Responses to Work Complexity: The Novice to Expert ... - SAGE Journals

Responses to Work Complexity: The Novice to Expert Effect

Western Journal of Nursing Research 32(4) 497–510 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945909355149 http://wjn.sagepub.com

Jeri L. Burger,1 Karen Parker,1 Linda Cason,2 Sheila Hauck,3 Denise Kaetzel,4 Cathy O’Nan,5 and Ann White1

Abstract The purpose of this study was to explore the differences in how advanced beginners, competent, and expert nurses prioritize and reprioritize patient care. This qualitative study had a purposive sample of 23 nurses on cardiac/ telemetry units at five hospitals. Four themes emerged from the data: cognitive strategies, communication, integration of roles, and response to the work environment. As the nurses progressed in expertise, they were better able to organize, more effectively deal with interruptions, anticipate patient needs, integrate varied nursing roles into their work, and communicate effectively. The significance of this study is the identification of factors that affect the nurse’s ability to work productively in today’s care environment. It increases understanding of the graduate nurses’ perception and response to the complexity and work of nursing. An understanding of these factors provides the basis for further research to understand and promote transition of nurses from advanced beginner to expert.

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University of Southern Indiana, Evansville Deaconess Hospital, Evansville, Indiana 3 St. Mary’s Medical Center, Evansville, Indiana 4 Memorial Hospital and Healthcare Center, Jasper, Indiana 5 Methodist Hospital, Henderson, Kentucky 2

Corresponding Author: Jeri L. Burger, University of Southern Indiana, Evansville, IN Email: [email protected]

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Western Journal of Nursing Research 32(4)

Keywords work complexity, qualitative research, prioritization, novice to expert, nursing The complexity of care in the acute care environment provides significant challenges for all nurses. How the nurse responds to these challenges influences the patient care provided and the nurse’s satisfaction with work performance. The increasing demands in the acute care setting affects patient safety as nurses navigate through prioritization, communication with other members of the health care team, provision of continuity of care between providers, and management of a challenging workload. To improve patient care, it is essential to understand how the level of nurse competency affects the individual nurse’s response to this complex work setting. The work of nursing includes the implementation of technical skills along with cognitive processes and decision making. Research has shown that skill development and cognitive processing develops over time with experience and varies with level of competency. This study builds on the work on skill acquisition, work complexity, and nurse competency. Benner (1984) applied the Dreyfus model of skill acquisition to nursing. This systematic study described five levels of proficiency (novice to expert) that nurses go through to achieve expertise in skilled nursing interventions and clinical judgment. The cognitive work of nursing is complex and nonlinear. The environment includes frequent interruptions requiring redirection of patient care. The multiple interruptions require the nurse to redirect patient care every 6 to 7 min, and approximately half of these disruptions occur during nurse– patient interventions (Potter et al., 2005). In addition to interruptions, the nurse must cope with missing supplies and equipment, missing medications, and patients in different areas of the clinical unit (Ebright, Patterson, Chalko, & Render, 2003). Nurses of different competency levels deal with work complexity differently. Ebright and colleagues (2003) first identified a strategy referred to as stacking that allowed expert nurses to reprioritize fluidly when actions that were started could not be completed at that moment. The nurse’s ability to cope with the complex care environment affects patient safety. In two studies, no errors were observed, but multiple omissions of care were noted (Ebright, Urden, Patterson, & Chalko, 2004; Potter et al., 2005). Expert nurses are more likely to gather preparatory information from a larger variety of sources than novice nurses. Novice nurses have more difficulty processing the information and sorting out relevant data from data of lesser importance (Ebright et al., 2004; Taylor, 2002).

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Purpose The purpose of this study was to explore the differences in how advanced beginners, competent, and expert nurses prioritize patient care and identify factors that influence reprioritization. This study investigated two research questions. 1. Are there differences in how advanced beginners, competent, and expert nurses prioritize planning for patient care during their work shift? 2. What factors influence the change of plans for patient care during the nurses’ work shift?

Method Design A descriptive, comparative design using qualitative and quantitative data collection was used. Data collection included a short survey, priority list, and field observation followed by a semistructured interview. The design of this study was modified from the work done by Ebright and colleagues in investigating the complexity of nurse work (Ebright et al., 2004).

Sample The study was conducted in five Midwestern acute care hospitals on cardiac telemetry units. These units all had nonremote telemetry and were not classified as critical care units. Three of the five units had electronic medical records. All units had similar organizational structures and skill mix with the use of nurses and technicians to provide patient care. The complexity of work environment and the severity of patient illnesses were comparable on all five units observed. IRB approval was obtained from the university and the five hospitals. A purposive sample of advanced beginner, competent, and expert nurses was recruited for this study. The researchers agreed on a definition of each of these categories using Benner’s work on novice to expert (1984). Definitions are found in Table 1. Inclusion criteria for all participants were (a) employed for at least 3 months as a registered nurse on a cardiovascular telemetry unit that was not classified as a critical care unit, (b) employed a minimum of a 0.8 full-time equivalent, (c) at least 80% of the time was spent on the unit caring

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Table 1. Level of Competence Definitions Advanced Beginner

Competent

Expert

Demonstrates Marginally Acceptable Performance Recognizes and can cope with aspects of common clinical situations Typically new registered nurse up to one year of experience Does considerable conscious deliberate planning Able to prioritize plan of care Able to recognize an overall picture of the situation and which aspects are most salient Efficient delivery of patient care Intuitive grasp of the clinical situation based on background knowledge Consistently meets clinical performance expectations Typically has 2 to 5 years’ experience Shows expertise in theoretical and practical knowledge in clinical situations Has an intuitive grasp of the situation based on deep background understanding and past experiences Is able to compare the similarities and dissimilarities among clinical situations. Consistently exceeds clinical competence expectations Typically has experience in one clinical area for more than 5 years

for patients at the bedside, and (d) scheduled to work during the hours of 7 a.m. to 7 p.m. The researcher identified the manager who was the immediate supervisor on each unit and shared the definitions for the levels of nurse expertise with those managers. They were asked to identify nurses working on the unit who would meet these definitions. The researcher then approached the nurses to determine interest in participating in the study and if interested, informed consent was obtained and a time set for data collection.

Data Collection The researchers held a series of meetings and were in agreement with the observation process and questions to be asked during the interview. Data were collected at the hospitals where some of the researchers were employed but the researchers held no direct line of authority or responsibility to the unit where the data was collected. Researchers collected data at multiple sites. One member of the research team who was not employed at any of the hospital settings collected data at three of the five locations.

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Data collection began after the nurse had finished listening to the report. Each nurse was asked by the member of the research team to create a list of morning activities and prioritize those activities. The list was written down for the purpose of reviewing it later in the day. The nurse was also asked to complete a short survey that included demographic data and factors affecting work. The nurse was asked to identify her personal stress level, if she had worked the day before, and her perception of that day’s workload as normal, less than normal, or greater than normal so the researchers could determine other factors that may influence the nurse’s prioritization and organization. The researcher then followed the nurse for 2 to 3 hr, writing down each nursing activity in the order the activity was done. Immediately on completion of the field observation, the nurse was asked to look at the priority list and reorder that list based on the actual activities of the morning and then was interviewed by the researcher using a semistructured interview guide. The researchers used the same interview guide when interviewing each nurse. The questions asked explored the nurse’s perception and response to the day’s events. Examples of the questions included “Tell me about the things or events that had an impact on your to-do list” and “What did you take into consideration when deciding what to do next?” The nurse was asked to again rate her perceptions of the activity level of the unit and of her morning assignment. The researcher asked for clarification about how the priority list was created and revised, factors that influenced the nurse’s being able to carry out the morning activities, and her perceptions of the morning.

Procedures Each participant was assigned a code that identified the hospital location but did not identify the nurse. This code was written on each piece of data collected for each nurse. A separate list of the code names, names of the nurses, and category as identified by the nurse manager was maintained by one member of the research team. The survey data were entered into a spreadsheet, and the field observation notes were typed. Each interview was transcribed verbatim. Data used for analysis included the nurse’s priority list, the survey, typed field notes, and transcribed interview.

Analysis Data analysis was completed by a research team of three nurses with expertise in qualitative research. Each researcher reviewed the data collected from each category of nurse, including the nurses’ priority lists, the field notes, reordered priority lists, and the transcribed interviews. The researchers

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independently wrote an interpretive summary for each category of nurse expertise. For interpretive analysis, all sources of data were analyzed as a whole. To allow themes or patterns to emerge from the data, thematic analysis was done without predetermined coding (Benner, 1994). The researchers met to discuss the summaries and data analyzed reaching agreement regarding the themes that emerged from the data. After multiple meetings to discuss and to review the data, the team identified common themes across all categories of nurses. Rigor for this study was established following Lincoln and Guba (1985). Credibility was established by sending the results of the study to other members of the research team who were involved in collecting the data. The team members affirmed that the results represented their experiences in collecting the data. An audit trail was maintained while collecting data and during data analysis. The results of the study were also presented to nurses at two of the participating hospitals. The nurses affirmed that the described experiences represented their experiences on the nursing units.

Sample Attributes A total of 23 nurses were recruited and they participated in the study. Eight were categorized by the nurse manager as advanced beginners, eight as competent, and seven were identified as expert nurses. All of the nurses who were willing to participate in the study were female. The results of the survey, including demographic characteristics for the three categories of nurses, are presented in Table 2. The demographic data were representative of the unit nursing staff in age and years of experience.

Results Four themes emerged from the data that illustrated differences in responses to the acute care’s complex work environment. The themes identified were cognitive strategies, communication, integration of roles, and response to the work environment.

Cognitive Strategies Cognitive strategies addressed how the participants cognitively organized their work. Three subthemes were identified that described the nurses’ cognitive strategies: prioritization and reprioritization, anticipation, and organizational tools.

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Burger et al. Table 2. Survey Results Advanced Beginner

Competent

Expert

Age

28 (21 to 43 years)

28 (25 to 36 years)

Degree

6 and 2 BSN 7 months (3 months to 1 year) 1 year (6 months to 2 years) 4 to 5 patients

6 ADN 2 BSN 4 years (1.5 to 6 years) 3.3 years (1.5 to 5 years) 2 to 4 patients

41 (27 to 60 years) 6 ADN 2 BSN 11 years (7 to 17 years) 10 years (7 to 17 years) 2 to 5 patients

5 worked day before

3 worked the day before 3 normal

3 worked the day before 6 normal

4 less than normal 1 did not answer

1 less than normal

RN experience Experience on unit Patient assignment Worked the day before Perceived work load

6 normal 2 less than normal

Note: ADN = associate’s degree in nursing; BSN = bachelor of science in nursing.

Prioritization and Reprioritization The advanced beginners prioritized in a linear manner, doing one thing at a time. They were able to prioritize based on immediate concerns, and their focus was on getting all the required care done. Task orientation was evident. One nurse stated, “Just a basic day. Passing meds, checking blood sugars, covering blood sugars, reassessing, . . . getting the paperwork together for the transfer, making the right phone calls. . . . Just a busy day.” They could stay on task when they had small interruptions such as someone asking a simple question, but most interruptions significantly affected their organization. Even though the advanced beginner nurse would like to address broader patient concerns and help other members of the nursing team, most days all they could do was complete the required care. One nurse stated, “You saw how hard it was for me to even go help pull someone up in bed . . . and I felt so bad.” The advanced beginner nurses relied on experienced nurses to guide actions. They could handle the routine problems but looked to the charge nurse when they encountered unfamiliar situations. In contrast, competent nurses considered multiple factors when establishing priorities, stacking their priorities to allow shifting from one task to another, and more efficiently completing nursing care. Fewer things were

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viewed as interruptions and they were able to keep on task when faced with interruptions. One nurse noted, “I wouldn’t say anything really interrupted . . . it was just the everyday, a normal admission, and it wasn’t anything out of the ordinary.” The competent nurses had a better sense of when to delegate something and when to just do it themselves. Teamwork was evident and several addressed the importance of teamwork. One noted, “We work as a team a lot. You try to get the patient what they need, their bathing, and their plan of care for the day.” Another nurse addressed concerns about delegation stating, “I try not to give them anything that would make me feel really dumped on . . . something that would be simple for somebody else to pick up without having to give them a whole report.” The expert nurse focused on the patient rather than the task, with a holistic view of the patient. One nurse noted, “She has a horrible support system. She is separated from her family so it is really hard for her. . . . She has all of us here, but who is going to check on her at home. She has a great church family.” The nurse knew the patient well and considered physical and psychosocial issues while caring for her. One expert nurse described how she decided which patient to assess first. She identified factors she considered then noted her choice that morning. “I thought I would see him first just because of his history last night [ICD firing]. He was pretty anxious about it and just very scared from it. It was the first time it shocked him.” When the nurse was unable to complete a task, she immediately went on to something else. Stacking was so effective that interruptions were transparent. Interruptions and helping others appeared to be just part of the job. One nurse was seen getting an IV bag for a patient not included in her assignment. She not only hung the IV bag but also addressed whether the patient had any other needs. The expert nurses also had a very good sense of when to delegate, frequently providing patient care while doing assessments and giving medications. One expert nurse faxed orders to pharmacy stating it was easier to do it herself and be sure it was done and that she could be sure she would get the right medication.

Anticipation It is easier to plan and prioritize when you know what to expect. Advanced beginner nurses anticipated immediate events such as scheduled procedures or tests. Most of their actions were in response to a situation or event. The competent nurses anticipated procedures, tasks, and patient needs, whereas the expert nurses acted to facilitate meeting those needs. For example, a competent nurse noted, “I have no discharges at this time. I expect I might since two patients had procedures yesterday. If they are stable, they usually go home the next day. There are no orders, so I will keep treating as if they are staying.”

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In contrast, the expert nurse noted that whether or not she has an order she goes ahead and starts on their discharge papers if she anticipates a patient is going home. She stated, “By the time you get the discharge, they’re ready to go.”

Organizational Tools All the nurses used an organizational tool such as a worksheet, but the advanced beginners were less skilled in using a tool effectively. They had difficulty determining what was important to include on a worksheet. One noted, “I write down every little detail during report.” Another noted, “I usually like to chart after I have seen each patient. I did not get to do that because the doctor came in. So you kind of have to memorize your information and go back and chart.” The competent nurses had developed a worksheet or method of using a worksheet that fit the individual nurse’s style and modified it to fit the assignment. They took time at the beginning of the shift to record information in a way that helped them stay organized, often coming in early to allow time for information gathering. One way they used the worksheet was to help them remember medications, treatment plans, or assessment findings, not relying on memory. Regarding a medication that was not given, one nurse stated, “I always write it down and underline it so I know that I have to go back and give it.” The expert nurse used organizational tools in a very deliberate fashion. A detailed worksheet with careful organization of each patient’s data was created. In completing this preparatory work, the expert nurses had all the data required for the rest of the shift, resulting in a seamless and transparent routine of care provided to each individual patient.

Communication Communication patterns varied with the level of nursing expertise. Communication by the advanced beginners was oriented toward the patient’s immediate needs. They communicated with unlicensed assistive personnel and nursing students on a need-to-know basis, seldom anticipating what else they might need to know to provide optimal care and make the day go smoothly. Communication with other nurses focused on getting direction and assistance. They provided specific information to patients and families, but there was little therapeutic communication regarding unmet needs and concerns. In one case, there was a patient who was very unhappy. Rather than addressing his concerns or complaints, the nurse just basically said that’s the way things are. Another nurse encountered a situation in which the patient was upset about something that had happened during the previous shift. The patient said he would die if he stayed another night. The nurse went ahead with tasks and did not address

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his concerns. Later the nurse stated, “I really, I didn’t know what to say to that. I guess he couldn’t sleep so I kind of didn’t say anything.” The competent nurses were able to communicate based on anticipated problems or needs and their communication with other nurses was consultative in nature. They communicated some with other disciplines such as talking with the speech therapist about a swallowing study. The expert nurse communication was distinctively different. They communicated with everyone. They were constantly consulting and clarifying various aspects of the patient care to meet all of the patient’s needs. They consistently used therapeutic communication to address a wide range of patient concerns. For example, one expert nurse was observed talking with her manager about taking a patient to emergency room to see his brother who had just been admitted. Nurses were also observed communicating with a variety of disciplines, including respiratory therapy and social services. They also had many more direct discussions with physicians regarding the plan of care.

Integration of Roles Although the nurses took on a variety of roles, patient teaching and therapeutic communication best exemplified the nurses’ ability to integrate roles. For the advanced beginner, patient teaching was limited to immediate concerns, and they made a special trip to the patient’s room to teach. The competent nurses addressed immediate concerns and addressed some broader concerns and were more likely to include the family in the instruction. They did some teaching while doing other tasks such as teaching about activity and oxygen while doing the assessment. They considered psychosocial issues but often did not incorporate that into other activities. One nurse stated, “I didn’t get into his social issues until after I was done with my assessment and the doctor came . . . until after my assessments were done, because everyone needs to be seen and everybody needs their meds and immediate care first.” The expert nurses took a more holistic approach to patient teaching and communication, addressing immediate concerns as well as anticipating what the patient may need to know for discharge or home care. For example, while doing an initial assessment, one of the expert nurses was observed teaching the patient and family member about a scheduled stress test and also included teaching about diet and medications.

Response to Work Environment Stress in the work environment was a common theme, but the nurses responded differently. The advanced beginner nurses experienced much stress at work

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and perceived some events as crises. One stated, “I am always nervous coming into work because you don’t know how your patients are going to be.” Another noted that when she first started her job, she would be “just hysterical” at the beginning of the shift, but now “just a little stressed.” The competent nurses mentioned that they have days when they are very stressed and frequently mentioned things they do to avoid “getting stressed out.” One nurse stated, “I clock in at 6:30, so that half hour keeps me from feeling like I’m rushed. . . . I don’t want to get a really late start especially if I have early procedures for any of my patients, So it keeps me from stressing out.” They perceived fewer events as crises. The expert nurses did not discuss “stressing out” or mention experiencing a crisis. Rather than identifying doing things to avoid stress, they identified doing things to keep the unit functioning smoothly. The participants all rated their perceived workload for the day as normal or less than normal, so the data did not provide any insight into the effect of perceived heavy workloads on the nurse’s response to the work environment. Although more than half of the nurses had not worked the day before, the data revealed no variance in affective or cognitive responses between those who had worked the day before and those who were off.

Discussion The purpose of this study was to explore the differences in how advanced beginners, competent, and expert nurses prioritize patient care and identify factors that influence their change in plans and reprioritization. The results of this study are similar to those found by Ebright in her research on work complexity (Ebright et al., 2003; Ebright et al., 2004). Research indicates that the work of nursing is complex and nonlinear (Potter et al., 2005), but this study found that advanced beginner nurses organize care and prioritize in a linear fashion. The competent and expert nurses used more complex and nonlinear approaches to prioritization. Even though the “Millennial” generation may come with multitasking, experience is necessary to develop the cognitive skills to prioritize the multiple demands on their time and attention. The advanced beginner’s difficulty with organization and focus on tasks is consistent with research related to nurses during the first year of practice (Atencio, Cohen, & Gorenberg, 2003; Fink, Krugman, Casey, & Goode, 2008; Olson, 2009). Advanced beginner nurses may want to help others on the nursing team, be involved in unit activities such as quality improvement and shared governance, and meet all the expectations of a new professional. Their organizational skills are such that all they can do is complete all required tasks. This affects the ability to participate in professional activities such as shared governance.

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In addition to the cognitive responses to work, the data revealed significant differences in the nurses’ affective responses to work. The advanced beginner nurses perceived significant stress in their work environment to the point that one nurse described herself as hysterical. As their ability to handle the work complexity improved, their affective response changed. The competent nurse perceived some situations as stressful, but did not describe events as crises. Expert nurses seldom expressed significant stress and were able to incorporate additional activities to keep the unit running smoothly. The advanced beginner nurses relied heavily on more experienced nurses for guidance and support when dealing with patient care situations. This is consistent with the literature about the importance of availability of resources to improve safety and retention (Batcheller, Burkman, Armstrong, Chappell, & Carelock, 2004; Runy, 2006; Taylor, 2002). Breakdown in communication is the most frequent cause of serious injuries in health care settings (World Health Organization, 2007). Communication is essential to patient safety, yet this study found that advanced beginners communicated on a need-to-know basis whereas the competent nurses anticipated communication needs. Expert nurses communicated frequently to consult with others and clarify patient treatment to achieve optimal patient outcomes. The expert nurses were much more aware of what they needed to communicate and the information they needed to ensure safe hand-offs, whereas the advanced beginners responded to questions and communicated the bare essentials. Similar challenges with nurse physician communication, communication with other disciplines, and hand-off communication has been noted in other studies (Fink et al., 2008; Olson, 2009; Taylor, 2002). This study was conducted at five hospitals, which increases the applicability to other acute care settings. The reader will need to determine if the results can be generalized to their practice environment. The units were all cardiac telemetry units not classified as critical care units. The consistency in units provided a more homogeneous sample, which allowed for a better understanding of the phenomena. Collection of data by multiple researchers may have resulted in attention to different aspects of nursing care during the observation period. Observations and interviews were completed one time, which limits the understanding of the effect varied patient assignments may have on the nurse. The nurses all rated workload as normal or less than normal. Observations during a time of heavy workload may have uncovered different responses to work complexity. This research adds to the understanding of how nurses of different competency levels respond to today’s complex care environment, and the study findings have implications for nursing education and nursing practice. Graduate nurses are expected to step into the complex care environment but

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they do not yet have all of the skills to effectively handle that complexity. Education needs to examine approaches to increase the student’s ability to organize, prioritize, and communicate. Additional research is also needed regarding methods to help nurses increase competency, such as how new graduate nurses develop the cognitive skills to effectively deal with the complex care environment and learn to communicate more effectively. There is little doubt that expert nurses provide the highest quality of care, yet few nurses reach the expert level of competency. Additional research to investigate what measures help nurses become expert practitioners is needed. As nursing strives to increase quality of care in an economically challenging environment, competency levels must be considered. Initiatives designed to improve patient safety, nurse retention, and overall quality of care may need to be modified to fit the needs of the nurse. Some measures, such as involvement in shared governance, may increase job satisfaction and retention for the expert nurse, but for the advanced beginner, it may feel like just one more thing to do. Understanding the needs of the advanced beginner nurse and the more experienced nurses will help address the issues related to responses to the complex care environment. Addressing the needs of the advanced beginner nurses while enhancing the practice of the competent and expert nurses will be important in meeting the challenge of providing quality nursing care. Declaration of Conflicting Interests The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding The authors received no financial support for the research and/or authorship of this article.

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