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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Expertise in Community Health Nursing Anne McMurray Published online: 07 Jun 2010.
To cite this article: Anne McMurray (1992) Expertise in Community Health Nursing, Journal of Community Health Nursing, 9:2, 65-75, DOI: 10.1207/s15327655jchn0902_1 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_1
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNALOF COMMUNITY HEALTH NURSING, 1992,9(2), 65-75 Copyright @ 1992, Lawrence Erlbaum Associates, Inc.
Expertise in Community Health Nursing Anne McMurray, RN, PhD
Downloaded by [Johns Hopkins University] at 07:45 11 January 2015
Edith Cowan University
This article reports on a study of expertise in community health nursing. The objective of the study was to develop a model of expertise derived from identification of the characteristics and factors influencing clinical expertise in community health nurses (CHNs) practicing in district nursing, school health, and child health. Participant observations, individual interviews, and written retrospective accounts of clinical episodes were analyzed from 37 nurses (10 novices within the first year of community practice and 27 experts identified by peers and colleagues). The data identified the expert as someone in whom the following characteristics operate synchronously: knowledge; empathy; appropriate communication; holistic understanding; an ability to get right to the problem at hand; and self-confidence in her or his perceptions, judgments, and intervention strategies. The findings suggest that there is a combination of factors which influences the development of expertise. These include educational factors, personal factors, and experience. These factors are incorporated into the model of expertise. The data also suggest that, in order to educate for expert levels of practice, the educational process must be designed to stimulate the learner's perceptual as well as analytic abilities. This can best be achieved through clinical practice opportunities and through demonstrations and case studies which stimulate inferential and intuitive thinking in students.
One of the most promising developments for the profession in the last decade has been the heightened interest in researching nursing's practice base from a qualitative perspective. Studies have described and interpreted clinical practice in order to identify the competencies and domains of practice, deduce appropriate educational strategies which prepare for practice competencies, and generate theory from the real or "lived" world of practice rather than from theoretical abstractions (Benner, 1984; Bryckzynski, 1989; Fenton, 1985). However, with few exceptions (e.g ., Kenyon et al., 1990), community health nursing practice has been underrepresented in this body of research. The study reported here was thus designed to make a contribution to practice-based knowledge of community health nursing. Specifically, it attempted to describe the practice behaviors of CHNs in order to identify shared meanings embedded in practice and the difference in practice behaviors and shared meanings between novice and expert nurses. The ultimate objectives of the study Requests for reprints should be sent to Anne McMurray, RN, PhD, Associate Professor, Head, School of Nursing, Edith Cowan University, Pearson Street, Churchlands, West Australia 6018.
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were to develop a model of expertise and to suggest strategies for educating towards expertise in community health nursing.
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METHOD
Thirty-seven CHNs participated in the study conducted in Perth, Australia throughout 1990. Participants included 9 experts (identified by supervisors) from each of child health, school health, and district nursing practice; and 10 novices (within the first year of community health nursing practice), 5 each from child health and district nursing. The study adopted a qualitative, interpretive approach. A field study was designed to maximize the range of clinical situations sampled and consisted of collecting data from three sources: participant observation by the researcher; individual interviews with study participants; and written retrospective accounts of clinical episodes, which were called critical incidents. Transcripts from the observations, interview data, and narrative accounts of clinical episodes were then systematically interpreted using the constant comparative method suggested by Glaser and Strauss (1967). Information provided by each participant was summarized and analyzed in order to identify emerging themes. Themes were then compared between and within groups until both the common and unique characteristic~of each group were circumscribed. At this stage, the summary information was referred back to the original transcripts to ensure that the themes being extrapolated did not sever the connection to the original responses and observations. In some cases frequency counts were used to substantiate or call into question impressions evoked by the data. Three data segments (one from each of child health, school health, and district nursing) were also analyzed by independent reviewers in order to cross-validate interpretations.
FINDINGS
All but one of the study participants were female, the single male being an expert district nurse. All subjects were registered nurses (RNs), with seven in the expert group and two in the novice group having attained a post-registration baccalaureate degree. A total of 483 client encounters were observed within the context of interactive clinical situations. These included 104 with novice nurses and 379 with experts.
PRACTICE CHARACTERISTICS
The common practice characteristics observed in all subjects incorporated behaviors directed at self-management and those directed at client management. Self-management behaviors included planning the case load or clinic; organizing for personal needs such as time, space, transportation, and information; and forward planning
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for such matters as educational needs. Client management behaviors followed a sequence which began with establishing contact and rapport with the client, then proceeded through an investigative process of screening and interviewing. During client assessment interviews, cues emerged which formed the basis of clinical judgments made by the nurse. The judgment process consisted of attending to these cues, judging the situation, validating judgments with the client, and setting priorities for meeting the needs of the client. The nurse's involvement in enabling needs to be met consisted of one or more of the following activities: advising, reassuring, explaining, counseling, and referring. Finally, the nurse engaged in a variety of activities aimed at monitoring progress. These were all accompanied by meticulous documentation and included ongoing surveillance, coordination activities related to client needs, and evaluating outcomes (see Figure 1).
COMMON KNOWLEDGE, BELIEFS, AND MEANINGS Study subjects appeared to be operating from a vast wealth of knowledge in their interactions with clients. They were required to judge an individual's capacity for self-care and self-monitoring; to understand individual functioning, family dynamics, patterns of human responses in the face of illness and disruption, and of how emotional states serve to either inhibit or potentiate health. This behavioral knowledge, together with their knowledge of health and illness and an understanding of the social conditions which precipitated many of the problems dealt with (poverty, unemployment, single parenthood, discrimination), formed the essential components of the knowledge base for practice. Thematic analysis of the data revealed that nurses in all subject groups held certain shared beliefs and meanings. These included a belief in the philosophy of holism, a commitment to facilitating self-care while maintaining a close emotional bond with clients, and a common conviction that the health of their clients was directly related to the comfort of caregivers and other family members.
NOVICE-EXPERT DIFFERENCES Clinical judgment represents the essence of clinical practice, and was therefore of paramount importance to the study. It was expected that within the context of forming and discussing clinical judgments, subjects would demonstrate the depth and breadth of their knowledge and expertise. The data produced several examples where the clinical judgments of novices and experts were indistinguishable for similar types of client encounters. However, a profile of the expert emerged which clearly demonstrated superior processes in judging clinical situations. Many of these processes corresponded closely to differences identified by Tanner (1984) and Benner and Tanner (1987). Tanner (1984) categorized the differences between novices and experts according to four phases of the diagnostic process: narrowing the
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The Process of Community Health Nursing Practice
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Self Management Planning Case LoadfClinic Organizing : time space transportation information Forward Planning : education information TO ENABLE -
Client Management Establishing Contact/Rapport Screening Interviewing Making Judgments : attending to cues judging vahdanng judgments setting priorities Enabling Needs to be Met : care giving advising reassuring explaining counselling refemng Monitoring Progress : surveillance coordination evaluation documentation
FIGURE 1 The process of community health nursing practice.
search field, hypothesis activation, information seeking, and hypothesis evaluation. In this study, these processes were analyzed separately for child health, school health, and district nurses, with no clear differences emerging related to the situational aspects of their roles or their varying education and experience levels. Narrowing the Search Field
Tanner (1984) suggested that the novice tends to stereotype situations on the basis of pre-encounter information, then looks for confirming data, often failing to recognize cue patterns in the situation which would direct the search field. The following client encounter illustrates: A novice nurse visited a terminally ill man to administer an injection and reassess his pain control regime. During the visit, a television segment on volun-
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tary euthanasia began. The man was seated in front of the television and, unnoticed by the nurse, began to weep. Throughout the duration of the encounter, he became increasingly upset, yet in the nurse's preoccupation with the task at hand, she failed to attend to the cues. In contrast, experts extracted maximal information from cues, recognizing patterns, and consistently demonstrating deep understanding of client situations. When asked to reflect on this understanding, subjects described it in terms of intuitive hunches. A school health nurse explained: "I knew there was something going on there . . . something in her body language told me something else was going on . . . a little bit of eye evasiveness, pale face, something about her that wasn't quite right. " Activating Hypotheses
The novice, according to Tanner (1984) often uses a single cue, which may either be very global or very specific, to trigger a hypothesis, ignoring cues that do not fit. Experts, on the other hand, use cue patterns as triggers for hypotheses, generating hypotheses at varying levels of abstraction and holding in reserve for later exploration cues that cannot be "chunked" into an activated hypothesis. Evidence of this was also seen in the study data. Novice nurses, when asked following an encounter what they had been looking for or ruling out, replied: "Whether the family is coping," hypothesizing about coping as if it were a polar end-state rather than a graded distinction on a continuum of experience. Such hypotheses formed the bases for setting priorities which, in the case of the novice, were set according to what problems were amenable to intervention rather than according to severity or intensity of need. An example of this was observed during an encounter with a multiproblem family when the novice nurse kased her plan of care on the hypothesis that transportation to the immunization clinic (a solvable problem) was a more pressing issue than ensuring that the mother's recently diagnosed infection was being treated. Like the expert described by Tanner (1984) and Benner (1984), expert subjects in this study had developed a knowledge of what is salient, and on the basis of this knowledge, set priorities which were tempered by a sense of time. One expert nurse illustrates this in her reflections on a case she was involved in with a young mother: She repeatedly comes to me with a variety of problems, yet when it comes time for dealing with them, "roadblocks" my attempts to help. With each encounter I look at alternatives as to why she is doing this, gathering cues, and knowing that in time I will get to the real problem. Information Seeking
With few exceptions, novices asked an overwhelming number of questions of their clients in order to gather evidence which supported their hypothesis. When clients offered new information on different or peripheral issues, the nurse's response was
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to offer reassurance, such as: "You're doing a great job," or "You've made such good progress." These comments themselves are appropriate; however this type of reassurance was given indiscriminately and appeared to be a way of controlling the conversation in the direction of the nurse's hypothesis rather than acting as a stimulus for further discussion. Experts, on the other hand, provided reassuring comments, but attempted to avoid premature closure by encouraging clients to express concerns or complaints, often interrupting their line of questioning if a client wished to pursue a particular direction. One expert nurse explained this discriminatory ability as having learned from experience to distinguish between reassuring to pacify the client and reassuring to reinforce a behavior. Experts generally attempted to validate impressions at each stage of an interview, shifting the focus of the search for information according to responses of the client. Their communication strategies were highly refined and clearly superior to those of the novices. They listened, clarified, responded, and allowed the clients to explore priorities for intervention. In this respect, they functioned as a therapeutic partner, collaborating with the client in goal setting. They were also persistent in gathering information and in pursuing a course of action as the following vignette from a high school nurse illustrates: My cues were lethargy, repeated infections and the mother's faith in her GP who kept telling her that her daughter was fine. I knew there was something wrong with the girl and that it was serious. I finally confronted the mother and had a battery of tests done confirming my suspicions. The girl turned out to have leukemia. Hypothesis Evaluation According to Tanner (1984), novices may evaluate hypotheses inappropriately because they tend to be nonselective in data collection, often underestimating the value of disconfirming data and overestimating the value of confirming data on their favored hypothesis. This was observed in the case of a novice nurse who visited a client exhibiting signs of marked dehydration, yet on the basis of pre-encounter information she declared that he was hydrated. Experts used previous experiences to evaluate present situations and were less influenced by the confirming or disconfirming nature of the available data. They demonstrated what Benner and Tiinner (1987) called deliberative rationality-integrating data in the presenting situation with memory of previous cases and trusting in their intuitive judgment. Several expert subjects were observed to assess a case, then discuss it with a colleague, or review a research report and ultimately involve the client and others in the health-care team (teachers, caregivers, family physicians) before making a final decision. One expert explained: You don't generalize. You add new literature (research findings) to what you know from experience, then you gain information by open-ended questions and by pacing your questions over time.
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THE EXPERT Expert CHNs in this study closely resembled the experts described in previous studies (Benner, 1984; Bryckzynski, 1989; Fenton, 1985). The data revealed that the expert is someone in whom the following characteristics operate synchronously: knowledge; empathy; appropriate communication; holistic understanding; an ability to get right to the problem at hand; and self-confidence in her or his perceptions, judgments, and intervention strategies. They were motivated learners who were skilled in communicating with others and self-confident in their abilities. They were also receptive to information from a variety of sources, nominating education, role models, and opportunities to accumulate both life and clinical experiences as the important influences contributing to their knowledge and skills as CHNs. Analysis of study data suggests that the development of expertise is influenced by education, experience, and by a combination of personal factors which interact with both education and experience. These factors are illustrated in Figure 2. The model suggests that both educational factors and personal factors assist the individual to capitalize on experiences. Educational factors include foundation or pre-registration studies; continuing education, which consists of post-registration learning experiences; and specialized study, which includes formal study towards gaining a specialist credential, such as midwifery or child health. Role models provide an additional educational factor, and according to study subjects, life experiences such as parenting and travel (particularly for intercultural experience) also exert an important educational influence on the development of expertise. It is suggested that the following personal factors are also instrumental in the development of expertise: motivation, receptivity, and self-confidence. Each of these is discussed. Motivation
Behavior changes which are destined to endure require personal motivation. Psychological theories from the early part of this century suggest that most people's interactions with their environment are motivated by a need for feelings of competence and efficacy (White, 1959). Bandura's theory of self-efficacy asserts that an individual is motivated by the expectation of success which is fueled by past performance accomplishments, vicarious experience (e.g., observing others' successes), verbal persuasion from others, and emotional arousal (Bandura, 1979, 1984). Some individuals have a much higher need for self-efficacy and achievement than others (Atkinson, 1977). These highly motivated individuals are those most likely to pursue higher levels of learning, to strive for expertise, and to be responsive to others demonstrating expertise in their work environment. Experts in this study appeared to fit this pattern of behavior. One of the distinguishing characteristics of the expert subjects was their history of having actively pursued a variety of educational strategies throughout their years of practice. At interview all experts identified experience as the most important influence in their
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A Model of Expertise
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Educational Factors
Personal Factors
(
Motivation
1
I
Receptivity
(
H Specialized Study
I
F Role Models
Life Experience
learning, then added that in order to maintain practice expertise, they sought out continuing education, formal study, individual reading, and discussion with colleagues. These were all considered to be necessary adjuncts to that experience. Such responses suggest that this group was very highly motivated towards gaining and maintaining knowledge and skills. Receptivity
Knowledge and skills cannot become highly developed unless an individual has highly developed perceptual/attentional abilities and is open or receptive to new ways of perceiving (Dawson, Zeitz, & Wright, 1989; Shanteau, 1988; Young, 1987). When an individual is receptive to unique situations, her or his experiences transform knowledge rather than merely aggregate, allowing those experiences to be used creatively in response to future situations. Receptivity is cultivated by reflecting on previous situations; that is, reviewing one's repertoire of experience and knowledge
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to invent novel approaches to complex problems (Saylor, 1990; Schon, 1983). This characteristic was demonstrated by participants in this study who considered that their practice experiences were very much influenced by client perspectives and continually changing circumstances. As one expert commented: "You have to develop for the type of client you have." The tendency to spend a large proportion of client encounter time just listening was evident in observing expert nurses' interactions with their clients. This was also confirmed during interviews. Expert nurses were of the opinion that being receptive to the client in the context of her or his physical, emotional, and social environment was an important element which enable6 &hem to conduct comprehensive assessments and develop a holistic, client-centered perspective. Self-Confidence Self-confidence was a highly visible characteristic of all expert subjects in the study, particularly in the way these nurses reflected on their clinical judgments. Expert study subjects described self-confidence as being able to plan a course of action and predict what the outcome will be. As one nurse explained: "With experience you see more and you know what you're looking at." It is highly likely that experts in the study had become self-confident as a history of successful judgments was built up. However, those who develop the selfconfidence to excel may be the type of individuals who are able to maintain a sense of perspective about themselves and the situations they find themselves in. Further research is thus needed to investigate self-confidence as both a predisposing factor and an outcome of expertise. The most conspicuous aspect of self-confidence in this study was the expert nurses' persistence. This was a subtheme which emerged particularly from critical incident reports, but which was also observed and confirmed during interviews. For example, one nurse sent her client back to hospital twice upon discharge, tenaciously convinced (and rightly so) that he had been misdiagnosed. A school nurse, confident that one of her students had multiple sclerosis, yet having been informed by the doctor that he did not, went so far as to consult a specialist herself to discuss the case. Eventually, after enough evidence had been gathered her hypothesis was confirmed.
DISCUSSION In order to encourage and reward expertise in community health nursing, the educational process must prepare for the complex and knowledge-rich practice requirements of community health nursing. Study data indicated that nurses have reconceptualized their role as a therapeutic partnership between nurse and client. Programs which educate for expertise must therefore be progressive enough to recognize this role. To prepare for the opportunistic management of families and com-
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munities, curricula must continue to emphasize expertise in caregiving, as individual competence establishes the credibility which enables the nurse to function as a consultant to the family and the community. To deal with the ever increasing proportion of social issues in the community, the curriculum must also include the study of current trends in society, in illness, and in the organization of health care. Major emphasis must be placed on communication skills in preparation for interviewing, advising, reassuring, and counseling clients, as well as for efficient processing of information, establishing professional networks, and for interdisciplinary collaboration. The study participants acknowledged continuing education components as having a major influence on their level of practice in the community. This needs to be exploited as an important counterpart to basic nursing education, particularly insofar as it provides a well-timed opportunity for learning when the student is motivated and is able to consolidate theoretical and practical knowledge. In an attempt to provide achievement incentives, educators must serve as role models who inspire creative and critical thinking and who acknowledge the value of intuitive as well as analytic processes. This can best be accomplished by exposing students to a variety of expertly handled clinical cases either through field experiences or simulated case studies which stimulate the student to impute meaning and make inferences about client outcomes and the process of nursing. At all levels the role of the mentor is paramount. Expertise cannot be taught, but it can be nurtured by recognizing and reinforcing competence in the neophyte; encouraging achievement, motivation, receptivity, and self-confidence; and by providing an environment in which formal and informal learning experiences are shared. The study findings suggest that further research should explore the relative influences of various experiential and educational factors on the development of expertise, and whether there are other critical variables, either personal or situational, which help to foster expertise in community health nursing. This study has attempted to provide a beginning step in this direction.
REFERENCES Atkinson, J. (1977). Motivation for achievement. In T. Blass (Ed.), Personality variables in social behavior (pp. 67-77). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Bandura, A. (1979). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191-215. Bandura, A. (1984). Recycling misconceptions of perceived self-efficacy. Cognitive Therapy and Research, 8, 23 1 -255. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P., & Tanner, C. (1987). How expert nurses use intuition. American Journal of Nursing, 87(1), 23-3 1 . Bryckzynski, K. (1989). An interpretive study describing the clinical judgment of nurse practitioners. Scholarly Inquiry for Nursing Practice, 3(2), 75-104. Dawson, V., Zeitz, C., & Wright, J. (1989). Expert-novice differences in person perception: Evidence of experts' sensitivities to the organization of behavior. Social Cognition, 9(1), 1-30.
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Fenton, M. (1985). Identifying competencies of clinical nurse specialists. Journal of Nursing Administration, 15(2), 31-37. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine. Kenyon, V., Smith, E., Vig Hefty, L., Bell, J., McNeil, J., & Martaus, T. (1990). Clinical competencies for community health nursing. Public Health Nursing, 7(1), 33-39. Saylor, C. (1990). Reflection and professional education: Art, science and competency. Nurse Educator, 15(2), 8-11. Schon, D. (1983). The ~flectivepractitioner.London: Temple Smith. Shanteau, J. (1988). Psychological characteristics .and strategies of expert decision makers. Acta Psychologica, 68, 203-215. Tanner, C. (1984). Factors influencing the diagnostic process. In D. Carnevali, D. Mitchell, R. Woods, & C. Tanner (Eds.), Diagnostic reasoning in nursing (pp. 61-82). Philadelphia: Lippincott. White, J. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66, 297-23 3. Young, C. (1987). Intuition and nursing process. Holistic Nursing Practice, 1(3), 52-62.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Expertise in Community Health Nursing Anne McMurray Published online: 07 Jun 2010.
To cite this article: Anne McMurray (1992) Expertise in Community Health Nursing, Journal of Community Health Nursing, 9:2, 65-75, DOI: 10.1207/s15327655jchn0902_1 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_1
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNALOF COMMUNITY HEALTH NURSING, 1992,9(2), 65-75 Copyright @ 1992, Lawrence Erlbaum Associates, Inc.
Expertise in Community Health Nursing Anne McMurray, RN, PhD
Downloaded by [Johns Hopkins University] at 07:45 11 January 2015
Edith Cowan University
This article reports on a study of expertise in community health nursing. The objective of the study was to develop a model of expertise derived from identification of the characteristics and factors influencing clinical expertise in community health nurses (CHNs) practicing in district nursing, school health, and child health. Participant observations, individual interviews, and written retrospective accounts of clinical episodes were analyzed from 37 nurses (10 novices within the first year of community practice and 27 experts identified by peers and colleagues). The data identified the expert as someone in whom the following characteristics operate synchronously: knowledge; empathy; appropriate communication; holistic understanding; an ability to get right to the problem at hand; and self-confidence in her or his perceptions, judgments, and intervention strategies. The findings suggest that there is a combination of factors which influences the development of expertise. These include educational factors, personal factors, and experience. These factors are incorporated into the model of expertise. The data also suggest that, in order to educate for expert levels of practice, the educational process must be designed to stimulate the learner's perceptual as well as analytic abilities. This can best be achieved through clinical practice opportunities and through demonstrations and case studies which stimulate inferential and intuitive thinking in students.
One of the most promising developments for the profession in the last decade has been the heightened interest in researching nursing's practice base from a qualitative perspective. Studies have described and interpreted clinical practice in order to identify the competencies and domains of practice, deduce appropriate educational strategies which prepare for practice competencies, and generate theory from the real or "lived" world of practice rather than from theoretical abstractions (Benner, 1984; Bryckzynski, 1989; Fenton, 1985). However, with few exceptions (e.g ., Kenyon et al., 1990), community health nursing practice has been underrepresented in this body of research. The study reported here was thus designed to make a contribution to practice-based knowledge of community health nursing. Specifically, it attempted to describe the practice behaviors of CHNs in order to identify shared meanings embedded in practice and the difference in practice behaviors and shared meanings between novice and expert nurses. The ultimate objectives of the study Requests for reprints should be sent to Anne McMurray, RN, PhD, Associate Professor, Head, School of Nursing, Edith Cowan University, Pearson Street, Churchlands, West Australia 6018.
66
McMurray
were to develop a model of expertise and to suggest strategies for educating towards expertise in community health nursing.
Downloaded by [Johns Hopkins University] at 07:45 11 January 2015
METHOD
Thirty-seven CHNs participated in the study conducted in Perth, Australia throughout 1990. Participants included 9 experts (identified by supervisors) from each of child health, school health, and district nursing practice; and 10 novices (within the first year of community health nursing practice), 5 each from child health and district nursing. The study adopted a qualitative, interpretive approach. A field study was designed to maximize the range of clinical situations sampled and consisted of collecting data from three sources: participant observation by the researcher; individual interviews with study participants; and written retrospective accounts of clinical episodes, which were called critical incidents. Transcripts from the observations, interview data, and narrative accounts of clinical episodes were then systematically interpreted using the constant comparative method suggested by Glaser and Strauss (1967). Information provided by each participant was summarized and analyzed in order to identify emerging themes. Themes were then compared between and within groups until both the common and unique characteristic~of each group were circumscribed. At this stage, the summary information was referred back to the original transcripts to ensure that the themes being extrapolated did not sever the connection to the original responses and observations. In some cases frequency counts were used to substantiate or call into question impressions evoked by the data. Three data segments (one from each of child health, school health, and district nursing) were also analyzed by independent reviewers in order to cross-validate interpretations.
FINDINGS
All but one of the study participants were female, the single male being an expert district nurse. All subjects were registered nurses (RNs), with seven in the expert group and two in the novice group having attained a post-registration baccalaureate degree. A total of 483 client encounters were observed within the context of interactive clinical situations. These included 104 with novice nurses and 379 with experts.
PRACTICE CHARACTERISTICS
The common practice characteristics observed in all subjects incorporated behaviors directed at self-management and those directed at client management. Self-management behaviors included planning the case load or clinic; organizing for personal needs such as time, space, transportation, and information; and forward planning
Downloaded by [Johns Hopkins University] at 07:45 11 January 2015
Expertise in Community Health Nursing
67
for such matters as educational needs. Client management behaviors followed a sequence which began with establishing contact and rapport with the client, then proceeded through an investigative process of screening and interviewing. During client assessment interviews, cues emerged which formed the basis of clinical judgments made by the nurse. The judgment process consisted of attending to these cues, judging the situation, validating judgments with the client, and setting priorities for meeting the needs of the client. The nurse's involvement in enabling needs to be met consisted of one or more of the following activities: advising, reassuring, explaining, counseling, and referring. Finally, the nurse engaged in a variety of activities aimed at monitoring progress. These were all accompanied by meticulous documentation and included ongoing surveillance, coordination activities related to client needs, and evaluating outcomes (see Figure 1).
COMMON KNOWLEDGE, BELIEFS, AND MEANINGS Study subjects appeared to be operating from a vast wealth of knowledge in their interactions with clients. They were required to judge an individual's capacity for self-care and self-monitoring; to understand individual functioning, family dynamics, patterns of human responses in the face of illness and disruption, and of how emotional states serve to either inhibit or potentiate health. This behavioral knowledge, together with their knowledge of health and illness and an understanding of the social conditions which precipitated many of the problems dealt with (poverty, unemployment, single parenthood, discrimination), formed the essential components of the knowledge base for practice. Thematic analysis of the data revealed that nurses in all subject groups held certain shared beliefs and meanings. These included a belief in the philosophy of holism, a commitment to facilitating self-care while maintaining a close emotional bond with clients, and a common conviction that the health of their clients was directly related to the comfort of caregivers and other family members.
NOVICE-EXPERT DIFFERENCES Clinical judgment represents the essence of clinical practice, and was therefore of paramount importance to the study. It was expected that within the context of forming and discussing clinical judgments, subjects would demonstrate the depth and breadth of their knowledge and expertise. The data produced several examples where the clinical judgments of novices and experts were indistinguishable for similar types of client encounters. However, a profile of the expert emerged which clearly demonstrated superior processes in judging clinical situations. Many of these processes corresponded closely to differences identified by Tanner (1984) and Benner and Tanner (1987). Tanner (1984) categorized the differences between novices and experts according to four phases of the diagnostic process: narrowing the
68
McMurray
The Process of Community Health Nursing Practice
Downloaded by [Johns Hopkins University] at 07:45 11 January 2015
Self Management Planning Case LoadfClinic Organizing : time space transportation information Forward Planning : education information TO ENABLE -
Client Management Establishing Contact/Rapport Screening Interviewing Making Judgments : attending to cues judging vahdanng judgments setting priorities Enabling Needs to be Met : care giving advising reassuring explaining counselling refemng Monitoring Progress : surveillance coordination evaluation documentation
FIGURE 1 The process of community health nursing practice.
search field, hypothesis activation, information seeking, and hypothesis evaluation. In this study, these processes were analyzed separately for child health, school health, and district nurses, with no clear differences emerging related to the situational aspects of their roles or their varying education and experience levels. Narrowing the Search Field
Tanner (1984) suggested that the novice tends to stereotype situations on the basis of pre-encounter information, then looks for confirming data, often failing to recognize cue patterns in the situation which would direct the search field. The following client encounter illustrates: A novice nurse visited a terminally ill man to administer an injection and reassess his pain control regime. During the visit, a television segment on volun-
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tary euthanasia began. The man was seated in front of the television and, unnoticed by the nurse, began to weep. Throughout the duration of the encounter, he became increasingly upset, yet in the nurse's preoccupation with the task at hand, she failed to attend to the cues. In contrast, experts extracted maximal information from cues, recognizing patterns, and consistently demonstrating deep understanding of client situations. When asked to reflect on this understanding, subjects described it in terms of intuitive hunches. A school health nurse explained: "I knew there was something going on there . . . something in her body language told me something else was going on . . . a little bit of eye evasiveness, pale face, something about her that wasn't quite right. " Activating Hypotheses
The novice, according to Tanner (1984) often uses a single cue, which may either be very global or very specific, to trigger a hypothesis, ignoring cues that do not fit. Experts, on the other hand, use cue patterns as triggers for hypotheses, generating hypotheses at varying levels of abstraction and holding in reserve for later exploration cues that cannot be "chunked" into an activated hypothesis. Evidence of this was also seen in the study data. Novice nurses, when asked following an encounter what they had been looking for or ruling out, replied: "Whether the family is coping," hypothesizing about coping as if it were a polar end-state rather than a graded distinction on a continuum of experience. Such hypotheses formed the bases for setting priorities which, in the case of the novice, were set according to what problems were amenable to intervention rather than according to severity or intensity of need. An example of this was observed during an encounter with a multiproblem family when the novice nurse kased her plan of care on the hypothesis that transportation to the immunization clinic (a solvable problem) was a more pressing issue than ensuring that the mother's recently diagnosed infection was being treated. Like the expert described by Tanner (1984) and Benner (1984), expert subjects in this study had developed a knowledge of what is salient, and on the basis of this knowledge, set priorities which were tempered by a sense of time. One expert nurse illustrates this in her reflections on a case she was involved in with a young mother: She repeatedly comes to me with a variety of problems, yet when it comes time for dealing with them, "roadblocks" my attempts to help. With each encounter I look at alternatives as to why she is doing this, gathering cues, and knowing that in time I will get to the real problem. Information Seeking
With few exceptions, novices asked an overwhelming number of questions of their clients in order to gather evidence which supported their hypothesis. When clients offered new information on different or peripheral issues, the nurse's response was
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to offer reassurance, such as: "You're doing a great job," or "You've made such good progress." These comments themselves are appropriate; however this type of reassurance was given indiscriminately and appeared to be a way of controlling the conversation in the direction of the nurse's hypothesis rather than acting as a stimulus for further discussion. Experts, on the other hand, provided reassuring comments, but attempted to avoid premature closure by encouraging clients to express concerns or complaints, often interrupting their line of questioning if a client wished to pursue a particular direction. One expert nurse explained this discriminatory ability as having learned from experience to distinguish between reassuring to pacify the client and reassuring to reinforce a behavior. Experts generally attempted to validate impressions at each stage of an interview, shifting the focus of the search for information according to responses of the client. Their communication strategies were highly refined and clearly superior to those of the novices. They listened, clarified, responded, and allowed the clients to explore priorities for intervention. In this respect, they functioned as a therapeutic partner, collaborating with the client in goal setting. They were also persistent in gathering information and in pursuing a course of action as the following vignette from a high school nurse illustrates: My cues were lethargy, repeated infections and the mother's faith in her GP who kept telling her that her daughter was fine. I knew there was something wrong with the girl and that it was serious. I finally confronted the mother and had a battery of tests done confirming my suspicions. The girl turned out to have leukemia. Hypothesis Evaluation According to Tanner (1984), novices may evaluate hypotheses inappropriately because they tend to be nonselective in data collection, often underestimating the value of disconfirming data and overestimating the value of confirming data on their favored hypothesis. This was observed in the case of a novice nurse who visited a client exhibiting signs of marked dehydration, yet on the basis of pre-encounter information she declared that he was hydrated. Experts used previous experiences to evaluate present situations and were less influenced by the confirming or disconfirming nature of the available data. They demonstrated what Benner and Tiinner (1987) called deliberative rationality-integrating data in the presenting situation with memory of previous cases and trusting in their intuitive judgment. Several expert subjects were observed to assess a case, then discuss it with a colleague, or review a research report and ultimately involve the client and others in the health-care team (teachers, caregivers, family physicians) before making a final decision. One expert explained: You don't generalize. You add new literature (research findings) to what you know from experience, then you gain information by open-ended questions and by pacing your questions over time.
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THE EXPERT Expert CHNs in this study closely resembled the experts described in previous studies (Benner, 1984; Bryckzynski, 1989; Fenton, 1985). The data revealed that the expert is someone in whom the following characteristics operate synchronously: knowledge; empathy; appropriate communication; holistic understanding; an ability to get right to the problem at hand; and self-confidence in her or his perceptions, judgments, and intervention strategies. They were motivated learners who were skilled in communicating with others and self-confident in their abilities. They were also receptive to information from a variety of sources, nominating education, role models, and opportunities to accumulate both life and clinical experiences as the important influences contributing to their knowledge and skills as CHNs. Analysis of study data suggests that the development of expertise is influenced by education, experience, and by a combination of personal factors which interact with both education and experience. These factors are illustrated in Figure 2. The model suggests that both educational factors and personal factors assist the individual to capitalize on experiences. Educational factors include foundation or pre-registration studies; continuing education, which consists of post-registration learning experiences; and specialized study, which includes formal study towards gaining a specialist credential, such as midwifery or child health. Role models provide an additional educational factor, and according to study subjects, life experiences such as parenting and travel (particularly for intercultural experience) also exert an important educational influence on the development of expertise. It is suggested that the following personal factors are also instrumental in the development of expertise: motivation, receptivity, and self-confidence. Each of these is discussed. Motivation
Behavior changes which are destined to endure require personal motivation. Psychological theories from the early part of this century suggest that most people's interactions with their environment are motivated by a need for feelings of competence and efficacy (White, 1959). Bandura's theory of self-efficacy asserts that an individual is motivated by the expectation of success which is fueled by past performance accomplishments, vicarious experience (e.g., observing others' successes), verbal persuasion from others, and emotional arousal (Bandura, 1979, 1984). Some individuals have a much higher need for self-efficacy and achievement than others (Atkinson, 1977). These highly motivated individuals are those most likely to pursue higher levels of learning, to strive for expertise, and to be responsive to others demonstrating expertise in their work environment. Experts in this study appeared to fit this pattern of behavior. One of the distinguishing characteristics of the expert subjects was their history of having actively pursued a variety of educational strategies throughout their years of practice. At interview all experts identified experience as the most important influence in their
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A Model of Expertise
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Educational Factors
Personal Factors
(
Motivation
1
I
Receptivity
(
H Specialized Study
I
F Role Models
Life Experience
learning, then added that in order to maintain practice expertise, they sought out continuing education, formal study, individual reading, and discussion with colleagues. These were all considered to be necessary adjuncts to that experience. Such responses suggest that this group was very highly motivated towards gaining and maintaining knowledge and skills. Receptivity
Knowledge and skills cannot become highly developed unless an individual has highly developed perceptual/attentional abilities and is open or receptive to new ways of perceiving (Dawson, Zeitz, & Wright, 1989; Shanteau, 1988; Young, 1987). When an individual is receptive to unique situations, her or his experiences transform knowledge rather than merely aggregate, allowing those experiences to be used creatively in response to future situations. Receptivity is cultivated by reflecting on previous situations; that is, reviewing one's repertoire of experience and knowledge
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to invent novel approaches to complex problems (Saylor, 1990; Schon, 1983). This characteristic was demonstrated by participants in this study who considered that their practice experiences were very much influenced by client perspectives and continually changing circumstances. As one expert commented: "You have to develop for the type of client you have." The tendency to spend a large proportion of client encounter time just listening was evident in observing expert nurses' interactions with their clients. This was also confirmed during interviews. Expert nurses were of the opinion that being receptive to the client in the context of her or his physical, emotional, and social environment was an important element which enable6 &hem to conduct comprehensive assessments and develop a holistic, client-centered perspective. Self-Confidence Self-confidence was a highly visible characteristic of all expert subjects in the study, particularly in the way these nurses reflected on their clinical judgments. Expert study subjects described self-confidence as being able to plan a course of action and predict what the outcome will be. As one nurse explained: "With experience you see more and you know what you're looking at." It is highly likely that experts in the study had become self-confident as a history of successful judgments was built up. However, those who develop the selfconfidence to excel may be the type of individuals who are able to maintain a sense of perspective about themselves and the situations they find themselves in. Further research is thus needed to investigate self-confidence as both a predisposing factor and an outcome of expertise. The most conspicuous aspect of self-confidence in this study was the expert nurses' persistence. This was a subtheme which emerged particularly from critical incident reports, but which was also observed and confirmed during interviews. For example, one nurse sent her client back to hospital twice upon discharge, tenaciously convinced (and rightly so) that he had been misdiagnosed. A school nurse, confident that one of her students had multiple sclerosis, yet having been informed by the doctor that he did not, went so far as to consult a specialist herself to discuss the case. Eventually, after enough evidence had been gathered her hypothesis was confirmed.
DISCUSSION In order to encourage and reward expertise in community health nursing, the educational process must prepare for the complex and knowledge-rich practice requirements of community health nursing. Study data indicated that nurses have reconceptualized their role as a therapeutic partnership between nurse and client. Programs which educate for expertise must therefore be progressive enough to recognize this role. To prepare for the opportunistic management of families and com-
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munities, curricula must continue to emphasize expertise in caregiving, as individual competence establishes the credibility which enables the nurse to function as a consultant to the family and the community. To deal with the ever increasing proportion of social issues in the community, the curriculum must also include the study of current trends in society, in illness, and in the organization of health care. Major emphasis must be placed on communication skills in preparation for interviewing, advising, reassuring, and counseling clients, as well as for efficient processing of information, establishing professional networks, and for interdisciplinary collaboration. The study participants acknowledged continuing education components as having a major influence on their level of practice in the community. This needs to be exploited as an important counterpart to basic nursing education, particularly insofar as it provides a well-timed opportunity for learning when the student is motivated and is able to consolidate theoretical and practical knowledge. In an attempt to provide achievement incentives, educators must serve as role models who inspire creative and critical thinking and who acknowledge the value of intuitive as well as analytic processes. This can best be accomplished by exposing students to a variety of expertly handled clinical cases either through field experiences or simulated case studies which stimulate the student to impute meaning and make inferences about client outcomes and the process of nursing. At all levels the role of the mentor is paramount. Expertise cannot be taught, but it can be nurtured by recognizing and reinforcing competence in the neophyte; encouraging achievement, motivation, receptivity, and self-confidence; and by providing an environment in which formal and informal learning experiences are shared. The study findings suggest that further research should explore the relative influences of various experiential and educational factors on the development of expertise, and whether there are other critical variables, either personal or situational, which help to foster expertise in community health nursing. This study has attempted to provide a beginning step in this direction.
REFERENCES Atkinson, J. (1977). Motivation for achievement. In T. Blass (Ed.), Personality variables in social behavior (pp. 67-77). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Bandura, A. (1979). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191-215. Bandura, A. (1984). Recycling misconceptions of perceived self-efficacy. Cognitive Therapy and Research, 8, 23 1 -255. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P., & Tanner, C. (1987). How expert nurses use intuition. American Journal of Nursing, 87(1), 23-3 1 . Bryckzynski, K. (1989). An interpretive study describing the clinical judgment of nurse practitioners. Scholarly Inquiry for Nursing Practice, 3(2), 75-104. Dawson, V., Zeitz, C., & Wright, J. (1989). Expert-novice differences in person perception: Evidence of experts' sensitivities to the organization of behavior. Social Cognition, 9(1), 1-30.
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Fenton, M. (1985). Identifying competencies of clinical nurse specialists. Journal of Nursing Administration, 15(2), 31-37. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine. Kenyon, V., Smith, E., Vig Hefty, L., Bell, J., McNeil, J., & Martaus, T. (1990). Clinical competencies for community health nursing. Public Health Nursing, 7(1), 33-39. Saylor, C. (1990). Reflection and professional education: Art, science and competency. Nurse Educator, 15(2), 8-11. Schon, D. (1983). The ~flectivepractitioner.London: Temple Smith. Shanteau, J. (1988). Psychological characteristics .and strategies of expert decision makers. Acta Psychologica, 68, 203-215. Tanner, C. (1984). Factors influencing the diagnostic process. In D. Carnevali, D. Mitchell, R. Woods, & C. Tanner (Eds.), Diagnostic reasoning in nursing (pp. 61-82). Philadelphia: Lippincott. White, J. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66, 297-23 3. Young, C. (1987). Intuition and nursing process. Holistic Nursing Practice, 1(3), 52-62.
