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Expertise among critical care nurses: A grounded theory study
Intensive & Critical Care Nursing xxx (xxxx) xxx
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Research article
Expertise among critical care nurses: A grounded theory study Teresa D. Welch ⇑, Melondie Carter Capstone College of Nursing, The University of Alabama, Box 870358, Tuscaloosa, AL 35487, United States
a r t i c l e
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Article history: Received 4 February 2019 Revised 10 December 2019 Accepted 17 December 2019 Available online xxxx Keywords: Critical care Experience Expertise Grounded theory Nursing Qualitative
a b s t r a c t Objectives: Explore critical care nurses’ personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice. Design: Following constructivist approach to grounded theory this investigation used qualitative openended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process. Setting: A multi-site urban area in the southeastern United States. Participants: 10 certified critical care nurses, three males and seven females, with 10–30+ years of critical care experience. Findings: Experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses’ aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care. Conclusion: Key findings suggested that clinical experience and personal motivation combined with selfactualisation, the drive to maximise personal potential, determine critical care nurse’s trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise. Ó 2020 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice
Clinical experience and personal motivation determine critical care nurse’s trajectory towards professional excellence. Contextual expectations and experiences have a direct impact on professional aptitude and development of expertise. Lifelong learning is a personal motivation that begins outside the clinical setting and is manifested within the clinical setting. Structured deliberate practice provides a proactive approach to promote expert performance and clinical excellence in critical care.
Introduction The expertise of the nurse has a direct impact on patient outcomes (Conley, 2019; Jantzen, 2019; Bathish, 2018; McHugh and Lake, 2010; Christensen and Hewitt-Taylor, 2006). The concept of expertise refers to characteristics, skills and knowledge separating experts from everyone else in clinical practice (Ericsson et al., 2006; Ericsson and Towne, 2010). The development of expertise ⇑ Corresponding author. E-mail addresses: [email protected] (T.D. Welch), [email protected] (M. Carter).
requires three fundamental elements: 1) relevant experience, 2) dedicated, purposeful work and 3) time (Ericsson et al., 2006; Ericsson and Towne, 2010; Weiss and Shanteau, 2014; Bathish et al., 2018). Development of expert performance evolves over a period of 7–10 years (Ericsson and Towne, 2010; Weiss Shanteau, 2014; Bathish et al., 2018). Research has defined objective criteria to identify experts within the domains of sports, music and chess, recognising those individuals who consistently demonstrate superior performance (Ericsson et al., 2006, Ericsson and Towne, 2010; Bourne, et al., 2014). Based on this research, empirical expectations and
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definitions of expert performance have been developed. These expectations are based on the objective measurement and analysis of reproducible skills and behaviours essential to expert performance (Ericsson and Poole, 2017). For the profession of nursing the opposite remains true (Ericsson, 2017; Hutchinson et al., 2016; Morrison and Symes, 2011; Ericsson, 2008; Ericsson et al., 2007; Christensen and Hewitt-Taylor, 2006). Expert nurses are defined by subjective social criteria and anecdotal perceptions of what it is to be an expert. The specific skills and expectations that set expert nurses apart and define expert performance have not been identified in measurable terms (Ericsson, 2017; Hutchinson et al., 2016; Causer et al 2014; Morrison and Symes, 2011; Ericsson et al., 2007). The impetus for this research was the desire to understand how individuals recognised as experts in critical care nursing consistently do what they do and equally important, how have they achieved and maintained their performance standard? As in other domains, the requisite skills and behaviors defining excellence and expert performance in practice should be clearly articulated and defined (Ericsson et al., 2007; Casuer et al., 2014; Bathish et al., 2018). Identifying those influential factors impacting the expert nurses’ successful transition to expert performer and the skills that set them apart would enable reproduction of key elements within that transitional process. This knowledge is pivotal in providing a framework for others to follow as they strive to develop and refine their own skill set (Bathish, 2018; Welch and Carter, 2018; Ericsson and Poole, 2017; Hutchinson et al., 2016; Ericsson et al., 2007). With this knowledge we can begin to strategically develop structured learning opportunities to abridge the evolutionary journey. Research questions The purpose of this study was to explore critical care nurses’ personal perceptions of expertise, expert performance and the transition to expert performer in clinical practice. The study addressed the following questions: a) How is expert critical care nursing socially constructed? b) What is the experiential process involved in becoming an expert in critical care practice?
efforts continued until interviews failed to yield new information indicating that data saturation had occurred. Inclusion criteria were defined as: a) registered nurses (RN) who met eligibility criteria for critical care certification and b) RN’s with 10 years of critical care experience who had successfully passed and maintained critical care certification. Participants meeting inclusion criteria who completed the interview received a token gift card purchased by the PI. Critical care was defined as anyone working in an intensive care unit, emergency department, critical care transport, or anesthesia care unit. The target population was contacted through professional webpages, email, public flyers, and professional referral. The target population was not contacted through the PI’s employer. Ethical considerations The Institutional Review Board of The University of IRB#15-OR256 reviewed and approved the research prior to initiation of data collection (IRB#15-OR-256). Participants were self-selecting and informed of their right to decline participation prior to and at any time during the interview process. Participant anonymity and confidentiality were guaranteed. All participants were introduced to the study with informed consent being obtained. Multiple strategies were employed to ensure anonymity and data integrity. The PI conducting interviews was an experienced critical care nurse and nurse manager. Precautions were taken to ensure that professional affiliations did not impact data collection and analysis. All participants were given contact information for the Research Compliance Officer independent of the PI or research setting for questions that may have arisen during or after the interview. Setting and context All interviews were held within the southeastern U.S. in an urban area. Study participants were contacted by telephone to verify study eligibility and if possible to schedule the interview appointment. Participants chose the time and location of the interview. All participants preferred to meet in a professional or public location just prior to or following a work shift or rotation.
Methods
Data collection
Research approach and objectives
Information was gathered through semi-structured face-to-face interviews using open ended questions. These open-ended questions were developed in broad terms and used to stimulate conversation in each of the interviews prompting participants to openly share personal impressions and experiences. Follow-up questions were used to clarify concepts presented by the participant and to stimulate further exploration and sharing. Each participant was interviewed once, but the possibility of a follow up interview was discussed during the initial interview process for verification of research findings. After the informed consent was signed, non-descript demographic data was collected prior to beginning interviews and documented in the interview notes. Interviews were audio recorded for accuracy and verbatim transcription. Immediately following the interview all field notes, observations, tapes or references to the interview were labeled with a random automotive pseudonym for ease of collective filing and referencing during coding. Once labeled all materials were organized in a file folder with the same pseudonym. The informed consent was secured and filed separately. There is no identifying data to link interview or interview materials to the informed consent or the participant. Recorded interviews were transcribed verbatim by the PI. Transcripts provided the primary source of data for analysis. Field
Grounded theory methodology was chosen for this study based on its strength in explicating human behavior in context. According to Charmaz (2014) and Corbin and Strauss (2015), human behaviour related to health issues, developmental transitions and situational challenges are well suited to grounded theory research. The inductive qualities and propensity to identify social processes explaining human behavior makes grounded theory particularly useful to social inquiry (Wuest, 2012). Remaining true to the participants’ perspective is the foundational principle of a grounded theory approach making it particularly useful in the study of expertise in critical care nursing (Charmaz, 2014; Corbin and Strauss, 2015). The objectives of this research project were: 1) explore critical care nurses’ personal perceptions of expertise and expert performance, 2) describe the transition from novice to expert performer in clinical practice. Recruitment This was a purposeful sample of convenience that after the initial interview, developed through snowball effect. Recruitment
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notes, observational and reflective memos were also used for coding and analysis. Data analysis Data analysis began with the first interview. Transcription of interview material began within 24 hours. Audio-recorded material was destroyed upon verification of accuracy. With the task of transcription complete, the transcript was then read through in
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its entirety to give a general impression of the data. This process was repeated for each interview. These initial high-level impressions were noted in the margins of transcribed text for analysis. After this first reading the PI collected multi-colored pencils to begin the task of re-reading data. Only this time, data were read carefully, line-by-line, deliberately colour coding for descriptive data. Each new code received a new colour. As codes began to repeat themselves, they were highlighted with repeating colours. See Example 1: Interview Transcript.
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This iterative process of constant comparison proceeded in an alternating repetitive sequence of data collection and analysis. As concepts emerged in earlier interviews, subsequent interviews attempted to explore these concepts in an attempt to develop and refine concepts, categories and themes. See Graph 1: Theoretical sampling. As codes and concepts were reinforced the process of categorizing began to take shape. As categories began to reach saturation definitions began to take shape. This constant back and forth comparative method required continual revision, modification, and amendment of categories until all new codes could be placed into an appropriate category. The constant comparative process of data analysis in grounded theory follows a standardized systematic format: 1) open coding focused on text is the process of line by line coding, 2) axial coding is the conceptual process of categorising the initial codes based upon familial patterns or relationships to develop categories and 3) thematic or selective coding, the final stage of analysis, concentrates on linking the findings to evidence. (Corbin and Strauss,
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2015; Charmaz 2014; Guest et al., 2012). See Table 1: Code Frequency Table.
Rigour: Three strategies were used to ensure credibility of research processes and findings. An in-depth literature review searching multiple databases was conducted prior to beginning the study to establish clear and congruent concepts related to expertise in the current body of literature. The basic definition and tenets of expertise and the expert performer were found to be congruent across domains (Guest et al., 2012). A systematic analytic process, including constant comparison and member-checking, was adopted to enhance the credibility. The originality of the findings in this research was examined by reviewing the extant literature. Charmaz (2014) described the process of member checking as a viable process to verify research findings. As concepts and themes evolved participants given an opportunity to review the findings for accuracy.
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Graph 1. Theoretical sampling. Table 1 Code frequency table. Structural Codes
Frequencies
Research Question 1: How would you define the expert nurse in clinical practice in critical care? Experiences are important (did not specify) 4 Diversity/Intensity of experience 6 10 of 10 responses to experience Knowledgeable with a solid grasp on 7 concepts Confidence 1 Collaboration 1 Continuing education 1 Research Question 2: What criteria or characteristics would you use to define expert performance in clinical practice in the critical care unit? Experienced 10 Knowledgeable 6 Independent thinkers who know what to do 8 Calm cool demeanor 6 Comfortable 2 Communication 1 Teamwork 3 Research Question 3: How does one become Experience Proactive pursuit of lifelong learning Time Spiritual Calling
an expert in critical care? 7 7 4 1
Research Question 4: Describe any factors that in your experience may have supported or hindered that development. Positive Factors Diversity of experiences 3 Specialty Education 2 Opportunities 2 Professional mentors/role models 2 Professional recognition 1 Personal drive to be best 4 Negative Factors Nurses eat their young 4 Vulnerability 1 Fear 4 Laziness 1 Complacent 4 Lack of opportunities 1
Credibility of the research process and the findings was further supported through the in-depth literature review defining concepts and process of peer debriefing. Findings: Sample: Participants were registered nurses (RN) who held an active unencumbered nursing license and currently worked within the specialty of critical care. Of the 10 participants three were male and seven were female with no attrition. Five of the participants had previous paramedic, fire rescue, practical nursing or emergency management experience prior to becoming a RN. Years of experience in critical care nursing spanned 12–39 years with an average of 24.5 years. Participant ages ranged from 38 to 61 years of age with an average of 49 years. All held multiple nationally recognised critical care certifications. Five of the participants were certified instructors for advanced critical care and trauma certifications. Academically, four held baccalaureate degrees, four held associate degrees, and two held master’s degree. Participant files were randomly assigned the make or model of an automobile to ensure anonymity and confidentiality.
Themes: Three themes emerged from data to describe rather than define the performance of the expert critical care nurse: experience, knowledge, and self-actualisation. Detailed explanations of these themes and their respective sub themes are as follows in order of priority as defined by data.
Experience: When asked what defined the expert critical care nurse all of the participants responded: experience. Descriptive words such as ‘‘graduated experience”, diversity, and ‘‘hands on experience” were used to express their thoughts regarding experience. Participant 1: ‘Well, I tell them the first thing, number one is experience. Every chance you get the opportunity to do something new,
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or to see something new. . .. You need to be involved. You need to question the physician; why did he make that decision? That’s how you learn’. Participant 2: ‘The best training is experience. The best experience was on the intermediate step down unit. All of those patients were unstable and critically ill’. Participant 2: ‘I think that people who work in a specialty unit or a unit where you get sicker patients tends to progress a lot faster than those who work on a regular floor where people are not as sick’.
Participant 4: ‘They think outside the box and have the ability to anticipate and prevent problems with minimal resources’. Participant 2: ‘They can see the entire situation. You don’t have to tell them, the situation is handled calmly and coolly’. Participant 5: ‘They can quickly assess a patient and make a decision. . . It doesn’t take them very. You’re assessing the patient before you ever get to them. You’re assessing the scene, you’re assessing the body language of other people around them’. Participant 5: ‘Somebody who can take in the whole picture and not just the specifics’.
Diversity/Intensity. All participants discussed experience as the foundational element of expert nursing practice. Of those participants, six specifically described the importance of ‘‘types”, ‘‘intensity” and ‘‘diversity” of experiences. The nature of the experience in relation to the intensity and severity of illness is significant in the development of expert performance.
Self-actualisation: Self-actualisation is the conceptual interpretation of two related themes emerging from data that collectively spoke to the intrapersonal domain of self-actualisation. Seven participant’s directly or indirectly discussed the positive impact of the expert’s presence in stressful situations. They were described as possessing a selfconfidence that transcended the situation and those around them.
Participant 4: ‘I have prior experiences in emergency and fire rescue before becoming a nurse. Those experiences helped me to develop as a strong nurse. . .. I’ve always worked trauma and rescue. Those experiences are intense’. Participant 8: ‘The bad experiences. It’s through those really bad situations, when something went wrong and you had to figure out why’. Participant 8: ‘You don’t forget those really bad experiences. I’ve learned the most from those really bad situations and experiences than anything else in my career’. Knowledge: Seven participants discussed ‘‘knowledge” directly during the interview process. Each time knowledge was discussed so was experience. Participants used phrases such as: ‘‘I know what the numbers mean”, ‘‘stay ahead of the patient”, ‘‘know how and why things work”, ‘‘firm grasp of concepts”. Participant 1: ‘You need to know the ‘why’ of what you do. If you don’t understand the ‘why’, then you’ll never know what the outcome should be. And the whole goal is to get a patient to a specific outcome’. Participant 2: ‘If you can walk into a room, assess what’s going on and know exactly what to do; you’re an expert’. Participant 2: ‘When I first started. . .. I didn’t have a clue what was going on. Now I know what the numbers mean’. Participant 1: ‘One thing experts have in common is that they know what to do and when to do it. They don’t need direction’. Participant 1: ‘An expert nurse can look in that room, take it all in. They know exactly what’s going on and how to react’. Participant 6: ‘It’s like they know what you need before you need it. No one has to tell them, you don’t have to ask’. Critical Reason. Eight participants specifically mentioned ‘‘independent thinker” or ‘‘they just knew what needed to be done” in the interview process describing the subconscious process of critical reasoning and automaticity of action. The term ‘‘critical reason” was a conceptual interpretation. Participants had difficulty describing their thoughts as they attempted to articulate abstract concepts; ‘‘thinking” and ‘‘action”. Instead they used broad concepts to relate the nature of the patient engagement at the expert level; ‘‘whole picture”, ‘‘don’t need guidance”, ‘‘take it all in”, and ‘‘just know what to do”. Participant 3: ‘They’re all independent thinkers’. Participant 3: ‘I wouldn’t have to worry about my patient. They’re going to take over and do what needs to be done without anyone asking them to’.
Participant 6: ‘The monitor alarm went off. The patient’s rhythm started to change and he went into v-tach. Before I could process what was going on I looked around and Edgar had already gone in there, shocked him and come right back out to the desk. I’m thinking, what just happened?! Edgar just shocked him out of v-tach’. Participant 5: ‘They’re calm, collected, taking in the whole scene at once. . . They quickly assess a patient and come to a judgement, make a decision on the plan of care’. Participant 8: ‘The people that we work with and always go to them for advice. They always know the answer’. Personal Presence. The first sub theme of self-actualization is personal presence a conceptual interpretation reflective of ‘‘demeanor”, a term specifically used by study participants. Six of the participants specifically discussed demeanor or attitude in the interview process in relation to the expert’s ability to be present in highly charged stressful situations. They collectively used words such as: ‘‘calm”, ‘‘cool”, ‘‘confident”, ‘‘collective”, and ‘‘comfortable” to express their perceptions. Participant 2: ‘New nurse get excited, and bring anxiety with them when there’s a crisis. But the experienced nurse, the one who’s been doing it over and over again; they come in, look at the situation and say, ‘‘you need to do this”’. Participant 2: ‘They don’t get upset or yell. They understand the situation and it’s handled; no fuss’. Participant 4: ‘They’re confident and make quick decisions. They de-escalate the tension’. Participant 4: ‘They have a self-confidence that new nurses don’t have. It’s a trust factor’. Participant 7: ‘You ask them to take care of an unstable patient and they’re okay with it. They’re calm, cool, collected’. Life-long learner. The second sub them of self-actualisation is the pursuit of lifelong learning. Seven of the participants addressed personal expectations for lifelong learning and the impact that it has had in their professional development. They used words such as: ‘‘initiative to learn”, ‘‘seek opportunities to learn”, ‘‘watch”, ‘‘listen”, and ‘‘ask questions”. Participant 6: ’I take patient care personal’. Participant 6: ‘The first two years I was a nurse, I went home and I looked up every disease process that patients had. I read everything that I could get me hands on’. Participant 9: ‘I want to know as much as I can. It’s important to continually learn’.
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Participant 9: ‘I want to do the best that I can regardless of what I commit to’. Participant 8: ‘My motivation to be the best that I can be; the compassion for the patient. I imagine myself in their situation’. Participant 9: ‘When I see people hurting I try to be the best that I can possibly be’. Additional findings: Additional findings emerged from data beyond the boundaries of research questions. The difference between male and female participants and their responses when asked to describe personal skill level. As demonstrated by body language and verbal inflection, male participants appeared proud and assertive with no hesitance in acknowledging their expertise in clinical practice. When asked the same question, all of the female participants had difficulty acknowledging their professional accomplishments; instead, they chose to illustrate achievements through examples of experiences in social context. This self-effacing behavior, again, demonstrated in body language and verbal inflection implied a social inequality that was not expected from individuals at this level of skill and performance.
Discussion: Study findings related to the first research question revealed three fundamental themes to describe the development of expert nursing practice; experience, knowledge and self-actualisation. A detailed explanation of each will follow. In response to the second research question describing the experiential processes involved in the development of expertise in critical care practice we will discuss the impact of experience. Specifically, the nature and intensity of those experiences as they influence the development expert practice.
development of expert performance; b) prior experiences shape and mold the expert defining current practice and c) the intensity of experiences served to push the limits of understanding to expand current boundaries of understanding. Experience is crucial to the learning process. The extant literature supports this assertion and also asserts that experience provides context for factual knowledge and learned concepts providing the means to transfer learned concepts into practical application (Jantzen, 2018; Welch and Carter, 2018; McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007). Knowledge: Knowledge and learning are defined as a continuously evolving process. Data suggested that knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Findings suggested that the two concepts are inextricably interdependent and selfperpetuating; one building upon the other. Beyond knowledge there must be understanding, and understanding is refined in experience. The review of literature supports these assertions (Bathish et al., 2018; McHugh and Lake, 2010; Bobay et al., 2009). James et al (2010) asserted that nurses knowledge ensues from interaction and is a constantly evolving process. According to the National Research Council (2000), for the student to develop competence in an area they must have a strong foundation of factual knowledge and have an understanding of that knowledge in the context of a conceptual framework. As knowledge increases critical reason and the ability to be an independent thinker evolves. Critical reasoning is a conceptual interpretation of the data. Data results defined critical reason as the ability to make quick accurate assessments and judgments in a situationally comprehensive manner effectively managing immediate needs of patients. Findings suggested expert thinking at this level is: a) conceptual and broad where salient concepts are quickly noticed without focus on specific details; b) both a conscious and an unconscious thought process, continuously evolving and developing and c) quick, accurate and automatic. According to the literature the nurse’s ability to recognise the unexpected when specific details are lost to conscious thought and difficult to verbalize because they have become sub-conscious and embedded in memory is a hallmark of expert behavior in clinical practice (Benner et al., 2009; Bobay et al., 2009; Christensen and HewittTaylor, 2006).
Experience: The lived experience in clinical practice was repeatedly described and emphasized within each interview as the defining element in the development of expert performance. Each participant stressed the significance of their clinical experiences, and each one of them could vividly recount patient experiences and interactions that have defined their practice and who they are as nurses today. The significance of clinical experience through patient interactions cannot be undervalued or overlooked and denotes the importance of experience in social context in the development of expert performance. As described by participants, the lived experience of caring for patients give meaning and understanding to learned concepts through practical application and reflective understanding. The review of literature supports this assertion (McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007). Expert performance is built on a foundation of relevant clinical experiences where learned concepts take on meaning in the authentic contexts in which they are applied. New understandings are then constructed on a foundation of pre-existing knowledge, context, and experiences (Jantzen, 2018; Welch and Carter, 2018; McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007).
Self-actualisation: Self-actualisation emerged from the data as a third theme supporting development of expert performance. The term self-actualisation is an interpretation of inter-related themes that collectively spoke to the intra-personal domain of selfactualisation: a) desire to achieve maximum potential and b) lifelong learner. According to James et al (2010), Jantzen (2018) and Bathish et al (2018) ‘‘life-long learning” and maximizing personal competence is imperative to knowledge construction. Maslow (1970) defined self-actualization as an individual’s need for selffulfillment and described the self-actualised individual as one who seeks their fullest potential in all things.
The patient interaction, the experience itself was described as being more meaningful and more impactful to the nurses learning when the intensity of the situation was dire and the consequences of their actions or inaction was uncertain and perilous. The more intense the situation, and the more diverse the actual experiences, the more relevant they are to continued learning, and the more meaningful to the individual. Data suggested that: a) experience in its most elemental form is the foundational component in the
Through self-actualisation experts develop a self-confidence that transcends the situation and those around them. The expert critical care nurse’s presence and interaction in a crisis was described as one of knowledge, self-confidence and re-assurance. Their ability to make quick decisive decisions brought calm and order to an otherwise chaotic situation. Expert nurses can deescalate emotionally charged situations, a code situation for example, to facilitate a cohesive and productive team approach to
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patient care that promotes and optimizes the team’s collective potential. Self-actualisation is vitally important to the development of expert performance. As described by the participants, experts have an internal drive to be the best that they can be. They seek opportunities for continued learning, research new concepts to improve clinical practice, and explore all avenues to maximize personal growth. Without this level of commitment to clinical practice they would never reach their fullest potential as a nurse allowing them to make decisive decisions and exude the self-confidence that promotes the trust of their colleagues and patients. Additionally, without a strong driving need to fulfill personal potential, individuals would never commit the necessary time and energy needed to attain expert performance. The literature supports the findings and describes the expert clinician as having dedicated themselves to life-long learning and deliberate purposeful efforts to improve personal performance (James et al., 2010; Jantzen, 2018; Bathish et al., 2018, Bathish, 2015; Welch and Carter, 2018). Limitations: This was a purposeful sampling process limited to a single urban area. The interviews were conducted over a two-month period. Eighty percent of the participants were female. Although the sample group had diverse professional backgrounds, they were a homogenous group similar in age and professional role. While this could present a limitation, their diverse backgrounds in clinical practice offered a strength to the study in terms of their personal perceptions of expertise which was based on their interactions with others in a variety of contexts and experiences in the social world. Participants reflected on and drew from diverse clinical experiences to vividly describe the expert performance of critical care nurses in social context. These descriptions were given in subjective terms through detailed stories of social interactions generating rich data to explore the intangible nature of expert performance. The PI was an experienced critical care nurse and manager.
Conclusion: This study was an attempt to understand the concept of expertise in critical care nursing and the experiential process involved in the development of expert performance in critical care. Through the personal perceptions of critical care nurses, we can begin to understand the motivation, experiences, and social constructs that coalesce in this journey to expert performance. Key findings suggested that experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent and intense the experience the greater the nurses’ aptitude and opportunity for learning and professional growth. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise. Secondly, self-actualisation is a major determinant in the successful transition to expert performer. Expert nurses possess an inherent need, an internal drive to maximise their personal potential and to be the absolute best that they can be. These key elements of expert performance and their relationships to one another add to the current body of knowledge helping us to understand the developmental journey to expertise. The impetus for research in the development of expert performance is the desire to understand the processes within the transformational experience to expert performer. How do exceptional
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individuals consistently do what they do and equally important, how did they achieve and maintain those performance standards? In order to provide a framework for professional development that would facilitate an individual’s transformation to expert performer we must first identify and understand that process and any enabling factors that contributed to their personal and professional growth and development to that of expert. (Ericsson and Towne, 2010). The significance of self-actualisation as a motivational factor in the pursuit of life-long learning is a new concept in the expertise discussion. Future implications for research would include exploration of this concept as a predictor of successful transition to expert performer. Ethical Statement: All procedures were performed in compliance with relevant laws and institutional guidelines and that the appropriate institutional committee(s) have approved them. Authors should include a statement in the manuscript that informed consent was obtained for experimentation with human subjects. The Institutional Review Board of The University of Alabama reviewed and approved the research prior to initiation of data collection (IRB#15-OR-256). Participants were self-determinant and informed of their right to decline participation prior to and at any time during the interview process. Participant privacy, anonymity and confidentiality were guaranteed. All participants were introduced to the study with informed consent being obtained. Multiple strategies were employed to ensure anonymity and data integrity. This research was conducted in partial fulfillment of the degree requirements of Doctor in Education at the University of Alabama. Oversight of the research was closely managed by the dissertation chair.
Funding: This research did not receive any specific grant funding from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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forms of knowledge. Qual. Health Res. 20 (11), 1500–1518. https://doi.org/ 10.1177/1049732310374042. Jantzen, D., 2019. Refining nursing practice through workplace learning: A grounded theory. J. Clin. Nurs., 1–12 https://doi.org/10.1111/jocn.14841. Maslow, A.H., 1970. Motivation and Personality. Donnelly & Sons Company, United States of America. R. R Retrieved from: https://books.google.com. Morrison, S.M., Symes, L., 2011. An integrative review of expert nursing practice. J. Nurs. Scholarsh. 43 (2), 136–170. https://doi.org/10.1111/j.15475069.2011.01398.x. McHugh, M.D., Lake, E.T., 2010. Understanding Clinical Expertise: Nurse Education, Experience, and the Hospital Context. Res. Nur. Health 33 (4), 276–287. https:// doi.org/10.1002/nur.20388. National Research Council, 2000. How People Learn: Brain, Mind, Experience, and School. The National Academies Press, Washington, DC. doi: 10.17226/9853. Weiss, D.J., Shanteau, J., 2014. Who’s the best? A relativistic view of expertise. Appl. Cogn. Psychol. 28, 447–457. https://doi.org/10.1002/acp.3015. Welch, T.D., Carter, M., 2018. Deliberate practice and skill acquisition in nursing practice. J. Contin. Educ. Nurs. 49 (6), 269–273. https://doi.org/10.3928/ 00220124-20180517-07. Wuest, J., 2012. Grounded theory: the method. In: Munhall, P.L. (Ed.), Nursing Research: A Qualitative Perspective. 5th ed. Jones & Bartlett Learning, MA, pp. 225–256.
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Research article
Expertise among critical care nurses: A grounded theory study Teresa D. Welch ⇑, Melondie Carter Capstone College of Nursing, The University of Alabama, Box 870358, Tuscaloosa, AL 35487, United States
a r t i c l e
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Article history: Received 4 February 2019 Revised 10 December 2019 Accepted 17 December 2019 Available online xxxx Keywords: Critical care Experience Expertise Grounded theory Nursing Qualitative
a b s t r a c t Objectives: Explore critical care nurses’ personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice. Design: Following constructivist approach to grounded theory this investigation used qualitative openended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process. Setting: A multi-site urban area in the southeastern United States. Participants: 10 certified critical care nurses, three males and seven females, with 10–30+ years of critical care experience. Findings: Experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses’ aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care. Conclusion: Key findings suggested that clinical experience and personal motivation combined with selfactualisation, the drive to maximise personal potential, determine critical care nurse’s trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise. Ó 2020 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice
Clinical experience and personal motivation determine critical care nurse’s trajectory towards professional excellence. Contextual expectations and experiences have a direct impact on professional aptitude and development of expertise. Lifelong learning is a personal motivation that begins outside the clinical setting and is manifested within the clinical setting. Structured deliberate practice provides a proactive approach to promote expert performance and clinical excellence in critical care.
Introduction The expertise of the nurse has a direct impact on patient outcomes (Conley, 2019; Jantzen, 2019; Bathish, 2018; McHugh and Lake, 2010; Christensen and Hewitt-Taylor, 2006). The concept of expertise refers to characteristics, skills and knowledge separating experts from everyone else in clinical practice (Ericsson et al., 2006; Ericsson and Towne, 2010). The development of expertise ⇑ Corresponding author. E-mail addresses: [email protected] (T.D. Welch), [email protected] (M. Carter).
requires three fundamental elements: 1) relevant experience, 2) dedicated, purposeful work and 3) time (Ericsson et al., 2006; Ericsson and Towne, 2010; Weiss and Shanteau, 2014; Bathish et al., 2018). Development of expert performance evolves over a period of 7–10 years (Ericsson and Towne, 2010; Weiss Shanteau, 2014; Bathish et al., 2018). Research has defined objective criteria to identify experts within the domains of sports, music and chess, recognising those individuals who consistently demonstrate superior performance (Ericsson et al., 2006, Ericsson and Towne, 2010; Bourne, et al., 2014). Based on this research, empirical expectations and
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definitions of expert performance have been developed. These expectations are based on the objective measurement and analysis of reproducible skills and behaviours essential to expert performance (Ericsson and Poole, 2017). For the profession of nursing the opposite remains true (Ericsson, 2017; Hutchinson et al., 2016; Morrison and Symes, 2011; Ericsson, 2008; Ericsson et al., 2007; Christensen and Hewitt-Taylor, 2006). Expert nurses are defined by subjective social criteria and anecdotal perceptions of what it is to be an expert. The specific skills and expectations that set expert nurses apart and define expert performance have not been identified in measurable terms (Ericsson, 2017; Hutchinson et al., 2016; Causer et al 2014; Morrison and Symes, 2011; Ericsson et al., 2007). The impetus for this research was the desire to understand how individuals recognised as experts in critical care nursing consistently do what they do and equally important, how have they achieved and maintained their performance standard? As in other domains, the requisite skills and behaviors defining excellence and expert performance in practice should be clearly articulated and defined (Ericsson et al., 2007; Casuer et al., 2014; Bathish et al., 2018). Identifying those influential factors impacting the expert nurses’ successful transition to expert performer and the skills that set them apart would enable reproduction of key elements within that transitional process. This knowledge is pivotal in providing a framework for others to follow as they strive to develop and refine their own skill set (Bathish, 2018; Welch and Carter, 2018; Ericsson and Poole, 2017; Hutchinson et al., 2016; Ericsson et al., 2007). With this knowledge we can begin to strategically develop structured learning opportunities to abridge the evolutionary journey. Research questions The purpose of this study was to explore critical care nurses’ personal perceptions of expertise, expert performance and the transition to expert performer in clinical practice. The study addressed the following questions: a) How is expert critical care nursing socially constructed? b) What is the experiential process involved in becoming an expert in critical care practice?
efforts continued until interviews failed to yield new information indicating that data saturation had occurred. Inclusion criteria were defined as: a) registered nurses (RN) who met eligibility criteria for critical care certification and b) RN’s with 10 years of critical care experience who had successfully passed and maintained critical care certification. Participants meeting inclusion criteria who completed the interview received a token gift card purchased by the PI. Critical care was defined as anyone working in an intensive care unit, emergency department, critical care transport, or anesthesia care unit. The target population was contacted through professional webpages, email, public flyers, and professional referral. The target population was not contacted through the PI’s employer. Ethical considerations The Institutional Review Board of The University of IRB#15-OR256 reviewed and approved the research prior to initiation of data collection (IRB#15-OR-256). Participants were self-selecting and informed of their right to decline participation prior to and at any time during the interview process. Participant anonymity and confidentiality were guaranteed. All participants were introduced to the study with informed consent being obtained. Multiple strategies were employed to ensure anonymity and data integrity. The PI conducting interviews was an experienced critical care nurse and nurse manager. Precautions were taken to ensure that professional affiliations did not impact data collection and analysis. All participants were given contact information for the Research Compliance Officer independent of the PI or research setting for questions that may have arisen during or after the interview. Setting and context All interviews were held within the southeastern U.S. in an urban area. Study participants were contacted by telephone to verify study eligibility and if possible to schedule the interview appointment. Participants chose the time and location of the interview. All participants preferred to meet in a professional or public location just prior to or following a work shift or rotation.
Methods
Data collection
Research approach and objectives
Information was gathered through semi-structured face-to-face interviews using open ended questions. These open-ended questions were developed in broad terms and used to stimulate conversation in each of the interviews prompting participants to openly share personal impressions and experiences. Follow-up questions were used to clarify concepts presented by the participant and to stimulate further exploration and sharing. Each participant was interviewed once, but the possibility of a follow up interview was discussed during the initial interview process for verification of research findings. After the informed consent was signed, non-descript demographic data was collected prior to beginning interviews and documented in the interview notes. Interviews were audio recorded for accuracy and verbatim transcription. Immediately following the interview all field notes, observations, tapes or references to the interview were labeled with a random automotive pseudonym for ease of collective filing and referencing during coding. Once labeled all materials were organized in a file folder with the same pseudonym. The informed consent was secured and filed separately. There is no identifying data to link interview or interview materials to the informed consent or the participant. Recorded interviews were transcribed verbatim by the PI. Transcripts provided the primary source of data for analysis. Field
Grounded theory methodology was chosen for this study based on its strength in explicating human behavior in context. According to Charmaz (2014) and Corbin and Strauss (2015), human behaviour related to health issues, developmental transitions and situational challenges are well suited to grounded theory research. The inductive qualities and propensity to identify social processes explaining human behavior makes grounded theory particularly useful to social inquiry (Wuest, 2012). Remaining true to the participants’ perspective is the foundational principle of a grounded theory approach making it particularly useful in the study of expertise in critical care nursing (Charmaz, 2014; Corbin and Strauss, 2015). The objectives of this research project were: 1) explore critical care nurses’ personal perceptions of expertise and expert performance, 2) describe the transition from novice to expert performer in clinical practice. Recruitment This was a purposeful sample of convenience that after the initial interview, developed through snowball effect. Recruitment
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notes, observational and reflective memos were also used for coding and analysis. Data analysis Data analysis began with the first interview. Transcription of interview material began within 24 hours. Audio-recorded material was destroyed upon verification of accuracy. With the task of transcription complete, the transcript was then read through in
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its entirety to give a general impression of the data. This process was repeated for each interview. These initial high-level impressions were noted in the margins of transcribed text for analysis. After this first reading the PI collected multi-colored pencils to begin the task of re-reading data. Only this time, data were read carefully, line-by-line, deliberately colour coding for descriptive data. Each new code received a new colour. As codes began to repeat themselves, they were highlighted with repeating colours. See Example 1: Interview Transcript.
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This iterative process of constant comparison proceeded in an alternating repetitive sequence of data collection and analysis. As concepts emerged in earlier interviews, subsequent interviews attempted to explore these concepts in an attempt to develop and refine concepts, categories and themes. See Graph 1: Theoretical sampling. As codes and concepts were reinforced the process of categorizing began to take shape. As categories began to reach saturation definitions began to take shape. This constant back and forth comparative method required continual revision, modification, and amendment of categories until all new codes could be placed into an appropriate category. The constant comparative process of data analysis in grounded theory follows a standardized systematic format: 1) open coding focused on text is the process of line by line coding, 2) axial coding is the conceptual process of categorising the initial codes based upon familial patterns or relationships to develop categories and 3) thematic or selective coding, the final stage of analysis, concentrates on linking the findings to evidence. (Corbin and Strauss,
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2015; Charmaz 2014; Guest et al., 2012). See Table 1: Code Frequency Table.
Rigour: Three strategies were used to ensure credibility of research processes and findings. An in-depth literature review searching multiple databases was conducted prior to beginning the study to establish clear and congruent concepts related to expertise in the current body of literature. The basic definition and tenets of expertise and the expert performer were found to be congruent across domains (Guest et al., 2012). A systematic analytic process, including constant comparison and member-checking, was adopted to enhance the credibility. The originality of the findings in this research was examined by reviewing the extant literature. Charmaz (2014) described the process of member checking as a viable process to verify research findings. As concepts and themes evolved participants given an opportunity to review the findings for accuracy.
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Graph 1. Theoretical sampling. Table 1 Code frequency table. Structural Codes
Frequencies
Research Question 1: How would you define the expert nurse in clinical practice in critical care? Experiences are important (did not specify) 4 Diversity/Intensity of experience 6 10 of 10 responses to experience Knowledgeable with a solid grasp on 7 concepts Confidence 1 Collaboration 1 Continuing education 1 Research Question 2: What criteria or characteristics would you use to define expert performance in clinical practice in the critical care unit? Experienced 10 Knowledgeable 6 Independent thinkers who know what to do 8 Calm cool demeanor 6 Comfortable 2 Communication 1 Teamwork 3 Research Question 3: How does one become Experience Proactive pursuit of lifelong learning Time Spiritual Calling
an expert in critical care? 7 7 4 1
Research Question 4: Describe any factors that in your experience may have supported or hindered that development. Positive Factors Diversity of experiences 3 Specialty Education 2 Opportunities 2 Professional mentors/role models 2 Professional recognition 1 Personal drive to be best 4 Negative Factors Nurses eat their young 4 Vulnerability 1 Fear 4 Laziness 1 Complacent 4 Lack of opportunities 1
Credibility of the research process and the findings was further supported through the in-depth literature review defining concepts and process of peer debriefing. Findings: Sample: Participants were registered nurses (RN) who held an active unencumbered nursing license and currently worked within the specialty of critical care. Of the 10 participants three were male and seven were female with no attrition. Five of the participants had previous paramedic, fire rescue, practical nursing or emergency management experience prior to becoming a RN. Years of experience in critical care nursing spanned 12–39 years with an average of 24.5 years. Participant ages ranged from 38 to 61 years of age with an average of 49 years. All held multiple nationally recognised critical care certifications. Five of the participants were certified instructors for advanced critical care and trauma certifications. Academically, four held baccalaureate degrees, four held associate degrees, and two held master’s degree. Participant files were randomly assigned the make or model of an automobile to ensure anonymity and confidentiality.
Themes: Three themes emerged from data to describe rather than define the performance of the expert critical care nurse: experience, knowledge, and self-actualisation. Detailed explanations of these themes and their respective sub themes are as follows in order of priority as defined by data.
Experience: When asked what defined the expert critical care nurse all of the participants responded: experience. Descriptive words such as ‘‘graduated experience”, diversity, and ‘‘hands on experience” were used to express their thoughts regarding experience. Participant 1: ‘Well, I tell them the first thing, number one is experience. Every chance you get the opportunity to do something new,
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or to see something new. . .. You need to be involved. You need to question the physician; why did he make that decision? That’s how you learn’. Participant 2: ‘The best training is experience. The best experience was on the intermediate step down unit. All of those patients were unstable and critically ill’. Participant 2: ‘I think that people who work in a specialty unit or a unit where you get sicker patients tends to progress a lot faster than those who work on a regular floor where people are not as sick’.
Participant 4: ‘They think outside the box and have the ability to anticipate and prevent problems with minimal resources’. Participant 2: ‘They can see the entire situation. You don’t have to tell them, the situation is handled calmly and coolly’. Participant 5: ‘They can quickly assess a patient and make a decision. . . It doesn’t take them very. You’re assessing the patient before you ever get to them. You’re assessing the scene, you’re assessing the body language of other people around them’. Participant 5: ‘Somebody who can take in the whole picture and not just the specifics’.
Diversity/Intensity. All participants discussed experience as the foundational element of expert nursing practice. Of those participants, six specifically described the importance of ‘‘types”, ‘‘intensity” and ‘‘diversity” of experiences. The nature of the experience in relation to the intensity and severity of illness is significant in the development of expert performance.
Self-actualisation: Self-actualisation is the conceptual interpretation of two related themes emerging from data that collectively spoke to the intrapersonal domain of self-actualisation. Seven participant’s directly or indirectly discussed the positive impact of the expert’s presence in stressful situations. They were described as possessing a selfconfidence that transcended the situation and those around them.
Participant 4: ‘I have prior experiences in emergency and fire rescue before becoming a nurse. Those experiences helped me to develop as a strong nurse. . .. I’ve always worked trauma and rescue. Those experiences are intense’. Participant 8: ‘The bad experiences. It’s through those really bad situations, when something went wrong and you had to figure out why’. Participant 8: ‘You don’t forget those really bad experiences. I’ve learned the most from those really bad situations and experiences than anything else in my career’. Knowledge: Seven participants discussed ‘‘knowledge” directly during the interview process. Each time knowledge was discussed so was experience. Participants used phrases such as: ‘‘I know what the numbers mean”, ‘‘stay ahead of the patient”, ‘‘know how and why things work”, ‘‘firm grasp of concepts”. Participant 1: ‘You need to know the ‘why’ of what you do. If you don’t understand the ‘why’, then you’ll never know what the outcome should be. And the whole goal is to get a patient to a specific outcome’. Participant 2: ‘If you can walk into a room, assess what’s going on and know exactly what to do; you’re an expert’. Participant 2: ‘When I first started. . .. I didn’t have a clue what was going on. Now I know what the numbers mean’. Participant 1: ‘One thing experts have in common is that they know what to do and when to do it. They don’t need direction’. Participant 1: ‘An expert nurse can look in that room, take it all in. They know exactly what’s going on and how to react’. Participant 6: ‘It’s like they know what you need before you need it. No one has to tell them, you don’t have to ask’. Critical Reason. Eight participants specifically mentioned ‘‘independent thinker” or ‘‘they just knew what needed to be done” in the interview process describing the subconscious process of critical reasoning and automaticity of action. The term ‘‘critical reason” was a conceptual interpretation. Participants had difficulty describing their thoughts as they attempted to articulate abstract concepts; ‘‘thinking” and ‘‘action”. Instead they used broad concepts to relate the nature of the patient engagement at the expert level; ‘‘whole picture”, ‘‘don’t need guidance”, ‘‘take it all in”, and ‘‘just know what to do”. Participant 3: ‘They’re all independent thinkers’. Participant 3: ‘I wouldn’t have to worry about my patient. They’re going to take over and do what needs to be done without anyone asking them to’.
Participant 6: ‘The monitor alarm went off. The patient’s rhythm started to change and he went into v-tach. Before I could process what was going on I looked around and Edgar had already gone in there, shocked him and come right back out to the desk. I’m thinking, what just happened?! Edgar just shocked him out of v-tach’. Participant 5: ‘They’re calm, collected, taking in the whole scene at once. . . They quickly assess a patient and come to a judgement, make a decision on the plan of care’. Participant 8: ‘The people that we work with and always go to them for advice. They always know the answer’. Personal Presence. The first sub theme of self-actualization is personal presence a conceptual interpretation reflective of ‘‘demeanor”, a term specifically used by study participants. Six of the participants specifically discussed demeanor or attitude in the interview process in relation to the expert’s ability to be present in highly charged stressful situations. They collectively used words such as: ‘‘calm”, ‘‘cool”, ‘‘confident”, ‘‘collective”, and ‘‘comfortable” to express their perceptions. Participant 2: ‘New nurse get excited, and bring anxiety with them when there’s a crisis. But the experienced nurse, the one who’s been doing it over and over again; they come in, look at the situation and say, ‘‘you need to do this”’. Participant 2: ‘They don’t get upset or yell. They understand the situation and it’s handled; no fuss’. Participant 4: ‘They’re confident and make quick decisions. They de-escalate the tension’. Participant 4: ‘They have a self-confidence that new nurses don’t have. It’s a trust factor’. Participant 7: ‘You ask them to take care of an unstable patient and they’re okay with it. They’re calm, cool, collected’. Life-long learner. The second sub them of self-actualisation is the pursuit of lifelong learning. Seven of the participants addressed personal expectations for lifelong learning and the impact that it has had in their professional development. They used words such as: ‘‘initiative to learn”, ‘‘seek opportunities to learn”, ‘‘watch”, ‘‘listen”, and ‘‘ask questions”. Participant 6: ’I take patient care personal’. Participant 6: ‘The first two years I was a nurse, I went home and I looked up every disease process that patients had. I read everything that I could get me hands on’. Participant 9: ‘I want to know as much as I can. It’s important to continually learn’.
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Participant 9: ‘I want to do the best that I can regardless of what I commit to’. Participant 8: ‘My motivation to be the best that I can be; the compassion for the patient. I imagine myself in their situation’. Participant 9: ‘When I see people hurting I try to be the best that I can possibly be’. Additional findings: Additional findings emerged from data beyond the boundaries of research questions. The difference between male and female participants and their responses when asked to describe personal skill level. As demonstrated by body language and verbal inflection, male participants appeared proud and assertive with no hesitance in acknowledging their expertise in clinical practice. When asked the same question, all of the female participants had difficulty acknowledging their professional accomplishments; instead, they chose to illustrate achievements through examples of experiences in social context. This self-effacing behavior, again, demonstrated in body language and verbal inflection implied a social inequality that was not expected from individuals at this level of skill and performance.
Discussion: Study findings related to the first research question revealed three fundamental themes to describe the development of expert nursing practice; experience, knowledge and self-actualisation. A detailed explanation of each will follow. In response to the second research question describing the experiential processes involved in the development of expertise in critical care practice we will discuss the impact of experience. Specifically, the nature and intensity of those experiences as they influence the development expert practice.
development of expert performance; b) prior experiences shape and mold the expert defining current practice and c) the intensity of experiences served to push the limits of understanding to expand current boundaries of understanding. Experience is crucial to the learning process. The extant literature supports this assertion and also asserts that experience provides context for factual knowledge and learned concepts providing the means to transfer learned concepts into practical application (Jantzen, 2018; Welch and Carter, 2018; McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007). Knowledge: Knowledge and learning are defined as a continuously evolving process. Data suggested that knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Findings suggested that the two concepts are inextricably interdependent and selfperpetuating; one building upon the other. Beyond knowledge there must be understanding, and understanding is refined in experience. The review of literature supports these assertions (Bathish et al., 2018; McHugh and Lake, 2010; Bobay et al., 2009). James et al (2010) asserted that nurses knowledge ensues from interaction and is a constantly evolving process. According to the National Research Council (2000), for the student to develop competence in an area they must have a strong foundation of factual knowledge and have an understanding of that knowledge in the context of a conceptual framework. As knowledge increases critical reason and the ability to be an independent thinker evolves. Critical reasoning is a conceptual interpretation of the data. Data results defined critical reason as the ability to make quick accurate assessments and judgments in a situationally comprehensive manner effectively managing immediate needs of patients. Findings suggested expert thinking at this level is: a) conceptual and broad where salient concepts are quickly noticed without focus on specific details; b) both a conscious and an unconscious thought process, continuously evolving and developing and c) quick, accurate and automatic. According to the literature the nurse’s ability to recognise the unexpected when specific details are lost to conscious thought and difficult to verbalize because they have become sub-conscious and embedded in memory is a hallmark of expert behavior in clinical practice (Benner et al., 2009; Bobay et al., 2009; Christensen and HewittTaylor, 2006).
Experience: The lived experience in clinical practice was repeatedly described and emphasized within each interview as the defining element in the development of expert performance. Each participant stressed the significance of their clinical experiences, and each one of them could vividly recount patient experiences and interactions that have defined their practice and who they are as nurses today. The significance of clinical experience through patient interactions cannot be undervalued or overlooked and denotes the importance of experience in social context in the development of expert performance. As described by participants, the lived experience of caring for patients give meaning and understanding to learned concepts through practical application and reflective understanding. The review of literature supports this assertion (McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007). Expert performance is built on a foundation of relevant clinical experiences where learned concepts take on meaning in the authentic contexts in which they are applied. New understandings are then constructed on a foundation of pre-existing knowledge, context, and experiences (Jantzen, 2018; Welch and Carter, 2018; McHugh and Lake, 2010; Bobay et al., 2009; Ericsson et al., 2007).
Self-actualisation: Self-actualisation emerged from the data as a third theme supporting development of expert performance. The term self-actualisation is an interpretation of inter-related themes that collectively spoke to the intra-personal domain of selfactualisation: a) desire to achieve maximum potential and b) lifelong learner. According to James et al (2010), Jantzen (2018) and Bathish et al (2018) ‘‘life-long learning” and maximizing personal competence is imperative to knowledge construction. Maslow (1970) defined self-actualization as an individual’s need for selffulfillment and described the self-actualised individual as one who seeks their fullest potential in all things.
The patient interaction, the experience itself was described as being more meaningful and more impactful to the nurses learning when the intensity of the situation was dire and the consequences of their actions or inaction was uncertain and perilous. The more intense the situation, and the more diverse the actual experiences, the more relevant they are to continued learning, and the more meaningful to the individual. Data suggested that: a) experience in its most elemental form is the foundational component in the
Through self-actualisation experts develop a self-confidence that transcends the situation and those around them. The expert critical care nurse’s presence and interaction in a crisis was described as one of knowledge, self-confidence and re-assurance. Their ability to make quick decisive decisions brought calm and order to an otherwise chaotic situation. Expert nurses can deescalate emotionally charged situations, a code situation for example, to facilitate a cohesive and productive team approach to
Please cite this article as: T. D. Welch and M. Carter, Expertise among critical care nurses: A grounded theory study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102796
T.D. Welch, M. Carter / Intensive & Critical Care Nursing xxx (xxxx) xxx
patient care that promotes and optimizes the team’s collective potential. Self-actualisation is vitally important to the development of expert performance. As described by the participants, experts have an internal drive to be the best that they can be. They seek opportunities for continued learning, research new concepts to improve clinical practice, and explore all avenues to maximize personal growth. Without this level of commitment to clinical practice they would never reach their fullest potential as a nurse allowing them to make decisive decisions and exude the self-confidence that promotes the trust of their colleagues and patients. Additionally, without a strong driving need to fulfill personal potential, individuals would never commit the necessary time and energy needed to attain expert performance. The literature supports the findings and describes the expert clinician as having dedicated themselves to life-long learning and deliberate purposeful efforts to improve personal performance (James et al., 2010; Jantzen, 2018; Bathish et al., 2018, Bathish, 2015; Welch and Carter, 2018). Limitations: This was a purposeful sampling process limited to a single urban area. The interviews were conducted over a two-month period. Eighty percent of the participants were female. Although the sample group had diverse professional backgrounds, they were a homogenous group similar in age and professional role. While this could present a limitation, their diverse backgrounds in clinical practice offered a strength to the study in terms of their personal perceptions of expertise which was based on their interactions with others in a variety of contexts and experiences in the social world. Participants reflected on and drew from diverse clinical experiences to vividly describe the expert performance of critical care nurses in social context. These descriptions were given in subjective terms through detailed stories of social interactions generating rich data to explore the intangible nature of expert performance. The PI was an experienced critical care nurse and manager.
Conclusion: This study was an attempt to understand the concept of expertise in critical care nursing and the experiential process involved in the development of expert performance in critical care. Through the personal perceptions of critical care nurses, we can begin to understand the motivation, experiences, and social constructs that coalesce in this journey to expert performance. Key findings suggested that experience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent and intense the experience the greater the nurses’ aptitude and opportunity for learning and professional growth. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise. Secondly, self-actualisation is a major determinant in the successful transition to expert performer. Expert nurses possess an inherent need, an internal drive to maximise their personal potential and to be the absolute best that they can be. These key elements of expert performance and their relationships to one another add to the current body of knowledge helping us to understand the developmental journey to expertise. The impetus for research in the development of expert performance is the desire to understand the processes within the transformational experience to expert performer. How do exceptional
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individuals consistently do what they do and equally important, how did they achieve and maintain those performance standards? In order to provide a framework for professional development that would facilitate an individual’s transformation to expert performer we must first identify and understand that process and any enabling factors that contributed to their personal and professional growth and development to that of expert. (Ericsson and Towne, 2010). The significance of self-actualisation as a motivational factor in the pursuit of life-long learning is a new concept in the expertise discussion. Future implications for research would include exploration of this concept as a predictor of successful transition to expert performer. Ethical Statement: All procedures were performed in compliance with relevant laws and institutional guidelines and that the appropriate institutional committee(s) have approved them. Authors should include a statement in the manuscript that informed consent was obtained for experimentation with human subjects. The Institutional Review Board of The University of Alabama reviewed and approved the research prior to initiation of data collection (IRB#15-OR-256). Participants were self-determinant and informed of their right to decline participation prior to and at any time during the interview process. Participant privacy, anonymity and confidentiality were guaranteed. All participants were introduced to the study with informed consent being obtained. Multiple strategies were employed to ensure anonymity and data integrity. This research was conducted in partial fulfillment of the degree requirements of Doctor in Education at the University of Alabama. Oversight of the research was closely managed by the dissertation chair.
Funding: This research did not receive any specific grant funding from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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