STUDENT PROGRESSION: FROM NOVICE TO EXPERT

Laurie Heline CRNA, MS

Clinical Coordinator Oakland University-Beaumont Graduate Program of Nurse Anesthesia

OBJECTIVES At the conclusion of this presentation,

the learner will:1. Discuss the five stages of progression

an RN takes to become a CRNA in clinical education.

2. Identify the clinical instructor's role in each of these five stages of development.  

CLINICAL INSTRUCTION IMPORTANCE

A profession that is not growing is dying.

CLINICAL INSTRUCTORFill many different roles:

Anesthesia providerEmployeeClinical teacher

NOVICE TO EXPERT THEORY

Developed by Dr. Patricia Benner Develop skills over time through a

sound educational base as well as a multitude of experiences

Difference between “knowing that” versus “knowing how”

5 STEPS AN RN TAKES TO BECOME A CRNA

Novice learner Advanced Beginner Competent Student Proficient Student Expert Practitioner

Graduate students are exposed to more facts in one year than their

grandparents were in a lifetime

The sum of all that is known is doubling every seven years.

Think of a student at each stage Anesthesia is both a science and an art

NOVICE LEARNER

Enter as successful ICU nurses Unfamiliar with the OR Process of anesthesia is mysterious No anesthesia experience, little

knowledge

NOVICE LEARNER

Learning must begin somewhere Learn from didactic work theories to

guide actions Theories and rules provide general

rules but do not cover all possible situations

Task-oriented Vary greatly in abilities

NOVICE LEARNER Eager Enthusiastic Motivated Lack of Flexibility Anxious Afraid Uncertain Frustrated Overwhelmed

NOVICE LEARNER Anesthesia students in the first months Average cases:

27 cases at end of first semester155 at end of second semester

NOVICELEARNERWHAT CAN WE DO?

Set clear, detailed expectationsProvide as much consistency as

possibleRemind to focus on patientGuide in organizing tasks

Checklists Mnemonics

Care plansRecognize that students need to gain

confidence

THE ADVANCED BEGINNER

Generally sometime within second semester to beginning of third semester

Marginally acceptable performance Acquired enough knowledge and

experience to:Recognize important aspects Begin to feel comfortableMake some interventions based on

experience

THE ADVANCED BEGINNER

Students have:Limited knowledgeMisunderstood conceptsMay apply knowledge incorrectly

Still focused on tasks but not as overwhelmed by the environment

Small deviations from routine may derail

THE ADVANCED BEGINNER

Perform routine preparation in 30 minutes

Can plan for successive case Skills improving but can continue to

struggle with mask ventilation, poor body mechanics, intubation

Still need constant supervision, should be able to recognize when to ask for help

THE ADVANCED BEGINNER Quickly doubt own ability leading to a

viscous cycle of:performance anxietyself-flagellationfurther failure

Feel responsibility for decision making lies with those who have superior knowledge and experience

THE ADVANCED BEGINNERWHAT CAN WE DO?

Help student with psychomotor skillsRecognize that:

Dependent on instructor’s knowledge Hesitant to voice opinions Still task focused Need help with prioritization Don’t always have good rationale

Allow students to make good and bad decisions

THE ADVANCED BEGINNERWHAT CAN WE DO?

Instructors hesitant to ask questions because think student may have more theory knowledge than themDevelop stock questionsAsk student to explain concept to them

Help identify distinctions of common anesthesia events and share rationale for decision making

THE COMPETENT STUDENT

After 150-200 anesthetics3rd semester end with 271 cases

Able to manage an ASA 1-2 patient undergoing a simple surgical procedure with minimal assistance

THE COMPETENT STUDENT

Demonstrate:Familiarity with variety of basic anesthesia

situations Identify significant aspects of a situationAnticipate events that may occur Improved organizational skillsCan integrate sensory input from

numerous sourcesOwnership, becoming patient advocateTrust in self and comfort with knowledge,

skills, and abilities

THE COMPETENT STUDENT

Must still analyze possibilities of each situation and think through options

Challenge instructor’s knowledge and authority at this stage

Demonstrate competency in some areas and “novice” behavior in others

Complacent

THE COMPETENT STUDENTWHAT CAN WE DO?

Suggest alternatives Ask the student to teach the instructor

something When challenged by a student,

understand this may be part of growth processWhen time is right, discuss with the student and attempt to elicit rationale for behavior

THE PROFICIENT STUDENT

Not necessarily related to the number of months the student has been in the program

Students soon to graduate exemplify proficient level behavior, an entry-level practitioner

Can see the big picture Beginning to show signs of intuitive decision

making Some technical skills excellent, others may

need more practice

THE PROFICIENT STUDENT

May feel overly responsible OR become overly confident Believe their knowledge is more current

than instructorsResults in the potential for humbling errors

No longer concerned with merely performing tasksSeek to prevent common problems and

minimize adverse events

THE PROFICIENT STUDENTWHAT CAN WE DO?

Encourage the independenceRemind them even seasoned

practitioners:Seek help Share tasksRequest consultation when needed

Complacence, so continue to challenge

“Senioritis” behaviors

THE EXPERT PRACTITIONER

Unusual for students to reach Not all CRNAs reach No longer rely on principles, rules, or

guidelines Have difficulty verbalizing how they

make decisions or respond to certain events

Can deal with various possibilities and quickly switch plan of action

THE EXPERT PRACTITIONER Even expert can revert to novice role

when confronted with:New drugNew techniqueUnfamiliar situation

Can still make wrong decisions

NOVICE TO EXPERT MODEL

Way to examine SRNAs clinical growth and development

Some grow rapidly, while others take longer to achieve milestones

We must recognize impact we have on facilitating or hindering learning as we are held in high esteem by students

CLINICAL INSTRUCTORS

Thank you for all you do for our students and the

profession of Nurse Anesthesia!

BIBLIOGRAPHY Benner PA. From Novice to Expert: Excellence

and Power in Clinical Nursing Practice. Commemorative Ed Upper Saddle River, NJ: Prentice-hall, Inc, 2001.

Benner PA, Tanner PA, Chesla CA. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. New York, NY: Springer Publishing Company, Inc; 1996.

Hendrichs B, Thompson J. A Resource for Nurse Anesthesia Educators. Park Ridge, Ill: AANA Publishing, Inc; 2009.

http://currentnursing.com accessed 6/15/2011

http://typhongroup.net accessed 9/15/2011