The widespread void of practice development programs for experienced practicing nurses is harmful to the profession and underscores the notions that a graduate of an accredited school is a finished product and the fallacy that “a nurse is a nurse is a nurse.”1 The 2010 Institute of Medicine Future of Nursing report2 recommends that nurses complete a residency program after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas. Activities related to this recommendation have focused primarily on newly licensed nurses at entry-level positions. An expanded perspective that supports experienced direct care nurses along the Novice to Expert trajectory is presented here. Supporting the changing developmental needs of all nurses can help expand their practice and facilitate them to work to the full extent of their education and training, as recommended by the Institute Of Medicine.2
Exemplars from practice are used to illustrate the transitional needs and characteristics of direct care nurses along Benner's Novice to Expert trajectory.3 Clinical leaders play an essential role in the development and execution of strategies to support these transitions, including the use of exemplars to define and measure practice levels. Factors that have been found to positively influence the progression of skill development and acquisition of excellence in many practice domains include time, experience, personal engagement, and sustained practice efforts within a supportive and focused learning environment.4 The progression along Benner's clinical developmental continuum is distinct from most career development models that typically focus more on professional leadership and service than clinical practice.
Upon completion of orientation, a newly licensed nurse transitions the Advanced Beginner stage. Nurses at this stage are guided by policies, procedures, and standards. They are building a knowledge base through practice, are most comfortable in a task environment, and often describe a clinical situation from the viewpoint of what they need to do, rather than relating the context of the situation or how the patient responds.5 The Advanced Beginner exemplar below illustrates these characteristics.
When I arrived at work for my shift... a group of nurses were discussing assignments for the evening. I overheard the clinical nurse specialist (CNS) say “J... can handle that patient.” The patient I would be caring for had recently returned to our mother/baby unit from the ICU [intensive care unit]. She had become a “code” during recovery period following a cesarean delivery. Two feelings were going on inside me as I was getting report from the day nurse. I felt afraid and excited by the challenge.
When I walked into her room for the first time, I was overwhelmed by the amount of tubes and machines. She had a foley, surgical drain an NG [nasogastric] tube and a peripheral IV [intravenous catheter]. For an experienced nurse this might not seem intimidating, but I had only 1 and 1/2 years in nursing. As I checked each tube and machine, I tried to talk to my patient and put her at ease. I found myself concentrating more on my assessment of the physical environment than on what she was saying.
My shift progressed and things improved. I was able to change my focus from the machines to the person connected to them. I was able to get to know her and learn about her experience. She shared her excitement about her new baby and her fears about her recovery. I felt it was a very rewarding day. I learned about the tubes and machines, but more importantly, about the person.5(p58)
Notice the validating and supportive role the CNS played in assisting J. in this unfamiliar clinical situation. Supportive relationships early in practice greatly influence whether or not new nurses will become emotionally involved in the practice or withdraw and become disembodied in their care.6 Having a mentor can also help new nurses navigate and explore challenging clinical and social aspects of the unit.7 A mentor can assist with new knowledge acquisition and confidence building as nurses continue to expand their practice and move into the Competent phase.
In the Competent phase, nurses integrate theoretical knowledge with their clinical experiences in the care. They demonstrate confidence in providing routine and complex care on the basis of standard of care using conscious, deliberate planning. They perceive the expected progression of clinical events on the basis of concrete past experiences and modify interventions accordingly. Competent nurses desire to limit the unexpected by actively managing the environment.8 Competent stage nurses function well in the charge nurse position and should be involved in the development of policies and procedures that guide their practice. Many experienced nurses remain at the Competent level throughout their entire career. Their desire to limit the unexpected and conscious deliberate planning according to policy and procedures contributes to tension and potential conflict between Expert nurses, who, when working side by side with them, often expand the boundaries of practice in innovative ways for the patient. Risk taking is an essential factor that facilitates transition to the Proficient and Expert stage.8
Proficient stage practitioners have in-depth knowledge of nursing practice, and perceive situations as a whole and comprehend the significant aspects. They recognize situational changes that require unplanned interventions, often creating possibilities.5 Struggling with ethical/moral dilemmas is a hallmark of this stage. Notice how the Proficient nurse in the exemplar below deliberately took calculated risks to advocate for the patient and family.
I first met the parents of a little boy, born at 28 weeks by cesarean section, in the operating room just prior to the birth of their son. I went to the head of the bed and introduced myself ... as the nurse who would take their baby to the NICU [neonatal ICU] after delivery. I also let them know that the baby would need a breathing tube placed shortly after birth ... They asked if they could see the baby before going to NICU. I let them know that I would do my best to make sure they could see him, but this might not be possible. They also told me that their baby was a boy named James.
Immediately after delivery, James was intubated. He was pink and active being hand ventilated by the respiratory therapist. The neonatologist at the resuscitation told me that he wanted us to bring the baby back to the NICU “right away” and then left the OR [operation room]. The respiratory therapist (RT) helped me get James settled into the transport isolette and then noting that he was still very pink, active, and in no apparent distress, we wheeled the isolette to the head of the bed so his parents could meet James for the first time. I encouraged mom and dad to take a look and touch his perfect little body. The RT continued to handbag James while his parents touched and admired him. I continued to monitor him for signs of distress... We stayed at the head of the bed for a couple of minutes and then departed for the NICU.
As we left the OR, James' grandmother was waiting in the hallway. We stopped for her to see him and I noticed that she had a camera. I asked if she would like to take a picture and rearranged his covers so that grandmother could get a better shot of her new grandson.
When I returned to the NICU with James, I found a very unhappy neonatologist waiting. (He is one of our more seasoned team members and very set in his ways.) He was upset that I had taken so long bringing the baby back to the unit. It had only been about 7 minutes since he had left the OR. I explained to him that I was carefully watching the baby during the transport and had not noted any distress. He stated that I “should have come right back.” I didn't agree with this statement but kept quiet. I felt secure having the RT with me... I had caused no delay in treatment and had not endangered the baby in any way. If a situation like this were ever to arise again, I would do the same thing. These parents already had lost the opportunity to have a “normal” birth and newborn child. James will never be able to stay with his Mom in her postpartum room and the parents will experience a very different bonding process. I felt that it was important for these parents to be able to see James and to know that he was okay before we rushed him out of the room and out of sight. James's parents have since told me that my small gesture made a big impact on them. That made it worth it.
Skillful attention to the unique challenges the nurse faces at this developmental juncture, especially in the area of risk taking, supports progression to the Expert stage. Environments that inhibit clinically sound alternations in approaches to care at this stage of development impede individual and organizational learning and progression to the Expert stage of development.7 Expert practitioners have comprehensive knowledge grounded in experience with a deep understanding of the total situation. Their practice is characterized by a flexible, innovative, and confident self-directed approach. Experts put into perspective their own personal values and are able to encourage and support patient and family choices. The following Expert exemplar illustrates this transition. Note that this is the same patient described in the Advanced Beginner narrative described earlier.
C. was a g[ravida] 1 para 0 who had an emergency cesarean section for placenta previa who was transferred to the ICU following a silent code during recovery. C. didn't look up as I entered the room. When I spoke she diverted her gaze. Responses were very limited. C. was described to me in report as scared and demanding at times with many physical cares including a NG and drain. My thoughts focused on working with her, not doing to her. I also wondered about her emotional needs that hadn't been addressed.
I sat on her bed, I searched out her eyes, we made contact, and together we planned her morning. I stayed with her as she provided care for her new baby. At times we would talk, but at other times silence seemed most comfortable. Finally she opened up. I listened and explored her experience with birth, near death and slow recovery... She shared her fears as she tried to piece together her experiences over the previous 2 weeks. I listened to her. I reached out, hugged her, and cried with her as she described her thoughts of dying and not being here for her new baby.
Her storytelling was piecing her puzzle together. She needed mothering more than physical care. She needed my mothering, caring, concern, and confidence in her ability to heal physically and emotionally. She needed my reaching out so she could reach out and mother herself and her baby. Sitting with her, touching, sharing, explaining her physical concerns to her, exploring her concerns helped give her what she needed to heal. Energy level improved, appetite increased, diarrhea decreased. She spoke of how good she felt. She wanted to keep her baby with her.
Surely I provided the physical care she needed but I also provided an opportunity for her to incorporate her birth and near-death experience unto herself. Her energy, now increasing, allowed for more activity with her baby and family. I could step away and become the onlooker as she assumed more responsibility. That feeling of knowing what to focus on so this patient could make sense of her experience and continue in her transition to motherhood was priority for my care.5(pp58–59)
Benner's Novice to Expert framework is an evidence-based approach for identifying the unique characteristics and transitional needs of direct care nurses. Using practice exemplars to identify and measure characteristics of practice helps makes the practice visible and accessible to others in ways external observation cannot. Supporting clinical practice transitions using exemplars can help advance the practice of nursing both individually and collectively.
—Barb Haag-Heitman, PhD, PHCNS-BC, RN
Barb Haag-Heitman and Associates, Milwaukee, Wisconsin
1. Barnum BS. Foreword. In: Benner P, Tanner CA, Chesla CA, eds. Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York, NY: Springer; 1996:vii–ix.
2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010.
3. Benner P. From Novice to Expert. Menlo Park, CA: Addison-Wesley; 1984.
4. Ericsson KA. Attaining excellence through deliberate practice: insights from the study of expert performance. In: Ferrari M. ed. The Pursuit of Excellence Through Education. Mahwah, NJ: Lawrence Erlbaum; 2002:21–55.
5. Haag-Heitman B. Clinical Practice Development Using Novice to Expert Theory. Gaithersburg, MD: Aspen; 1999.
6. Dreyfus HL. On the Internet. New York, NY: Routledge; 2001.
7. Haag-Heitman B. The development of expert performance in nursing. J Nurs Staff Dev. 2008;24(5):203–211.
8. Haag-Heitman B. The Development of Expert Performance in Nursing
[unpublished dissertation]. Santa Barbara, CA: Fielding Graduate University; 2006.