The acquisition and exercise of nephrology nursing expertise: a grounded theory study

Aims and objectives. This purpose of this study was to describe the process of expertise acquisition in nephrology nursing practice. Background. It has been recognized for a number of decades that experts, compared with other practitioners in a number of professions and occupations, are the most knowledgeable and effective, in terms of both the quantity and quality of output. Studies relating to expertise have been undertaken in a range of nursing contexts and specialties; to date, however, none have been undertaken which focus on nephrology nursing. Design. This study, using grounded theory methodology, took place in one renal unit in New South Wales, Australia and involved six non‐expert and 11 expert nurses. Methods. Simultaneous data collection and analysis took place using participant observation, semi‐structured interviews and review of nursing documentation. Findings. The study revealed a three‐stage skills‐acquisitive process that was identified as non‐expert, experienced non‐expert and expert stages. Each stage was typified by four characteristics, which altered during the acquisitive process; these were knowledge, experience, skill and focus. Conclusion. This was the first study to explore nephrology nursing expertise and uncovered new aspects of expertise not documented in the literature and it also made explicit other areas, which had only been previously implied. Relevance to clinical practice. Of significance to nursing, the exercise of expertise is a function of the recognition of expertise by others and it includes the blurring of the normal boundaries of professional practice.     

Uncovering the evidence of non-expert nephrology nursing practice

Expertise in nursing has been widely studied although there have been no previous studies into what constitutes expertise in nephrology (renal) nursing. This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, provides evidence of the characteristics and practices of non-expert nephrology nurses. Using the grounded theory method, the study took place in one renal unit in New South Wales, Australia, and involved six non-expert and 11 expert nurses. Sampling was purposive then theoretical. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semistructured interviews was undertaken. The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Non-expert nurses showed superficial nephrology nursing knowledge and limited experience; they were acquiring basic nephrology nursing skills and possessed a narrow focus of practice.     

Understanding the role of knowledge in the practice of expert nephrology nurses in Australia

This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the role of knowledge in expert practice. Using grounded theory methodology, the study involved 17 registered nurses who were practicing in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participants' observations and interviews. Having extensive nephrology nursing knowledge was a striking characteristic of a nursing expert. Expert nurses clearly relied on and utilized extensive nephrology nursing knowledge to practice. Of importance for nursing, the results of this study indicate that domain-specific knowledge is a crucial feature of expert practice.     

Nephrology nursing: blurring the boundaries: the reality of expert practice

Background. Expertise in nursing has been widely studied; there have been no previous studies into what constitute expertise in nephrology (renal) nursing. This paper describes a ‘real‐world’ characteristic of expert nephrology nursing practice. Aims and objectives. This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept blurring the boundaries. Design. The study utilized grounded theory methodology and symbolic interactionism. Methods. The study took place in one renal unit in New South Wales. Sampling was purposive then theoretical; the sample consisting of six non‐expert and eleven expert nurses. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semi‐structured interviews was undertaken. Results. The study revealed that only expert nephrology nurses ‘blurred the boundaries’ of professional nursing practice. They did this by moving intermittently and purposefully, for the benefit of particular patients, into medical domains in the areas of prescribing, dispensing and ordering of pathology tests. Non‐expert nurses did not cross these professional boundaries. Conclusions. Blurring the boundaries was a significant feature of expert nursing practice, and this study was the first to describe explicitly nursing boundaries as two distinct entities; that is, formal and informal. Relevance to clinical practice. There are some nephrology nurses who have sufficient knowledge and experience to prescribe some medications and to order certain investigations.     

Exploring haematology nurses' perceptions of specialist education's contribution to care delivery and the development of expertise

The role that educational preparation may play in the delivery of care and the development of expertise is a point of some debate [Manley, K., Garbett, R., 2000. Paying Peter and Paul reconciling concepts of expertise with competency for a clinical career structure. Journal of Clinical Nursing 9 (3), 347; King, L., Macleod Clark, J., 2002. Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing 37(4), 322-329; Bonner, A., 2003. Recognition of expertise: an important concept in the acquisition of nephrology nursing expertise. Nursing & Health Sciences Journal 5, 123-131; Dunphy, B.C., Williamson, S.L., 2004. In pursuit of expertise. Advances in Health Sciences Education 9, 107-127]. Though education is a concept that may be universally valued, it may be more difficult to clearly discern the significance it has for practitioners who are developing their expertise. This research project employed an interpretive phenomenological design to explore the perceptions of specialist haematology nursing staff on the extent to which specialist education contributes to care delivery and the development of expert practice. A non-representative purposive sample of qualified nurses who had undertaken specialist education in haemopoiesis and work in specialist haematology participated in a focus group and semi-structured interviews. The report concludes that, for these specialist practitioners, specialist educational input had a beneficial impact on their levels of knowledge and confidence. Further to this, involvement in higher education had enabled them to become more active in the learning process. Perhaps the key finding of the study was the assertion by respondents that specialist educational input had enabled them to develop their specialist practice to a level that experience alone could not achieve.     

The relationship of nurses' professional characteristics to levels of clinical nursing expertise

Many hospitals are searching for guidelines for professional practice models, which are a requirement for Magnet recognition. This study was undertaken to determine the professional nursing characteristics that may contribute to the development of clinical nursing expertise. Experience as an RN was found to be highly correlated with initial level of expertise. Educational preparation and certification were not correlated with expertise. This research suggests that nurses may require more on-the-job experience for the development of clinical nursing expertise than what has been reported in the literature.     

Re-defining nursing expertise in the United kingdom

There is now international recognition of the importance of practice expertise in modern and effective health services. The Expertise in Practice Project in the United Kingdom began in May 1998 and continued to 2004. It included nurses working in all four countries of the United Kingdom, and it covered clinical specialists from pediatrics to palliative care. The project added to the current understanding of what nursing practice expertise is, through the identification and verification of attributes and factors which enable expert practice. The proposed framework offers a language for sharing what constitutes practice expertise and offers insight into what occurs between the expert practitioner and the people that experience their care. The Expertise in Practice Project demonstrates that nurses affect change and facilitate performance and organizational development.     

Online mentoring: ANNAConnections.

As the number of patients with chronic kidney disease (CKD) rises exponentially, there is an increased demand for nephrology nurses with expertise in all areas of practice. At this time of a serious nursing shortage, professional associations are needful of members able to assume leadership positions and prepare the organizations for the future. Novices to nursing, to nephrology or to leadership present a challenge to all areas of practice, from CKD clinics to dialysis units to transplant units, and to the maintenance and growth of professional associations. The purpose of this article is to introduce an innovative mentoring program that allows facilitation of the growth and development of nephrology nurses from novice to expert in multiple areas of career or leadership development.     

The expertise of Finnish occupational health nurses

This study describes the self-assessed activities, features, prerequisites, and consequences of occupational health nurses' expertise. The quantitative data were gathered from 468 Finnish occupational health nurses, of whom 373 (80%) returned the completed questionnaire. The data were analyzed by using one-way-anova, the Kruskal-Wallis or the chi(2)-tests. The activities of the occupational health nurses included working with employees, workplaces, and collaborative partners, administrative and office work, and other duties. The most important expert features were the holistic perspective and listening to clients. Continuing training and a positive attitude were the most necessary prerequisites for expertise. The main benefits of expertise, from the perspective of the occupational health nurses, were improved health and a decreased number of work-related health risks. Support by the work community and good educational possibilities were important for expert practice. Occupational health nurses need to develop their expertise continually because they play a key role in promoting workers' health.     

Expert thinking in nursing practice: implications for supporting expertise

Abstract The complexity of the art of expert nursing practice is an elusive phenomenon, which is difficult to articulate in concrete terms that can be translated into achieving quality patient care outcomes. The present study describes the findings of two hermeneutic (interpretive) studies on expert thinking that captured the holistic practice of expert clinicians. The findings from these studies provide insight into how expert practice can be administratively supported. These findings also have strong implications for strategies to facilitate the development of expertise in practice. In order to provide holistic care, nurses must spend time with their patients so that the particularities and meaning inherent in each unique patient situation can be understood. The art of expert thinking is a temporal and ethical activity, which needs to be supported and cultivated in a changing health-care delivery system.     

Producing the magnum opus: a metaphor for nephrology nursing expertise acquisition

AIM: This paper elucidates the nature of metaphor and the conditions necessary to its use as an analytic device in qualitative research, and describes how the use of metaphor assisted in the analytic processes of a grounded theory study of nephrology nursing expertise. BACKGROUND: The use of metaphor is pervasive in everyday thought, language and action. It is an important means for the comprehension and management of everyday life, and makes challenging or problematic concepts easier to explain. Metaphors are also pervasive in quantitative and qualitative research for the same reason. In both everyday life and in research, their use may be implicit or explicit. METHODS: The study using grounded theory methodology took place in one renal unit in New South Wales, Australia between 1999 and 2000 and included six non-expert and 11 expert nurses. It involved simultaneous data collection and analysis using participant observation, semi-structured interviews and review of nursing documentation. FINDINGS: A three stage skills-acquisitive process was identified in which an orchestral metaphor was used to explain the relationships between stages and to satisfactorily capture the data coded within each stage. CONCLUSION: Metaphors create images, clarify and add depth to meanings and, if used appropriately and explicitly in qualitative research, can capture data at highly conceptual levels. Metaphors also assist in explaining the relationship between findings in a clear and coherent manner.     

A & E nurses' constructs on the nature of nursing expertise: a repertory grid technique

The concept of nursing expertise has been the focus of considerable debate since the early 1980s, yet an agreed definition of the concept and the precise criteria by which it can be evaluated remains elusive. This paper will describe an exploratory study into A & E nurses' constructs of the nature of nursing expertise.Seven first level Accident and Emergency (A & E) nurses were interviewed using Kelly's Repertory Grid Technique. Each was asked to provide examples of nurses with whom they are working or have worked, to match eight given examples designed to represent varying levels of clinical expertise. The informants were asked to consider in what way two of their chosen examples were alike and differed from a third in their clinical practice.A total of 55 bi-polar constructs emerged which were clustered under four main headings. These suggested that A & E nurses perceived expert practice to be characterized by a high level of empirical knowledge, supportive team building, assertive clinical leadership and patient-focused involvement.     

Science, abduction and the fuzzy nurse: an exploration of expertise

Benner's work on expertise in nursing drew heavily on the writing of Dreyfus and Dreyfus in the field of computing. Dreyfus and Dreyfus argued that the continued failure of computer programmers to create an 'expert system', a program which could replicate the way that a human expert thinks, implied that experts do not think in a rational, analytic way. Dreyfus and Dreyfus therefore concluded that expertise is an intuitive process, and that 'the expert is simply not following any rules! He is … recognising thousands of special cases'. Applied to nursing, this model of expertise has a number of profound implications for practice and education, and has been criticised for being elitist and deliberately obscure. This paper examines some recent innovations in computer logic, and arues that nursing can learn from a new breed of 'fuzzy' compurter programmes which appear to be able not only to perform better than experts, but to verbalize their decision-making processes. By beginning to understand how experts think, it might be possible to dvelop expertise in a more controlled and logical way, thereby improving the practice of nursing.     

Defining characteristics of expertise in Japanese clinical nursing using the Delphi technique

A four-round Delphi technique was conducted on 127 experienced Japanese nurses to develop a consensus of opinion on the defining characteristics underlying expertise, and the prime requirements for the development of expertise in clinical nursing. Sixteen statements identified as the prime defining characteristics underlying expertise indicated that experienced Japanese nurses' picture of expertise is general, comprehensive and focused on task expertise. Four prime requirements for the development of expertise identified indicated that neither experience nor accumulation of theoretical knowledge alone is sufficient to develop expertise; but that motivation and attitude do play an essential role in the development of expertise.     

From expert to tasks,expert nursing practice redefined?

Aim. The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background. Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method. The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion. Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision‐making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice. The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.     

Exploring nursing expertise: nurses talk nursing

It has become increasingly important for practitioners to articulate their expertise in modern healthcare settings that demand high levels of accountability and evidence-based practice. The material presented within this article has been interpreted drawing from discourse analysis1 to help explore the discourses that shape and influence understandings of nursing practice. What we present are extracts from four of the 35 participant nurses who applied to take part in the Royal College of Nursing Institute's Expertise in Practice (pilot) Project (EPP). The material presented is used to provide a starting point for exploring how nurses talk about and construct expertise in nursing practice. The four nurse participants' clinical practice areas cover palliative care, mental health, intensive care and fertility care. The material reveals high levels of intensity in the nurse-patient relationship, 'maverick' nursing practices and ongoing reflexivity. All of these aspects appear to capitalize on expertise as a 'catalyst' that alters treatment pathways and maximizes patient-centred outcomes. Exploring a discourse of nursing expertise exposes the tacit situated nature of professional practice that is heterogeneous and most difficult to articulate and explain. It is proposed that expertise tends to be understood from traditional and dominant discourses of medicine, management and technology. Explaining expertise in practice exposes non-conventional practice that in itself can be isolating and challenging to the status quo of contemporary health-care.     

We need to know more: nurse educators' interest and expertise in gerontology.

An assessment was made of 129 faculty who teach nursing students about the care of aged clients to determine their level of interest and expertise in 21 content areas related to gerontology. Faculty rated their expertise consistently lower than the relevance of, and their interest in, each of the content areas. Areas identified as most important for their professional growth tended to be areas where faculty ranked their expertise as already being high. The mean self-rated expertise of faculty who taught a course in gerontological nursing was significantly higher than those who did not. Most respondents lacked formal education in gerontology: 9% of respondents had gerontology in their undergraduate program; 27% in their graduate program. Only 4% were certified as gerontological nurses or gerontological nurse practitioners.     

Early examination of the middle-range theory of flight nursing expertise

Reliance on expert flight nurses to move critically ill or injured patients generates considerable need for these nurses to obtain advanced education and maintain clinical expertise. The newly proposed middle-range theory of flight nursing expertise provided an initial framework to guide education and training in this rapidly changing specialty, but the framework had yet to be compared to the actual experiences of flight nurses in research. A cooperative inquiry approach was used to guide an investigation into the validity of the theory. The study consisted of two cycles of inquiry. In the first cycle, post-flight questionnaires were administered after patient missions to assess the presence or absence of each concept described in the theory. In the second cycle, individual interviews were used to further explore the flight nurses' decision-making during patient transport missions. Data collected from flight nurses about their decision-making on patient transport missions supported the presence of all the concepts in the newly proposed theory. Another concept, partner cuing, emerged as a concept to be added to the theory, while the concept decision-making, was revised to expanded decision-making. The importance of partner cuing was confirmed by flight nurses as reflecting their expanded decision-making during patient missions.     

Loss of clinical nursing expertise: A discussion paper

There is evidence to suggest that there is a general decline in clinical expertise in nursing as a result of experienced clinicians leaving the profession. The expertise of clinical nursing practice is an important resource and needs to be captured and made available to others as loss of this knowledge and expertise has implications for clinical outcomes. This paper aims to discuss the current nursing workforce, loss of clinical expertise, the nature of expertise and the way it can be captured. Clarification and articulation of clinical knowledge of nursing experts provides the means for knowledge to be transferred to a less experienced workforce and be available in an accessible form in the workplace. Leverage of nursing expertise in this manner has the potential to benefit less experienced staff, hold clinical nursing expertise in the workplace and improve clinical outcomes and satisfaction with performance.