The Roles and Responsibilities of Critical Care Nurses in Their Workplace - Literature review Example

TABLE OF CONTENTS Introduction 2 Critical Care Nursing 3 Expertise in the Workplace 3 Developing Expertise in the Workplace 4 Competent stage 5 Proficient stage 5 Expertise stage 5 Types of Knowledge in Learning 6 Propositional Knowledge 6 Procedural Knowledge 6 Dispositional Knowledge 7 Conclusion 11 References 12 Propositional Knowledge……………………………………………………………….....6 Procedural Knowledge ………………………………………………………………… ...6 Dispositional Knowledge……………………………………………………………….....7 Resources available in the Workplace to develop Expertise……………………………………...7 Direct Method…………………………………………………………………………....8 Indirect Method…………………………………………………………………………..9 Appropriateness of affordances for Developing Expertise………………………………………9 Strengths………………………………………………………………………………....10 Weaknesses………………………………………………………………………………10 Conclusion……………………………………………………………………………………….11 References………………………………………………………………………………………..12 Workplace Learning Introduction Nurses operate in a dynamic and ever changing professional environment. A significant proportion of the learning experience for nurses occurs in the workplace and the nurses envision themselves as lifelong learners in the pursuit of expertise in providing nursing care. For nurses, the work environment also doubles up as a learning environment. This paper will discuss how expertise is developed in the workplace by examining how the expertise required performing effectively as a critical care nurse in a hospital. A hospital, St Vincent’s Hospital Melbourne, is the workplace selected to examine the extent to which the expertise required for effective performance is developed the workplace. The paper will also identify the factors that support or hinder the development of expertise for critical care nurses in the hospital by evaluating the suitability of the resources provided for the development of expertise among the nurses. The hospital is a public tertiary referral center which provides a variety of services such as medical and surgical services, aged care, rehabilitation and mental health care. The hospital has over 5,000 staff members and a capacity estimated at 848 beds (St Vincent’s Hospital 2011). At the head of the hospital’s organizational chart is the Chief Executive officer to who the various directors of several departments report such as the director of surgical and specialist services and director of medical services, aged and community care. In the hospital’s organizational structure, nurses operate under the chief nursing officer and in specialized departments such as surgical services, specialty services and aged and community care (St Vincent’s Hospital 2011). Critical care nurses operate under general practitioners and surgeons under medical and surgical services. The paper will concentrate on the development of expertise among the critical care nurses only. The paper will first identify and illustrate some of the roles and responsibilities of critical care nurses in their workplace and the kind of learning that is required to achieve expertise in nursing. The paper will outline some of the basic requirements for becoming a critical care nurse and then use literature on nursing to describe what is considered as expertise in nursing by identifying the various kinds of learning required for nurses to become experts in their respective jobs. Critical Care Nursing Critical care nursing plays a fundamental role in the delivery of health care services in any health care facility. A critical care nurse is a licensed professional responsible for ensuring that all acutely and critically ill patients receive optimal nursing care (ACCCN 2002: Benner et al 2009). Critical care nurses mainly operate in several specialty fields such as cardiac care, intensive care, and neurological and cardiac surgical intensive care focusing on the care of patients who are critically ill, suffering from life threatening health crises or unstable patients. Critical nursing care focuses on several areas in supporting medical care such as diagnosis, treatment, care planning and priority setting. They do a majority of patient assessment, evaluation and care delivery within intensive care units (Brilli et al 2001). Expertise Expertise is relative. According to Dreyfus (2008), a novice and an expert lie at the two extreme ends of skill acquisition and learning. Selinger and Crease (2006) define an expert as someone who possesses an extensive fund of knowledge and a set of skills or methods to be able to aptly and successfully deploy this knowledge in response to situations or questions that may be new to them in the domain. An expert knows what to do, when to do it and how to do it. In essence, an expert has achieved a comparatively high level of mastery of their domain as compared to others (or novices) and are able to rely on their intuition rather than analysis in assessing a situation and determining how to respond to it (Dreyfus 2008: Benner et al 2009). Expertise in the Workplace The basis for expertise in the workplace is competence. The ACCCN has developed several competency standards for critical care nurses which are important for evaluating the expertise of critical care nurses in the workplace (Scholes 2006). These competency standards provide the elements of the specific competency benchmarks for critical care nursing practice and can be applied to the evaluation of the expertise of critical care nurses in practical situations (ACCCN 2002). In the case of an emergency situation such as a cardiac arrest, an expert critical care nurse in their reaction would be expected to conform to the standard of evaluating and effectively responding to changing situations by making rapid decisions which may be crucial to the survival of the patient such as whether to use a defibrillator (Scholes 2006). Developing Expertise in the Workplace Effectively developing expertise among critical care nurses encompasses several stages. For instance, Farrar & Trorey (2008) discuss five key stages of developing expertise. These stages include; the novice stage, advanced beginner stage, competent stage, proficient stage and the expert stage. In St Vincent’s Hospital, hospital staffs working as critical care nurses are already qualified with relevant clinical knowledge and skills thus this section will only focus on the competent, proficient and the expert stages of developing expertise in the hospital. Competent stage During this stage, critical care nurses should have solid knowledge and experience in working with patients and their families. They should be able to effectively apply their clinical knowledge and skills towards providing interventions that promote health, disease prevention and the overall well-being of patients. Furthermore, they should also be able to maintain high standards of nursing care through the use of relevant and up to date nursing strategies or approaches. According to Alspach (2008), understanding the needs of patients is critical to providing effective clinical services. Thus during this stage, nurses should be in a position to identify the medical needs of patients and find ways of addressing these needs in order to promote the well-being of patients. Proficient stage Currently, technology is a very important tool in nursing practice since it helps to promote efficiency. A general understanding of information technology and how hospital information systems works is imperative for critical care nurses as this can help to enhance efficiency in operations and processes of service delivery. It is expected that during this stage, critical care nurses should be able to effectively diagnose, conduct patient assessment administer medical and therapeutic interventions, monitor and coordinate care for a wide range of patient groups. They should also be able to contribute to research based practices. Moreover, during this stage critical care nurses should be able to effectively plan for patients’ medical and therapeutic interventions and efficiently utilize the available resources (Wyckoff et al 2009). Expertise stage During this stage, critical care nurses should exemplify effective leadership and decision making in complex situations. They should posses solid knowledge and experience in providing a wide range of medical and therapeutic interventions to patients with terminal illness. It is in this stage that critical care nurses should demonstrate their leadership attributes in their work relations by effectively communicating and collaborating with other professions in a bid to enhance the delivery of quality health care services. They should also act as mentors in promoting the professional development of others and building a supportive work environment. In cases of emergency, they are expected to make quick and effective decisions that will promote the wellbeing of patients and their families. Types of Knowledge in Learning Billet (2001) identifies three types of knowledge that professionals (critical care nurses) should learn and apply at all levels of expertise: propositional knowledge, procedural knowledge and dispositional knowledge or personal dispositions. Propositional Knowledge Propositional knowledge can essentially be described as the knowledge of facts or the knowledge that such and such is the case. Propositional knowledge is what Ryle (1949) refers to as “knowledge that”. Propositional knowledge is generated by two conditions; truth and belief O’Donnell et al 2011). In critical care nursing, propositional knowledge includes internalization of the Hippocratic Oath and knowledge of the laws and standards of practice governing the nursing practice. The trainee nurse must be aware of the roles, responsibilities and expectations of nurses in general as well as the ethical guidelines of nursing practice. Procedural Knowledge Procedural knowledge is arguably the most important form of knowledge required by a nurse to become an expert in critical care nursing. Procedural knowledge essentially describes knowledge about how to do things, the know-how (Ryle 1949). It is knowledge underlying an action, including decision making, anticipation, reaction and responses (Haibach et al 2011). Procedural knowledge is essentially the knowledge required to perform an action or task (Anderson 2001). Procedural knowledge is kinaesthetic; it can be stored in the mind and body and become almost automated. In critical care nursing, the nurse must obtain procedural knowledge such as how to administer resuscitative first aid, how to hook up a patient to urinary and intravenous catheters, how to operate a defibrillator, how to monitor a patient’s vital signs, how to prepare a patient and surgical equipment for emergency operations and other basic tasks expected in critical care nursing. Dispositional Knowledge As Billet (2001) states, ‘individuals are unlikely to engage enthusiastically in acquiring knowledge that they do not value' (p54). For any professional to become an expert they must have a disposition towards certain behaviors consistent with expertise. Ryle (1949) refers to a disposition as the inclination, due to a belief, to do or say various things. A disposition is thus a principle that brings about actual consideration. Dispositional knowledge (also described as dispositional knowledge-how) is a therefore a sort of standing knowledge which does not require the learner to be conscious of their belief in it (O’Donnell et al 2011). The will or belief to act in a certain way is what is required for dispositional knowledge. To become an expert in critical care nursing, a nurse should have a disposition to act in certain ways. For example, due to accumulated knowledge and experience, an expert critical care nurse would identify appropriate situations and language to use when informing the family of the patient about impending demise or advising them appropriately on whether to continue or discontinue life support. Resources available in the Workplace to develop Expertise For a workplace to be suitable as a learning environment that supports the development of expertise, it must have some sort of curriculum, modeling and guiding (Billett 2004). The workplace must also possess some optimal combination of both material and non-material resources to scaffold the development of expertise. As one of the largest hospitals in Melbourne, St Vincent’s hospital provides a supportive environment for development of expertise. The hospital has a wealth of experience through trained, certified and experienced physicians and general practitioners, surgeons, administrators and technical support staff (St Vincent Hospital 2012). The hospital also has ultra-modern medical, surgical and intensive care facilities ranging from some of the latest defibrillator technologies, MRI scanners and a modernized emergency surgical unit. These resources enable critical care nurses to continuously update their stock of knowledge and experience in operating such equipment which is important for the development of expertise. Over the years, the hospital has also modernized its patient management system and through implementation of quality standards. Critical care nurses at the hospital have access to some of the latest patient management software which facilitates their roles and enhances their decision making. Billet (2001) proposes three key contributors to learning through the workplace from investigations in a range of industry sectors. These are engagement in everyday work tasks, direct or close guidance of co-workers and the indirect guidance provided by the workplace itself and others in the workplace. The following section will discuss the direct and indirect methods, subsuming everyday work tasks as constituent of both methods. Direct Method The direct method is based on the philosophy that people are the best source of experience and practical knowledge in the workplace (Billett 2001). On joining the hospital, critical care nurse are placed under the tutelage and supervision of senior nurses in intensive care whose role is to support the seamless integration of new nurses into the hospital’s operations schedule and protocols. This allows critical care nurses to draw directly on the experience of senior nurses in developing their own expertise (Chaboyer and Patterson: Fulbrook 2003). In addition, the chief nursing officer convenes weekly meetings of all critical care staff in the hospital to review the week’s operations and to brief nurses on any recent developments. The hospital also conducts regular simulation exercises to update critical care nurses on best practice standards and the efficient use of new technologies which are critical to development of expertise as they allow critical care nurses to iron out flaws and kinks in their practice (Elizabeth and Cunnigham 2005). Critical care nurses also learn from their fellow co-workers. More experienced critical nurses often provide direction and guidance to newer and inexperienced nurses in the hospital. They advise them on what to do, respond to their queries in unfamiliar situations and even suggest improvements to their care delivery practices. Most significant to the development of expertise is the collaboration between critical care nurses, their co-workers and physicians (also as co-workers) (Chaboyer and Patterson 2001). Critical care nurses are directly given information and gain invaluable experience from their interactions with surgeons, doctors or other specialized practitioners in the hospital as they undertake their daily activities. Indirect Method Billet (2001) mentions that indirect guidance in the workplace is provided by the workplace itself and by others in the workplace. The first of these two forms of learning, observing and listening, takes place daily in the hospital. Critical care nurses watch as co-workers (senior nurses), doctors and surgeons perform their duties in the workplace and this builds towards the mastery of their own tasks and roles. As they engage in both work-related and off-work team activities, they learn how to improve optimal care delivery in the ICU (Reader et al 2009). They also learn through the informal discussions at the hospital canteen or at they hold conversations where they narrate their day’s experiences and trade stories on some of the challenges they have faced in the ICU. This stimulates enhances reflective practice which is essential for critical care nursing. Critical care nurses are also required to attend counseling and peer support sessions where they can share their experiences with counselors and peers (Fulbrook 2003, Bucknall 2000). Secondly, critical care nurses also receive indirect guidance from the hospital as the physical environment of the workplace itself. Critical care nurses shape their development of expertise by learning to operate the medical equipment in the intensive care unit and surgical theatre. They also learn from observing how the hospital’s various administrators operate and from the variety of learning materials in the form of literature, training videos available to them or from conducting simulations on mannequins. Appropriateness of the Affordances for developing Expertise The hospital as a workplace has a variety of material and non material resources available to critical care nurses. However, the effect of these resources varies not only from nurse to nurse but also due to their availability, consistency and quality. The following section evaluates the appropriateness by discussing some of the strengths and weaknesses of the resources available at the hospital in developing expertise for critical care nurses. Strengths As indicated earlier, the hospital has diverse and in-depth experience. The hospital has a mix of highly qualified medical practitioners and administrators from Melbourne and from the larger Australia. The hospital also serves as a training ground for many gifted nurses from universities and nursing colleges around Melbourne therefore ensuring a steady supply of talent. These combined with the hospital’s ultra modern facilities makes it an ideal workplace for critical care nurses. The nature of the medical industry is also one that guarantees work around the year and consequently unlimited opportunities for learning. In addition, the hospital has a very well structured program for integrating “rookie” critical nurses and their training and development under the tutelage of senior nurses and physicians. This enriches the sharing of experiences and learning from the workplace (Johns 1995). Weaknesses While the hospital has as its disposal an impressive variety of material and non material resources, their organizational structure is complex and multilayered therefore there is no clear definition of roles. This would negatively affect learning and development of expertise since nurses are often required to serve with different physicians and in different roles which reduces their likelihood of fine tuning their expertise in a particular area (Fulbrook 2003). For example, critical care nurses may have to perform multiple responsibilities in ICU, surgery and emergency which may not allow them to become experts in any one area. This also makes their performance evaluation unclear. In addition, the multiracial nature of Australia’s population may also negatively affect learning. In the hospital, for instance, nurses from indigenous Aboriginal and Torres Strait Islander communities may discriminate or be discriminated against by co-workers. In addition, nurses may encounter difficulty reconciling cultural beliefs and best practice while providing care to some demographics (Fulbrook 2003). For example, some critical care nursing practices may not be consistent with religious and cultural beliefs- such as providing emergency blood transfusion for Jehovah Witness patients. Conclusion Basically, this paper has examined the kind of learning that is required to achieve expertise in critical care nursing. The findings in this paper depict that the role of critical care nurses encompasses a wide range of demanding tasks that involve taking care of patients and families experiencing life-threatening illnesses. Therefore, developing expertise in this field is very crucial (Wyckoff, Houghton & LePage, 2009). Expertise in this area is mainly characterized by ethical conduct, professional responsibility, leadership and complex decision making. Currently, the St Vincent’s Hospital has the required resources, structures, policies and human recourses that can help to develop expertise among critical care nurses. It is important for the hospital to streamline its organizational structure and to address several gray areas of overlapping roles and responsibilities to make it a suitable learning environment for critical care nurses. References Alspach, G. (2008). ‘Recognizing the primacy of competency and exposing the existence of incompetence’. Critical Care Nurse 28(4), 12-14. Anderson, J.R. (2001) ‘Acquisition of cognitive skill’. In Billett, S. (ed.), Learning in the workplace: Strategies for effective practice. Crows Nest, Australia: Allen & Unwin. Australian College of Critical Care Nurses Inc. (ACCCN) 2002. Competency standards for specialist critical care nurses. 2nd edn. Carlton: ACCCN. Benner, P., Benner, P.A, Tanner, C. A. & Chelsa, C.A. (2009). Expertise in Nursing Practice: Caring, Clinical Judgment & Ethics, Second Edition. New York: Springer. Billet, S. (2010). Learning through practice: models, traditions, orientations and approaches. Dordrecht: Springer. Brilli, R.J., Spevetz, A., Branson, R.D. et al (2001). Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Critical Care Medicine 29(10): 2007-2019. Bucknall, T. K. (2000). Critical care nurses’ decision-making activities in the natural clinical setting. Journal of Clinical Nursing, 9(1): 25–36. Chaboyer, W. P. and Patterson, E. (2001). Australian hospital generalist and critical care nurses' perceptions of doctor–nurse collaboration. Nursing & Health Sciences, 3 (2): 73-79. Dreyfus, H. L. (2008) “What computers still can't do”. In Farrar, N. & Trorey, G. “Maxims, tacit knowledge and learning: Developing expertise in dry stone walling”. Journal of Vocational Education & Training 60(1): 35- 48. Elizabeth, H. & Cunningham, H. (2005). Using clinical simulation to teach patient safety in an acute/critical care nursing course. Nurse Educator 30(4): 172–177. Fulbrook, P. (2003). Developing best practice in critical care nursing: knowledge, evidence and practice. Nursing in Critical Care 8(3): 96-102. Haibach, P.S., Reid, G. & Collier, D.H. (2011). Motor Learning and Development. Champagne, Illinois: Human Kinetics. Hay, D. & Oken, D. (1972). The Psychological Stresses of Intensive Care Unit Nursing. Psychosomatic Medicine 34 (2): 109-118. Kelly, J., & Ahern, K. (2008). Preparing nurses for practice: a phenomenological study of the new graduate in Australia. Journal of Clinical Nursing, 18 (1); 910–918. Johns, C. (1995). The value of reflective practice for nursing. Journal of Clinical Nursing, 4 (1): 23–30. Marshall, P., Currey, J., Aitken, M. & Elliott, D. (2007). Key stakeholders’ expectations of educational outcomes from Australian critical care nursing courses: A Delphi study. Australian Critical Care, 20, 89-99 O’Donnell, A., Reeve, J. & Smith, J. (2011). Educational Psychology: Reflection for Action. New Jersey: John Wiley and Sons. Reader, T. W. Flin, R., Mearns, K. & Cuthbertson, B.H. (2009). Developing a team performance framework for the intensive care unit. Critical care medicine, 37(5): 1787-1793. Ryle, G. (1949). The Concept of Mind. London: Hutchinson. Selinger, E. & Crease, R.P. (2006). The Philosophy of Expertise. New York: Columbia University Press. Scholes, J. (2006). Developing Expertise in Critical Care Nursing. New York: Wiley-Blackwell. St Vincent’s Hospital (2011). Accessed on March 5, 2012 from < http://www.svhm.org.au/aboutus/Pages/aboutus.aspx> Wyckoff, M., Houghton, D. & LePage, C. (2009). Critical Care: Concepts, Role and Practice for the Acute Care Nurse Practitioner. New York: Springer. Read More