Nursing Integrative Practicum Program
Comparison of Critical Thinking Processes of Novice & Expert Nurses
Their knowledge is organized as separate facts. They must rely heavily on resources (texts, notes, preceptors). They lack knowledge gained from actually doing (e.g., listening to breath sounds).
The Novice Nurse:
- Tends to focus so much on actions, they forget to assess before acting
- Need clear cut rules
- Is often hampered by unawareness of resources
- Is often hindered by anxiety and lack of self-confidence
- Must be able to rely on step-by-step procedures. Tends to focus more on procedures than on the patient response to the procedure.
- Becomes uncomfortable if patient needs preclude performing procedures exactly as they learned.
- Have limited knowledge of suspected problems; therefore they question and collect data more superficially.
- Tends to follow standards and policies by rote.
- Learns more readily when matched with a supportive, knowledgeable preceptor or mentor.
Their knowledge is highly organized and structured, making recall of information easier. They have a large storehouse of experiential knowledge (e.g., what abnormal breath sounds sound like, what subtle changes look like).
The Expert Nurse:
- Assesses and think things through before acting.
- Knows when to bend the rules.
- Is aware of resources and how to use them.
- Is usually more self-confident, less anxious, and therefore more focused.
- Knows when it's safe to skip steps or do two steps together. Are able to focus on both the parts (the procedures) and the whole (the patient response).
- Comfortable with rethinking procedure if patient needs require modification of the procedure.
- Has a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data.
- Analyzes standards and policies, looking for ways to improve them.
- Is challenged by novices' questions, clarifying their own thinking when teaching novices.
Excerpts borrowed from Alfaro-LeFevre, R. (1999). Critical thinking in nursing. Philadelphia: W.B. Saunders.
Reprinted with permission.
After several weeks of classes and partnered orientation to patient care, novice nurses in our large acute-care health system have learned a great deal. Still, most admit their priority-setting skills could be better. Preceptors, mentors, and other veteran nurses can help them develop prioritizing skills by giving them ample opportunities to make choices while providing support and guidance.
Novice nurses can quickly feel overwhelmed and overloaded. Their efficiency may suffer as they struggle to learn how to group simultaneous interventions. Patience is the first imperative for guiding them. Orientees’ time-management skills improve as they develop routines and get familiar with the facility’s policies, procedures, and supply locations. Urge them to be patient as they explore routines and processes—to take the time to deliberate and reflect. They must recognize that even if they work diligently, they may fall behind in terms of tasks completed in a given period. Nonetheless, emphasize that they should value safety over speed. Encourage their efforts, give helpful feedback, and share your expertise.
Understanding is the second imperative. Transitioning from student to staff, they leave behind the ideal world of nursing school and jump into the real world, which mandates quick but comprehensive planning for multiple patients. They may feel an overwhelming sense of urgency—and stress—from the constant changes and forces pulling them in opposite directions. In choosing what’s most important for patients, they find out that selecting a particular intervention may preclude other desirable ones. Few novices are flexible enough to deviate from plans when new exigencies arise. They must be coached to do so.
The preceptor’s advisory and support roles
While all nurse graduates are schooled in the ABCs of emergencies (airway, breathing, circulation), most lack the judgment, confidence, and experience to act decisively. Until they fully develop their clinical judgment, they must follow the rules. If the rules don’t cover a particular situation, they must rely on more experienced team members for advice and support.
Further confusion may arise when new nurses are called to help teammates while operating within the multiple time demands of a shift. They must learn how to prioritize competing tasks in a way that best serves their patients, respects the team, and maintains energy and focus throughout the shift. An open environment that supports processing of these choices is crucial.
Pacing a shift: The heart analogy
Preceptors in the medical specialty and on our units have developed strategies for helping new nurses become better at prioritizing. I like to give them an analogy borrowed from R. Navuluri—a beating heart—to help them conceptualize the shift and the work pace. A heart, I tell them, can beat faster to induce the physiologic responses needed during a patient code. But if this adrenaline rush is sustained, organic damage results, and stress and exhaustion ensue. For the long term, the heart must adopt a more reasonable pace, beating at a sustained rhythm and resting after challenging episodes.
Similarly, nurses must set a pace that’s steady, sustainable, and equal to the workload. But they also must expect that pace to be disrupted from time to time by emerging demands, and they need to be flexible enough to accommodate these. Just as the body has many mechanisms to restore equilibrium, a work team can change its pace, reorganize care tasks, reconfigure itself, and redelegate responsibilities. To do so requires knowledge of the big picture and refined communication skills, which preceptors should model for new nurses.
Beating a periodic retreat
During diastole, the heart “retreats” as it fills with blood. We advise new nurses to take a similar periodic retreat from work demands, going to a place and time of quiet or solitude so they can be “filled.” This promotes a healthier outflow (systole) of energy they need when they care for patients.
For any nurse—new or veteran—self-care is crucial to survival. Experienced nurses should model quick breaks between patient-care activities to refocus their intentions and restore their energy. Cue them to perform brief “centering” exercises or take brief breaks to drink water, eat lunch, smile for a colleague, or simply express gratitude for the good things in their lives.
Preceptors should teach orientees to think about their own thinking—a process known as metacognition. At our hospital, we do this in a workshop that teaches elements of critical thinking, stressing the Socratic method and reflective practice. The workshop teaches novices how to recognize if they have a tendency to trust assumptions too much, accept obvious explanations, or focus on details instead of seeing the whole picture. Most importantly, it helps novices think critically about what a particular situation demands. Doing this with confidence comes with experience and reflection, an awareness of one’s own thinking, and dialogue with veterans.
As preceptors, we should encourage a questioning mind, acknowledge and embrace ambiguity, and reflect skepticism. To help novices learn how to prioritize, ask them:
- “What are you going to do first? Why?”
- Which is more important? Why?”
- “What could happen if you don’t do this now?”
- “What is most important to the patient?”
Return to these questions throughout the shift as situations change. This coaching and invitation to self-reflection is the best kind of teaching—individualized and respectful, yet direct and targeted.
Our preceptors and other staff are committed to orientees’ success. If a new nurse seems tentative or overwhelmed, colleagues jump in to help her and then debrief her afterward. This behavior requires support from leadership. Conferences among nurse managers, nursing education specialists, preceptors, and orientees occur routinely and as needed to support growth and target areas for increased focus.
Orientation includes a time dedicated to reviewing crisis management, critical thinking, and early detection of patient decline. Preceptors talk about clinical decisions throughout orientation as they share assignments with orientees. “Tell me why you are doing this.” “Why did you decide to intervene at this time?” “Why did you make this choice?” “What would happen if you’d missed this clue?” They strive to keep the novice focused on the big picture, not details. (See Advice for novice nurses.)
Our orientation tools are well-developed so that necessary skills are modeled, taught, and reviewed. Preceptors rededicate to their mission in preceptor forums. Our nursing care model supports us in serving patient needs in multiple roles—as caring healers, teachers, communicators, navigators, problem solvers, vigilant guardians, and transformational leaders. Preceptors revisit these roles throughout the orientees’ first year.
Sustaining the rhythm
Caring about patients is central to quality nursing care. To do this, we must support one another and promote an environment in which experienced nurses assist novice ones and welcome their questions. We must give high priority to nurturing novices and integrating them into the work team. When preceptors have their own priorities straight, they’re better able to help novices make good choices.
Joyce L. Nelson is a nursing education specialist in the Department of Nursing at the Mayo Clinic in Rochester, Minnesota.