This book is based on a dialogue with nurses and nursing, descriptive research that identified five levels of competency in clinical nursing practice. These levels novice, advanced beginner, competent, proficient, and expert are described in the words of nurses who were interviewed and observed either individually or in small groups. Only patient care situations where the nurse made a positive difference in the patient's outcome are included. These situations offer vivid examples of excellence in actual nursing practice. They are not abstract ideals, however; they emerge from the imperfections and contingencies with which nurses work daily.
A Note to the Skeptics
Some who read the exemplars will be skeptical that such nursing is possible. Their skepticism is warranted, because these examples are drawn from outstanding clinical situations where the nurse learned something about her practice or made a significant contribution to a patient's welfare. But if the reader's skepticism stems from a generalized disillusionment with nursing in hospitals and from the belief that nurses are rendered impotent to give compassionate, lifesaving care in hospitals then this book offers a resounding rebuttal to the skeptic and a ray of hope to the disillusioned.
The Perceptual Origins of Excellence
This book questions some of nursing's most dearly held beliefs and assumptions. The book asserts that perceptual awareness is central to good nursing judgment and that this begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than it precedes. Experienced nurses often describe their perceptual abilities using phrases such as "gut feeling," a "sense of uneasiness," or a "feeling that things are not quite right." This kind of talk makes educators and clinicians uncomfortable, because the assessment must move from these perceptual beginnings to conclusive evidence. Expert nurses know that in all cases definitive evaluation of a patient's condition requires more than vague hunches, but through experience they have learned to allow their perceptions to lead to confirming evidence.
In the quest for a scientific rationale, the importance of perceptual skills can be overlooked by any clinician nurse, physician, or counselor. If nurses were disembodied computers or mechanical monitoring devices, they would have to wait for clear, explicit signals before identifying one singular feature of a problem. Fortunately, however, expert human decision makers can get a gestalt of the situation and proceed to follow up on vague, subtle changes in the patient's condition with a confirmatory search aided by the whole health care team. Experts dare not stop with vague hunches, but neither do they dare to ignore those hunches that could lead to early identification of problems and the search for confirming evidence.
The Importance of Discretionary Judgment
Considering the early history of nursing education in this country, I am concerned that the model of skill acquisition described here could be misinterpreted as advocating informal trial-and-error learning. Therefore, it is important to point out that the Dreyfus Model of Skill Acquisition was originally developed in research designed to study pilots' performance in emergency situations. In that context, no one worried that people might misinterpret the model and suggest that the pilot should just go out and "get the feel of the plane" through trial and error; under those circumstances the beginning pilot would not even survive basic training. The same holds true for nursing. Providing nursing care involves risks for both nurse and patient, and skilled nursing requires well-planned educational programs. Experience-based skill acquisition is safer and quicker when it rests upon a sound educational base.
This book's purpose is to present the limits of formal ales and call attention to the discretionary judgment used actual clinical situations. This does not place the expert a special, privileged position outside the principles of physiology, nursing, and medicine. The book does not advocate a chaotic or anarchical position that would claim there are no rules that would confer a license, for instance, to ignore the rules of asepsis simply because sterile technique must be sometimes ignored in life-and-death emergencies. Attending to the particular contingencies of a situation does not warrant the inclusion that the general principles governing that station can be generally ignored. My position is not a careless recommendation for the abandonment of rules. Instead, I am claiming that a more skilled, advanced understanding of the situation allows orderly behavior without rigid rule following.
Once the situation is described, the actions taken can understood as orderly, reasonable behavior that demands of a given situation rather than rigid principles and rules. More descriptive rules could be generated to allow for multiple exceptions, but the expert would still function flexibly in other new situations requiring new exceptions. The book addresses the risky, situation-specific decisions that are usually covered up but that nurses face daily in their practice. Menzies (1960) referred to hiding behind rules and policies as a defense against anxiety, a coping strategy. But as a coping strategy it is unrealistic and creates the additional burden of lack of recognition and legitimization of actual nursing performance.
Reflecting the Realities of Practice
Readers would probably prefer that I had chosen only exemplars reflecting ideal collaborative behaviors and ideal relationships with physicians. In fact, nursing administrators and physicians have warned me that they do not like the exemplars showing the doctor-nurse relationship in a bad light. I, too, wish that in conducting this study I had found only enlightened, collaborative relationships between nurses and physicians, but that would have been fiction and not descriptive research an ideal model instead of an empirically tested one. If there is a bias, it is probably in the other direction: that troubled nurse-physician exchanges are under-represented, given the amount of interview time nurses spent describing troubled interactions.
In the real world, nurses and physicians alike have good and bad days; some are frankly incompetent. When immediate physician attention to a crisis is not available, the nurse fills the gap far more often than is formally acknowledged. We can claim that this is not nursing, but we do so only by ignoring what nurses actually do. Therefore, skilled performance was considered excellent because, even lacking the best of circumstances (e.g., collaborative relationships or formally acknowledged nursing functions), the nurse procured or did what was needed for the patient. By attending to the ideal and presenting only what we hope to become, we would miss much of what is significant about our actual practice. Not knowing who and what we are about now will seriously impede what we want to become.
A Kaleidoscope of Intimacy and Distance
The reader would be correct to question the representativeness of this work. The goal was not to describe a typical day or hour but rather the highlights, the ,growing edges of clinical knowledge. The participants were asked to present clinical situations that stood out in their minds. Nurses make many contacts with patients daily; most of the time they are unaware of the impact their interventions have on the patient's recovery. Many of these contacts and interventions are routine and not even remembered by the nurses. In other words, the nurse-patient relationship is not a uniform professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life. The mundane moments were not captured because this research strategy asked specifically for outstanding clinical situations. So this bias remains, even though we asked for descriptions of both typical and unusual days. Since we sought to describe skilled performance, deficits were not the point of inquiry, there are no negative examples of deficits identified (see Fenton, pp. 262-74 for an example of identification of deficits).
Not an End but a Beginning
I am concerned about hasty system builders who will want deify the 31 competencies described or who might want p complete the list, as though there were a finite list of competencies that can be captured for all time. Ending with 31 is indeed a bit whimsical, but the intent of this work is to encourage nurses to collect their own exemplars and to pursue the lines of inquiry and research questions raised by their own clinical knowledge. This work presents new ways to view nursing practice so that we do not continue to limit the description of such practice to a simplified, linear, problem-solving process. Such uniformity and constriction limit our understanding of the complexity and significance of our practice. As one nurse said with a note of realization, in a group discussion: "You know, I acted very quickly and saved a baby's life today. That's not insignificant!" It seemed that she had failed to take account of the import of her actions in her earlier analytical reporting.
I am grateful to colleagues who have enriched this work by providing descriptions an early map, so to speak of the practical applications of this work (see Epilogue).