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Developing expertise – the contribution of paediatric accident and emergency nurses to the care of children, and the implications for their continuing professional development
Accident and Emergency Nursing (2003) 11, 96–102 0965-2302/03/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0965-2302(02)00211-4
Developing expertise – the contribution of paediatric accident and emergency nurses to the care of children, and the implications for their continuing professional development Karen Cleaver
Karen Cleaver RGN, RSCN, MSc, BEd (Hons) Principal Lecturer, Children’s Nursing, University of Greenwich, Avery Hill Campus, Mansion Site, Bexley Road, Eltham, London SE9 2PQ, UK E-mail: k.p.cleaver@ gre.ac.uk Manuscript submitted: 5 October 2002 accepted: 1 November 2002
96
Aim: The purpose of this paper is to explore the contribution of paediatric accident and emergency nurses to the care of children. Method: Using a case study approach, the paper focuses on the experiences of three nurses working in this setting, obtained through working alongside the nurses and discussing and observing their experiences. Findings: It became apparent that the nurses were regarded as ‘‘experts’’ in the care of children in this setting. The nurses themselves however, did not share this perception. Their experiences are analysed with reference to literature on expertise, focussing specifically on published accounts of children’s nurses’ experiences, and research which has explored the concept of expertise within the context of accident and emergency work. The implications for continuing professional development needs are discussed within the context of recent government reports, which make recommendations in respect of access and delivery of on-going professional education. To this end it is advocated that a multi-professional approach is adopted, with children’s nurses sharing learning and thus access to, courses customarily provided to adults nurses working in this setting. c 2003 Elsevier Science Ltd. All rights reserved.
Introduction In recognition of the specific needs of children in the accident and emergency (A&E) setting, it has been proposed that children’s nurses in the A&E department are a necessity rather than a luxury (Webb & Cleaver 1991). This view has
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 6 –1 0 2
now become accepted, with recent evidence that the numbers of children’s nurses being employed in this setting have increased (Audit Commission 2001a). However, while the contribution of children’s nurses to the work of A&E departments has been determined in
ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise
paediatric benchmarking statements (University of Central Lancaster 1997), there is evidence that their contribution to nursing care in the A&E setting is variously interpreted. Dolan (1997) notes that, as an ‘‘ideal’’, children’s nurses should be a resource for staff, children and families. However, arguably children’s nurses could make a wider contribution, as Bentley’s (1996) study identified. Bentley surveyed 136 A&E departments, 68% of which employed children’s nurses who fulfilled various roles, which Bentley categorised as service provider, service regulator and educator (Bentley 1996). Nevertheless Bentley’s study also identified an element of tokenism with 20% of the managers who employed children’s nurses reporting that they had no specific responsibility for the care of children. Watson (2000) notes that as a paediatric nurse manager she had encountered difficulties in recruiting and retaining children’s nurses for paediatric A&E, and proposes that this is partly due to the requirement of departmental managers that they also care for adult patients, a factor confirmed by Bentley’s (1996) study. A further consideration is likely to be that opportunities for education and training in paediatric A&E care, are limited (Smith & Jones 1998, Lee 2000). These reported limited opportunities are of concern in light of recent government policy, which clearly articulates a commitment to ongoing continuing professional development (Department of Health 1999, 2000).
The context of the study It is against this background that the author set out to determine the contribution of paediatric nurses to the care of children in a local A&E department, and their consequent continuing professional development needs. A case study approach was used, as this design can be adopted in order to study individuals, groups or specific phenomena, within a social setting. As Mariano (1993) notes, case studies can be conducted at various levels of complexity, using differing levels of analysis – factual, interpretative and evaluative. Lincoln & Gruba (1985) propose that case studies can fulfil four
ª 2003 Elsevier Science Ltd. All rights reserved.
purposes: to chronicle facts and events; to render, through description, depiction or characterisation; to teach, through instruction; and to test, using a particular case to test theories or hypothesis. Using a case study approach, it was possible to study the nurses within the context of their work environment, with the primary purpose of chronicling and rendering their experiences as children’s nurses, within a paediatric A&E setting. I was known to the staff in the department through my role as ‘‘link teacher’’. However, to determine the continuing professional development needs of staff, I spent additional time working alongside the three E grade children’s nurses employed by the department. The following narrative provides a summary of the recounted experiences of these nurses, followed by an analysis of how this is supported by the literature which discusses expertise in nursing, focussing specifically on children’s and A&E nursing.
A descriptive account of the nurses’ experiences The nurses concerned had all taken up post within the previous 18 months. For two this was their second appointment post-qualifying; the third nurse, also a RGN, had varied experience, but not in this setting. They described how initially they had felt overwhelmed by the nature of accident and emergency work. Notably the nurses felt unskilled, even in areas where previously they had felt competent, for example in caring for children with asthma and other respiratory problems. Additionally they encountered areas of practice they had not previously engaged in, particularly related to the management of minor injuries – ‘‘neighbour strapping’’ being one such example where even the terminology was unfamiliar. This unfamiliarity served to engender feelings of uncertainty as any confidence previously acquired within their nursing roles, dissipated when faced with aspects of care, seemingly ‘‘basic’’ and ‘‘routine’’ to A&E nurses. All reported embarking on a steep learning curve, which they found challenging and rewarding. After a period of time (around six months) the nurses reported that having undergone
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 6 –1 0 2
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what they saw as a steep learning curve, they then felt they had become established in their roles, having adapted to the nature of A&E work. The longer they remained in the department the more established they became with their colleagues, who increasingly relied on them to provide advice and opinions around the care of children. However, parallel to this the nurses became increasingly frustrated with their roles, feeling that having acquired and mastered new skills and knowledge, they no longer had a challenge. Indeed the nurses became de-motivated by what they increasingly perceived as the routine nature of A&E work. This de-motivation was exacerbated by feelings of frustration as they felt they were being held back in developing their role, and were not being allowed to develop autonomously. Although they could triage children, having undertaken an in-house course, the nurses could not initiate treatment, even though they were frequently consulted (as ‘‘experts’’) with regards to the course of treatment or issues around care management. Subsequently the three E grade nurses have left (none having stayed longer than two years). One has remained within the speciality
(paediatric accident and emergency), having obtained a promotion.
Developing expertise – the context of care A number of issues arise from this description in relation to the perceived and actual expertise of the paediatric A&E nurses, in relation to the roles they were fulfilling. When considering Bentley’s categories (see Fig. 1) it is evident that initially the nurses only fulfilled the role of service provider. Indeed to begin with, this aspect of their role was problematic for them, as they had limited knowledge of the context, and lacked the specific skills required for A&E nursing. Nevertheless they frequently cited how, even when they first started, they were seen as the ‘‘experts’’ as they were the children’s nurses, and thus left in charge of the paediatric area. It is possible that the paediatric nurses were perceived as ‘‘experts’’ as they had previous experience, a recognised qualification in children’s nursing, and thus by implication a degree of knowledge, skills and competence. The association of children’s nurses with
Fig. 1 Role categories for RSCNs in the accident and emergency department.
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ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise
children and families equating to expertise by virtue of role has parallels with the notion of mothers knowing their children best. Callery (1997:27) notes that ‘‘although it is common-place to describe mothers as ‘‘experts’’ about their own children, there has been little examination of the nature of mothers expertise in the assessment of sick children’’. Similarly if the nurses’ colleagues were asked to describe the components of the expertise possessed by these children’s nurses, it is likely that difficulty would be encountered. In his study Callery found that mothers made assessments of their child’s health status based on subtle changes in their children’s appearance and behaviours. He cites a GP who proposes that only parents have the skills to judge what is normal or not in their own children, a supposition which is leant some support in his findings (Callery 1997). The ability to judge what is normal or abnormal, or to recognise sick and well patients, is fundamental to A&E nursing practice. Initial assessment of patients’ needs in the A&E setting is almost always undertaken by a nurse. Decisions arising from this assessment determine the patient’s progression through the A&E department, as is the case in the department concerned. Sbaih (1998a) reports on an in-depth study examining the work of A&E nurses which describes how they use mental lists of signs and symptoms derived through knowledge and experience to determine ‘‘what is different’’. In so doing they are able to establish symptoms of concern and non-concern. However, not all A&E nurses are able to distinguish thus, a factor acknowledged by Sbaih who goes on to conclude that: ‘‘A&E nurses also operate in knowing and having seen the cases before. Symptoms presented by the patients have to have meaning in the past and future as well as the present’’ (Sbaih 1998a, p. 6). Thus novice A&E nurses are more likely to rely on the present, and as their experiences increase can draw on past mental lists of signs and symptoms, and place these within an increasingly varying context of situations, which ultimately enables them to predict and plan for future experiences. Sbaih in a later paper reporting the same study discusses how having the ability to recognise symptoms and
ª 2003 Elsevier Science Ltd. All rights reserved.
gaining an accurate impression has to then be translated into a course of action. Ultimately, just knowing the normal case is not enough, acting appropriately at the right time and with the right people is also required (Sbaih 1998b). The use of mental lists of signs and symptoms increasingly applied to differing contexts with appropriate actions determined corresponds with Benner’s (1984) model of skill acquisition. The oft quoted phrase ‘from novice to expert’ reflects Benner’s proposition that nurses can ultimately achieve expert status, having started as novices, progressing through the stages of advanced beginners, competent and proficient practitioners. Thus in relation to aforementioned discussion of nursing assessment, the nurse who uses signs and symptoms within a limited context, equates to Benner’s novice who ‘‘has no experience of a situation, thus uses text book rules which have been learned objectively with no contextual meaning to apply’’ (Benner 1984). However, as the nurse applies a wider repertoire of signs and symptoms, derived from varying situations and contexts, so does her ability to determine concern from non-concern develop as she achieves competency and proficiency.
Experience as a constituent of expertise Within pre-registration nursing and midwifery, the term competence is often used to denote the required level of achievement in order to achieve registration. This potentially results in ambiguity as to when competence is achieved. Assessments underpinning nursing curricula are often based on Benner’s framework of novice to expert, which muddies the water when considering the notion of expertise, and its development for the post-qualifying nurse or midwife. The nurses who participated in the case study, have been deemed to have achieved a level of ‘‘competence’’ to enable them to register as children’s nurses. However concerns and debates about the extent to which pre-registration programmes have adequately prepared practitioners for practice subsequent to registration are widely documented. Pratt (2001) discusses her anxieties on her first day
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as a staff nurse, having qualified as a children’s nurse, acknowledging that she has been judged to be competent by virtue of registration, thus able to practice safely and effectively without direct supervision (UKCC 1999). She describes how she was asked to look after a baby with bronchiolitis, who was being cared for in a head box, requiring humidified oxygen, and comments that ‘‘all my fears were wrapped up in one patient’’ (Pratt 2001). Nevertheless, one year on she recounts how she now has to frequently look after up to six infants with bronchiolitis, regarding the care of just one baby as a luxury. Clearly therefore this nurse has moved along Benner’s continuum, arguably from advanced beginner to competent practitioner. She was evidently not (according to her description) at Benner’s level of competence on registration. When considering the accounts of the nurses in the A&E setting it is possible that they would empathise with this nurses story, relating it to their early experiences of A&E work, although they were not newly qualified. Similar experiences are described in ‘‘Delya’s Story’’ (Hargreaves & Lane 2001). Delya, an experienced ward based children’s nurse changed her role, becoming a school nurse. During this role transition she was undertaking a post-registration Diploma course, and with her tutor reflected on this transition. In her reflective narrative Delya analyses her practice within the context of Benner’s five levels of skills acquisition. On reflecting on her practice on the children’s ward, Delya identifies that depending on the situation, her level of skill varied from competent in some, to expert in others. However, despite her experience and self-assessed expertise, when taking up her appointment as a school nurse she identified that she returned to novice status, and only following preceptorship, and a term’s experience, did she feel she had moved on to competence. Hargreaves & Lane (2001) comment that: ‘‘Having examined Delya’s narrative it can be seen that the context in which she is working is pivotal to her perceived level of skill’’. They argue that it is not merely a case of a nurse moving from expert to novice due to a change in post, as in-fact Delya ‘‘quickly grasps the basics and is
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considered competent by her peers in six weeks’’. They highlight how this is contrary to Benner’s suggestion that it takes 18 months to 2 years to achieve competence. They propose that Benner’s work did not fully explore and debate the importance of context in the acquisition of skills and that in so doing factors (apparent in Delya’s story) such as the individual themselves, prior experience and motivation also need to be considered (Hargreaves & Lane 2001). Clearly the experiences of the nurses working in the A&E department have some parallels with Delya’s story. They described feelings of uncertainty about their knowledge base in areas of children’s nursing that on a ward they would have felt confident in managing. Moreover, there were some areas of skills and knowledge to which they have had no previous exposure. Thus in these circumstances they were clearly novices, although like Delya, it was evident that they knew what they didn’t know, had skills which were transferable, and a disposition to learn (Hargreaves & Lane 2001). Edwards (1998) identified A&E nurses constructs of expertise using a repertory grid technique. Four main constructs emerged: high level of empirical knowledge, supportive team building, assertive clinical leadership and patient focussed involvement. While these are the defining attributes, Edwards (1998) discusses how the nurses in the study identified that expertise is characterised by insight into the specific approach to care needed in A&E, which could be interpreted as contextual. Edwards notes that novice A&E nurses find the setting chaotic and unstructured. This corresponds with the early impression of the E grade nurses when first working in A&E, which they identified impinged on their initial ability to deliver care they had routinely delivered on the ward, in particular the management of intravenous fluids was cited by one nurse. Fluid replacement rates can differ in an emergency situation, and the range of fluids used was outside this nurse’s experience, not to mention the fundamental issue of rapidly (due to urgency) locating the equipment required, problematic when in a strange environment and under pressure. However, as their
ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise
experience in the department lengthened, and their ‘‘expertise was refined through repeated exposure to similar clinical situations’’ (Edwards 1998, p. 19) they felt able to transfer their previously acquired skills to this setting. Edwards’s (1998) participants also identify that an expert is not afraid to become involved in a situation thereby sharing their expertise, providing constructive feedback to peers, while not being afraid to learn from others. Initially the E grade nurses felt unable to share their expertise in caring for sick children, as the context in which the care was occurring was different. They were however, keen to learn from other nurses, who although not qualified children’s nurses had experience of caring for children in this setting. However, as over a period of time they became more established, they became less reliant on others. Conversely their peers increasingly sought their opinions, hence they moved towards Bentley’s (1996) service regulator role.
Implications for addressing continuing professional development needs It is evident that the nurses in this A&E setting progressed from being novices, however, the label ‘‘expert’’ often applied by their colleagues had no real objective basis, and was not helpful to the nurses concerned. Ultimately they were able to transfer skills and knowledge previously acquired to their new setting, and as they gained experience, the different contexts and circumstances in which children presented with similar problems enabled the nurses to apply an increasingly wider repertoire of solutions to situations they encountered. However a recurring theme throughout the literature included in this paper is that expertise is accompanied by a sound theoretical underpinning, derived from ongoing education, which is then grounded in everyday practice, through the process of reflection and clinical supervision. The nurses had been provided with opportunity to develop their knowledge and skills, particularly in relation to assessment skills and advanced life support. However, opportunity had not subsequently been provided to enable them to begin to further develop their expertise
ª 2003 Elsevier Science Ltd. All rights reserved.
due to lack of opportunity and availability of appropriate accredited courses. The consequent potential for turnover in staff arising from perceived lack of career progressions, if not addressed, could result in departmental managers having to appoint on an ongoing basis, to a succession of vacancies in paediatric accident and emergency, requiring further investment in essential ‘‘basic’’ training. Hargreaves & Lane (2001) caution against an educational philosophy based on a concept of linear progression towards expertise. This is imperative in the field of paediatric A&E care, where recognised courses in this speciality are few and far between as no ‘‘traditional’’ route to obtaining a qualification exists. The Audit Commission (2001b) found tremendous variations in access to training and development. The reasons for this are varied and complex, but include the limitations imposed by use of the Non-Medical Education and Training (NMET) levies with single higher education providers, and the allocation of post-registration courses for nursing and midwifery being partly dependent on what had historically been commissioned. Barriers to accessing courses included the availability of assessors and mentors, but most commonly cited reasons were lack of appropriate courses, not all courses being perceived as appropriate to the needs of the individual nurses’ client group. All of these factors are arguably applicable to paediatric A&E nursing. As previously discussed there are a limited number of institutions providing courses within this speciality. Thus, when continuing professional development needs are considered based on an historical perspective, the number of courses is likely to remain small, as is the pool of appropriately qualified staff who can supervise, mentor and assess students wishing to develop in this speciality. Moreover, the resource implications for both developing and releasing staff for specific courses in paediatric A&E care means that it is unlikely that an abundance of new courses will emerge in the near future. A potential solution is to consider existing course provision in the field of A&E nursing. In line with recommendations from recent reports (Department of Health 1999, 2000, Audit Commission 2001b) such
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courses should move away from a uni-professional perspective, and as they are reviewed, a priority should be to consider the extent to which access can be widened and learning shared.
References Audit Commission 2001a Acute hospital portfolio. Review of national finding. Accident and Emergency. Audit Commission Audit Commission 2001b Hidden talents. Education, training and development for healthcare staff in NHS trusts. The Audit Commission Benner P 1984 From Novice to Expert. Addison-Wesley, California Bentley J 1996 Child-related services in general accident and emergency departments. Journal of Advanced Nursing 24: 1184–1193 Callery P 1997 Maternal knowledge and professional knowledge: co-operation and conflict in the care of sick children. International Journal of Nursing Studies 34 (1): 27–34 Department of Health 1999 Making a difference. Strengthening the nursing, midwifery and health visiting contribution to healthcare. Department of Health Department of Health 2000 A health service of all the talents. Developing the NHS workforce. Department of Health Dolan K 1997 Children in accident and emergency. Accident and Emergency Nursing 5: 88–91 Edwards B 1998 A&E nurses constructs on the nature of nursing expertise: a repertory grid
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technique. Accident and Emergency Nursing 6: 18–23 Hargreaves J, Lane D 2001 Delya’s story: from expert to novice, a critique of Benner’s concepts of context in the development of expert nursing practice. International Journal of Nursing Studies 38: 389–394 Lee P 2000 Education of nurses in accident and emergency. Paediatric Nursing 12: 27–28 Lincoln YS, Gruba EG 1985 Naturalistic Inquiry. Beverley Hills, CA Sage Mariano C 1993 Case study: The method. In: Munhall PL, Oiler-Boyd C (eds). Nursing Research. New York National League for Nursing Press Pratt S 2001 Competent on qualifying? Paediatric Nursing 13: 32–33 Sbaih LC 1998a Initial assessment in the A&E department. Accident and Emergency Nursing 6: 2–6 Sbaih LC 1998b Initial assessment: gaining impressions and ‘‘normal cases’’. Accident and Emergency Nursing 6: 70–74 Smith SJ, Jones JM 1998 Expanding roles and practice within paediatric A&E departments – the children’s nurse practitioner. In: Glasper EA, Lowson S (eds). Innovations in Paediatric Ambulatory Care. Macmillan, New York UKCC 1999 Fitness for practice. London UKCC University of Central Lancashire 1997 Best paediatric nursing practice benchmark. Accident & Emergency Provision. http://www.uclan.ac.uk/facs/health/ bench/benchf.htm Watson S 2000 Children’s nurses in the accident and emergency department: literature review. Accident and Emergency Nursing 8: 92–97 Webb J, Cleaver K 1991 The child in casualty. Nursing Times 87: 26–31
ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise – the contribution of paediatric accident and emergency nurses to the care of children, and the implications for their continuing professional development Karen Cleaver
Karen Cleaver RGN, RSCN, MSc, BEd (Hons) Principal Lecturer, Children’s Nursing, University of Greenwich, Avery Hill Campus, Mansion Site, Bexley Road, Eltham, London SE9 2PQ, UK E-mail: k.p.cleaver@ gre.ac.uk Manuscript submitted: 5 October 2002 accepted: 1 November 2002
96
Aim: The purpose of this paper is to explore the contribution of paediatric accident and emergency nurses to the care of children. Method: Using a case study approach, the paper focuses on the experiences of three nurses working in this setting, obtained through working alongside the nurses and discussing and observing their experiences. Findings: It became apparent that the nurses were regarded as ‘‘experts’’ in the care of children in this setting. The nurses themselves however, did not share this perception. Their experiences are analysed with reference to literature on expertise, focussing specifically on published accounts of children’s nurses’ experiences, and research which has explored the concept of expertise within the context of accident and emergency work. The implications for continuing professional development needs are discussed within the context of recent government reports, which make recommendations in respect of access and delivery of on-going professional education. To this end it is advocated that a multi-professional approach is adopted, with children’s nurses sharing learning and thus access to, courses customarily provided to adults nurses working in this setting. c 2003 Elsevier Science Ltd. All rights reserved.
Introduction In recognition of the specific needs of children in the accident and emergency (A&E) setting, it has been proposed that children’s nurses in the A&E department are a necessity rather than a luxury (Webb & Cleaver 1991). This view has
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 6 –1 0 2
now become accepted, with recent evidence that the numbers of children’s nurses being employed in this setting have increased (Audit Commission 2001a). However, while the contribution of children’s nurses to the work of A&E departments has been determined in
ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise
paediatric benchmarking statements (University of Central Lancaster 1997), there is evidence that their contribution to nursing care in the A&E setting is variously interpreted. Dolan (1997) notes that, as an ‘‘ideal’’, children’s nurses should be a resource for staff, children and families. However, arguably children’s nurses could make a wider contribution, as Bentley’s (1996) study identified. Bentley surveyed 136 A&E departments, 68% of which employed children’s nurses who fulfilled various roles, which Bentley categorised as service provider, service regulator and educator (Bentley 1996). Nevertheless Bentley’s study also identified an element of tokenism with 20% of the managers who employed children’s nurses reporting that they had no specific responsibility for the care of children. Watson (2000) notes that as a paediatric nurse manager she had encountered difficulties in recruiting and retaining children’s nurses for paediatric A&E, and proposes that this is partly due to the requirement of departmental managers that they also care for adult patients, a factor confirmed by Bentley’s (1996) study. A further consideration is likely to be that opportunities for education and training in paediatric A&E care, are limited (Smith & Jones 1998, Lee 2000). These reported limited opportunities are of concern in light of recent government policy, which clearly articulates a commitment to ongoing continuing professional development (Department of Health 1999, 2000).
The context of the study It is against this background that the author set out to determine the contribution of paediatric nurses to the care of children in a local A&E department, and their consequent continuing professional development needs. A case study approach was used, as this design can be adopted in order to study individuals, groups or specific phenomena, within a social setting. As Mariano (1993) notes, case studies can be conducted at various levels of complexity, using differing levels of analysis – factual, interpretative and evaluative. Lincoln & Gruba (1985) propose that case studies can fulfil four
ª 2003 Elsevier Science Ltd. All rights reserved.
purposes: to chronicle facts and events; to render, through description, depiction or characterisation; to teach, through instruction; and to test, using a particular case to test theories or hypothesis. Using a case study approach, it was possible to study the nurses within the context of their work environment, with the primary purpose of chronicling and rendering their experiences as children’s nurses, within a paediatric A&E setting. I was known to the staff in the department through my role as ‘‘link teacher’’. However, to determine the continuing professional development needs of staff, I spent additional time working alongside the three E grade children’s nurses employed by the department. The following narrative provides a summary of the recounted experiences of these nurses, followed by an analysis of how this is supported by the literature which discusses expertise in nursing, focussing specifically on children’s and A&E nursing.
A descriptive account of the nurses’ experiences The nurses concerned had all taken up post within the previous 18 months. For two this was their second appointment post-qualifying; the third nurse, also a RGN, had varied experience, but not in this setting. They described how initially they had felt overwhelmed by the nature of accident and emergency work. Notably the nurses felt unskilled, even in areas where previously they had felt competent, for example in caring for children with asthma and other respiratory problems. Additionally they encountered areas of practice they had not previously engaged in, particularly related to the management of minor injuries – ‘‘neighbour strapping’’ being one such example where even the terminology was unfamiliar. This unfamiliarity served to engender feelings of uncertainty as any confidence previously acquired within their nursing roles, dissipated when faced with aspects of care, seemingly ‘‘basic’’ and ‘‘routine’’ to A&E nurses. All reported embarking on a steep learning curve, which they found challenging and rewarding. After a period of time (around six months) the nurses reported that having undergone
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 6 –1 0 2
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Developing expertise
what they saw as a steep learning curve, they then felt they had become established in their roles, having adapted to the nature of A&E work. The longer they remained in the department the more established they became with their colleagues, who increasingly relied on them to provide advice and opinions around the care of children. However, parallel to this the nurses became increasingly frustrated with their roles, feeling that having acquired and mastered new skills and knowledge, they no longer had a challenge. Indeed the nurses became de-motivated by what they increasingly perceived as the routine nature of A&E work. This de-motivation was exacerbated by feelings of frustration as they felt they were being held back in developing their role, and were not being allowed to develop autonomously. Although they could triage children, having undertaken an in-house course, the nurses could not initiate treatment, even though they were frequently consulted (as ‘‘experts’’) with regards to the course of treatment or issues around care management. Subsequently the three E grade nurses have left (none having stayed longer than two years). One has remained within the speciality
(paediatric accident and emergency), having obtained a promotion.
Developing expertise – the context of care A number of issues arise from this description in relation to the perceived and actual expertise of the paediatric A&E nurses, in relation to the roles they were fulfilling. When considering Bentley’s categories (see Fig. 1) it is evident that initially the nurses only fulfilled the role of service provider. Indeed to begin with, this aspect of their role was problematic for them, as they had limited knowledge of the context, and lacked the specific skills required for A&E nursing. Nevertheless they frequently cited how, even when they first started, they were seen as the ‘‘experts’’ as they were the children’s nurses, and thus left in charge of the paediatric area. It is possible that the paediatric nurses were perceived as ‘‘experts’’ as they had previous experience, a recognised qualification in children’s nursing, and thus by implication a degree of knowledge, skills and competence. The association of children’s nurses with
Fig. 1 Role categories for RSCNs in the accident and emergency department.
98
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 6 –1 0 2
ª 2003 Elsevier Science Ltd. All rights reserved.
Developing expertise
children and families equating to expertise by virtue of role has parallels with the notion of mothers knowing their children best. Callery (1997:27) notes that ‘‘although it is common-place to describe mothers as ‘‘experts’’ about their own children, there has been little examination of the nature of mothers expertise in the assessment of sick children’’. Similarly if the nurses’ colleagues were asked to describe the components of the expertise possessed by these children’s nurses, it is likely that difficulty would be encountered. In his study Callery found that mothers made assessments of their child’s health status based on subtle changes in their children’s appearance and behaviours. He cites a GP who proposes that only parents have the skills to judge what is normal or not in their own children, a supposition which is leant some support in his findings (Callery 1997). The ability to judge what is normal or abnormal, or to recognise sick and well patients, is fundamental to A&E nursing practice. Initial assessment of patients’ needs in the A&E setting is almost always undertaken by a nurse. Decisions arising from this assessment determine the patient’s progression through the A&E department, as is the case in the department concerned. Sbaih (1998a) reports on an in-depth study examining the work of A&E nurses which describes how they use mental lists of signs and symptoms derived through knowledge and experience to determine ‘‘what is different’’. In so doing they are able to establish symptoms of concern and non-concern. However, not all A&E nurses are able to distinguish thus, a factor acknowledged by Sbaih who goes on to conclude that: ‘‘A&E nurses also operate in knowing and having seen the cases before. Symptoms presented by the patients have to have meaning in the past and future as well as the present’’ (Sbaih 1998a, p. 6). Thus novice A&E nurses are more likely to rely on the present, and as their experiences increase can draw on past mental lists of signs and symptoms, and place these within an increasingly varying context of situations, which ultimately enables them to predict and plan for future experiences. Sbaih in a later paper reporting the same study discusses how having the ability to recognise symptoms and
ª 2003 Elsevier Science Ltd. All rights reserved.
gaining an accurate impression has to then be translated into a course of action. Ultimately, just knowing the normal case is not enough, acting appropriately at the right time and with the right people is also required (Sbaih 1998b). The use of mental lists of signs and symptoms increasingly applied to differing contexts with appropriate actions determined corresponds with Benner’s (1984) model of skill acquisition. The oft quoted phrase ‘from novice to expert’ reflects Benner’s proposition that nurses can ultimately achieve expert status, having started as novices, progressing through the stages of advanced beginners, competent and proficient practitioners. Thus in relation to aforementioned discussion of nursing assessment, the nurse who uses signs and symptoms within a limited context, equates to Benner’s novice who ‘‘has no experience of a situation, thus uses text book rules which have been learned objectively with no contextual meaning to apply’’ (Benner 1984). However, as the nurse applies a wider repertoire of signs and symptoms, derived from varying situations and contexts, so does her ability to determine concern from non-concern develop as she achieves competency and proficiency.
Experience as a constituent of expertise Within pre-registration nursing and midwifery, the term competence is often used to denote the required level of achievement in order to achieve registration. This potentially results in ambiguity as to when competence is achieved. Assessments underpinning nursing curricula are often based on Benner’s framework of novice to expert, which muddies the water when considering the notion of expertise, and its development for the post-qualifying nurse or midwife. The nurses who participated in the case study, have been deemed to have achieved a level of ‘‘competence’’ to enable them to register as children’s nurses. However concerns and debates about the extent to which pre-registration programmes have adequately prepared practitioners for practice subsequent to registration are widely documented. Pratt (2001) discusses her anxieties on her first day
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as a staff nurse, having qualified as a children’s nurse, acknowledging that she has been judged to be competent by virtue of registration, thus able to practice safely and effectively without direct supervision (UKCC 1999). She describes how she was asked to look after a baby with bronchiolitis, who was being cared for in a head box, requiring humidified oxygen, and comments that ‘‘all my fears were wrapped up in one patient’’ (Pratt 2001). Nevertheless, one year on she recounts how she now has to frequently look after up to six infants with bronchiolitis, regarding the care of just one baby as a luxury. Clearly therefore this nurse has moved along Benner’s continuum, arguably from advanced beginner to competent practitioner. She was evidently not (according to her description) at Benner’s level of competence on registration. When considering the accounts of the nurses in the A&E setting it is possible that they would empathise with this nurses story, relating it to their early experiences of A&E work, although they were not newly qualified. Similar experiences are described in ‘‘Delya’s Story’’ (Hargreaves & Lane 2001). Delya, an experienced ward based children’s nurse changed her role, becoming a school nurse. During this role transition she was undertaking a post-registration Diploma course, and with her tutor reflected on this transition. In her reflective narrative Delya analyses her practice within the context of Benner’s five levels of skills acquisition. On reflecting on her practice on the children’s ward, Delya identifies that depending on the situation, her level of skill varied from competent in some, to expert in others. However, despite her experience and self-assessed expertise, when taking up her appointment as a school nurse she identified that she returned to novice status, and only following preceptorship, and a term’s experience, did she feel she had moved on to competence. Hargreaves & Lane (2001) comment that: ‘‘Having examined Delya’s narrative it can be seen that the context in which she is working is pivotal to her perceived level of skill’’. They argue that it is not merely a case of a nurse moving from expert to novice due to a change in post, as in-fact Delya ‘‘quickly grasps the basics and is
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considered competent by her peers in six weeks’’. They highlight how this is contrary to Benner’s suggestion that it takes 18 months to 2 years to achieve competence. They propose that Benner’s work did not fully explore and debate the importance of context in the acquisition of skills and that in so doing factors (apparent in Delya’s story) such as the individual themselves, prior experience and motivation also need to be considered (Hargreaves & Lane 2001). Clearly the experiences of the nurses working in the A&E department have some parallels with Delya’s story. They described feelings of uncertainty about their knowledge base in areas of children’s nursing that on a ward they would have felt confident in managing. Moreover, there were some areas of skills and knowledge to which they have had no previous exposure. Thus in these circumstances they were clearly novices, although like Delya, it was evident that they knew what they didn’t know, had skills which were transferable, and a disposition to learn (Hargreaves & Lane 2001). Edwards (1998) identified A&E nurses constructs of expertise using a repertory grid technique. Four main constructs emerged: high level of empirical knowledge, supportive team building, assertive clinical leadership and patient focussed involvement. While these are the defining attributes, Edwards (1998) discusses how the nurses in the study identified that expertise is characterised by insight into the specific approach to care needed in A&E, which could be interpreted as contextual. Edwards notes that novice A&E nurses find the setting chaotic and unstructured. This corresponds with the early impression of the E grade nurses when first working in A&E, which they identified impinged on their initial ability to deliver care they had routinely delivered on the ward, in particular the management of intravenous fluids was cited by one nurse. Fluid replacement rates can differ in an emergency situation, and the range of fluids used was outside this nurse’s experience, not to mention the fundamental issue of rapidly (due to urgency) locating the equipment required, problematic when in a strange environment and under pressure. However, as their
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experience in the department lengthened, and their ‘‘expertise was refined through repeated exposure to similar clinical situations’’ (Edwards 1998, p. 19) they felt able to transfer their previously acquired skills to this setting. Edwards’s (1998) participants also identify that an expert is not afraid to become involved in a situation thereby sharing their expertise, providing constructive feedback to peers, while not being afraid to learn from others. Initially the E grade nurses felt unable to share their expertise in caring for sick children, as the context in which the care was occurring was different. They were however, keen to learn from other nurses, who although not qualified children’s nurses had experience of caring for children in this setting. However, as over a period of time they became more established, they became less reliant on others. Conversely their peers increasingly sought their opinions, hence they moved towards Bentley’s (1996) service regulator role.
Implications for addressing continuing professional development needs It is evident that the nurses in this A&E setting progressed from being novices, however, the label ‘‘expert’’ often applied by their colleagues had no real objective basis, and was not helpful to the nurses concerned. Ultimately they were able to transfer skills and knowledge previously acquired to their new setting, and as they gained experience, the different contexts and circumstances in which children presented with similar problems enabled the nurses to apply an increasingly wider repertoire of solutions to situations they encountered. However a recurring theme throughout the literature included in this paper is that expertise is accompanied by a sound theoretical underpinning, derived from ongoing education, which is then grounded in everyday practice, through the process of reflection and clinical supervision. The nurses had been provided with opportunity to develop their knowledge and skills, particularly in relation to assessment skills and advanced life support. However, opportunity had not subsequently been provided to enable them to begin to further develop their expertise
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due to lack of opportunity and availability of appropriate accredited courses. The consequent potential for turnover in staff arising from perceived lack of career progressions, if not addressed, could result in departmental managers having to appoint on an ongoing basis, to a succession of vacancies in paediatric accident and emergency, requiring further investment in essential ‘‘basic’’ training. Hargreaves & Lane (2001) caution against an educational philosophy based on a concept of linear progression towards expertise. This is imperative in the field of paediatric A&E care, where recognised courses in this speciality are few and far between as no ‘‘traditional’’ route to obtaining a qualification exists. The Audit Commission (2001b) found tremendous variations in access to training and development. The reasons for this are varied and complex, but include the limitations imposed by use of the Non-Medical Education and Training (NMET) levies with single higher education providers, and the allocation of post-registration courses for nursing and midwifery being partly dependent on what had historically been commissioned. Barriers to accessing courses included the availability of assessors and mentors, but most commonly cited reasons were lack of appropriate courses, not all courses being perceived as appropriate to the needs of the individual nurses’ client group. All of these factors are arguably applicable to paediatric A&E nursing. As previously discussed there are a limited number of institutions providing courses within this speciality. Thus, when continuing professional development needs are considered based on an historical perspective, the number of courses is likely to remain small, as is the pool of appropriately qualified staff who can supervise, mentor and assess students wishing to develop in this speciality. Moreover, the resource implications for both developing and releasing staff for specific courses in paediatric A&E care means that it is unlikely that an abundance of new courses will emerge in the near future. A potential solution is to consider existing course provision in the field of A&E nursing. In line with recommendations from recent reports (Department of Health 1999, 2000, Audit Commission 2001b) such
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courses should move away from a uni-professional perspective, and as they are reviewed, a priority should be to consider the extent to which access can be widened and learning shared.
References Audit Commission 2001a Acute hospital portfolio. Review of national finding. Accident and Emergency. Audit Commission Audit Commission 2001b Hidden talents. Education, training and development for healthcare staff in NHS trusts. The Audit Commission Benner P 1984 From Novice to Expert. Addison-Wesley, California Bentley J 1996 Child-related services in general accident and emergency departments. Journal of Advanced Nursing 24: 1184–1193 Callery P 1997 Maternal knowledge and professional knowledge: co-operation and conflict in the care of sick children. International Journal of Nursing Studies 34 (1): 27–34 Department of Health 1999 Making a difference. Strengthening the nursing, midwifery and health visiting contribution to healthcare. Department of Health Department of Health 2000 A health service of all the talents. Developing the NHS workforce. Department of Health Dolan K 1997 Children in accident and emergency. Accident and Emergency Nursing 5: 88–91 Edwards B 1998 A&E nurses constructs on the nature of nursing expertise: a repertory grid
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technique. Accident and Emergency Nursing 6: 18–23 Hargreaves J, Lane D 2001 Delya’s story: from expert to novice, a critique of Benner’s concepts of context in the development of expert nursing practice. International Journal of Nursing Studies 38: 389–394 Lee P 2000 Education of nurses in accident and emergency. Paediatric Nursing 12: 27–28 Lincoln YS, Gruba EG 1985 Naturalistic Inquiry. Beverley Hills, CA Sage Mariano C 1993 Case study: The method. In: Munhall PL, Oiler-Boyd C (eds). Nursing Research. New York National League for Nursing Press Pratt S 2001 Competent on qualifying? Paediatric Nursing 13: 32–33 Sbaih LC 1998a Initial assessment in the A&E department. Accident and Emergency Nursing 6: 2–6 Sbaih LC 1998b Initial assessment: gaining impressions and ‘‘normal cases’’. Accident and Emergency Nursing 6: 70–74 Smith SJ, Jones JM 1998 Expanding roles and practice within paediatric A&E departments – the children’s nurse practitioner. In: Glasper EA, Lowson S (eds). Innovations in Paediatric Ambulatory Care. Macmillan, New York UKCC 1999 Fitness for practice. London UKCC University of Central Lancashire 1997 Best paediatric nursing practice benchmark. Accident & Emergency Provision. http://www.uclan.ac.uk/facs/health/ bench/benchf.htm Watson S 2000 Children’s nurses in the accident and emergency department: literature review. Accident and Emergency Nursing 8: 92–97 Webb J, Cleaver K 1991 The child in casualty. Nursing Times 87: 26–31
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