Assessing patients’ needs: does the same information guide expert and novice nurses?
Transcript of Assessing patients’ needs: does the same information guide expert and novice nurses?
© 2002 International Council of Nurses
Keywords
Expert/Novice
Differences, Handover,
Patient
Documentation,
Pre-Encounter Data
Qualitative Research
Assessing patients’ needs: does the sameinformation guide expert and novice nurses?
C.Taylor RN, RCNT, DipCNE, BappSc(adv nurs), MEd Pol&Admin, PhD, FRCNA
Senior Consultant, ACT NOW SERVICES, Business, Education and Research Consultants, Melbourne,Victoria, Australia
Abstract
The difficulties experienced by nurses in assessing patients before providing care
have been the subject of enquiry for many years. Much has been written about the
nursing process and, in particular, the data-collection component, where the nurse
gathers information before deciding on a diagnosis and nursing intervention.
There is, however, very little published on the differences between expert and
novice nurses, in either the way they gather information or the emphasis placed
on the different data sources accessed when preparing to carry out a nursing
procedure. Communication between nurses is essential in the provision of safe,
competent care, and yet we have minimal understanding of how experts use data
sources to plan procedural care giving. This article reports on the findings of one
component (the differences between expert and novice nurses in accessing data
before implementing a nursing procedure) of a larger study into the identification
of problem-solving strategies adopted by nurses during procedural care giving.
The study was conducted in clinical settings and used a qualitative research
methodology of observation followed by an in-depth semistructured interview.
The study results indicate that expert and novice nurses accessed four similar
information sources before meeting a patient. However, there were differences
noted between the two groups in the amount of information accessed, as well as
in the interpretation and use of that information. This is an important issue for
nurse educators.
Correspondence address: Dr Catherine Taylor, SeniorConsultant, ACT NOWSERVICES, Business, Educationand Research Consultants, 82Fulton Road, Mount Eliza,Melbourne, Victoria 3930,AustraliaTel.: +61 39787 9367Fax: +61 39787 9367E-mail:[email protected]
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Original article
Introduction
Nursing is a unique profession ‘because of its broad
focus on understanding and managing a persons
health’ (Potter 1999). It is essential therefore that
nurses are educated and are able to assess the health
needs of patients before delivering care, including
those care practices commonly referred to as
nursing procedures. The nursing process, which
emphasizes the collection of data prior to making a
nursing judgement, has been written about exten-
sively, to enable nurses to share a common approach
to the provision of care. Senior nurses in clinical sit-
uations are frequently role models for less experi-
enced nurses, both in the preparation and delivery
of nursing care. Investigators of expertise in nursing
12 C.Taylor
practice in their respective seminal works (Benner
1984; Carnevali et al. 1984) endeavoured to expose
the essence of why some individuals perform at a
higher level than others. To date, there is still no
common set of theoretical principles that appear to
cross professional disciplines. According to Van
Lehn (1989), however, having a highly developed
level of skill is recognized as essential in all expert
practice.
Why compare experts andnovices?
Differences between expert and novice nurses are
of considerable interest to practitioners and re-
searchers for a number of reasons. Educators, for
example, believe that if the differences between
expert and novice nurses (in different situations)
can be identified, then application of evidence-
based practice will provide improved education for
novices and safer care provision for patients. Com-
paring the performance of experts and novices as a
method of understanding how expertise develops is
supported by a number of researchers (Benner
1984; Corcoran 1986; Westfall et al. 1986; Tanner
et al. 1993; Benner et al. 1996) because it contributes
to the body of nursing knowledge.
The literature suggests that the development of
expertise depends on the availability of relevant
experience in order to expand a clinician’s knowl-
edge base. Ericsson & Smith conducted studies in
1991 to determine whether expert performance is
an inherited trait in individuals or if it is acquired.
They concluded that ‘superior performance is pre-
dominantly acquired’and to understand it properly,
expert practice should be studied whenever possible
in real-life settings. Chenitz & Swanson (1986)
argue more vigorously and suggest that ‘scientific
discovery is based on the judicious use of induction,
deduction and intuition’, and that analysis of clini-
cal practice through inductive logic will generate
appropriate research questions that will ultimately
lead to the discovery of nursing theory.
According to Dowie & Elstein (1988), clinicians
hold expert clinical judgement in high regard. It is
therefore an important professional responsibility
to help novices to acquire competency in clinical
practice, without causing distress to themselves and
their patients during the learning process. In order
to educate and support novices effectively, we must
understand how clinical knowledge is acquired and
used.
Although adequate preparation to give care is
essential for safe practice, and much nursing work is
carried out through routine procedures, very little
has been written on the differences between expert
and novice nurses in how they gather information
about patients before they implement a procedure,
or what emphasis is placed on different data sources
accessed.
This article reports on the findings of one com-
ponent (expert/novice differences in accessing data
before implementing a nursing procedure) of a
larger study by Taylor (1997) into the identification
of problem-solving strategies adopted by nurses
during procedural care giving.
Methods
The literature-retrieval approach used for the study
included electronic searches of MEDLINE and
CINHAL databases, manual searches of nursing
indexes in both University and Hospital libraries,
examination of PhD theses related to clinical deci-
sion making and reasoning, as well as review of ref-
erence lists in the retrieved literature. Many of the
studies reviewed were valuable in helping to identify
approaches used by other researchers to gain an
understanding of how nurses problem-solve.
However, no articles were identified which dealt
with the cognitive strategies used by novice and
expert practitioners in carrying out basic nursing
procedures.
Assumptions
Taylor’s (1997) study into the identification of
problem-solving strategies adopted by nurses
during procedural care giving was shaped by her
understanding of nursing practice, plus insights
gained from the literature (Taylor 2000) and, as
such, directly influenced the methodological ap-
proach to the study. The following assumptions
were made:
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
Assessing patients’ needs 13
• nurses collect information related to patients
before carrying out procedures on them,
• knowledge and experience empower the nurse to
be able to make decisions in clinical situations,
• during nursing procedures, the nurse becomes
aware of individual patient differences, which may
require changes in routine,
• the ‘becoming aware’ stage requires problem
recognition and action by the nurse and, as a result,
a change in procedural routine occurs. This change
in routine can be observed. Questions can then be
asked that relate to the thinking behind the decision
to change the routine,
• as a result of observing a nurse’s practice and
asking related questions, it is possible to identify the
cognitive strategies used by the nurse in deciding to
change the routine,
• nurses use the information gained while carrying
out procedures to plan future care for patients,
• nurses concentrate on the patient receiving care
during a procedure,
• nurses consider their own safety during
procedures and as a result of this may choose to
modify the way they provide care to the patient,
and
• problem-solving occurs when procedures are
carried out.
Design
The design of the study was influenced by a concern
to access nurses’ thinking processes when providing
routine care-giving procedures. Additional con-
cerns related to the ability to access practice situa-
tions that allowed comparisons to be made between
novice and expert nurses when carrying out similar
procedures. The contextual intricacies of the clini-
cal environment were therefore deemed to be the
best setting for examining nurses’ problem-solving
strategies. Given the complexity of the investiga-
tion, a qualitative methodology was employed to
capture the required data. Qualitative research,
according to Burns & Grove (1987) enlightens
nursing practice by allowing exploration of ‘the
depth, richness and complexity inherent in holistic
nursing care’. Sherman & Webb (1988) also support
the qualitative approach to nursing research and
additionally state that ‘events can be understood
adequately only if they are seen in context’.
Setting for the study
Acute medical-surgical and rehabilitation hospitals
were selected for data collection.
Participants
Undergraduate students from years 1 and 3
(novices) in a Bachelor of Nursing course leading to
registration were identified at random from the uni-
versity database. Registered nurses (RNs) (experts)
were identified from hospital personnel records
relating to having had 5 or more years of postgradu-
ate experience. Five years was accepted as an appro-
priate time frame for the clinicians to have devel-
oped expertise in the basic procedures chosen, as
Patel & Groen (1991) suggest that the development
of expertise requires opportunities for repetitive
practice. The procedures chosen (discussed below)
are carried out daily or more frequently by RNs.
Letters of invitation to participate, including an
explanatory statement of the study and a consent-
to-participate form, were sent out. Eighty sets of
data were collected from the participants and 33 sets
were used in the final analysis.
Procedures chosen for the study
The procedures chosen were: showering a patient;
taking blood pressure; testing a urine sample; carry-
ing out a complex dressing; and taking a blood
glucose measurement. These procedures were
chosen because undergraduate students are intro-
duced to them at different stages of the education
process. In the programme that the students were
enrolled in, year 1 students were taught to shower
patients, to test urine and to measure and record
blood pressure. Students were taught to take blood
samples for glucose monitoring and carry out
complex dressings in year 3. As these procedures are
carried out daily in wards, depending on patients’
needs, there are numerous opportunities for stu-
dents to practice and for postgraduate nurses to
develop expertise.
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
14 C.Taylor
Table 1 represents the sample distribution and
indicates participant experience across procedures.
Sample distribution (see Table 1)
Three novices (year-1 students), three intermediate
participants (year-3 students) and three experts
(RNs) were observed when conducting a showering
procedure. This was the only procedure for which
an intermediate group was observed.
Six participants – three novices (year-1 students)
and three experts (RNs) – were observed when con-
ducting the blood pressure recording procedure.
Six participants – three novices (year-1 students)
and three experts (RNs) – were observed testing
urine samples.
Six participants – three novices (year-3 students)
and three experts (RNs) – were observed conduct-
ing a complex dressing procedure.
Six participants – three novices (year 3 students)
and three experts (RNs) – were also observed con-
ducting a blood glucose measurement.
Data-collection methods
Observation of participants carrying out the
selected procedures, followed by in-depth, semi-
structured interview, was the method used for data
collection.
A schedule was developed and used during the
observation phase to assist with the systematic recall
of events. A semistructured open-ended interview
format using the same questions as starting points
enabled in-depth probing of replies during the
interviews. This technique allowed an in-depth
analysis of the thinking process for each participant.
Questions related to the notes made on the observa-
tion schedule during the procedure were also asked.
Interviews were taped and lasted for ª 20–45 min.
A transcript of each was made later to assist with
the analysis process.
A field log was also maintained to assist with any
ongoing issues that were encountered.
Ethics approval
Application to conduct the study was made to the
research and ethics committees in each hospital and
the university. As the study did not directly involve
patients as active participants, the most important
issue considered by the committees was confiden-
tiality. All participants were given a code number
known only to the researcher.
Analysis process
A large volume of data was generated by the study
and a complete record was kept of all aspects of the
research. Several different methods of retention of
data were used. The interviews were taped and tran-
scribed to ensure that an accurate and comprehen-
sive record of the discussions was available for
future reference. A separate file, which included a
transcript of the interview, a field log, an observa-
tion schedule and a copy of the interview format,
was maintained for each subject in the study.
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
Table 1 Sample distribution indicating participant experience across procedures
Procedure
Blood Blood Complex Showers Urine
glucose pressure dressing testing
RNs (more than 5 years of experience) 3 3 3 3 3
Year-1 students (first experience) 3 3 3
Year-3 students (first experience, except for showers 3 3 3
where year-3 students had previous experience)
RNs, registered nurses.
Assessing patients’ needs 15
The processes described by Miles & Huberman
(1984; 1994) were used to manage the data for
analysis.
A preliminary analysis was made concurrently
with collection of the data. Before proceeding with
the formal analysis, the immense volume of data
produced by the study had to be categorized and
reduced. Reduction involved selecting, focusing,
simplifying, abstracting and transforming the raw
data from the written-up field notes and transcrip-
tions. From the initial sample of 80 data sets, care
was taken when transcribing the recorded inter-
views into written text. This process comprised lis-
tening to each of the 80 tapes and typing the verba-
tim statements. When this process was complete,
each tape was listened to again and checked for
errors in the transcribed text. Shifts in meaning that
might have been introduced by small errors in tran-
scription were eliminated. Tapes that were difficult
to hear owing to background noise or technical
problems, were, at this stage, regarded as not yield-
ing a complete record of the interview and were
discarded.
The remaining 33 transcripts, observation sched-
ules and field notes were read and reread. An inter-
pretive summary of each participant’s clinical
episode was prepared and used to develop the start-
ing description of recurring themes. The data were
coded according to major themes. The transcripts
were entered into a computer software package
called NUDIST (Non-numerical Unstructured Data
Indexing, Searching, Theorizing). This programme
allowed data to be sorted and coded into specific
themes, identified by the researcher and supervisor,
to be retrieved during the analysis process.
Rigour
Credibility is essential in all research; however,
validity and reliability measures are not so obvious
in qualitative research. According to Lo Biondo-
Wood & Haber (1990), rigour applied to the data-
collection process is the best check of validity and
may be enhanced by describing the exact process
of data collection. The data-collection process in
this study is referred to above. Displaying partici-
pants’ verbatim statements according to Miles &
Huberman (1984; 1994) assists with internal reli-
ability. Selected participant statements are provided
below, in the Results.
Reliance on the participants behaving honestly
(as direct observation of individuals can change
their behaviour) during the observed procedure,
and reporting their thoughts during the interview
process, was an important factor in this study. In
an attempt to minimize altered behaviours, the
researcher’s role during each procedure was one of
observer without concealment and without inter-
vention. According to Lo Biondo-Wood & Haber
(1990), when ‘the observer makes no attempt to
change the subjects’ behaviour and informs them
that they are to be observed, then this type of obser-
vation allows a greater depth of material to be
studied than if the observer is separated from the
subjects by an artificial barrier’. This frank approach
allowed the researcher to collect data openly and to
ask related questions later during the interview
phase.
Limitations of the study
The limitations of this study relate mainly to the
methodology chosen. The sample size, the settings
and the procedures chosen were specific to the
conduct of this research and are therefore represen-
tative of this group at a specific point in time.
Results
The results identified that a similar problem-solving
process to that of diagnostic reasoning described in
the seminal work of Carnevali et al. (1984) and later
by Carnevali & Thomas (1993), was being used in
this study.
The nurses accessed four main data sources when
preparing to carry out a procedure. These were:
nursing handover; patient documentation; previ-
ous knowledge of the patient; and a selection of
other sources grouped as a miscellaneous category.
These categories are briefly discussed below.
The nursing handover
Much has been written on the types, duration
and rituals involved in handovers (Taylor 1993;
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
16 C.Taylor
Wise 1994; Prouse 1995; Parker 1996; Strange
1996). However, there was nothing in the literature
that discussed differences between expert and
novice nurses in the perceived value of handover
information.
Seven of the 18 novices in the study mentioned
the nursing handover as a source of data used to
prepare for implementing a procedure. All were in
the year-3 sample group. The comments made were
varied, as some found value in them but colleagues
did not. When asked how they knew about the
patient, two of the replies (Taylor 1997; p. 332) were:
[From the handover] She’s got a thrombosis,
I think. She hasn’t got exacerbated COAD
(chronic obstructive airways disease) . . . she has
a nebuliser.
Handover, yes, I always have trouble remem-
bering from the handover and I like the nursing
notes.
It was noted that there was an obvious reliance of
some participants on written notes taken during the
handover. In some instances, the nurse in charge
handed preprepared notes to the nursing staff
coming on duty before the handover. When this
approach was taken, it was noted that the partici-
pants recorded very little additional information,
even though the written information generally only
provided the patient’s name, bed number and
medical diagnosis. It was also noted that the novice
group tended to be silent during the handover.
Ten of the 15 experts used nursing handover
information as pre-entry guidance to the patient
care situation and expected the handover to be a
major source of patient information both on com-
mencing a shift and throughout a patient’s stay. It
was frequently the main source of information used
for maintaining and updating their general and spe-
cific knowledge of patients. When asked how they
knew about the patient, two of the replies were:
First I was aware of [the patient] was at handover.
The handover sheet is three computer print-
outs long and you get a bit of history on that.
It was noted that the experts frequently asked ques-
tions during handover to clarify issues. This behav-
iour appeared to require ‘in-depth knowledge of
patient care issues and good cue recognition, as well
as the ability to store, link and retrieve information
quickly from long-term memory’ (Taylor 1997).
Patient documentation
The two most significant sets of documents used by
the nursing staff were the patient’s history (often
referred to as progress notes) and the nursing care
plan.
The patient’s history is a very comprehensive
document containing the past medical information
of the patient, notations from all health professional
groups who provide care management, and all
pathology and test results.
The nursing care plan is intended to communi-
cate, to the nursing staff who provide care, the
specific nursing measures to be implemented.
However, many of the nursing care plans reviewed
in this study did not convey the specific information
necessary to carry out the required procedures.
Seven out of 18 novices mentioned accessing
written documentation but did not express a prefer-
ence for patients’ histories or nursing care plans as
an information source:
I got information from a lot of different things,
his nursing history, his admission notes and the
doctor’s notes . . . and the nursing care plan.
I read his care plan so I knew about his cyto-
toxic drugs . . . the bit I got through the history
told me he was from New Zealand.
The novices who reviewed the patients’documenta-
tion tended to look at a variety of documents and
relied heavily on the written orders for the patient:
The nursing care plan, that’s how we knew to put
him on the toilet, even if he didn’t really have to
go . . . (Taylor 1997).
Eleven out of 15 experts used the patient’s docu-
ments to obtain comprehensive information. Most
of this group showed a preference for the patient’s
history as the major source.The group who accessed
the patient’s documents showed a tendency to read
sections of the patient’s history document to answer
any queries they had. Very few comments were
made about the use of the care plan:
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
Assessing patients’ needs 17
Reading it myself in the history [that the dressing
had to be done].
It appeared that not one participant read a complete
set of documents. The comment below was a typical
response to the question, ‘how do you know about
this patient?’
I just read her past observations for the night
before and I haven’t actually read her history
completely.
Previous contact with the patient
There are a variety of ways in which a nurse may
have had previous contact with patients. For
example, patients may return to the same ward
weeks, months or even years after an initial admis-
sion and be cared for by the same nurse. When a
patient is admitted to hospital, the same nurse may
look after him/her for several shifts. Such continu-
ous interaction allows the nurse to develop a bank of
current knowledge about the patient. It was noted in
this study that previous knowledge seemed to
obviate in some way the need to read the patient’s
progress notes before performing some care activi-
ties. This may or may not be appropriate, depending
on what information has been added to the notes by
other members of the health care team and what
information (if any) may have been missed by the
nurse or omitted at handover.
Four out of 18 novices indicated that prior per-
sonal contact with the patient influenced their
approach to working with patients:
I had already seen the wound before, so I knew
what to expect.
I’d watched the dressing the night before, so I
got out all the materials that I needed (to do the
dressing).
Of the expert group, only two of the 15 participants
mentioned previous knowledge of the patient as an
information source influencing daily care. They
inferred that they used this previous knowledge as
the basis of continual assessment and judgement of
the patient’s current health status:
I’ve known him from before . . . he’s had quite a
lot of admissions for haematoma.
The experts who reflected on previous patient
knowledge indicated that assessment of the patient
was taking place, whereas the novices did not.
Miscellaneous other sources
There are a number of sources of information avail-
able to nurses. Examples of these are families and
other members of the health care team. The data
analysis suggested that novices looked at different
sources of information from expert nurses.
In the novice group, eight out of 18 reported
accessing other sources of information to assist in
understanding their patients:
Her daughter, I spoke to her . . . she was just
saying . . . she’s deteriorating and things.
I just probably asked her [the patient] . . . the
nurse told me when I got in what things she likes,
the cold water and all that.
Eight out of 15 experts accessed other data sources
of patient information. Characteristically, the
doctor or the charge nurse was a frequent source:
From the charge nurse who mentioned it earlier
in the day.
From the charge nurse who had actually done
the round with the doctor.
The type of person from whom the nurse obtained
extra information on the patient’s condition
seemed to reflect the practitioner’s confidence level
and knowledge base. Novices reported feeling more
comfortable asking the patient’s relatives and RNs
for information. The experienced nurses, on the
other hand, appeared to select the person most
likely to supply the information they required.
Discussion
It was found that all 33 participants had accessed at
least one source of preparatory data, suggesting that
before attempting each procedure, some form of
problem framing had taken place to assist the nurses
to enter the patient environment. This is consistent
with the theory of Carnevali et al. (1984) on the
nurses’ use of pre-encounter data. It was noted that
the experts in the study were more likely to access
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
18 C.Taylor
multiple sources of preparatory information
than the novices. The ability of the RNs to link the
information gathered from a variety of sources is
characteristic of expert performers in a variety of
disciplines and is reliant on the components of
memory. According to Van Lehn (1989), ‘experts
seem better at monitoring the progress of their
problem-solving and allocating their effort appro-
priately’. Novices, on the other hand, tend to
solve problems on the ‘basis of literal, superficial
features of a specific problem’ (Van Lehn 1989).
Of the four categories identified as sources of
information, two seemed to be more important for
both experts and novices; these were the nursing
handover and the miscellaneous category. As dis-
cussed previously, handover information was
important to the experts in the study, but meant
very little, and in some cases nothing at all, to the
novices. It is also worth noting that only the year-3
novices referred to handover information, even
though the year-1 group attended handover daily
whilst on clinical placement. A combination of
information overload, lack of clinical experience
and little or no understanding of medical terminol-
ogy, may all have contributed to the novices’ appar-
ent inability to recognize or absorb meaningful
information during handover. As there is such a
reliance on the handover as a vehicle for communi-
cating patient information, the contrast between
the experts and the novices in this study is signifi-
cant enough to warrant further investigation.
Authors such as Wise (1994) and Strange (1996)
suggest that the traditional handovers offer a chance
for experienced nurses to pass on information to
inexperienced nurses.
This can only be possible if novices are capable of
understanding and, as this study suggests, there
seems to be a gap between what we think novices
recognize from attending handovers and what they
really do.
The miscellaneous category of information
sources gave the impression that there was an infor-
mal hierarchy of professional relationships in the
hospital wards. Novices asked those whom they
apparently regarded as less authoritarian, for infor-
mation to help them. Although the information
gained about patients by the novices was frequently
of a personal nature and, as such, is important, the
RNs’ use of more senior people to provide care
instructions needs to be acknowledged and in-
corporated into the education process, perhaps
through mentoring programmes. Nothing in the
literature discusses this particular topic.
While patient documentation was widely ac-
cessed, particularly by the experts, it was disquieting
to note that none of the participants reviewed a
patient’s documents comprehensively. ‘Documen-
tation is a vital aspect of nursing practice’ according
to Elkin (1999) and the result of inadequate com-
munication for whatever reason can affect patient
care and recovery. Although novices are taught the
importance of reading and writing patient care
information, once in the care environment they
often rely on copying the practices of more senior
nurses. This type of role modelling seems to help
them fit into the nursing team. However, it appears
from this study that the expert RNs selected discrete
information, as required, to help them solve clinical
problems, and the novices had very little under-
standing of the information selection process of the
RNs. The novices often only saw the RNs flicking
through patient documents. More research needs to
be carried out on expert practice in the use of docu-
mentation in order to identify the major principles
and practices involved.
A difference was also noted between experts and
novices in how they used previous contact with the
patient to influence their practice, although insuffi-
cient information was provided by the RNs for any
conclusions to be drawn. However, the novices’
comments of basing their care on previous patient
contact and, as a result, copying what they did or
witnessed previously, is congruent with a descrip-
tion of the novice by Benner (1984), where she sug-
gests that novices use rules to guide their behaviour.
Conclusion
The results presented in this study indicate that
expert and novice nurses accessed four information
sources before meeting a patient. However, there
were differences between the two groups in the
amount of information accessed as well as the inter-
pretation and use of that information. If accessing
© 2002 International Council of Nurses, International Nursing Review, 49, 11–19
Assessing patients’ needs 19
data prior to carrying out procedures influences
nursing actions, then further study into expert
behaviour is required to determine the relationship
between the thinking processes (problem framing)
that drive the selection and the use of information.
In advance of available research on this topic, the
employment of expert mentors should be consid-
ered to help novices develop clinical reasoning
skills, especially in the use of clinical communica-
tion pathways.
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