Mentoring-Precepting: Transition from Novice Expert Susan A. Boyer, RN, M.Ed. Vermont Nurses In Partnership Executive Director

Mentoring & Precepting New graduates struggle with building capability as they enter into practice In new specialties even capable nurses revert to a novice level of capability This morning we will explore what is needed to support transition along the continuum towards competence as a nurse and as a preceptor in the clinical setting

Objectives: Differentiate the practice of a colleague with consideration of "novice to expert" levels of capability. Build a teaching plan that fosters the development of critical thinking capability. Describe the impact of developmental support in the clinical setting.

Experiential Learning Dreyfus' theory of experiential learning A developmental model Benner worked with Dreyfus model of skill acquisition for 21 years Application of experiential learning theory to the development of nursing practice

Nursing Requires: Benner writes that nursing requires both Techne and Phronesis Techne – explicit knowledge related to procedural or scientific knowledge Phronesis – is more complex; it is reasoned practice that is developed through experiential learning, where the nurse is continually improving her or his practice

Techne The rational method involved in producing an object or accomplishing a goal/objective The intent is making or doing, not simply "disinteresting understanding.“ Also has meanings/implications that relate it to art – techne is the craft presentation of the art, in this case the art of nursing

Phronesis The virtue of moral thought, usually translated "practical wisdom” Aristotle - not only the ability to decide how to achieve a certain end, but also to reflect upon and determine that end, the ability to achieve the application of practical knowledge - knowledge framed by exposure to other perspectives, ideas and disciplies. 

Phronesis - More than Just knowledge To think about how and why we should act in order to change things, for the best. Gaining phronesis requires time, as one must gain both the habit and understanding of correct deliberation Phronesis is reasoned practice, employed through experiential learning, where the nurse is continually improving their practice

Novice to expert Novice Advanced beginner Competent Proficient Expert

Traits and capabilities Framework, Berliner (1988); Years experience data from James Leach (1996)

Transition between levels Transition does not equal time/years Regression when faced with new situation/specialty Transition takes time and experience Experiential learning Reasoned practice Gain the habit and understanding of deliberation Move more quickly to next level Apply prior learning See what the core concepts are See how concepts can be applied in new situation

Application to competence Development & evaluation Performance Scoring Identified Limitation (Novice) Capable (Advanced Beginner) Performs Independently (Competent) Proficient Expert

Scoring key categories 1 – Identified Limitation requires direct guidance & support, little or no experience with skill 2 – Capable - familiar with skill/equipment, but may need assistance, seeks help when unfamiliar with process/skill BENNER’S Novice - Inflexible, rule-based. Little or no background understanding Advanced Beginner – start to use and make sense of situational elements & depend on the context. Temporal focus is immediate & present

Benner’s Competent 3 – Performs independently 4 – Proficient Increased efficiency, planning is still conscious, abstract, analytic, and deliberate. -situations are perceived as a whole rather than as unconnected aspects - Understanding of task, also the decision of what to do next, is intuitive and fluid. 3 – Performs independently knowledgeable to perform these tasks safely as a result of training & experience 4 – Proficient extensive experience in this area/skill, able to teach and mentor others 5 – Expert all of the above; fluid performance; ensures evidence-based practice for clients and agency

Transition from novice What supports development and transition along these levels of capability?   

To develop capability, competence & confidence Use reflection, questioning, story- telling, feedback, experience and success to foster development Support holistic care Focus on concrete critical thinking development questions/discussion Clearly defined expectations A plan for the learning process

What are the goals ? What patients need – a safe and effective care provider What a preceptor needs – evidence that this care provider can provide safe and effective care What will this evidence look like?

Competency Expectations Clearly defined expectations Performance outcomes statements What does a nurse do? What is most important? Tasks vs. Phronesis Procedures vs. Critical Thinking

Concrete Teaching Plan Clinical teaching is more effective when it is planned Components of a teaching plan Goals Clearly defined expectations Instructional strategies Teaching time is required for instruction, observation, allowing practice, giving feedback, documentation, discussion of case scenarios/stories/issues/what ifs.

Critical elements - For planning Performance expectations Instructional strategies Concrete Critical Thinking Development

Clinical Coaching Plans Instructional Strategies Performance Expectations Met? Comments Reflection on practice/learning (concrete C.T. development)

Critical elements - for learner, for safety Identify and explore resources How to find the info? Recognize limits of capability Seek help/assistance/information

Fostering critical thinking skill development Assist with organization/prioritization Provide reflection regarding aspects of a clinical situation Focus on concrete critical thinking development questions/discussion Clearly defined expectations A plan for the learning process

Learning Environment What every learner needs – a safe learning environment Basic principles of teaching/learning Simple to complex Success builds success Allow practice, even failure Allow time for learning and discussing Feedback, Correction, Change direction Safety for patient and learner

Experiential Learning Instruction in the clinical setting Differentiating between performance outcomes and instructional strategies Determining behaviors that foster Critical Thinking development

Critical Thinking: Novice Expert Data gathering from multiple sources Distinguish relevant from irrelevant Identifies missing information Checks accuracy Predicts beyond the presentation Extends thinking beyond the medical record Evaluates differing points of view Identifies and examines alternatives Flexibility - change in assignment Willingness to reconsider Anticipates & Manages complications

Support for Internship/Orientation

Teaching preceptors Communication Interpersonal skills How to provide experiential learning while protecting safety Teaching how to teach, how to foster critical thinking development

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History of VNIP What we have learned Measurable outcomes - help to ‘sell the concepts/program’ The value of standardization and collaboration Expectations for the future of this collaborative project www.vnip.org

References: Benner, P. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188-199 NCSBN Position paper (2005) Clinical Instruction in Prelicensure Nursing Programs. August 2005. Accessed on 3/21/08 at https://www.ncsbn.org/pdfs/Final_Clinical_Instr_Pre_Nsg_pr ograms.pdf