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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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. 

8. 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

9. Novice to expert
Novice
Advanced beginner
Competent
Proficient
Expert

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

11. 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

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

13. 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

14. 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

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

16. 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

17. 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?

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

19. 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.

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

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

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

23. 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

24. 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

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

26. 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

27. Support for Internship/Orientation

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

29. 29

30. 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

31. 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,
NCSBN Position paper (2005) Clinical Instruction in Prelicensure Nursing Programs. August Accessed on 3/21/08 at ograms.pdf