Contents
Magnet can be a lifesaver
Read first-hand account of how Magnet hospitals save lives.
RNs gain support
The Magnet culture dictates fitting education into nurses' routine.
Understand Magnet nursing
Interim director discusses past and future of the Magnet program.
The Magnet difference
Experts discuss some of the unique characteristics of Magnet hospitals.
Seeking Magnet: Pros and cons
A look at some of the benefits and costs of pursuing Magnet status.
Improve patient care
Research suggests Magnet status can improve patient outcomes.
Nurses battle Hurricane Harvey
Nurses at Magnet hospitals in Houston stepped up during crisis.
Find your Magnet hospital
A breakdown by state of all the Magnet hospitals in the U.S.
Magnet has global appeal
Hospitals in other countries are seeking Magnet recognition.
Frontline nurses take the lead
Nurses are taking on leadership roles as Magnet Champions.
RNs are at the helm
Transformational leadership plays big role in Magnet process.
Free CE: Novice to expert
Build your expertise by adding to your skills and experience.
Achieve accreditation
Key steps hospitals can take to help them in the Magnet process.
Lifelong learning in nursing
Magnet program places a strong emphasis on continuing education.
Continuing education catalog
A look at courses that can help nurses on the Magnet journey.
It takes a special leader
Find out how transformational leadership leads to satisfaction.
APRNs and Magnet nursing
Magnet status can elevate nurse educational standards.
Achieve nursing excellence
Read stories of recent Magnet Nurses of the Year winners.
What being Magnet means
Learn about the continuing journey of the nation's first Magnet hospital.
When you get the Magnet call
Read testimonial from CNO of one of the newest Magnet hospitals.
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Nursing Competency: From Novice to Expert
Nursing Competency: From Novice to Expert
By
Sheila J. Leis, MS, RN-BCThis course is 1 contact hour
Course must be completed by February 29, 2024
Goals and objectives:
Nursing competency develops over time — the product of lessons learned from wide-ranging experiences. As the profession evolves, competency in a rapidly changing healthcare environment remains a key component of excellent nursing care. Competency gives nurses confidence to care for their patients. This module addresses how expertise develops from novice to expert and the importance of supporting one another with this challenging journey, including Patricia Benner’s five stages of moving from novice-to-expert.
The goal of this course is to help nurses in acute care settings to use Benner's novice-to-expert model to coach nurses through various stages of competency development.
After taking this course, you should be able to:
1) Recall Patricia Benner’s five stages of moving from novice to expert.
2) Recognize why it is important to help nurses on their journey from novice to
expert.
3) Identify strategies nurses can use to support one another as they develop competency in handling various clinical situations.
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit
Nurse.com/Accreditation
. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education”
to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx
.Florence Nightingale understood the importance of nurturing nursing competence long before it became a favorite topic of conversation in the nursing profession. In letters she wrote, her passion for excellence in nursing shines through.
For example, several letters from 1861 refer to the need to provide training and to attract qualified candidates (Nightingale, 1861). However, Nightingale also knew that completing a basic nursing education didn’t guarantee competency years later and even recommended that nurses receive certificates for recent experience, a concept analogous to today’s continuing education (McDonald, 2002).
As our profession evolves, competency in rapidly changing healthcare settings remains a key component of excellent nursing care. Competency is at the heart of patient safety, satisfaction, and clinical outcomes in any healthcare setting whether in acute care, home health, assisted living, or skilled nursing. It's also key to retaining good nurses, because it gives them the confidence they need to succeed.
But developing competency is only one step to becoming an expert nurse. Nursing proficiency grows over the years — a product of experiences. This module addresses how expertise develops from novice to expert and how to support one another during this challenging journey.
A well-thought-out orientation program is the key to a good start on the journey to gaining competence. Many organizations now also have nurse residency programs to facilitate the integration of newly licensed RNs into professional practice roles (Perron et al., 2020).
Consider the case of Emily. An excited new nurse grad, Emily reports for duty at her first job: A med/surg staff nurse in a large hospital. Full of hope and confident the hospital is the right fit, Emily meets her new coworkers including Kelly, her preceptor, who has worked in med/surg for 7 years.
Maintaining a positive attitude and working to build mutual trust, Kelly helps Emily identify her learning needs. She frequently asks Emily how she's doing and whether she needs help. She monitors Emily's patients’ outcomes, and they discuss challenges and successes together.
Kelly assigns Emily to care for patients with similar conditions so she can improve her clinical reasoning skills. Kelly helps Emily identify priorities and points out complications that may occur in her patients. Emily attends a support group of new grad nurses at the hospital to discuss her experiences.
Emily is surrounded by nurses who mentor and nurture her growth as a professional, competent nurse. She benefits from attending ongoing support group meetings. By the end of a year, Emily is happy in her position and well on her way to becoming a clinically competent nurse.
But not all nurses have experiences like Emily. Too often, nurses find a gap between what they learned in schools and what they experience in the clinical setting (Hartung et al., 2020). They find themselves in a “trial by fire” sometimes feeling that there is no one to turn to help them with patient and practice dilemmas. This stress and lack of support causes job dissatisfaction and makes good nurses leave in search of greener pastures.
Nursing can’t afford to lose good nurses simply because they aren’t given the support that every new nurse needs to become a good clinician. From patient care perspectives and from moral and professional perspectives, we owe it to our peers to help them grow and succeed. From a financial perspective, nurturing and retaining nurses is extremely important. According to the 2016 National Healthcare Retention & RN Staffing Report, the average turnover cost ranges from $37,700 to $58,400 for each bedside nurse (NSI Nursing Solutions, 2016).
One of the most useful frameworks for addressing nurses’ needs at various stages of professional growth is the model of the stages of clinical competence first described by Patricia Benner, PhD, RN, FAAN, in her classic book, “From Novice to Expert: Excellence and Power in Clinical Nursing Practice,” published in 1984, with a commemorative edition in 2001 (Benner, 2001).
Benner, along with coauthors Christine Tanner, PhD, RN, FAAN, and Catherine Chesla, DNSc, RN, FAAN, expanded on these themes in the second edition of their book “Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics” (Benner et al., 2009). The Benner model helps nurses gain insight into how nursing expertise develops and what needs to be done to nurture new nurses through clinical challenges.
Benner’s stages of clinical competence
Benner (Benner, 2001; Benner et al., 2009) describes the following five stages of competency development:
Stage 1:
NoviceBeginners have no experience with the situations in which they are expected to perform. They learn “context-free” rules to apply universally. For example, “Check the blood pressure every hour. If the diastolic is over 100 mmHg, call the physician.” But rules can’t tell a novice which tasks to perform in each actual situation, and therefore behavior in the clinical setting may be limited and inflexible.
Novices have very limited ability to predict what might happen in a particular patient situation. It is not unusual for novices to miss subtle signs and symptoms that indicate a change in condition until after they have had experience caring for several patients with similar symptoms (Benner, 2001; Benner et al., 2009).
Stage 2:
Advanced BeginnerAdvanced beginners are defined as new graduates with less than 6 months of experience. Nurses with this level of proficiency have had enough experience to note recurring, meaningful components of a situation. The advanced beginner begins to formulate guidelines that dictate actions. They are new grads in their first job. Due to limited clinical experience, “advanced beginners demonstrate extraordinary dependence on the expertise of others” (Benner et al., 2009, p. 26)
Stage 3:
CompetentThese nurses begin to see their actions in terms of long-range goals and plans. Competent nurses lack the speed and flexibility of proficient nurses but have a feeling of mastery and can rely on advanced planning and organizational skills.
They have an increased sense of salience, meaning they know what important signs and symptoms to look for in various patient circumstances. They begin to recognize patterns and the nature of a clinical situation more quickly and accurately. They have better "hunches" and need to examine fewer options to make decisions.
Stage 4:
ProficientThe nurse views situations as “wholes” rather than parts. Maxims (general rules and principles) and reflecting on nuances (subtle differences in a situation) guide performance. Proficient nurses learn from experience what events typically occur and how to modify plans accordingly. They see goals and salient facts but still must deliberately make decisions.
Thanks to a well-developed ability to recognize demands, identify resources, and attain goals, experts know what needs to be done for each of their patients. They no longer rely solely on rules, guidelines, or maxims to connect understanding of a situation to the appropriate action. They have an intuitive grasp of each situation based on their deep knowledge and experience. Stage 5:
ExpertThey focus on the most relevant problems, not irrelevant alternative options. They use analytical tools only when they have no experience with an event or when events and behaviors don’t occur as expected. The expert often “just knows” a particular situation without internal analysis.
For an idea of the range, consider this example from Benner: Beginning nurses focus on tasks, such as checking vital signs; they basically have a “to do” list. Experts focus on the whole picture even when completing tasks. For example, they may be emptying a Foley catheter and notice subtle changes, such as the patient seems harder to arouse than in previous encounters.
Novice to expert
The Dreyfus Model of Skill Acquisition forms the foundation for Benner’s work. Hubert and Stuart Dreyfus developed their model based on their study of chess players, Air Force pilots, and Army commanders and tank drivers (Dreyfus & Dreyfus, 2009). They contend that expertise is based on:
• Experiential learning - Learning through reflection on experiences
• Situated learning - Learning that is situation-based
Learning in actual hands-on situations is essential for progressing from a novice to expert in any field (Benner, 2001; Benner et al., 2009). Benner found parallels in nursing, where improved practice depends on both science and experience. All of us who have nursing experience can remember patients who taught us important lessons. Developing clinical wisdom takes time. Experiential learning requires an engaged learner who is open to growth and development over time (Benner, 2001).
Benner and her colleagues say that as nurses are engaged in various situations, and learning from them, they develop skills of involvement, meaning that they know how close or distant to be with patients and families in critical times of threat and recovery (Benner, 2001; Benner et al., 2009). These skills are essential for nurses to manage the stress that comes with their careers. Faced with an emotionally challenging patient, an overprotective parent, or a relative who disagrees with a loved one’s end-of-life decision, nurses must know how to handle the situation to meet the person’s needs while not losing themselves in the process.
Completing the rite of passage from novice to expert is not a forgone conclusion. Responding to patient needs goes beyond “knowing what” to do and develops into “knowing what” and “knowing why” (Benner et al., 2009). Benner’s model has been described as having a significant impact on nursing practice, as well as being applicable to any adult learning situation, including mature adults who are entering nursing as a second career (Black, 2017).
As nurses develop expertise, particular changes in performance occur. The abilities of a new nurse develop from behaviors guided by rules, to the ability to see the “big picture” to a nurse who responds by intuition in a fluid and seamless manner (McDonald, 2002). According to Benner et al. (2009), as expertise grows, nurses move from reliance on abstract principles (principles that may not be practical in the current situation) to applying knowledge from concrete experiences in the past (they remember a similar patient who had similar issues).
They move from viewing a situation in bits to viewing it as a whole. They are involved performers, rather than detached observers (Black, 2017). These cumulative experiences help nurses move through the five stages.
The following is a closer look at strategies that help nurses progress through Benner’s five stages. As you consider the strategies, remember that nurses who change practice areas may revert to earlier stages of expertise.
For example, an expert nurse in the CCU would not be able to immediately function as an expert in the OR (although certainly the nurse’s expertise is valuable) or in home health. Understanding this concept helps nurses deal with the anxiety and uncertainty associated with changing specialties. It also helps specialty nurses understand why a nurse with lots of experience may still need a lot of support.
Novices
While many nurses consider new RNs in their first year of clinical practice to be novices, Benner and her colleagues write that the novice stage “typically occurs in the first year of students’ clinical education” (Benner et al., 2009, p. xvii). Novice nurses tend to learn through formal mechanisms, including review of policy or procedures, attendance at simulation experiences, or role playing with experienced facilitators (Thomas & Kellgren, 2017).
These nurses function at basic levels and need significant supervision and specific directions. Once students graduate from school and pass the National Council Licensure Examination (NCLEX®), Benner says they are no longer novices: “No one can get through nursing school and take the NCLEX-RN while remaining a novice!” (Benner et al., 2009. p. xvii).
Advanced beginners
Advanced beginners, typically new graduates, are beginning to intuitively observe elements of situations. They set priorities in linear ways and can be overwhelmed when they perceive all interventions to be equally important (Walton, 2016). They can’t yet see the bigger picture. Nurses at this stage need experience so that they can recognize aspects such as signs and symptoms that they may have only studied in the classroom.
Nurses need to understand that novices will never get enough experience-based knowledge in school. For this reason, Benner, her colleagues, and many educators today recommend a new-grad residency program of at least 1 year. The program should include coursework, mentoring, and use of clinical narratives to help nurses reflect on and learn from their experiences (Benner et al., 2009, p. 408).
A clinical narrative is a first-person “story,” written by a clinician, that describes a clinical situation (e.g., how a nurse managed a patient with signs and symptoms of heart failure). Narratives help nurses to analyze situations, reflect on their clinical practice, raise their consciousness about their knowledge, and share their experiences with others (Benner, 2001; Benner et al., 2009).
It’s best to initially limit advanced beginners to working with patients with a narrow range of conditions so that they are not overwhelmed with too many patient conditions and can focus on developing competency in caring for certain patient populations. Frequent clinical rotation is not recommended, because it makes it difficult for nurses to hone their abilities to recognize patterns within similar patient populations (Benner et al., 2009, p. 408).
With frequent clinical rotation, nurses are also less likely to develop in-depth clinical knowledge of specific conditions, because they have the “brain drain” of dealing with the “newness” of the various units.
Benner et al. (2009) recommends that preceptors of advanced beginners forecast what can be expected, because these nurses have not had opportunities to experience how clinical problems tend to progress. It is difficult for them to predict complications and what may happen in the future. A preceptor might say, “With this complex leg fracture injury, I would be looking for compartment syndrome as a possible complication.”
Advanced beginners also need help in articulating knowledge. Benner et al. (2009) suggest that if you go into a room, and the nurse looks overwhelmed, don’t ask, "What can I do for you?," because they will be too overwhelmed to stop and articulate what they need. Instead, just pitch in and help until the crisis passes. Responding to the needs of declining patients requires a “socially embedded web of attentiveness to details and to looking out for the patient’s best interest” (Benner et al., 2009, p. 250).
After providing patient assistance, you can help the nurse identify what was important and not important in the situation. As you might expect, advanced beginners need help setting priorities. For example, preceptors may stress to new nurses caring for patients with respiratory distress that maintaining airway patency and monitoring ABG results are key care priorities.
Feedback is important for new nurses and particularly for new grads, who are used to frequent feedback in school. Positive feedback, such as “You did a great job in getting Mrs. Jones to open up about what was bothering her,” builds confidence. Constructive criticism is also important. For example, “I noticed this patient assignment wasn’t easy for you. Can you think of some reasons why? Then we can talk about what I can do to help you.”
Read the full CE, including more about Benner’s strategies, online.
How to earn continuing education
THIS COURSE IS
1 CONTACT HOUR
1.
Read the Continuing Education article.
2.
Go to https://www.nurse.com/ce/nursing-competency-from-novice-to-expert
to take the test for $12
. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/sign-up.3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
Accredited
In support of improving patient care, Relias LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Relias LLC is also an approved provider by the Arkansas State Board of Nursing, District of Columbia Board of Nursing, Florida Board of Nursing, Georgia Board of Nursing, New Mexico Board of Nursing, South Carolina Board of Nursing, and West Virginia Board of Examiners for Registered Professional Nurses (provider # 50-290). Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.
Relias LLC's continuing education (CE) contact hours are generally accepted by most professional nursing organizations and state boards of nursing. Relias LLC has made substantial efforts to obtain appropriate providerships for CE offerings. However, Relias LLC does not warrant that all professional organizations or licensing authorities will accept its CE contact hours. If in doubt, nurses are advised to contact their professional organizations or licensing authorities to confirm their acceptance of these contact hours.
ONLINE
Nurse.com/CE
You can take this test online or select from the list of courses available. Prices subject to change.
EDITOR’S NOTE:
This educational activity is free from bias.
Sheila J. Leis, MS, RN-BC, is a full-time nursing faculty member at Indiana Wesleyan University. She has more than 15 years of experience as a professional development specialist in a Magnet hospital. She has previous experience as a nurse manager and has been certified in medical/surgical nursing for more than 25 years.