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The Transition From Expert to Novice and Back to Expert

Ensuring Competent and Safe Practice

Dunbar, Ghada, DNP, RN, MHA, CENP, CNML; Kawar, Lina Najib, PhD, RN, CNS; Scruth, Elizabeth Ann, PhD, MPH, CNS, CCNS, CCRN, FCCM, CPHQ; Column Editor:

doi: 10.1097/NUR.0000000000000442
DEPARTMENTS: Legal and Ethical
Free

Author Affiliations: Director of Tele Critical Care–Northern California, Clinical Quality Programs and Analytics, Regional Quality–Northern California (Dr Scruth); Nurse Scientist, Translational Research, Regional Nursing Research Program, Southern California Patient Care Services (Dr Kawar); and SCAL Regional Director, Patient Care Services, Professional Development & Education (Dr Dunbar), Kaiser Permanente, Oakland, California.

The authors report no conflicts of interest.

Correspondence: Elizabeth Ann Scruth, PhD, MPH, CNS, CCNS, CCRN, FCCM, CPHQ, 1950 Franklin Street, 14th Floor, Kaiser Permanente, Oakland, CA, 94612 (Elizabeth.Scruth@kp.org).

Transitioning from an expert to novice requires critically exploring the requirements to ensure competency and safe practice in the new field of practice. Expert clinicians build substantial knowledge bases allowing them to view situations differently than novice clinicians. The expert clinician also organizes and interprets data succinctly without bias. Clinical expertise is more than an accumulation of knowledge, experience, and time spent with patient populations in the field of practice. Expert clinicians excel in their domain of practice. Literature to date has demonstrated clinical expertise in one field does not translate to expertise and/or competence in another field of practice.1 Clinical expertise develops through deliberate practice and self-regulation. Expert clinicians can redirect their thought process when dealing with a complex issue due to not engaging in situational bias and being aware of all the possibilities, ensuring that an optimal outcome is reached.2

The Benner3 novice-to-expert model describes 5 levels that can be applied to any healthcare professional practice domain: novice, advance beginner, competent, proficient, and expert. The Dreyfus Model of Skill Acquisition states there are constant development of skills and performance and translational phases for the learner as they go through each stage from novice to expert.4 As described by Benner,3 expert clinicians possess the ability to prioritize automatically the care required for the patient and/or patients through experiential learning.

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Moving From Expert to Novice

Individuals go through a process and stages when they move from the expert to the novice role. Those stages take time, require patience, and need life balance maintenance, which are helpful for adjustment into the new role. First, comprehensive orientation would be necessary to introduce the individual to the people, culture, and surroundings to assist the person manage the transition.5 Second, it is important for the individual to detach from the previous role and embrace being a novice.6 The novice clinician will be required to acknowledge his/her lack of command in the new domain of practice. A reframing and self-reflection will need to occur to ensure the new domain of practice is viewed as new and that there will be milestones to be attained as the clinician goes through the stages of novice to expert. As a novice clinician, there is no experience to rely on. For the advanced practice registered nurse (RN), there are ethical and legal considerations when transitioning to a new field of practice. The following examples explore what is needed to move from one domain of practice to another.

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Nurse Practitioner: Moving From Family Practice to Acute Care Practice

Nurse practitioners (NPs) are uniquely educated, licensed, and regulated. The domain of practice an NP is educated in is structured to ensure that the knowledge base is applicable and has subsequent hours of instruction/supervised hours of practice to reflect that. An example is the field of family practice in which the curriculum and clinical practice hours are all focused around the patient populations that comprise the domain of family practice. The advanced practice RN completes the required education—graduate degree or post–master’s degree certificate and the clinical practice hours to be registered as an NP. Upon completing the required education, the Family Nurse Practitioner (FNP) can obtain certification in family practice from either the American Nurses Credentialing Center or the American Academy of Nurse Practitioners.7,8 Many patients are and will be comanaged by teams of physicians and FNPs to alleviate the shortage of healthcare providers both in cities and rural areas.9 Certification provides patients and their families, colleagues, and the disciplines collaborating in the care of the patient validation that the NP caring and treating the patient has demonstrated experience and knowledge in the specialty of family practice.8 What is required when an FNP wants to work in emergency care or acute care? To ensure competency, the FNP would devise a plan to acquire a post–master’s degree certificate through additional graduate education in emergency care or acute care and supervised clinical practice hours to meet the requirements for certification in the specialty. Once skills in the new specialty have reached an acceptable level of performance (progressing through the levels from competent to expert), they can be maintained with a minimal level of cognitive effort. Acknowledgement of novice status does not absolve one of professionalism. The NP is still expected to know criteria and treatments associated with health processes within one’s scope of practice.

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The Doctor of Philosophy Registered Nurse Transitioning to Nurse Scientist

A doctor of philosophy (PhD) in nursing is a research-focused doctoral degree and primarily prepares nurses for positions in nursing research. However, the degree can also prepare RNs for positions in both inpatient and outpatient settings. The PhD degree provides the RN with unique knowledge and expertise and a background that provides a lot of flexibility to move freely to different roles. One example is academia and being a professor where the emphasis is on nursing education and developing nurses across multiple settings. Another example is fulfilling the role of a nurse scientist to produce new evidence to advance the nursing profession and science. Most graduate programs offer PhD candidates training in teaching nursing courses. Once the degree is conferred, the doctoral-prepared nurse can assume the nurse educator or scientist role. A Board of Registered Nursing certification for nurse educator ensures students, colleagues, and the nursing community that the nurse educator is capable of teaching didactic and clinical courses and is competent in advancing the nursing students’ education. If the doctoral-prepared nurse decides to assume the nurse scientist role, further certification is required by the institutional review board (IRB). The trainings are pertinent to conducting nursing research, including (1) Collaborative Institutional Training Initiative Human Subjects Protection, (2) Health Insurance Portability and Accountability Act researcher training, and (3) Reportable Events and Incident Training.10 Additional training and certification for conducting clinical trials research are required. The IRB trainings provide the nurse scientist with the qualification to conduct safe research within the realm of the human subject protection and safeguard the nurse scientist. The IRB training enhances the scientists’ knowledge and skills and validates to the public and scientific community that research is led by accomplished scientist.

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The Clinical Nurse Specialist: Transitioning From Neonatal to Pediatric Practice

A clinical nurse specialist (CNS) who has completed a graduate-level program accumulating in a degree or postgraduate certificate in the field of neonatal practice is eligible to undertake the certification examination as a neonatal CNS. All CNS Consensus Model examinations cover wellness through acute care.11 A neonatal CNS wishing to add a pediatric population is required by national standards to acquire a post–master’s degree certificate through additional graduate education in the pediatric population to be added and appropriate practice hours. The CNS is then eligible to take the examination to become certified as a pediatric CNS. The CNS must hold themselves to these standards to ensure competency and proficiency for the patient population they are responsible for. Colleagues and the multidisciplinary teams the CNS collaborates with are dependent on the CNS to be responsible professionally for their own competence and expertise. Applying professional values to deliver high-quality care is the essence of leading in a new role. It is dependent on exercising work ethics, current evidence, and partnering with the new teams. As the CNS progresses through the stages of developing in the new role as a pediatric CNS, the CNS will engage in increasing complex problems, strategically aligned with his/her stage of development. It is the science of deliberate practice in which the CNS will solve problems that are challenging and relevant to the pediatric population and current situation.12

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Clinical Operational Leader: The Transition From Operational Medical Center Leader to Regional Professional Development and Education Leader for a Large Group of Hospitals in a System

Foundational leadership is essential for a healthy and successful healthcare organization. Transformational/ excellent leadership is critical to provide stability for an organization.13 There are some differences as well as commonalities between a clinical operational leader and professional development leader. Collaboration is essential in any leadership role as it impacts outcome.14 Leadership standards are published in The Joint Commission 2009 Comprehensive Accreditation Manual for Hospitals “Leadership” Chapter and in American Nurses Credentialing Center Magnet Application Manual.15,16 A transformational leader motivates, stimulates, inspires, and collaborates with team members to achieve extraordinary outcomes and at the same time develop their own leadership capacity.14

A personal experience of transition is captured in the following:

In my role as an operational leader with oversight over nursing services, patient flow, critical care areas, and hemodialysis in an acute care setting, I was an expert leading various department and overseeing multiple units. I had experienced this role for multiple years and was an expert in the structure, process, and outcomes. I transferred to a new role as a professional development and education leader, and I started as a novice all over again. I was nervous, worried, stressed, and anxious that I would not meet up to the expectations of my leaders and team members. My team was more knowledgeable—the experts, and now they were reporting to an individual who was new to the role and a novice. I leaned on the team and was very transparent and honest that I was not the expert and if I don’t know the answers to their questions, I would explore further and respond back to them later.17

As a leader in a new role and starting back on the journey to becoming an expert, it is no different than an operational leader, in that the leader will grow and develop others by responding to individual team members needs through empowerment and alignment with individual, department, and organizational goals and priorities.18

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Strategies for Success

The transition from expert to novice clinician is highly stressful. Different strategies and personal reflections are important for the successful transition. The strategies must involve the team as well as the individual. The first step is to partner with the new clinical team and form effective communication and workflows. At the personal level, the clinician must reflect and identify the reason for deciding to transition into a new practice domain and determine the goals to be achieved to ensure safe and competent practice. Second, reflect on the strengths the novice clinician is bringing and the areas that will need to be improved upon. Practicing openness and transparency are critical at this stage. The novice clinician should identify a mentor within the new team.6 Keeping a diary is often helpful to reflect on new experiences that can assist the novice clinician to critically appraise and evaluate competence.19

At the team level, applying the team work common rules and practices will help in making the transition successful and less challenging. Rehearsing civility, respect, fairness, caring for others and self, openness, clear communication, understanding, acceptance, encouragement, being approachable and available, self-plus-team reflection, and peer-to-peer feedback are strategies that need to be emphasized as the novice clinician joins the team.20 Use team-building activities and creativity that focus on learning about each other ways and encourage the team spirit and relationships. Working together on the above is an essential aspect to consider and ensure successful transitions.

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CONCLUSION

It is a distinctive experience to move from the expert to the novice. The expert-to-novice role arises during career advancement or when career change takes place. This process starts as the individual advances and must pick up the new skills on the job versus utilizing the academic knowledge and past experiences. For the clinician, it will mean acquiring new skills though additional certification and practicum to ensure safe and competent practice. Although challenging, the individual goes through certain stages that require time for adjustment. Specific approaches can be implemented by both the individual and team that can lead a successful transition and the new role fulfillment.

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References

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