Eloise Balasco Cathcart. MSN, RN, FAAN
Director of Education, EducatingNurses.com Patricia Benner, MSN, R.N. Ph.D., FAAN.
Executive Director, EducatingNurses.com
“Most acute care units are now staffed with less seasoned nurses. Many young nurses don’t experience that awe when they watch a mentor intuitively grasp that the patient is crashing, even before any data exists. I remember how humbling it was for me to watch my preceptor quickly take action when I never even realized there was a problem. If you don’t see that level of expert practice, it is probably not surprising that many newer nurses think they are performing at a higher level than they may be.” (Sherman, 2024)
The nurse engaged in the direct care of patients and families is living out the core work of the profession and the mission critical work of the healthcare system and as such, is the most important nurse in any organizational design. Those of us who are nurse educators or nurse executives also have consequential roles in meeting the ethical mandate of the profession. Nursing faculty have numerous opportunities to teach and mold pre-licensure and graduate students for eventual expertise in clinical and advanced practice roles. Nurse executives have profound responsibilities to create and lead care environments where nurses can perform their best work and continuously expand, refine, and strengthen their practice. All of us, regardless of the role we have, must share the commitment to achieve excellence in practice for the profession to survive and thrive.
In 2021, the nursing workforce experienced the most dramatic exodus of workers since annual workforce data collection began in 1982 (Buerhaus and Hayes, 2024) and many of those who left were expert clinical nurses. Patricia Benner’s research has demonstrated that the practice itself is a way of knowing, so it follows that the development of expertise requires the new nurse “to learn from the practice as well as learn how to learn from the practice” (Benner, P. and Benner, J. 2024). Staff nurses who have evolved from mastering the tasks of patient care to living out the highly skilled know-how that is the essence of expert nursing practice and who are recognized as clinical leaders are instrumental to that process. By working side by side with these clinical nurse experts, new-to-practice nurses learn how to engage in astute clinical reasoning in patients’ rapidly changing clinical conditions and to master the skill required to perform complex interventions to keep patients safe when margins for error are slim or non-existent. They also learn how to relate to patients and families in ways that respect and support their dignity and concerns in the midst of changes in the patient’s clinical condition.
But what happens to new-to-practice nurses when there are not enough clinical experts to guide them into the chaotic world of clinical practice?
Expert clinical practice:
Expert clinical nurses know more than what to do; they know how and when to do what is needed. The practical wisdom of the expert nurse may not be articulated well in theory or explained by science but can be demonstrated by experts who relinquish a reliance on rules and maxims dictating what one should do. Expert nurses respond instead with experience based wisdom about particular clinical situations using the clinical and moral skills learned from past similar and contrasting clinical situations (Benner, Hooper-Kyriakidis, Stannard, 2011).
In addition to mastering the skilled know-how of the practice, expert clinical nurses have undergone the personal transformation necessary to build the clinical judgment, clinical imagination and ethical comportment which serve as their most important leadership tools. They are clear about their purpose and have the courage to live it; their expert clinical know-how enables them to skillfully navigate the complex and sometimes chaotic world of clinical practice (Craig and Snook, 2014). Clinical experts have mastered the relational skills which allow them to build trust and sustain relationships with a myriad of people in the practice environment. Recognizing that each person comes to the workplace with different notions of how to work with others, clinical leaders embrace and manage conflict with respect for the other’s perspective and values, facilitating a collaboration which allows patient care agendas to move forward (Cathcart, 2014). Clinical experts have developed the character that enables them to live out the clinical and ethical demands of engagement and responsibility in a complex clinical practice (Benner, Tanner & Chesla, 2009; Sullivan and Rosin, 2008).
Traditionally, new-to-practice nurses have turned to expert clinical leaders working alongside them in patient care units when they have been uncertain or flummoxed by their patient’s situation and need confirmation of their own clinical judgment (Benner, Tanner, Chesla, 2009). Clinical leaders are the nurses who are asked to “come and take a look at my patient – I’m not sure what’s happening or what to do”. They are clinical leaders within the health care team who consistently drive solutions rather than wallow in problems or dysfunction. The ethical mandate to ensure that the right, timely and good thing is done for patients is clear to them, so they are generous and respectful in sharing their knowledge and skill with less experienced colleagues and maintain a watchful eye on patients assigned to less experienced nurses (Cathcart and Greenspan, 2012).
New-to-practice nurses need clinical nurse experts to teach them not only the “what” and “why” of the practice but also the “how” and “when,” which includes recognizing early warnings of critical changes in patients’ clinical condition. Clinical experts help new nurses safely deliver instantaneous therapies in response to patients’ physiological changes and to instantiate what the best in nursing practice can be by demonstrating clinical and moral imagination in complex clinical situations. The ability of the new nurse to grasp what matters and what is relevant to attend to in clinical situations can only be learned experientially. Learning this skilled know-how and clinical judgment requires situated coaching by expert practitioners who have a well-developed sense of salience about what is most urgent with high clinical priority and what is of lesser urgency.
Current Challenges in Developing Expert Practice:
Long-standing concerns of practicing nurses, such as insufficient staffing levels, work designs and staffing that do not match the actual clinical performance demands of nurses, not feeling listened to or supported at work, the desire for higher pay and the emotional toll of nursing work were exacerbated by the COVID-19 pandemic, and most healthcare settings are struggling to accommodate the unparalleled rapid workforce disruptions and acute staffing shortages experienced since then (Martin, et al, 2023; Pappas,2024). The resultant departure of highly experienced expert nurses has caused some hospitals to report that 50% of their nursing staff is comprised of new-to -practice nurses. Even specialty hospitals which previously hired only experienced nurses now report that 40% of their staff have three or fewer years of experience. It is not unusual to hear that the most experienced nurse in a patient care unit has been practicing for six months.
It is often necessary to assign new graduate nurses to preceptors who themselves are hovering at the advanced beginner or competent stage of practice development. These preceptors often lack sufficient clinical experience and are still learning how to cope with the responsibility that comes with nursing practice. They lack the authoritative knowledge, skilled ethical comportment, and clinical imagination of the expert nurse, and practice on these patient care units may feel “flat,” or may be ridden with high rates of “failure to rescue” (Clarke and Aiken, 2003). One nurse leader observed that there is “a lack of soul” in the practice; that how nurses connect with patients to offer comfort and connection, humanity, dignity, and reassurance into to their patients’ worlds of illness and treatment is missing.
New-to-practice nurses often enter the workplace with the aim of making strong connections with patients and coworkers, but they often feel overburdened by the simultaneous need to master multiple procedures required in complex patient care. The unrelenting need to complete a myriad of non-clinical tasks diminishes their time with patients. The pandemic prevented them as students from caring for the usual number of actual patients and thereby limiting their ability to learn the subtle and complex skills of involvement. Simulation was substituted but even the most well-planned simulations cannot capture nuanced skills of involvement or perceptual grasp of clinical changes in patients across time. Consequently, these new nurses are often at a loss to know how to relate to seriously ill patients or how to recognize early changes in patients’ clinical condition. The responsibility and fast pace of the practice may feel overwhelming to new nurses when expert clinical nurses are not immediately available to offer guidance about how to administer rapid treatment, how to make a case to a provider for urgently needed changes to a patient’s treatment orders or offer perspective about a medication error. New nurses rely on “rapid response teams” when patients’ clinical conditions worsen, but the judgment about when to institute these emergency measures and the feeling of incompetence a new nurse may have when moved aside by others who have come to rescue their patient may painfully remind the new graduate of their lack of experience-based knowledge and skilled know-how. Not having experience-based judgment and a sense of salience which allow meaningful situations to stand out as more or less important make the advanced beginner period of learning hazardous and exhausting (Benner, Tanner, Chesla, 2009). The disillusionment, stress and job dissatisfaction which often ensue for new nurses are reflected in high rates of turnover or the decision to leave the nursing profession (Song and Kim, 2023).
The alertness, awareness and capabilities of front-line staff are essential for safe patient care and contribute to organizational viability and reliability in complex high-risk situations. But when the nursing staff is primarily composed of new-to-practice nurses who lack experience-based clinical reasoning skills, safe and effective, patient care suffers and the incidence of “failure to rescue” rises (Clarke and Aiken, 2003). The fact that inexperienced nurses outnumber those with in-depth clinical experience and expertise is a critical and rightful concern of all who are responsible for insuring quality and safety in healthcare settings (Weick and Sutcliffe, 2015; Wears and Sutcliffe, 2020).
Two Ways to Intervene:
There may be an expectation that new graduate nurses should be fully functional immediately upon entering the workforce, but no practitioner can be beyond their level of clinical experience. The practice of advanced beginners is directed by “orders”, rules, procedures, protocols, and guidelines. Advanced beginners miss subtle cues of a patient’s rapidly changing situations as they struggle to match the patient’s actual presentation with textbook descriptions of expected signs and symptoms (Benner, Tanner, Chesla, 2009). They are easily overwhelmed by the sense of multiple urgent competing tasks that they find impossible to complete efficiently and carry an exaggerated sense of responsibility.
Two strategies which may help prepare nursing students to be more practice-ready and then to facilitate the practice development of advanced beginners merit consideration, especially when expert clinical leaders are scarce.
The first recommendation is to ensure that nursing students are practice ready. The Carnegie National Study of Nursing Education has described three professional apprenticeships upon which pre-licensure nursing education programs should be built. These apprenticeships reflect the embodied skilled knowledge that must be integrated, modeled, or demonstrated by the practitioner-teacher and include:
- The cognitive apprenticeship – the intellectual training that provides the academic and theoretical knowledge base required for nursing practice and that teaches the student how to think in ways important to the profession;
- The practice apprenticeship – clinical reasoning and skilled know-how that teaches students how to think and solve problems in actual clinical situations. Students should learn how to reason across time through changes in the patient or changes in the clinician’s understanding of the patient’s conditions and concerns;
- The formation and ethical comportment apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the student is introduced to having an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes (Benner, Sutphen, Leonard, Day, 2010).
Teaching for practice readiness requires a shift from using superficial descriptive language about nursing practice that delineates decontextualized “knowing that and about” to language that describes situated thinking-in-action across transitions in patients’ clinical condition (Benner, Hooper-Kyriakidis, & Stannard, 2011). Such narrative descriptions (Taylor, 2016) illustrate clinical reasoning about the particular case through transitions in the patient’s clinical condition and help students learn the “how and when and why” of excellent practice. The goal of teaching nursing practice is for the student to learn knowledge acquisition and knowledge use in particular clinical situations and how to live out the skilled know-how that is the essence of expert nursing practice. Practice is not static and requires more than mere application of generalized knowledge to unique clinical situations. Rather, practice is dynamic, requiring that the nurse be able to accurately read the patient’s situation, learn how to reason across transitions in patients’ critical, rapidly changing clinical conditions and institute responses that are required. Using unfolding case studies based on an actual patient situation and language that describes clinical reasoning, situated thinking in action, and the ability to triage and prioritize the patient’s most urgent care needs are effective pedagogies to achieve this goal and best help newly graduated nurses to be practice ready (Chan, G., & Burns E.M. (2021). Rather than emphasizing “snapshot” linear models of scientific reasoning such as the Nursing Process, teachers should model situated thinking-in-action and clinical reasoning across transitions in patient’s clinical conditions (Benner, Sutphen, Leonard-Kahn, & Day, 2010; Benner, Hooper-Kyriakidis, Stannard, 2011; Benner, P., 2022)). Carefully guided clinical practicum time should be maximized, and simulation should be an enhancement rather than a replacement for actual time given to learning directly from practice. Video exemplars of expert teaching strategies along with accompanying in-depth scholarly papers can be found on this website; the reader is particularly directed to Urgent Need: Teaching Strategies that Promote Lifelong Experiential Learning (Benner, P; September 26, 2023) and Enriching and Extending Experiential Learning from Clinical Practice: Why Learning from Practice is Indispensable (Benner, P and Benner J; January 9, 2024).
The second imperative is that chief nurse executives build narrative cultures that promote the collection and dispersing of clinical narratives for two reasons: first, to make widely visible and accessible expert nursing practice that is within the health care systems they lead; and, secondly, to provide administrative structures within which new nurses can enhance experiential learning by sharing, discussing, and comparing their clinical learning experiences with each other and with expert colleagues.
A major responsibility of the Chief Nurse Executive is to interpret for the healthcare system the ways in which nurses contribute to the mission, goals, and financial viability of the enterprise. But too often, nurse executives rely on decontextualized accounts of explicit knowledge and data that can be codified, measured, and generalized to make decisions, manage risk, and promote change. Such explicit knowledge and data assume a world independent of context in which answers are universal and predictive and where tacit skilled know-how and clinical judgments about patients across time are left out or are thought to be of lesser value (Nonaka and Takeuchi, 2011; Cathcart and Greenspan, 2013). The evaluation of quality, safety, and productivity achieved primarily through the application of metrics is rightfully an organizational priority, but the caring practices and clinical reasoning that constitute the foundation of safe and effective nursing practice cannot be captured by metrics alone. The danger in attempting to do so is that the countable and measurable tasks and procedures performed by the nurse are misconstrued for the totality of nursing practice. The life-saving contributions of the nurse, such as clinical reasoning and managing rapidly changing clinical situations are undescribed and unrecognized (Cathcart, 2008).
Because the ways in which nurses prevent and mitigate financial risk are not widely described, accounted for and discussed, nursing is seen as a cost burden rather than an asset in health care accounting practices (Pappas, 2024). Expert clinical nurses can see early changes in patients’ clinical conditions, discern what requires attention and what is inconsequential, and institute therapies which often lead to good patient outcomes rather than deleterious consequences, so expert practice is highly efficient and effective (Benner, Hooper-Kyriakidis, Stannard, 2011). But unless the expert nurse’s account of the situation is heard and understood, this practice remains covered up and marginalized, giving rise to the notion that “a nurse is a nurse”. The data-driven and cost-driven American health system, will not improve patient outcomes or reduce “failures to rescue patients” without a clear understanding of the value added by adequate expert nursing care (Pappas, 2024).
Because practice is learned in dialogue with actual clinical situations as they unfold, new-to-practice nurses need to hear narratives of expert practice to develop clinical know-how and situated thinking-in-action (Benner, Hooper-Kyriakidis & Stannard, 2011). Narrative comes closer than any other approach to describing actual nursing practice, and narrative pedagogy comes closest to demonstrating the experiential learning required for good clinical practice development (Taylor, 2016). Reflection and dialogue on actual clinical practice situations set up the new nurse’s readiness for the continuous learning acquired directly from clinical experience and foster changes in the nurse’s practice which are essential to achieving expertise. Experiential learning comes from having one’s preconceived notions turned around in particular clinical situations so that one’s clinical perception and understanding are enriched (Benner, Hooper-Kyriakidis, Stannard, 2011). Articulation of practice through narrative allows for interpretation of the clinical nurse-author’s story with emphasis on their perceptual grasp and reading of the clinical situation, the clinical reasoning, judgment, and their skilled know-how embedded in the actual situation, along with the nurse’s concerns, intents, and the patient’s outcomes. All of these areas of expert nursing practice require narrative accounts and as Taylor (2016) argues, narratives are substitutable for this kind of engaged and situated knowledge.
Good leaders look to nurses engaged in direct patient care for answers to challenging patient care situations, so collecting exemplars of best practice will provide a broad understanding of practice on the front lines and provide opportunities to reimagine and restructure care delivery models to insure safe and effective nursing care. Utilizing first-person accounts of actual practice situations that are meaningful to front-line expert clinical nurses provides younger nurses with vivid examples of clinical imagination and ethical comportment of expert nurses (Benner, in press). Read Clinical Reasoning: A Science-Using Form of Practical Reasoning that Includes a Concern for Responsible Actions Towards Patients/Families. (Benner, P.; October 12, 2022)
Intentionally creating opportunities for new nurses to speak about their experiences validates the value and worth of nursing as it is actually practiced rather than how it is described in textbooks. Reflecting on their practice keeps new nurses connected to the good in the practice and shows its value to the organization – factors which have been closely linked to retention of today’s younger workforce. Giving voice to the work of the new clinical nurse and to the practice of their expert colleagues is an effective way for nurse leaders and colleagues to recognize them and can demonstrate more meaningful acknowledgement than the often-provided pizza lunches.
The tendency to restrict “knowledge” to what can be verbalized or documented contributes to the failure to realize how much embodied skilled know-how and knowledge exist in nurses’ astute clinical reasoning and caring practices. One nurse in a large urban cancer center said this about her experience of narrative writing: “I’m often asked what exactly it is that I do all day. It is difficult to explain what is involved in preparing for clinic and taking care of post-op patients in an office. I often settle with trivializing my day-to-day work. But my experience described in this narrative highlights two of the things that I love about my position. First is the opportunity to build durable and strong relationships with patients over time that themselves became a form of treatment and healing. In a way, we become experts in our patients, understanding what’s normal for them and picking up on nuances that might otherwise be missed. Second is the opportunity and encouragement to continually seek out knowledge and expertise and utilize this daily. Knowing the pathophysiology of disease and its management and knowing my patients allow my clinical hunches to often pay off for them.”
References:
Benner, P. (In Press) “Studying Expert Ethical Comportment and Preserving the Ethics of Care and Responsibility Embedded in Expert Nursing Practice.” M. Fowler, (Ed.) Nursing Ethics, 1800’s to the Present: An Archeology of Lost Wisdom and Identity. New York: Routledge In Press ISBN 9781032200729.
Benner, P. and Benner, J., (July 16, 2023). “Facilitating Students’ Learning from Practice: The Centrality of Experiential Learning in Practice Disciplines.” EducatingNurses.com
Benner, P., Hooper-Kyriakidis, P, and Stannard, D. (2011). Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach. 2nd Ed. New York: Springer Publishing Co.
Benner, P., Sutphen, M., Leonard, V., and Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass.
Benner, P., Tanner, C., and Chesla, K. (2009). Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. 2nd Ed. New York: Springer Publishing Co.
Buerhaus, P. and Hayes, R. (2024). Leveraging nursing strengths: listening to nursing needs: A keynote paper from the 2022 Emory University Business Case for Nursing Summit.https://doi.org/10.1016/j.outlook.2023.101993.
Cathcart, E. (2008). The Role of the Chief Nursing Officer in Leading the Practice: Lessons from the Benner Tradition. Nursing Administration Quarterly. 32(2). 87-91.
Cathcart, E.B, and Greenspan, M. (2012). A new window into nurse manager development: Teaching for the practice. Journal of Nursing Administration. 42(12). 557-561.
Cathcart, E. (2014). Relational work: At the core of Leadership. Nursing Management. 45(3). 44-46.
Chan, G. K, & Burns E.M. (2021) “Quantifying and Remediating the New Graduate Nurse Resident Academic-Practice Gap Using Online Patient Simulation. Journal of Continuing Nursing Education. Vol.52 (5) 240-249).
Clarke. S. and Aiken, L. (2003). Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing. 103(1). 42-47.
Craig, N. and Snook, S. (2014). From purpose to impact: Figure out your passion and put it to work. Harvard Business Review.92(5). 105-111.
Martin B, Kaminski-Orturk, N, O’Hara C, Smiley R. (2023). Examining the impact of the COVID-19 pandemic on burnout and stress among US nurses. Journal of Nursing Regulation.14(1): 4-12.
Nonaka, I. and Takeuchi, H. (2011). The wise leader. Harvard Business Review. 89(3). 58-67.
Pappas, S., et al. (2024). Maximizing the potential value of the nursing workforce. Nursing Outlook. https://doi.org/10.10.16/j.outlook.2023.102016.
Sherman, R. (2024). Managing defensive staff. January 29. Emergingnurseleader,com.
Song, Y. and Kim, J. (2023). New graduate nurses’ competencies, organizational socialization, and turnover intention. Journal of Nursing Administration. 53(12). 675-682.
Sullivan. W. and Rosin, M. (2008). A New Agenda for Higher Education: Shaping a Life of the Mind for Practice. Stanford, CA: The Carnegie Foundation for the Advancement of Teaching.
Taylor, C. (2016) The Language Animal. The Full Shape of the Human Linguistic Capacity. Cambridge Mass., Harvard University Press Belknap Imprint.
Wears, R. and Sutcliffe. K. (2020). Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. New York: Oxford University Press.
Weick, K. and Sutcliffe, K. (2015). Managing the Unexpected: Sustained Performance in a Complex World. 3rd Ed. Hoboken, NJ: John Wiley and Sons.