Chapter 2

Experiential Learning: Skill Acquisition and Gaining Clinical Knowledge

Resource Library

MyNursingKit

ReviewQuestions

ImageLibrary

Figure2–1ANurseMustAlwaysBeEmotionallyAttunedtotheDemandsofaSpecificSituation.

Figure2–2AClinicalEducatorPresentsaBroadOverviewoftheExperiencesStudentsCanExpectinaParticularUnit.

Learning Objective 1

Recognizeanddescribetheirownclinicallearningintheformofanexperience-nearfirstpersonnarrativeaccount.

ConceptsforLecture

  1. Tobeasuccessfulexperientiallearner,onehastoremainengaged,ratherthansimplyapplywell-establishedknowledgeinpre-specifiedclearcircumstances.Experientiallearningrequires:
  2. Changingpreconceptions
  3. Addingnuancestoone’sunderstanding
  4. Opennessandresponsiveness

PowerPointLectureSlides

1aExperience-Near

FirstPersonNarratives

  • Tobeasuccessfulexperientiallearner,onemustremainengaged.
  • Experientiallearningrequires:
  • Changingpreconceptions
  • Addingnuancestoone’sunderstanding
  • Opennessandresponsiveness

1bExperience-Near

FirstPersonNarratives

  • Anexperience-nearfirstpersonnarrativeis:
  • Observingyourselfinyourincomingperceptionsofasituation
  • Gradualrealizationthatthesituationisnotwhatyouinitiallythoughtitwas

1cExperience-Near

FirstPersonNarratives

  • Oftencharacterizedbythefollowingspeech:
  • “IwentintothesituationthinkingthatIknewwhatwasgoingon.”
  • However,thisisnotconfirmedbythepatient.
  • Thisisevidencefordevelopinganabilitytoreadthesituationandlettingthesituationguidethepatientassessment.

1dExperience-Near

FirstPersonNarratives

  • Exampleofanurse’sincomingperception:
  • “Sotheymightcomeinandsay,‘Helooksstable,whydon’twetakehimoffthedopamine?’Andwesay,well,waitaminute,Ididn’twriteeverythingdown.Iturnedhimandhisbloodpressuredropped.”
  • Thehealthcareproviderssay:“Let’sgivehimsomeLasix.”Thenwesay,“No,he’snotreadyforthat...”
  • Inoticethatthehealthcareprovidersaregoodabouttalkingtoyoubeforemakingdecisions.”

1eExperience-Near

FirstPersonNarratives

  • Thenurseinthepreviousexampleisnowsynthesizingthemeaningofthepatient’sresponsesthroughtime.
  • Sheimaginesthatacomputercouldcaptureallofherreadings.

Butcoulditreally?

No.Herunderstandingofthepatientisnowsituatedandbasedonapracticalunderstandingofthepatient’sresponsesandqualitativechangesmadeovertime.

Herunderstandingisnolongeracollectionofdatapoints.

SuggestionforClassroomActivities

  • Whatdoesitmeantoreflectonourpractice?Leadstudentsinadiscussionaboutwhatitmeanstothinkaboutwhatwedoeachdayinourclinicalpractice.Discussthebenefitsofreviewingourstrengthsandweaknessesaspartofourongoinglearningneedsandplans.Askstudentstoshareanyexperiencestheyhavehadinreflectivepractice(whetherintheclinicalorclassroomsetting).Whatdidtheygainfromtheseopportunities?

SuggestionforClinicalActivities

  • Ask students to keep a reflective clinical journal of their patient care experiences. Talk with students about the need to reflect on our practice in terms of what is working well and what is challenging. Clinical logs can be brief paragraphs addressing what went well in your clinical practice today; what was most challenging for you; what further learning goals you will continue working on.

Learning Objective 2

Giveatleastthreeexamplesofpracticalandtheoreticalknowledgerelatedtoadultmedical–surgicalnursing.

ConceptsforLecture

  1. Nursesaremorethanmastersoftechnicalandscientificknowledge.Masteryassumesthatnursingneverchanges,andweknowthatnursingisconstantlychanging.Butnursingalsorequiresongoingexperientiallearning,reflectiononpractice,andcontinuousimprovementinpracticeasscienceandtechnologychange.Thestudyofthesefieldsnevercompletelycoverswhatactuallymightbeencounteredinclinicalpractice.
  2. Discoveryandexperientiallearningfavortheprepared,knowledgeablepractitionerwhoisengagedinattainingbothpracticalandtheoreticalknowledge.Scientific,formalknowledgeisnotsufficientforgoodclinicalpractice,whetherthedisciplineislaw,medicine,nursing,teaching,orsocialwork.Practitionersstillhavetolearnwhenandhowtousescientificknowledgeinpracticalsituations.
  3. Practicalknowledgemaybecomparedto,thoughnotcompletelyseparatedfrom,theoreticalknowledge.Forexample,knowledgeofgrowthanddevelopmentareessentialtodevelopingpracticalknowledgeaboutworkingwithyoungchildren.Practicalknowledgeincludesthefollowing:
  4. Clinicalknowledge
  5. Clinicaljudgment
  6. Skillsofengagement
  7. Clinicalreasoning
  8. Wecan’treducerationalitytoscientificexperimentalone,sincerationalityincludesreasoningacrosstimewithchangesinthepatient’sconditionandconcerns.
  9. Practicalrationality,asillustratedinclinicaljudgment,includesnoticingsubtlechangesandinformedemotionalresponses,suchasthosethathappenwhenapatient’sconditionchanges,butthechangesarenotlimitedtoexplicitvitalsigns.
  10. Forexample,inearlyimpendingshockduetobloodloss,thepatientusuallycompensatesatfirst,sotheactualchangesinvitalsignsaredelayedandarebestdetectedbyassessingthepatient’sdistressandfollowingvitalsigntrends,ratherthananisolatedfinding.

PowerPointLectureSlides

1aPracticalandTheoreticalKnowledge

  • Nursesaremorethanmastersoftechnicalandscientificknowledge.
  • Masteryassumesthatnursingneverchanges,butofcourse,weknowthatnursingdoeschange.
  • Nursingalsorequires:
  • Ongoingexperientiallearning
  • Reflectiononpractice
  • Continuousimprovementinpractice
  • Thestudyofthesefieldsnevercompletelycoverswhatactuallymightbeencounteredinclinicalpractice.

1bPracticalandTheoreticalKnowledge

  • Nursingalsorequires:
  • Ongoingexperientiallearning
  • Reflectiononpractice
  • Continuousimprovementinpractice
  • Thestudyofthesefieldsnevercompletelycoverswhatyouactuallymightencounterinpractice.

2PracticalandTheoreticalKnowledge

  • Aprepared,knowledgeablepractitionerwhoattainsbothpracticalandtheoreticalknowledgesucceeds.
  • Scientific,formalknowledgeisnotsufficientforgoodclinicalpractice.
  • Practitionersstillhavetolearnwhenandhowtousescientificknowledgeinpracticalsituations.

3aPracticalKnowledge

  • Practicalknowledgemaybecomparedto,thoughnotcompletelyseparatedfrom,theoreticalknowledge.
  • Forexample,knowledgeofgrowthanddevelopmentareessential—appliestoworkingwithyoungchildren.

3bPracticalKnowledge

  • Practicalknowledgeincludesthefollowing:
  • Clinicalknowledge
  • Clinicaljudgment
  • Skillsofengagement
  • Clinicalreasoning

4aPracticalKnowledge

  • Practicalrationality:
  • Noticingsubtlechanges
  • Noticinginformedemotionalresponses

–Forexample,whenapatient’sconditionchanges,butthechangesarenotlimitedtoexplicitvitalsigns.

  • Youapplypracticalrationalitytoclinicaljudgmentasanurse.

4bPracticalKnowledge—Example

  • Inearlyimpendingshockduetobloodloss:
  • Thepatientusuallycompensatesatfirst,sotheactualchangesinvitalsignsaredelayed.
  • Changesinvitalsignsarebestdetectedbyassessingthepatient’sdistressandfollowingvitalsigntrends.

SuggestionforClassroomActivities

  • Discussviacaseexamples(suchasaclientdecliningwithcongestiveheartfailure)whatismeantbypracticalinformation(suchasrecognizingsymptomsandpatterns)andwhatismeantbytheoreticalinformation(suchastheevidencebasetoguideclinicalinterventions).

SuggestionforClinicalActivities

  • Ask students to continue writing in their reflective clinical journals about their patient care experiences. Ask them to share an example of patient care they provided in a narrative format, including examples of how they (or they and their assigned staff) used practical information and how they used theoreticalinformation. Ask them to note in their reflections the impact of their interventions on their patient.

Learning Objective 3

Givetwoexamplesofclinicalinterventionsthatcanbestandardizedandtwoexamplesofclinicalinterventionsthatcannotbestandardized.

ConceptsforLecture

  1. EarlyGreeksdistinguishedbetweenwhatcanbestandardizedandreplicated,knownastechne(theknow-howandskillofproducingthings),andwhatrequiresproductivethinkingandjudgmentinparticularcases,calledpracticeorpraxis.
  2. Clinicalinterventionscouldbedividedintotwotypes:
  3. Clinicalinterventionsthatcanbestandardized
  4. Clinicalinterventionsthatcannotbestandardized
  5. Clinicalinterventionsthatcanbestandardizedstemfromscientificexperimentsthatarecapableofreplicationunderpreciseconditions.Rational-technicalthoughtisapowerfulstrategyforthoseareasofscienceandtechnologythatcanbestandardizedandroutinized.Examplesofstandardizationinnursingandmedicineinclude:
  6. Bloodpressuremeasurements
  7. Dosagerangesformedication
  8. Thepracticalknowledgeembeddedinthetraditionsofsciencecannotbemadecompletelyformalandexplicit.Whenclinicaljudgment,relationship,perception(ornoticing),timing,andskilledknow-howareinvolved,thenmorethantechneorrationalcalculationisrequired.Aristotleusedtheexampleofastatesmanwhodevelopedcharacter,skilledknow-how,practicalreasoning,andcomportment,allofwhichincludeappropriateemotionalresponsesandrelationships.
  9. Clinicalreasoningisappliedtoapracticethatoccursinrealtime,isuncontrolled,oftenaboutasinglecase,andisalmostalwaysunderdetermined.Clinicalinterventionsforthesesituationsneedtobeindividualizedforbestpracticeinagivencontext.
  10. Clinicalexample:Inaunitwhereallpatients’cardiacfunctioningismonitored,standardizedpracticemightincludeattendingtothefamiliarsoundsonthemonitoraswellaswatchingfordeviationsinexpectednormalrhythms.Todetectheartarrhythmias,thenursewouldneedtoidentifyhowthepatient’sheartrhythm,conveyedviathemonitor,deviatesfromtheexpectednormal.

PowerPointLectureSlides

1aClinicalInterventions

  • Techne=Theknow-howandskillofproducingthings
  • Praxis(practice)=Theuseofproductivethinkingandjudgmentinparticularcases

1bClinicalInterventions

  • Clinicalinterventionscouldbedividedintotwotypes:
  • Clinicalinterventionsthatcanbestandardized
  • Clinicalinterventionsthatcannotbestandardized

2ClinicalInterventions—Standardized

  • Clinicalinterventionsthatcanbestandardizedstemfromscientificexperimentsthatarecapableofreplicationunderpreciseconditions.
  • Examplesofstandardizationinnursingandmedicine:
  • Bloodpressuremeasurements
  • Dosagerangesformedication

3ClinicalInterventions—BeyondStandardization

  • Practicalknowledgecannotbemadecompletelyformalandexplicit.
  • Morethantechneisrequiredintheseexamples:
  • Clinicaljudgment
  • Relationship
  • Perception(ornoticing)
  • Timing
  • Skilledknow-how

4ClinicalInterventions—BeyondStandardization

  • ImagineAristotle’sexample:
  • Astatesmandevelopscharacter,skilledknow-how,practicalreasoning,andcomportment.
  • Thestatesmanusesappropriateemotionalresponsesandrelationships.

SuggestionforClassroomActivities

  • Whatdoesitmeantouseevidence-basedpractice?Helpstudentsconsiderwheretheevidencebaseforclinicalpracticecomesfrom(theory,clinicalexpertise,research).Thenhelpstudentsconsiderhowallindividualpatientsareuniqueintheirneedsevenwhenthereisanevidencebaseforthepatient’sparticularproblems.Provideexamplesshowingthatbestclinicalpracticesincorporatethepatientcontext,orneedsandsetting.Forexample,protocolsforfallpreventionaresimilar,butareappliedindifferentwaysforuniquepatientsindiversesettings.

SuggestionforClinicalActivities

  • In a clinical conference ask students to compare approaches to care of their various patients who have the same diagnoses (such as multiple patients with diabetes or dementia). Spend time considering what the evidence might be for treating the specific diagnoses identified, but also consider how the standard approach is individualized for different patients with different needs.

Learning Objective 4

Giveanexampleofphronesisorclinicaljudgmentthatillustratesadjustingtotransitionsinthepatient’sclinicalcondition,ortheclinician’sunderstandingofthepatient’sclinicalcondition.

ConceptsforLecture

  1. Phronesisisclinicaljudgmentandtheabilitytoactongoodclinicaljudgment.Nursingisabasichumanencounterandpracticethatrequiresphronesis.
  2. Technicalcareandrestorativecarearenotmutuallyexclusiveforthenurseorhealthcareprovider.Thenursecanunderstandmedicine,nursing,andotherhealthcaredisciplinesasencompassingmorethanthescienceandtechnologiesthattheyusetoeffectcures.
  3. Phronesisdevelopsovertimeandasaresultofpracticinginmultiplesituations.Sincepatientschangeovertime,nursesmustadjust.Rememberthatmasteryassumesthatnursingneverchanges,butofcourse,weknowthatnursingdoeschange.
  4. Clinicaljudgment,whennotrequiringinstantaneousaction(e.g.,titratingavasopressorIVmedicationtokeepthepatient’sbloodpressurewithinsafeparameters),mustbecommunicatedandadjudicatedbyotherclinicians.Ifanurserecognizesearlysignsofdeteriorationinapatient’sclinicalcondition,s/hemustbeabletodocumentandcommunicatetheevidenceforthechanges.Thisrequiressocialskillsandexperientialwisdomincommunicatingwithotherclinicianssothattheevidencecanbeverified.Thisishowothercliniciansverifytheevidence.
  5. Insituationswherepatternsandtrendsareclearandhavedefinitiveinterventionsassociatedwiththeclinicaltrend,thepractitionercanmakequickdecisiveresponses.
  6. Clinicallearningoccurswhenthesituationisnotasclear-cut.Whenthepractitioner’sgraspofthepatient’sclinicalsituationisjarredbychangesorunexpectedpatientresponses,thepractitionersearchesforanewgraspandexperientialclinicallearningoccurs.
  7. Tomaximizelearning,thelearnermustbeopentocorrectionanddisconfirmationthroughthetransition.Youwon’tbeabletopredictandcontrolinallsituations.Thus,one’sskilledemotionalresponsivenessguidesperceptualacuityandresponsivenesstochangesinthesituation.
  8. Exampleofphronesis(useofgoodclinicaljudgment)overtime:

Nurse:“Ihaddrawna[blood]gasonapersonandthegaswasprettypoorandItookanothergastothehouseofficer[doctor]andhelookedatitandsaid:‘Idon’tbelievethisgas,thepatienthasn’tchanged.’Ifeltcomfortableinsaying:‘Whatdoyoumean,thispatienthasn’tchanged?”Thispatient’sbloodpressurehasgoneupto200,’andIpresentedhimwithapictureofthispatientthathehadobviouslyoverlooked.Ittakesawhiletogettothepointwhereyoucan...gowithyourinstincts.”

Interviewer:“Whathappenedinthatsituation?”

Nurse:“Iwasright.”

Interviewer:“Howdidyoulearnthattheobjectivesignsthatyouwereseeingwerecorrelatedwithbloodgas?”

Nurse:“Justexperienceandseeingdifferentpatientsanddifferentbreathingpatternsandknowingbylookingatthepatientthatthisbreathingpatterniseffectiveandthisoneisn’t,knowingwhetherthereisairexchangethereornot.Thesebreathsaren’teffectiveandhe’swearinghimselfoutandthatcouldbethecauseofhisdeteriorationinhisgas,andjustexperienceandseeingdifferentcasesandhowpeopleadjusttophysicalthingsthataregoingon.”

PowerPointLectureSlides

1ClinicalInterventions—BeyondStandardization

  • Clinicalreasoningisappliedtoapracticethat:
  • Occursinrealtime
  • Isuncontrolled
  • Oftenrelatestoasinglecase
  • Isalmostalwaysdetermined
  • Clinicalinterventionsforthesesituationscannotbestandardized.

2ClinicalInterventions—BeyondStandardization

  • Example:
  • patientisinaunitwhereallpatients’cardiacfunctioningismonitored.
  • Standardizedpracticemightincludeattendingtothefamiliarsoundsonthemonitor.
  • Thenursewillonlynoticeaberrationsinsoundpatterns.
  • Todetectheartarrhythmias,thenursewouldneedtolookbeyondstandardizedpracticetorecognizewhenexpectationsarenotmet.

3PhronesisandPatientTransitions

  • Phronesisisclinicaljudgmentandtheabilitytoactongoodclinicaljudgment.
  • Nursingisabasichumanencounterandpracticethatrequiresphronesis.
  • Medicine,nursing,andotherhealthcarepracticesencompassmorethanthescienceandtechnologiesthattheyusetoeffectcures.

4aPhronesisandPatientTransitions

  • Phronesisdevelopsovertimeandasaresultofpracticinginmultiplesituations.
  • Sincepatientschangeovertime,nursesmustadjust.
  • Masteryassumesthatnursingneverchanges,butrememberthatnursingdoeschange.

4bPhronesisandPatientTransitions

  • Clinicaljudgmentmustbecommunicatedandadjudicatedbyotherclinicians.
  • Exception:Wheninstantaneousactionisrequired
  • Ifanurserecognizesearlysignsofdeteriorationinapatient’sclinicalcondition,shemustbeabletodocumentandcommunicatetheevidenceforthechanges.Thisishowothercliniciansverifytheevidence.
  1. PhronesisandPatientTransitions

Insituationswherepatternsandtrendsareclearandhavedefinitiveinterventionsassociatedwiththeclinicaltrend,thepractitionercanmakequickdecisiveresponses.

SuggestionforClassroomActivities

  • What does it mean for a patient’s condition to decline? Ask students if they have had experiences observing a patient decline (either rapidly in an acute care setting or over time in a long-term care setting). What types of symptoms and cues did students monitor and report (either themselves or as part of a staff nurse team)? What did they learn from their observations? What concerns do they have about their approaches?

SuggestionforClinicalActivities

  • Ask students to continue to document in their clinical journals specific examples of patient care where they saw specific changes in their patient’s health status (either patient decline or improvement). Ask them to write the types of symptoms and cues they monitored and reported (either themselves or as part of a staff nurse team). Ask them to additionally note what is going well in their clinical practice and what is still challenging. What goals will they continue to work on?

Learning Objective 5

Givetwoclinicalexamplesofhowthenurse’srelationshipwiththepatientmayalterthenurse’sclinicaljudgment.

ConceptsforLecture

  1. Clinicaljudgmentrequiresclinicalreasoningovertimeaboutaparticularpatient.Doctoringandnursingparticularpatientsrequiresrelationalandcommunicationskillsandart.Techniquealonecannotaddresstheinterpersonalandrelationalresponsibilities,discernment,andsituatedpossibilitiesrequiredwhencaringforpersonsmadevulnerablebyillnessandinjury.
  2. Phronesis(clinicaljudgmentandtheabilitytoactongoodclinicaljudgment)isrequired.Clinicianandpatientbendandrespondtoeachothersothatnewhorizonsappearorarereconstituted,leadingtotheemergenceofnewpossibilities.
  3. Onthepatient’sside,healingandrecoveryrequiresrelationship,openness,andtrust.Thepatientdetermines:
  4. Whattodisclose
  5. Whatcanbethoughtaboutandtalkedabouttogether
  6. Whatlevelofacceptanceandendorsementofthetherapieswillbeacceptable
  7. Thenurse’srelationshipwiththepatientmightalterthenurse’sclinicaljudgmentinthefollowingsituation:
  8. Apatientmightrehearsehismostfearfulconcernswithanurse.(Patientsoftenregardnursesasmoreapproachablethanhealthcareproviders.)
  9. Anursecanthenhelpthepatientcommunicatewithhishealthcareproviders.

PowerPointLectureSlides

1PhronesisandPatientTransitions

  • Clinicallearningoccurswhenthesituationisnotasclear-cut.
  • Whenthepractitioner’sgraspofthepatient’sclinicalsituationisjarredbychangesorunexpectedpatientresponses,thepractitionersearchesforanewgraspandexperientialclinicallearningoccurs.

2aPhronesisandPatientTransitions

  • Formaximumlearning,thelearnermustbeopentocorrectionanddisconfirmationthroughthetransition.
  • Inotherwords,youwon’tbeabletopredictandcontrolinallsituations.
  • Yourskilledemotionalresponsivenesswillguideperceptualacuityandyourresponsivenesstochangesduringthesituation.

2bPhronesisandPatientTransitions

  • Exampleofphronesis(useofgoodclinicaljudgment)overtime:

Nurse:“Ihaddrawna[blood]gasonapersonandthegaswasprettypoorandItookanothergastothehouseofficer[doctor]andhelookedatitandsaid:‘Idon’tbelievethisgas,thepatienthasn’tchanged.’Ifeltcomfortableinsaying:‘Whatdoyoumean,thispatienthasn’tchanged?Thispatient’sbloodpressurehasgoneupto200,’andIpresentedhimwithapictureofthispatientthathehadobviouslyoverlooked.Ittakesawhiletogettothepointwhereyoucan...gowithyourinstincts.”

3PhronesisandPatientTransitions

Nurse:“Iwasright.”

Interviewer:“Howdidyoulearnthattheobjectivesignsthatyouwereseeingwerecorrelatedwithbloodgas?”

Nurse:“Justexperienceandseeingdifferentpatientsanddifferentbreathingpatterns...knowingbylookingatthepatientthatthisbreathingpatterniseffectiveandthisoneisn’t,knowingwhetherthereisairexchangethereornot.

Thesebreathsaren’teffectiveandhe’swearinghimselfoutandthatcouldbethecauseofhisdeteriorationinhisgas,andjustexperienceandseeingdifferentcasesandhowpeopleadjusttophysicalthingsthataregoingon.”

4ClinicalJudgmentandPatientRelationships

  • Clinicaljudgmentrequiresclinicalreasoningovertimeaboutaparticularpatient.
  • Techniquealonecannotaddresstheinterpersonalandrelationalresponsibilitiesrequiredwhencaringforpersonsmadevulnerablebyillnessandinjury.
  • Nursingrequiresrelationalandcommunicationskillsandart.

SuggestionforClassroomActivities

  • Askstudentstoconsideranexperienceinhealthcareorarelatedvenuewhentheyfeltlistenedtoandcomfortablesharingwithahealthcareprovider.Askthosestudentswhowish,tosharetheirexamples.Asstudentssharetheirexamples,helpthemidentifyanycommonfactorsintheirexamplesthatareimportantinestablishingatrustinghealthcarerelationship.

SuggestionforClinicalActivities

  • Ask students to continue to reflect on and document in their clinical journals specific examples of patient communication and their progress (or challenges) in promoting and developing trusting relationships with their patients.

Learning Objective 6

Explainhowandwhythenurse’smoralagencymightchangewithexperience,accordingtotheDreyfusModelofSkillAcquisition.

ConceptsforLecture

  1. Moralagencyisdefinedastheabilitytoaffectandinfluencesituationsandisrequiredforclinicaljudgment.Moralagencychangeswithexperience.
  2. TheDreyfusModelofSkillAcquisitionisbasedondeterminingthelevelofpracticeevidentinparticularsituations.Themodeldescribesstrengthsaswellasproblems.
  3. Clinicianscanperformattheirbestateachstage.Forexample,onecanbethebestadvancedbeginnerpossible,typicallyduringthefirstyearofpractice.
  4. However,nopractitionercanbebeyondexperience,sinceifthenursehasneverencounteredaparticularclinicalsituation,experientiallearningwouldberequiredtomasterthesituation.
  5. ThestagesofexperientiallearningintheDreyfusmodelofskillacquisitionare:
  6. Novice
  7. Advancedbeginner
  8. Competent
  9. Proficient
  10. Expert
  11. Studieshaveshownthattheclinician’scapacityformoralagencychangeswiththegrowthofclinicaljudgment,perceptiveness,communicationskills,andskillfulcomportment.
  12. Moralagencyrequiresmorethantheintenttodogoodortobeagoodpractitioner.Rather,itrequirestheexperientialskilltorecognizewhenanethicalbreachinpracticehasoccurred.Italsorequiresthesocialandcommunicationskillstoeffectivelyinterveneonbehalfofthepatient.
  13. Thenursewhodevelopsanattuned,response-basedpracticelearnstorecognizewholesituationsandcomparethemwithpastexperiences,accordingtotheDreyfusmodel.Thenursemovesfromcomparingabstracttextbookaccountsofcurrentclinicalsituationstocomparingpastwholecaseswithcurrentclinicalsituations.Someactionsareconsideredplausibleandeffective;othersareimplausible.

PowerPointLectureSlides

1ClinicalJudgmentandPatientRelationships

  • Phronesisisclinicaljudgmentandtheabilitytoactongoodclinicaljudgment

2ClinicalJudgmentandPatientRelationships

  • Clinicians
  • Cliniciansbendandrespondtoapatient.
  • Newhorizonsappearorarereconstituted.
  • Newpossibilitiesemerge.
  • Patients
  • Patientsbendandrespondtoclinicians.
  • Newhorizonsappearorarereconstituted.
  • Newpossibilitiesemerge.
  • Healingandrecoveryrequiresrelationship,openness,andtrust.

3aClinicalJudgmentandPatientRelationships

  • Thepatientdetermines:
  • Whattodisclose
  • Whatcanbethoughtaboutandtalkedabouttogether
  • Whatlevelofacceptanceandendorsementofthetherapieswillbeacceptable

3bClinicalJudgmentandPatientRelationships

  • Nurse
  • Thenurse’srelationshipwiththepatientmightalterthenurse’sclinicaljudgmentinthefollowingsituation:
  • Patient
  • Apatientrehearseshismostfearfulconcernswithanurse.(Patientsoftenregardnursesasmoreapproachablethanphysicians.)
  • Anursecanthenhelpthepatientcommunicatewithhishealthcareproviders.

4aMoralAgencyandExperience

  • Moralagencyisdefinedastheabilitytoaffectandinfluencesituationsandisrequiredforclinicaljudgment.
  • Moralagencychangeswithexperience.

4bDreyfusModelofSkillAcquisition

  • TheDreyfusmodelofskillacquisitiondescribesstrengthsaswellasproblemsateachstage.
  • ThestagesofexperientiallearningintheDreyfusmodelofskillacquisitionare:
  • Novice
  • Advancedbeginner
  • Competent
  • Proficient
  • Expert
  • Clinicianscanperformattheirbestateachstage.

However,nopractitionercanbebeyondexperience.

  • Ifthenursehasneverencounteredaparticularclinicalsituation,experientiallearningwouldberequiredtomasterthesituation.

SuggestionforClassroomActivities

  • Lead the class in a discussion of role transitions. Ask students to think about a nurse they have worked with or their family has worked with, and identify their perspective on where that care provider might be on the Dreyfus Model of Skill Acquisition. What examples can they provide to illustrate how they are classifying the nurse according to the model?

SuggestionforClinicalActivities

  • Ask students to review the Dreyfus Model of Skill Acquisition and identify what point they hope to be at in a three-year time period. Ask them to discuss the types of informal and formal learning and practice activities they might need to pursue.
  • Assign students to skim one professional nursing journal in a specialty area of interest. Ask students to bring a sample table of contents to share at a clinical conference to discuss the variety of topics covered and benefits of professional journals in advancing career expertise.

Learning Objective 7

Characterizethreedistinctdifferencesbetweencompetentandexpertclinicalnursingpractice.

ConceptsforLecture

  1. Chart2–1characterizestheskillsetsofnursesatthevariousDreyfusstagesofcompetence.Thestagesofexperientiallearningare:
  2. Novice
  3. Advancedbeginner
  4. Competent
  5. Proficient
  6. Expert
  7. SomeprimarydifferencesthatthenursewithanExpertlevelofexperientiallearningcanachieveversusanurseataCompetentlevelincludetheabilitytohandletheunexpected.AnExpertnurse’spracticeisalsobecomingmoresituated,patient-responsebased.AnExpertnurseusesbothtechneandphronesisappropriately.Finally,thepracticeatthislevelofexperientiallearningtakesuptheoriesandendsofpracticeinmultiplewaysthatfitthesituation.
  8. Consequently,howfastsomeonecangaincompetencedependsonhowvariedandcomplexhispatientpopulationis.Obviously,nursesworkinginahigh-volumeheartsurgerycenterwherethepatientpopulationisthesamewillgainmoreexperiencesoonerabouttypicalpatternsinaspecificpatientpopulationthananurseworkingonageneralmedical–surgicalfloor.

PowerPointLectureSlides

1aMoralAgency

  • Studieshaveshownthattheclinician’scapacityformoralagencychangeswith:
  • Growthofclinicaljudgment
  • Perceptiveness
  • Communicationskills
  • Skillfulcomportment

1bMoralAgency

  • Moralagencyrequiresmorethantheintenttodogoodortobeagoodpractitioner.
  • Rather,itrequirestheexperientialskilltorecognizewhenanethicalbreachinpracticehasoccurred.
  • Italsorequiresthesocialandcommunicationskillstoeffectivelyinterveneonbehalfofthepatient.

2MoralAgencyandResponse-BasedPractice

  • Thenursewhodevelopsanattuned,response-basedpracticelearnstorecognizewholesituationsandcomparethemwithpastexperiences,accordingtotheDreyfusmodel.
  • Thenursemovesfromcomparingabstracttextbookaccountsofcurrentclinicalsituationstocomparingpastwholecaseswithcurrentclinicalsituations.
  • Someactionsareconsideredplausibleandeffective;othersareimplausible.

3aCompetentVersusExpertNursingPractice

  • Chart2–1:
  • NurseskillsetsatthevariousDreyfusstagesofcompetence.
  • Thestagesofexperientiallearningare:
  • Novice
  • Advancedbeginner
  • Competent
  • Proficient
  • Expert
  • Expertlevelnurse:
  • Canhandletheunexpected
  • Usesamoresituated,patient-responsebasedpractice
  • Usesbothtechneandphronesisappropriately
  • Takesuptheoriesandendsofpracticeinmultiplewaysthatfitthesituation

3bCompetentVersusExpertNursingPractice

  • Chart2–1:NurseskillsetsatthevariousDreyfusstagesofcompetence
  • Thestagesofexperientiallearningare:
  • Novice
  • Advancedbeginner
  • Competent
  • Proficient
  • Expert

3cCompetentVersusExpertNursingPractice

  • Expertlevelnurse:
  • Canhandletheunexpected
  • Usesamoresituated,patient-responsebasedpractice
  • Usesbothtechneandphronesisappropriately

Takesuptheoriesandendsofpracticeinmultiplewaysthatfitthesituation

3dGainingCompetence

  • How fast can someone gain competence?
  • It depends on how varied and complex the patient population.
  • Example:
  • Nursesworkinginahigh-volumeheartsurgerycenterwherethepatientpopulationisthesamewillgainmoreexperiencesoonerabouttypicalpatternsthananurseworkingonageneralmedical–surgicalfloor.

SuggestionforClassroomActivities

  • Invite advanced nurse clinicians to talk to the class about their career progression, including both informal and formal learning and practice activities they used in gaining expertise.

SuggestionforClinicalActivities

  • Assign students to interview or observe an expert nurse in practice (general nursing or a clinical specialty interest). Ask students to write a brief reflective paper including nursing traits they identified from this experience that they would like to emulate as they begin their nursing careers.

©2010 by Pearson Education, Inc.
Osborn, Wraa, Watson, Instructor’s Resource Manual for Medical-Surgical Nursing