized by governments and health care policies nowadays (Cronenwett et al., 2007; Delaney, 2018; OECD, 2010; Suhonen, Gustafsson, Katajisto, Välimäki, & Leino‐Kilpi, 2010a).

Individualized care constituting the basis of the holistic philosophy, values and ethical codes of nursing includes planning and practicing nursing care in accordance with the individual characteristics, requirements, preferences, experiences, feelings, perceptions and opinions of the individual and incorpating the individual to this process (Acaroglu & Sendir, 2012; Papastavrou et al., 2015; Suhonen et al., 2011; Suhonen, Stolt, Gustafsson, Katajisto, & Charalambous, 2014).On the other hand, in order to achieve the purpose of individualized care, the patients should comprehend nurses’ these approaches, and express their own perceptions about these approaches by experiencing and feeling them in his/her own care (Acaroglu &

Sendir, 2012). In this regard, it is important that nurses take into consideration factors such as their clinical condition, their personal life situation, and their preferences in order to promote patient participation in decision making (Idvall et al., 2012).

Nurses have an important role in evaluation and development of individualized care (Suhonen, Gustafsson, Katajisto, Välimäki, & Leino‐Kilpi, 2010b). Nurses need experiences in order to develop individualized nursing care perceptions and practices that are effective in the use of nursing process and classification systems to provide quality nursing care (Baraki et al., 2017; Suhonen et al., 2010b). Novice nurses need to be supported to implement individualized patient care affected by the length of clinical experience (Suhonen et al., 2010b).

Nursing theories and models contribute to the development of nursing profession by supporting the independent roles of nurses during care delivery in accordance with nursing process (Alligood, 2017; McCrae, 2012).Nurses can be in a powerful position to improve the quality of care and patient outcomes when they use the nursing models guiding them about what questions they can ask, how they can process the information

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that is learned, and what nursing activities can be included in their care practices (Alligood, 2013). In nursing profession, these models provide a mechanism for a systematic approach to teaching theoretical and clinical knowledge (Dobrina, Tenze, & Palese, 2014). Benner’s Novice to Expert Model is one of the most useful conceptual frameworks that guides the professional development of nurses (Oshvandi et al., 2016).This article describes how the Benner’s Model guides nurses’ practice for the development of individualized care perceptions and practices throughout their clinical experience.

Conceptual Framework: Benner’s Novice to Expert Model

The Novice to Expert Model introduced by Dr Patricia Benner in 1982 is generated from the Dreyfus Model of Skill Acquisition and essentially discusses how an individual gains new skills and knowledge from novice stage to expert stage (Davis & Maisano, 2016; Gentile, 2012). Patricia Benner’s model stands on how a nurse develop nursing knowledge, skill, clinical competence and comprehension of patient care through complete theoretical training and experiential learning from novice stage to expert stage (Davis & Maisano, 2016; Homard, 2013; Walker-Reed, 2016). Development through these phases is affected from clinical experience, length of working time in profession (Blum, 2010).

In the novice stage, nurses have no background practical experience while they have theoretical knowledge only. They have no information on how to transfer new knowledge and skills to their applications when they face with unique situations. Novice nurses can be considered honeymoon practitioners, they reached the advanced beginner level over by the time (Brykczynski, 2017; Thomas & Kellgren, 2017). Advanced beginner nurses still need to assistance of experienced nurses for patient care. They focus on completing all ordered treatments and procedures more than individualized nursing care. In the competent stage, nurses devise new procedures and develop new clinical knoweledge along with learned procedures for managing the patient care while they are learning ethical behaviors. At the proficient stage, nurses demonstrate new abilities for changing situations. Expert nurses have critical critical thinking skills to plan the patient care again in line with the

patient’s actual conditions, concerns and needs (Benner, Tanner, & Chesla, 2009; Brykczynski, 2017)

Application of Benner’s Novice to Expert Model to Improve Individualized Care Perceptions and Practices

Novice

Novices called theoritical knowledge as students learn domain-specific facts, features, and actions relevant to a particular skill and their actions (Benner et al., 2009; Gobet & Chassy, 2008; Lyneham, Parkinson, & Denholm, 2008). They have limited performance as they perform their practice under the guidance of context-free and inflexible rule (Benner et al., 2009; Brykczynski, 2017). Although they learn definition of individualized nursing care through the nursing education, the development of individualized nursing care perceptions and practices takes a period of time (Suhonen et al., 2010b).

Novices generally have limited experience to practices and discussion about their caring for patient at hospital settings before graduation. Novices have difficulties to perform the skills on patients having clinically different symptoms as these skills learned and performed easily on a simulation mannequin are inflexible. Students typically rely on nursing care plans in the textbooks without planning nursing care for individual applications. They tend to relate theoretical knowledge to clinical practices in a non critical thinking manner, thus having perception how this theoretical knowledge needs to be applied in individualized nursing care practices is very important for their professional development (Benner, 2004; Benner et al., 2009; Ortiz, 2016).

Guidance and education provided by educators coach to students to advance from one stage of development to the next. They can access to the culture and expectations of the clinical units thanks to clinical educators where they are gaining clinical experience to implement individualized patient care. Novice nursing students must be assisted to learn about individualized nursing care and entegrate this knowledge to actual patient care practices. The instructors must give students responsibility to plan and implement nursing care of patients who may have possible changes in their conditions (Benner, 2004).

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Advanced Beginner

Advanced beginners worked as a professional for 6 months or less are able to identify global characteristics of a situation (Benner et al., 2009; Lyneham et al., 2008). Grasping the aspects of patient current situation in terms of the holistic view is complex for advanced beginners as they have not enough experience to expand their vision to patients’ past experiences and future expectations. They are unable to decide the order of nursing diagnoses and practices according to the importance for the individual. Generally, they implement the care practices as a routine and task-oriented maintenance in their first working experiences. They can only focus on one aspect of individual during care such as their requirements, values, beliefs, behaviours, emotions, perceptions etc. Although they generally view the nursing proces as a task that need to be accomplished, they begin to perceive meaningful occurrences of this process (Benner et al., 2009; Brykczynski, 2017). King and Clark (2002) found that advanced beginner nurses focused upon processing routine tasks, and monitoring of clinical observations required for patient care without endeavoring to assess the patient’s emotional state.

They begin to work at a clinical environment without developing individualized caring practices. The first year of practice helps to further internalize nursing philosophy, nursing values and the code of ethics for nurses required for individualized care practices developed through their working experience. They cannot see the “big picture” involving the nursing cares’ all dimensions. The management of patients with complex conditions, heavy workloads, and sudden increases in responsibility could be stressor for advanced beginners. They may have difficulty to take independent decisions and implement individualized nursing care. Replanning the individualized nursing care make the advanced beginner nurses quite anxious and stressful when individuals’ needs were changed during the care process (Benner et al., 2009; Karahan, Toruner, Abbasoglu, & Ceylan, 2012).

Through trial and error, they may learn new ways to affect situations, which will aid them in their future care practices (Benner et al., 2009). They need for special advices and guidances from their more experienced colleagues to percept and implement the individualized patient care. They can improve cognitive, psychomotor and

emotional skills in a coordinated way required to implement individualized nursing care through planned interactions with other experience professionals. On the other hand, hospital management also has great responsibility in this regard. Many hospital managements have developed orientation education for advanced beginners to adapt to clinical environment and workplace conditions (Karahan et al., 2012). Internationally, On the other hand, many approaches such as internship programs, residency, mentorship, and perceptorship assisted them to consolidate theoretical learning, critical skills and judgement in their new professional role are designed to facilitate and support the development of skills to meet individualized care needs (Hezaveh, Rafii, & Seyedfatemi, 2014; Hussein, Everett, Ramjan, Hu, & Salamonson, 2017; Phillips, Esterman, & Kenny, 2015).

Competent

In the competent stage, nurses worked as a professional for 1 to 2 years focus on managing the individualized nursing care unlike advance beginners because they cope with a wide range of nursing situations. Although they have the confidence and ability to foresee patient’s recovery, they have not enough speed and flexibility for reflection and feedback of practice. Competent nurses gain the knowledge and skills over time about patients’ priority and urgency develop (Benner et al., 2009; Brykczynski, 2017; Lyneham et al., 2008).

Competent nurses better plan individualized nursing care for patients according to novices and advanced beginners as they can predict immediate likely events and changing needs of them (Benner, 2004). They have now little anxiety when they learn and perform well without making mistakes during care. Common programs including nurse internships, residencies, and mentoring programs help nurses to maintain their competencies. Evaluating nurse competence about the individualized nursing care may be important for development of nursing care. In this regard, nurses may also take national certification exams to develop and validate their specialized knowledge about the individualized nursing care in an effort to demonstrate competence (Smith, 2012). On the other hand, nurse’s annual competency can be checked by clinical education and hands-on demonstration programmes (Woody & Davis, 2013).

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Compotent nurses begin to develop a sense of agency and take responsibility alone effectively in clinical area. These sense of agencies and responsibilities enables to provide instructive feedback for their individualized nursing care knowledge and practices based on novice students’ and advanced beginners’learning needs (Benner et al., 2009). Although they can design and implement a programs for less experienced nurses about individualized nursing care based on knowledge, skills and attitudes, they should continue read evidence-based literature about care practices. When competents conduct evidence-based researches and present their results in a conference or publish them in peer- reviewed journals, these experiences contribute to nursing care literature. Theory and principles enable competent nurses to ask the right questions to hone in on patient problems to provide individualized nursing care and make good clinical decisions (Benner et al., 2009; McHugh & Lake, 2010)

Proficient

At the proficient stage, nurses worked as a professional for 3 or more years have respond- based skills which can be used to give information in accordance with patients’ demand (Benner et al., 2009; Brykczynski, 2017).They are analytical and fluid to cope with different clinical situation such as patient and system crises (Lyneham et al., 2008; Uhrenfeldt & Hall, 2007). Benner stated that they take clinical leadership when needed and they have a emotional responsiveness to patients’ discomfort situations (Benner et al., 2009; Uhrenfeldt & Hall, 2007).

They build on seeing aspects of a whole situation rather than understanding the situation in terms of rules and context-free attributes. They implement individualized nursing care based on responsibility, thinking, ethical discernment, and a drive for action (Uhrenfeldt & Hall, 2009). Emotional responses and moods what proficients exhibit toward the patients’ situation enable the patient to experience and feel the nurses’ individualized care perceptions and to express to them with feedback, and so individualized nursing care achieves its purpose (Benner et al., 2009). Although proficient-level nurses have experinces about individualized nursing care, they must refresh their knowledge and develop their practices to provide a better quality of care by attending scientific meetings, reading nursing

journals, attending the national and international project and researching (Benner, Kyriakidis, & Stannard, 2011).

On the other hand, they can mentor and coach the novices, advanced beginners and competents by demonstrating appropriate behaviors as an affective leader for development of individualized nursing care. Given education by proficients in nursing faculties or health centers generated from their clinical experiences and evidence-based practices help the nursing students and less experienced nurses to recognize the needs of patients and implement the care practices with holistic philosophy (Benner et al., 2009). They are able to assume the leadership roles in hospital managements or professional organizations to define and implement strategies or procedures that guide that less experienced nurses and novice students learn and implement individualized care practices. Nurses can make alterations to health policies and organizations processes which are effective in providing quality care (Benner et al., 2011; Benner et al., 2009).

Expert

Expert nurses responds in a fluid automatic manner to come to a judgement unlike proficient nurses (Lyneham et al., 2008). They make critical clinical decisions while grasping the whole by means of having intuitive ability or combining technical and existential skills for innovative solutions (Benner et al., 2009; Brykczynski, 2017; Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009; McHugh & Lake, 2010) . Expert nurses have a broad vision, sensing the needs and capability of patients (Benner et al., 2009).

Nurses who are both well-educated and experienced have no problem to give individualized nursing care as they better observe subtle relevant changes problems and use a developed keen intuition of future events that may occur (Amaral & Ferreira, 2014; Fraley, 2016). Expertise influences nurses’ clinical judgment and quality of care and develops the individualized care implementations when a nurse tests and refines both theoretical and practical knowledge about it (McHugh & Lake, 2010). Nurses should develop their experience furter by testing and refining both their scientific knowledge about individualized care since expertise influences nurses’ clinical judgment and quality of care . Counselling of expert nurses are critical that less experienced nurses are able to manage the nursing care by providing them to

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think critically and ethically during their practices (Benner et al., 2009).

On the other hand, they are able to develop comprehensive curriculum systems or training programs for novice studets or less experienced nurses and they can evaluate outcomes of these educations (Thomas & Kellgren, 2017). Since expert nurses have a high level of insight to analyze in-depth nursing interventions, they can develop new nursing theories, models and researches based on holistic and humanistic philopsophies intended for individualized nursing care perceptions and practices (Benner et al., 2009). Insights and accomplishments of expert nurses are one of the most important factors determine the national and international health policies related to individualized care practices (Benner et al., 2009; Charalambous, Katajisto, Välimäki, Leino‐Kilpi, & Suhonen, 2010; Douglas, 2018). Expert nurses have experience and knowledge to be able to integrate new technological development to individualized care practices. All these scientific and technological knowledge of expert nurses guide less experienced nurses to plan and implement the individualized care.

Conclusion

Nursing education, professional development programs, nursing theories and models and health policies help ensure that nurses develop the perception and experience about individualized care since nurses’ experiences play key roles in positively affecting the results of patient care. In this regard, the one of the professional goals for nurses should be to become an expert in individualized nursing care for quality care and they must develop their perceptions and implementations about individualized nursing care.

Nurses’ individualized care perceptions and implementations have to develop beginning from nursing faculties during to the years worked as a professional, even though according to Benner’s Novice to Expert Model nurses provide direct care beginning from advanced beginner level (Benner, 2004; Benner et al., 2009). Novice to Expert Model is relatively simple with regard to the five stages of skill acquisition, and it provides a comparative guide for identifying levels of nursing practice from individual nurse descriptions and observations and interpretations validated by consensus. Benner maintains that caring practices must be attuned to individual

being cared for and to the particular situation as it unfolds (Brykczynski, 2017). In this regard, this article guides all novice students, nurse educators and nurses at different levels according to Benner’s Novice to Expert Model to develop the individualized nursing care perceptions and implementions. The framework of this study also provides a foundation for ongoing research about individualized nursing care.

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