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This paper uses Patricia Benner's methodology for describing nursing knowledge to demonstrate the structures of nursing knowledge within the Australian context. Experienced nurses were interviewed and requested to relate a critical incident in which they felt that their interventions made a difference in the patients outcome. Their experiences are analysed within Benner's framework.
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Kathleen Ryan, CNS, Coronary Care Certificate, is currently the Clinical Co-ordinator, in the Coronary Care Unit, St. Vincent's Hospital, Sydney. Her nursing experience has been with high dependency cardiac patients and patients in Intensive Care Units. Kathleen is currently in 3rd year of a Bachelor of Education (Nursing) at New England University. |
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This paper explores Patricia Benner's methodology for demonstrating the structure of nursing knowledge.
In From Novice to Expert, (1984), Patricia Benner used exemplars as told by expert nurses in specific patient care situations to identify and demonstrate the nursing knowledge and expertise embedded in nursing practice.
Using Benner's methodology. Two clinical nurse experts from vastly different areas of nursing were selected and asked to describe a critical incident using narrative form and giving their intentions and interpretations of events (Benner, 1984: 44).
Both nurses were working at a 220-bed country Base Hospital situated 300 kilometres from the nearest referring Metropolitan Hospital. One nurse, 'Julie' was working in the combined Intensive Care/Coronary Care Unit, and has been in this area for 8 years. Following completion of her general nurse training at a large metropolitan hospital, 'Julie' undertook the Coronary Care Course at the College of Nursing, and is currently engaged in the Bachelor of Education (Nursing) programme.
Julie described in her interview a critical incident in which she felt her intervention really made a difference in patient outcome (Benner, 1984:300).
Julie:
"The patient was an 18 year-old male involved in a motorbike accident.
He was riding the bike without a helmet and sustained a head injury when he lost control of the bike on a dirt road on his property.
He was admitted to the ICU for neurological observation; initially he was drowsy, but easily rousable. He moved all limbs equally and both pupils were equal and brisk in reaction to light; vital signs were fine.
The following two days I was caring for him; he was alert, orientated and neuro obs were stable, however I was very worried when he started using inappropriate words in everyday conversation.
This was consequently reported to the surgical registrar and Honorary surgeon in charge of his care. Their response was "he's awake, therefore he's OK".
I was still unhappy, as I was sure there was something wrong with him, and that he needed to be looked at by a neuro specialist. I felt frustrated as it was not my 'place' to ask for another doctor to be called in to review the patient. This dilemma was compounded by the fact that the Honorary surgeon in question was related to the Medical Superintendent, whom I would normally turned to if I felt the patient's care was inadequate.
The patient's mother, also a Registered Nurse, had also noticed her son's use of inappropriate words, and asked me whether her son was to be assessed by a neurologist. I explained to her that he had been admitted under the care of the general surgeon, and it was up to him to ask for a neuro consult.
She became very angry: firstly toward her son for not carrying on with his private health cover, as she believed that as a Medicare patient he had no rights to ask for a second opinion. She was also very angry at her previous experiences with a surgeon who was managing her husband's care through a terminal illness. At this stage all I could do was listen to her anger, and when she calmed down and I was able to speak to her, I informed her that she did in fact have the right to seek a second opinion. This was met with a very surprised reaction.
Directly following this incident, I went to the Operating Theatre looking for the surgeon to inform him that Mrs D was very anxious to speak to him. His response was "She's an ex-nurse, isn't she? I'll see her on my rounds." Some two hours later the surgeon graced the ICU with his 'round'. Mrs D's anger had subsided a little, but she was very clear that she was not happy with her son's treatment and expressed the wish for her son to be seen by a neurologist.
This obviously angered the surgeon, but he did ring the neurologist requesting him to see the patient to "shut up the neurotic mother" and that "he was only a Medicare patient".
I left my shift feeling satisfied that the patient was to have a neuro consult. On returning to work the next day I found that the patient had been transferred to a neurological unit in Sydney. Talking to the other nursing staff, I discovered that the neurologist had been very angry at the fact that the patient had been in the ICU for three days without having a full neurological examination, and was exhibiting signs of raised intra-cranial pressure.
On ringing the Sydney hospital to enquire after his progress, I was informed that the CT-scan had revealed a sub-dural haematoma, not requiring surgery, but necessitating speech therapy".
The second nurse "Sue-Anne" is working in the capacity of Oncology Nurse Specialist. at the same country Base Hospital. She also completed her general training at a large metropolitan hospital. and went on to successfully complete her Oncology Certificate at the College of Nursing. Sue-Anne is now studying for the Bachelor of Social Science degree at tertiary level.
Sue-Anne has eight years post-grad experience with 5 years specialising in the field of oncology. Normally she is based in the Oncology Clinic, however this particular incident occurred in the Accident and Emergency Department.
The working hours for Sue-Anne are 0800-1630, Monday to Friday; the staff resources are the Medical practitioner, the Visiting Medical Oncologist who practises at the Clinic weekly, and Sue-Anne is the sole nurse practitioner in Oncology for this country region.
Sue-Anne describes a critical incident in which there was a breakdown; things didn't go as planned (Benner, 1984:300).
Sue-Anne:
"The client was a 45 year-old male with non-Hodgkins lymphoma, diagnosed in 1986. He had initially commenced with CHOP chemotherapy, relapsed in early 1989, and alternative chemotherapy, ABVD, was commenced as per the relapse protocol. These drugs are given when the client develops a resistance to the initial chemo.
This particular afternoon Mr Smith was admitted to the male medical ward for routine chemotherapy, with the ABVD drugs administered via a 'Portacath' inserted into the subclavian vein. Prior to administration, I attempted to check the patency of the Portacath by aspirating the catheter, which was the normal procedure. When unsuccessful, I rang the doctor who is Head of the Chemotherapy Team at a large Sydney teaching Hospital to discuss the problem. I just felt that things were not right.
However, following reassurance from the doctor that this was a "common problem", and he suggested that I run the infusion and if it was running freely that there was "no cause for concern, but watch the cannula site for obvious signs of extravasation". Still with an uneasy feeling, I went ahead and administered the usual 2 litres of fluid observing the client carefully; but he was cheery and not showing any signs of discomfort. He was discharged home that afternoon with no complaints.
The following afternoon at 3:00 pm. Mr Smith rang me to say he had a "dull ache" in his upper chest and neck, on the same side as the Portacath. I asked him to come in to the Accident and Emergency Dept as soon as he could to be assessed. I then contacted the medical physician and informed him of the impending arrival of Mr Smith.
The physician and myself met Mr Smith in the A & E Dept; he looked flushed. and felt hot from the nipple-line to the upper neck; the dull ache persisting in his neck. Vital signs were fine, and he was afebrile. I also noticed he had eartip cyanosis and his right hand was slightly oedemaous. At the time I felt these findings were somewhat vague but could not entirely dismiss them, as I had a 'gut feeling' that something was wrong.
One of the possible reasons for this unusual presentation was drug extravasation, and although the doctor had instructed me to continue with the administration of the chemotherapy, I still felt totally responsible, and I felt a sick feeling in my stomach.
The second possibility was a diagnosis of sepsis, however his temperature was normal. Even so, I commenced him on 2nd hourly observations, with strict orders to contact the RMO if Mr Smith spiked a temp, remembering the susceptibility of the immunosuppressed patient to infection.
The medical oncologist in Sydney was contacted, and suggested a 'portagram' to assess the position and patency of the portacath; the radiologist would be able to perform this at 5:30 pm, and I was committed to working overtime as I was the only member of the medical/nursing able to assess a portacath. The X-ray revealed that the dye had only reached a certain level in the jugular vein. The physician and myself were unsure as to the cause of this, and I again contacted the oncologist in Sydney who could not comment without seeing the X-ray; he suggested close observations.
The medical physician then insisted the catheter be removed; I was very reluctant to do this knowing the difficulty with venous access in this patient, and the likelihood that rV antibiotics would be needed.
At 9.00 pm Mr Smith developed a temperature of 39.7°C; I was now at home - 35 kms from the hospital, and was contacted to be informed that an inexperienced RMO was now attempting to access a now internal palpable-only line. Failing this the RMO found a peripheral vein and IV antibiotics were commenced.
At 0800 hours the next morning, I visited Mr Smith and asked for an urgent review of his blood pathology which had not been checked prior to the commencement of Gentamyein. Discovering a creatinine of 300mmol/Litre, I requested the Genta to be ceased. Blood cultures revealed septicaemia, and Mr Smith was urgently transferred by helicopter to the ICU in a large Sydney Teaching Hospital, suffering from septic shock and profound hypotension.
He recovered well and returned to his country home 10 days later".
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Following Benner's interview methodology both the nurses were asked to describe a critical incident using narrative form and giving their intentions and interpretations of the events. (Benner, 1984; 44).
Both Julie and Sue-Anne used phrases Benner has described as 'perceptual abilities' (1984: Preface xviii). Sue-Anne had what she termed as a 'gut-feeling' about Mr Smith's condition when she was reviewing him in the A & E Dept, and Julie had a 'feeling that something was not quite right' with the young head injury patient. As documented in the interview, these intuitive feelings were substantiated.
Benner also recognises another quality in an expert nurse; they do not ignore their 'hunches', but endeavour to validate the problem, hence ensuring a resolution. Julie and Sue-Anne both acted on their hunches and did not accept they could be wrong even though they lacked medical support. During the interview Julie was asked if she thought she could be wrong: a definite "no!" was the reply.
The communication skills of the nurse are most important; communication with the physician must be clear and convincing. (Benner 1984:142). Julie experienced problems communicating with the surgeon as he was unwilling to listen to her concerns; she was then in a different situation of not having an appropriate medical back-up to turn to, (Benner suggests that this is the most appropriate course of action to take) a not uncommon problem faced in a country Base hospital. For the patient's safety, Julie knew she could not follow up the surgeon's orders and "take no action". Julie not only had to contend with the non-caring attitude of the surgeon, but also faced the extremely emotional mother.
During the mother's angry outburst, Julie demonstrated qualities of compassion and understanding: she spoke professionally, assuredly and honestly to the mother about her son's condition. Although it appeared that Julie's hands were tied, she still managed to intervene appropriately. Benner (1984:66) describes the importance of emotional support for the family and stresses that the nurse must also know when to allow the family greater intervention in the patient care. Julie aptly displayed this skill.
Sue-Anne also exemplified the competency of providing Emotional and Informational Support to the Patient's Family (Benner, 1984:64). Following Mr Smith's transfer to Intensive Care at the country hospital for stabilisation before his trip to Sydney, Sue-Anne constantly reassured the patient and his wife, fully explaining procedures and organising transport and accommodation for Mrs Smith at the Sydney hospital. She also ensured that the medical oncologist and the Head of the Chemotherapy Department in Sydney were updated on Mr Smith's condition and kept them informed on the patient's expected time of arrival into their care. Thus Sue-Anne continued her involvement with Mr Smith through her availability at the expense of routine and timetable (Andrews, 1989:34).
During the interview it became obvious that these two nurse experts exhibited many of the 31 competencies illustrated by Benner, although only a few have been detailed. The essence of a clinical expert nurse is caring, and as Andrews (1989:34) cites Benner (1988) caring necessitates these nurses bend or break rules or make exceptions, and it is only through knowledge, experience and clinical expertise that the nurse expert is able to choose the appropriate course of action for optimal patient care.
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