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.     

Recognition of expertise: an important concept in the acquisition of nephrology nursing expertise

The present article, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept of recognition of expertise. The study used grounded theory methodology and involved 17 registered nurses who were practising in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participant observations and interviews. According to nurses in this study, patients, doctors and other nurses recognized that some nurses were experts while others were not. In addition, being trusted, being a role model and teaching others were important components of being recognized as an expert nephrology nurse. Of importance for nursing, the results of the present study indicate that knowledge and experience are not sufficient to ensure expert practice; recognition of expertise by others is an important function of expertise acquisition.     

Nursing expertise: a course of ambiguity and evolution in a concept

In this article, we clarify and describe the nature of nursing expertise and provide a framework to guide its identification and further development. To have utility and rigour, concept‐driven research and theories of practice require underlying concepts that are robust, valid and reliable. Advancing understanding of a concept requires careful attention to explicating its knowledge, metaphors and conceptual meaning. Examining the concepts and metaphors of nursing expertise, and how they have been interpreted into the nursing discourse, we aimed to synthesise definitions and similarities between concepts and elicit the defining characteristics and properties of nursing expertise. In clarifying the concept, we sought to move beyond the ambiguity that currently surrounds expertise in nursing and unravel it to make explicit the characteristics of nursing expertise from published peer‐reviewed studies and structured literature synthesis. Findings indicate a lack of clarity surrounding the use of the term expertise. Traditional reliance upon intuition as a way of explaining expert performance is slowly evolving. Emerging from the analysis is a picture of expertise as the relationship between networks of contextual reasoning, understanding and practice. Striking absences in the discourse include limited explication of ethical reasoning and theorising a broader interpretation of expertise reflective of contemporary forms of nursing.     

Evidence and expertise

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.     

Intuition: an important tool in the practice of nursing

AIM: The aim of the study reported here was to evaluate the role of intuition, to examine nurses' understanding of intuition and their perceptions of their use of intuition, and to assess the impact of intuition on nursing practice. BACKGROUND: When we read the dictionary definition of intuition, we have a sense of the meaning but there is also a sense of something still not quite defined. Yet we instinctively know what intuition is. That is, of course, an example of intuition in itself: an understanding of the concept based on our feelings, knowledge and experience. Intuition is a concept neither clearly articulated nor adequately theorized in nursing. There is evidence to suggest that practising nurses use intuition and that its use can change outcomes for patients. Because of its influence on patient well being, it needs to be recognized as an important tool in the practice of nursing. The very nature of intuition determines that there will be little agreement on a precise definition and little empirical evidence to support its existence or worth. Neither of these issues detracts from the fact that intuition is an important part of nursing. METHODS: Grounded theory was used as the overarching theoretical and methodological framework for this study. Using focus group interviews and the Delphi survey technique, data were collected from 262 Registered Nurses who volunteered to take part in the study. FINDINGS: The theory that emerged from this study provides nurses with a way of articulating their understanding of intuition and their perceptions of its use in nursing practice. CONCLUSIONS: Intuition is not some mystical power that appears from nowhere, with no rational explanation or basis. The findings from this study show that it is a product of the synergy that occurs as a result of the interaction of a number of factors.     

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.     

Commentaries: Intuition and Evidence: A Reaction to Watson and Clark

A consideration of evidence-based practice has led many to debate the nature of evidence. Rejecting the idea that randomized controlled trials should be the only legitimate source of evidence, writers have argued that other types of research and knowledge should be considered legitimate sources of evidence. This paper suggests that one should draw on systematic research, including qualitative research, for evidence, and that other types of knowledge such as craft and practice knowledge are part of the profession's expertise. This paper argues that evidence and expertise are both required for evidence-based practice to occur. Finally, a consideration of patients' values and expectations is explored as a third component of evidence-based practice. The paper argues that all three components are necessary for evidence-based practice.     

Understanding clinical expertise: Nurse education,experience, and the hospital context

Clinical nursing expertise is central to quality patient care. Research on factors that contribute to expertise has focused largely on individual nurse characteristics to the exclusion of contextual factors. To address this, we examined effects of hospital contextual factors and individual nurse education and experience on clinical nursing expertise in a cross‐sectional analysis of data from 8,611 registered nurses. In a generalized ordered logistic regression analysis, the composition of the hospital staff, particularly the proportion of nurses with at least a bachelor of science in nursing degree, was associated with significantly greater odds of a nurse reporting a more advanced expertise level. Our findings suggest that, controlling for individual characteristics, the hospital context significantly influences clinical nursing expertise. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:276–287, 2010     

Newly qualified nurses experiences in the intensive care unit

Aim: The aim of this research was to investigate newly qualified nurses (NQN) experiences of starting their career in the intensive care unit (ICU). The author also investigated the opinions of senior nurses from ICU in relation to NQN in ICU. Background: Although not a new concept, NQN in ICU has little substantive research to support recruitment. There is a current demand to investigate this topic, because of retention of staff and a shortage of qualified nurses. Method: This was a comparative, qualitative study using two forms of data collection. This study was conducted over two phases. Phase I, used semi‐structured interviews with eight NQN, with one participant for the pilot study. PHASE II used a focus group to interview seven senior nurses in ICU. Findings: NQN experienced anxiety about time management, accountability and socialization. Senior nurses felt NQN coped well with the demanding aspects of ICU but were aware that preceptors are under a lot of pressure. They were concerned about NQN lack of hospital knowledge. The competency‐based practice highlighted the importance of record keeping and its associated legal implications. Conclusion: NQN cope well with the complexity of ICU. Having student placements in this area seem to ease this transition and reduce some ‘reality shock’. They therefore seem better equipped to deal with the steep learning curve.     

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.     

Patient narratives in the investigation and development of nursing practice expertise: a potential for transformation

This paper is a review of the experiences gained whilst working with the 'expertise in practice project'. The project was concerned with understanding the complex phenomenon of practitioners investigating and evaluating their own practice. The research intention was focused on making a difference to how those nurses practised, through introducing systematic practice-based inquiry processes that could enable nurses to think more critically about their work and how their practice affects others. Particular attention is paid to the process of engaging people who use healthcare services, as research participants in the evaluation of nursing practice expertise. We outline how the project incorporated practitioners' concerns about asking people who use health care services opinions on nursing practice expertise and how a process of discovery emerged that enabled transformation of practice and consideration of the patient-participants' role as a sophisticated evaluator of health-care. As a result, we present a case for transformational qualitative research. Such research is values-driven and uses inclusive, collaborative and facilitative processes. It contributes to human flourishing, not only through its 'ends' (i.e. research products) but also, intentionally, through its 'means' (e.g. research processes and stakeholder involvement). Thus, transformational research is complex and requires that researchers engage in reflexivity (deep self-reflection) to examine and critique their personal values.     

Reflections on intuition and expertise

Reflective practice now appears firmly established in the English speaking world of professional nursing practice and development. Outside this linguistic context, however, the concept seems less well-known. This paper describes an experience drawn from clinical practice and education in French-speaking Switzerland followed by explicit reflection grounded in questions generated by Johns' model for structured reflection. Thus, a concept well-described in the English-language literature underpins an innovative approach to a French-language clinical teaching situation. The professional implications of this situation are explored through meaningful reflection providing new insight into familiar circumstances as they relate to the nurse tutor's role. This exploration is followed by a critical approach to the experience and the subsequent structured reflection in order to address relationships between intuition and expertise and self-awareness through reflection. A hermeneutic perspective provides additional insight into the nurse-patient relationship where both come to the situation with their own 'pre-understandings'. Individual horizons thus endorse a new understanding going beyond taken-for-granted meanings.     

Developing a qualitative approach to 360-degree feedback to aid understanding and development of clinical expertise

AIM: This paper presents one aspect of a 5-year multicentre action research study to develop an accreditation process for clinical nursing expertise. Part of the process consisted of the exploration, critique and refinement of qualitative 360-degree feedback as a tool for peer review. BACKGROUND: Three hundred and sixty-degree feedback is widely used as a personal and professional development strategy. This part of the overall study challenged assumptions about the necessity for anonymity and structured questionnaires to collect data. The study involved 32 experienced clinical nurses drawn from a range of clinical settings supported by 'critical companions' (colleagues from clinical practice, education, management and research, recruited to provide supervision and support). METHOD(S): Study participants, facilitated by the project team (the authors), engaged in critiquing and refining 360-degree feedback as a process to help them examine and develop their practice. CONCLUSION(S): On the basis of our findings this approach to gathering 360-degree feedback facilitates the collection of evidence that aids professional development. There are indications that it may also contribute to improved working relationships.     

Promoting teenage sexual health: an investigation into the knowledge, activities and perceptions of gynaecology nurses

AIM: Intuition has been cited as an integral part of nursing clinical expertise. Responding to the recent scholarly debate over the status of expert nursing intuition as part of the art or science of nursing, this article proposes an alternative view that may provide an informational basis for what has been described phenomenologically as intuition. RATIONALE: Two reasons for the dispute over the status of nursing intuition as 'art' or 'science' are proposed: The first is methodological. The second relates to intuition's close link with perception and underlying assumptions about perception. By examining intuition through an ecological psychology framework, the problem takes on a different character, one that is no longer focused solely on the expert's cognitive (or perceptual) processes, but also on the information provided by the patient and the context of care. CONCLUSIONS: This perspective has several implications for nursing. By investigating information sources (i.e. higher order variables or constraints) in the nurse-patient encounter, the problem of intuition may be clarified, and perhaps simplified. We may find that what nurse researchers have called 'intuition' is what Gibson (1966, 1986) termed 'direct perception.' Intuition as direct perception is information-based and lawful. Finally, although some aspects of intuition may be hard-wired through evolution, intuition as direct perception can be developed through education and extensive, deliberate practice with appropriate exemplars. Characterized as direct perception, intuition is an observable, lawful phenomenon that is measurable, potentially teachable, and appropriately part of nursing science.     

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.     

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.     

Explicating Benner's concept of expert practice: intuition in emergency nursing

Title. Explicating Benner’s concept of expert practice: intuition in emergency nursing. Aim. This paper is a report of a study exploring the experience of intuition in emergency nursing in relation to Benner’s fifth stage of practice development, ‘the expert practitioner.’ Background. Expert nurses anecdotally report actions and thoughts that present in their consciousness and have an impact on the care given. Benner used the term ‘intuition’ for the fifth stage of practice development. However, Paley has criticized Benner’s model for its lack of clarity about the nature of an expert practitioner. This criticism is further justified by Benner’s inadequate explanation of expert. Method. A hermeneutic phenomenological study was conducted using van Manen’s approach and a Gadamerian analysis. Fourteen expert emergency nurses in Australia were interviewed between January 2000 and December 2003. Findings. The analysis resulted in the reconstruction of Benner’s expert stage into three distinct phases: cognitive intuition, where assessment is processed subconsciously and can be rationalized in hindsight; transitional intuition, where a physical sensation and other behaviours enter the nurse’s awareness; and embodied intuition, when the nurse trusts the intuitive thoughts. Conclusion. The findings validate the use of intuitive decision‐making as a construct in explaining expert clinical decision‐making practices. The validity of intuitive practice should be recognized. It is essential to recognize the conditions that support practice development, and in the prenovice stage (during their university course) factors such as reflection, research (in its broadest sense) and clinical curiosity should be fostered.     

Stress, coping behaviors, and recommendations for intensive care and medical surgical ward registered nurses

Forty one intensive care unit and 61 medical surgical ward registered nurses from two large urban teaching hospitals completed a stress questionnaire to examine stress factors, coping behaviors, and recommendations for alleviating stress within the work environment. Stress variables were grouped into five clusters: patient-related, environmental, management-related, interpersonal, and knowledge and skills. Multivariate analysis of variance demonstrated a significant main effect, with the ward nurses perceiving environmental factors as more stressful. Stress factors tend to be related to the overall hospital environment, especially in relation to specific work areas within the institutions.