DEVELOPING CLINICAL REASONING IN

CRITICAL CARE PRACTICE

A Comprehensive Examination Presented to the Faculty

of

California State University, Stanislaus

In Partial Fulfillment

of the Requirements for the Degree

of Master of Science in Nursing

By

Marcelina Gracia-Lewis

May 2013

CERTIFICATION OF APPROVAL

DEVELOPING CLINICAL REASONING IN

CRITICAL CARE PRACTICE

By

Marcelina Gracia-Lewis

Signed Certification of Approval Page is

on file with the University Library

Dr. Carolyn Martin

Associate Professor of Nursing

Dr. Paula Le Veck

Professor of Nursing

Date

Date

© 2013

Marcelina Gracia-Lewis

ALL RIGHTS RESERVED

iv

DEDICATION

This comprehensive is dedicated to my husband Myke and my children

Melyka, Colizel, Anesia & Philomen. Without their encouragement and love; none of

this would be possible.

v

ACKNOWLEDGEMENTS

Drs. Carolyn Martin and Paula LeVeck are acknowledged for inspiring me to

seek my masters and their patience, guidance, and encouragement through the process

of completion.

My husband Myke Lewis-Tyson is acknowledged for the unwavering support,

understanding, and encouragement that he has given me through the duration of my

academic career.

vi

TABLE OF CONTENTS

PAGE

Dedication ............................................................................................................... iv

Acknowledgements ................................................................................................. v

Abstract ................................................................................................................... vii

CHAPTER

I. Clinical Reasoning in Critical Care Nursing ........................................ 1

II. Teaching and Learning Strategies ......................................................... 11

III. Building Proficiency ............................................................................. 21

IV. Critical Care Orientation Model ........................................................... 31

V. Discussion ............................................................................................. 41

References ............................................................................................................... 44

vii

ABSTRACT

In critical care, nursing knowledge and clinical skills are advancing and grow more complex

in practice. It requires registered nurses to understand complex interventions in a highly

technical environment with advanced problem solving, decision making, and clinical

reasoning. With these advancements and the growing complexity of critical care, traditional

orientation programs that continue to separate theory from practice do not promote clinical

reasoning and inadequately prepare registered nurses to practice independently. To develop

clinical reasoning and become proficient in practice, orientation programs must emphasize

and promote experiential learning in the class and clinical settings. When clinical reasoning

and proficiency are developed, registered nurses understand the global picture of individual

situations and have the ability to provide appropriate care by managing rapidly changing

situations through judgment, thinking, and action. How clinical reasoning and proficiency are

developed and nurtured will be explored through specific teaching/learning strategies, nursing

competencies, and an experiential orientation model.

1

CHAPTER I

DEVELOPING CLINICAL REASONING

The critical care environment is fast paced. A patient's condition may improve

or quickly deteriorate. Professional registered nurses (RNs) in an intensive care unit

(ICU) are faced with unpredictable situations and need to use evidence-based

knowledge to make quick decisions regarding patient care. They must be prepared to

anticipate and understand events that may threaten patient safety while preparing to

take action. Essentially, they must develop the ability to clinically reason. Clinical

reasoning is vital in critical care practice. It allows RNs to interpret new data and

changes in a patient's condition; to understand initial assessments and diagnostic

results. It allows RNs to identify a patient's changing condition and actions needed, in

order to provide safe care and to improve patient outcomes in an ICU (critical care)

environment.

Introduction

A critical care RN receives a patient from the emergency department (ED) that is

intubated, has two vasopressors infusing, normal saline (NS) at 200 milliliters (mls) per hour

and a NS bolus at 500 ml per hour. The patient’s systolic blood pressures remains low in the

80’s with the two vasopressors infusing at the maximum dose and the heart rate is accelerated

at 120-130 beats per minute. The oxygen (O2) demand and respiratory rate continues to

increase. The RN performs a complex assessment, with the primary focus on the cardiac and

respiratory status of the patient. The monitors are reassessed for accuracy and zeroed where

appropriate, medications are recalculated for accuracy and proper dosing, the ventilator is

2

assessed for any discrepancies and for possible adjustments that may be made to improve the

respiratory status and decrease the O2 demand. Adjustments on treatments are made per

ordered protocol and a further assessment is performed after treatments are adjusted but there

is no improvement. At this moment, the RN must dig deeper to resolve the current crisis that

the patient is in. What could cause the current treatments to fail? What tests and procedures

should now be taken to solve this puzzle? The RN pulls information about the unresolved

hypotension with treatment and the respiratory status together and decides to obtain an

emergent arterial blood gas (ABG) because he/she knows if the patient is in acidosis,

vasopressors may be ineffective and the respiratory status will continue to deteriorate. The

ABG results indicate that the patient has a Ph of 7.19 and a bicarbonate level of 8.0. The RN

immediately notifies the physician of the ABG results, explains the patient’s hemodynamic

status with current treatments, and requests a bicarbonate drip for treatment. A 50 milliliter

syringe of bicarbonate is given by intravenous push and a bicarbonate drip is started per

obtained orders. As the night progresses the acidosis is corrected, the vasopressors become

effective, and the respiratory status and O2 demand improves due to correcting the

bicarbonate level. To care for this critically ill patient, the RN had to grasp the clinical

situation and dig deeper than the obvious to understand and resolve the patient’s critical

status. The RN had to apply knowledge and practical skills simultaneously to solve the

problem and stabilize the patient; they had to clinically reason.

In critical care nursing, clinical reasoning goes beyond knowing and thinking;

it also involves the process of taking action and applying knowledge in clinical

practice. According to Benner (1984), nursing knowledge and clinical reasoning

consist of extending practical knowledge through scientifically based investigation

that is developed through clinical experience and practice. Without clinical reasoning,

3

RNs that transition into ICU can be dangerous. They may be a walking/talking

encyclopedia but may not have the ability to apply this knowledge in practice.

Clinical reasoning is practice-based and requires scientific and technical knowledge.

It requires the practical ability to apply knowledge in order to make clinical decisions

for each individual patient. It is the processes of thinking while taking an action and

performing skills (Himmerick, 2011; Jensen & Givens, 1999; Mattingly, 1991).

During the clinical orientation in the ICU, clinical reasoning is developed and

enhanced, preparing RNs to provide quality care to critically ill patients (Dunn,

Lawson, Robertson, Underwood, Clark, Valentine, 2000; Aari, Tarja & Helena, 2008;

Murphy & Nolan, 2006). If clinical reasoning is not further developed during the ICU

orientation, RNs can unknowingly be a danger to the patient and to self. The

development of clinical reasoning during orientation in the ICU is not a choice; it is

mandatory.

Clinical Reasoning Defined

Clinical reasoning is more than a simple application of theory; it is RNs

developing a treatment plan that addresses the medical and personal needs of each

patient. Clinical reasoning occurs when RNs move through available facts and

inferences to make a decision on the patient's plan of care (Simmons, 2009; May,

Greasley, Reeve, & Withers, 2008; Kaldjian, Weir, & Duffy, 2005). This chain

process involves the cognitive activities: judgments, decisions, and actions made

when caring for a patient.

Over time the understanding of critical thinking as it pertains to the clinical

4

setting has matured into the concept of clinical reasoning. The American

Philosophical Association (APA) Delphi Research Report defines critical thinking as:

... Purposeful, self-regulatory judgment that uses cognitive tools such

as interpretation, analysis, evaluation, and friends, and explanation of the

evidential, conceptual, methodological, criteriological, or contextual

considerations on which judgment is based (APA Delphi Report, 1990, p. 2).

Critical thinking is directed, disciplined, and monitored by self; however, it does not

address the application of knowledge and technical skills into clinical practice

(Petress, 2004; Colucciello, 1999). To critically think, RNs must assess and evaluate

data but to clinically reason, they must have the ability to take the data and apply it

theoretically and technically in nursing practice.

The development of clinical reasoning is not limited to the initial patient

assessment; it is an ongoing and changing, thinking, and decision-making process

(Himmerick, 2011). Clinical reasoning is the foundation of problem-solving. It

includes RNs self-confidence in clinical practice, ability to place events within proper

context, and the ability to adapt to new technology. Registered nurses that have fully

developed clinical reasoning analyze new information, seek out, and verify useful

discoveries that aid in caring for critically ill patients.

Most recently, a comprehensive definition of clinical reasoning was also

provided by the National League for Nursing Accreditation Commission (NLNAC):

The deliberate nonlinear process of collecting, interpreting, analyzing,

drawing conclusions about, presenting, and evaluating information that is

5

both factual and belief based. This is demonstrated in nursing by clinical

judgment, which includes ethical, diagnostic, and therapeutic dimensions and

research (NLNAC, 2002, p. 8)

The evaluation of knowledge, current practices, and research is ongoing in the

process of clinical reasoning.

Theoretical Foundation

Clinical reasoning is essential to the nursing profession. Elements that are

integral to the clinical reasoning process include deduction, analysis of data, and

efficient assimilation of data (Jensen & Givens, 1999; Mattingly, 1991; Simmons,

2009). In the end when RNs advance from novice to expert, there is no substitution

for experience (Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner, Hughes, &

Sutphen (2008) describe limitations in providing high-quality care as a lack of

experience needed to provide optimal treatment. To develop clinical reasoning it is

beneficial for RNs to care for many different patients with different medical histories

but similar diagnoses and pathology (Cohn, 1989; Himmerick, 2011). When RNs

receive patients who have common diagnoses but a difference in medical history,

they develop the ability to filter through information and gain the experience that is

needed to develop clinical reasoning.

Clinical reasoning requires multiple forms of nursing knowledge that involves

RNs ability to think, apply, and perform. Registered nurses (RNs) ability to practice

and replicate knowledge includes practical, scientific, and technical knowledge, while

the ability to reason and relate knowledge to practice includes theoretical, evidence-

6

based, and intuition. Clinical reasoning requires the practical ability to identify the

relationship between scientific and technical knowledge and to know how it applies to

individual patients in practice. It is developed and refined through experience in

actual situations (Benner et al., 2008). Applicable and theoretical knowledge

combined is known as nursing knowledge; required to develop clinical reasoning.

According to Benner, Chesla, & Tanner (1996), RNs who have developed

clinical reasoning portrays six characteristics: pattern recognition (the ability to

perceive relationships and identify patterns), similarity recognition (the ability to

recognize resemblance of patient cases past and current), common sense

understanding (the ability to see the cultural and emotional meaning of each patient),

skilled know-how (cognitive ability acquired in clinical practice), sense of salience

(the ability to differentiate important and unimportant events), and deliberate

rationality (ability to maximize judgment and consider options). Experiential and

practical knowledge is essential in the development of clinical reasoning and it is vital

in critical care. With balance, RNs are able to meet patient needs while using methods

that are impactful and lead towards positive outcomes in unique clinical situations.

Through clinical reasoning RNs are able to bring knowledge and experience into

practice and simultaneously apply them in patient care.

Developing Clinical Reasoning through Experiential Learning

Novice ICU RNs do not initially have the habits and preparation to clinically

reason as do veteran ICU nurses. It is developed through experiential learning and

initially requires clinical orientation and a conscious effort to pull book knowledge

7

and know how together when making clinical decisions. Clinical reasoning is

theoretical knowledge, clinical practice, and experience combined as one and it is

gained through a combination of multiple learning mechanisms. The mechanisms

involved in the development of theoretical knowledge and clinical repetition are case

studies, simulation, clinical orientation, and reflection.

The initial form of learning to assist in the development of clinical reasoning

is case studies. RNs learn initially through multiple written case studies, then

eventually experience that case in a clinical practice setting. This happens when RNs

pull their practical and theoretical knowledge together to make a decision. Through

case studies RNs are able to reason while in transition and evaluate the change in an

emerging situation by pulling out the "how" and "why" (Benner et al., 1999;

Grossman & O’Conner, 2010). Case studies can be the starting point in the

development of clinical reasoning in critical care.

Simulation is an artificial replication of events that may have occurred or may

occur in actual nursing practice. It allows RNs to learn in a closed and safe

environment. Simulation is a powerful teaching tool because it allows RNs to think

critically in a simple environment (Benner et al., 2008; Henneman & Cunningham,

2005). Registered nurses learn to think while in action through the evaluation of

interventions given to patients (Benner et al., 1999). This means RNs learn from a

practical application, a vital component in the development of clinical reasoning.

Simulation assists RNs in developing a strong theoretical nursing foundation and

efficient clinical skills needed to practice in ICU.

8

Clinical orientation is learning in a live setting. It is where RNs begin to

develop clinical reasoning through the processing and application of knowledge into

practice (Hicks, Merritt, & Elstein, 2003; Kreiter & Bergus, 2008; Lewis & Smith,

2001). During clinical orientation, novice RNs are mentored and guided by

experienced RNs who assist with the understanding of scientific and technical

knowledge in practice (Benner et al., 2008; Murphy & Nolan, 2006; Morris, et al.,

2007). It is through practice, experience, and guidance that RNs learn to pull nursing

knowledge together when forming a clinical decision.

The last form of learning that is beneficial in the development of clinical

reasoning is reflection which includes the processes of theoretical and clinical

learning. Through reflection the thinker examines assumptions and questions or

doubts the validity of arguments, assertions, and even facts in the case (Benner et al.,

2008; Grossman & O’Conner, 2010). Reflection contributes to the development of

clinical reasoning by teaching RNs to never assume that only one answer is correct.

The process of reflection teaches RNs to generate new ideas and endless possibilities.

They learn to think outside the box, which is a vital process in clinical reasoning and

experiential learning. With reflection, RNs are able to gather past experience, current

knowledge, and evidence-based practice together while making decisions regarding

their patient’s condition (Benner et al.,2008; Berkow, Virkstis, Stewart, Aronson, &

Donohue, 2011).

When clinical reasoning is developed through experiential learning (case

studies, simulation, clinical orientation, and reflection) it becomes second nature;

9

RNs are able to decide and act immediately with ease (Benner et al., 2008; Harjai

&Tiwari, 2009). Registered nurses know that similar symptoms have various

meanings and consequences for each patient. They are able to identify cues that

indicate system decompensation or improvement and know how to appropriately treat

the patient. The ability to clinically reason must be developed and nurtured in the

ICU.

Discussion

Clinical reasoning in nursing is a thinking process that includes theoretical

knowledge and clinical skills. With the inclusion of theory and clinical practice,

clinical reasoning is developed through experiential learning that may be obtained

through case studies, simulation, clinical orientation, and reflection. The development

of clinical reasoning occurs in a clinical setting that promotes the application of

knowledge and clinical skills simultaneously. Each form of learning promotes and

refines the use of current knowledge in order to develop a deeper understanding of

how, when, and why clinical reasoning is applied in nursing practice.

The study of clinical reasoning stresses the importance of RNs ability to apply

nursing knowledge at the bedside. Through experiential learning, RNs can gain a

significant amount of knowledge and the ability to practice safely in an ICU.

Registered nurses who have developed clinical reasoning will bring their knowledge

to a situation in which standard treatments and available resources may be insufficient

to preserve the life of the patient. When the patient’s outcome is uncertain and

consequences may be severe, critical care RNs must have the ability to clinically

10

reason and think beyond current practices to improve the patient’s outcome. When

RNs are able to combine knowledge and apply it to practice, they have developed

clinical reasoning.

11

CHAPTER II

TEACHING/LEARNING STRATEGIES FOR CLINICAL REASONING

When registered nurses (RNs) decide to transfer into critical care, they must

acquire advanced theoretical knowledge and clinical skills. Through the process of

learning, RNs eventually develop the ability to apply this new knowledge when

making clinical decisions. When RNs are able to combine in-depth knowledge and

clinical skills, they are using clinical reasoning. The purpose of this chapter is to

explore the stages of nursing development and learning strategies that will aid in the

development of clinical reasoning.

Introduction

The development of clinical reasoning is nurtured through experiential

learning (Benner, 1984). It occurs in clinical settings that may be either virtual in a

simulation lab or real in critical care orientation. Experiential learning also involves

the process of analyzing information from current and past experiences (Benner,

1984). Processing and analyzing information can be enhanced through strategies that

include case studies, simulation, clinical orientation, and reflection. By combining

hands-on practice in a clinical setting and information analysis, RNs can develop the

clinical reasoning that is imperative to provide sufficient patient care and to improve

patient outcome (Kreiter & Bergus, 2009).

To provide care to critically ill patients, RNs must assimilate technical skills,

establish priorities of care, and make clinical decisions regarding patient care (Dunn,

12

1992). With well-developed clinical reasoning, they are able to generate, apply, and

evaluate different approaches to care. Clinical reasoning develops and expands over

the course of a professional’s career, following a novice to expert path (Murphy,

2004; Morris et al., 2007). According to Benner (1984), clinical reasoning is

developed through experiential learning that occurs while RNs are in the clinical

setting. When utilized, experiential learning strategies enhance and reinforce clinical

reasoning.

Stages of Experience

Experience in critical care is obtained through an educational process that

involves the evaluation of performance and knowledge. Through experience RNs

learn to perform procedures, uncover gaps in practice, and apply treatments

recommended for specific patients (Benner, Hughes, & Sutphen, 2008). Excellence in

critical care nursing means generating more knowledge in science and technology,

through actual practice and learning strategies (Ellis & Hartley, 2009). Experience

and excellence in clinical practice are differentiated at various levels between novice

and expert (Benner, 1984). The application of RNs knowledge and skill will

determine if they have developed clinical reasoning and are able to apply it in

practice.

Each RN that transitions into critical care will enter with their own individual

skill set. This is dependent on the area of nursing from which they transition and the

length of time they have practiced as an RN in that specific area (Murphy & Nolan,

2006; Morris et al., 2007; Thomason, 2006). Benner (1984) categorizes nursing

13

experience into five levels: novice, advanced beginner, competent, proficient, and

expert. Each level has individual skill sets and levels of thinking. The initial levels of

novice and advanced beginner focus on building technical skills and tasks, whereas,

at the other levels, RNs are able to think outside the box, clinically reason, and

develop advanced skill sets (Benner, 1984). Each level of nursing requires different

teaching strategies to aid RNs in transitioning from novice to expert.

Novice.

At the beginning of a career, a person is a novice, defined as a beginner or an

inexperienced person (Webster New World Dictionary, 2003). In nursing, novices

RNs enter a clinical setting where they have no experience practicing independently

with that specific patient population. They are taught about clinical situations through

objective information such as a patient’s weight, intake, blood pressure, pulse, and

other anthropometric measure that describes measurable parameters of a patient’s

condition (Benner, 1984). When new RNs enter critical care, they are focused on

mastering tasks and skills versus analyzing the clinical situation.

Advanced Beginner.

The next category of experience is advanced beginner. As advanced

beginners, RNs new in the intensive care unit (ICU) have graduated from a focus on

technical skills and book knowledge to a stage of incorporating situations from

previous experiences. They are able to make decisions according to guidelines but

unable to differentiate aspects and attributes of a situation (Benner, 1984). Advanced

beginners need assistance in the clinical setting to set priorities and filter through

14

important data prior to making a clinical decision. They have learned from different

situations, and begin to recognize principles that will influence actions (Benner, 1984;

Fetter-Andersen, 1999; Hood & Leddy, 2003). Beginners focus on performance and

skill and remain technical and factual; they are not yet at the stage where the thinking

process involves reasoning. To transition from advanced beginner to competent, RNs

must learn to utilize past experience (personal case studies) in the process of making

clinical decisions (Benner, 1984).

Competent

Competent critical care RNs have experience in a specific critical care

specialty and are able to form a decision based on the goals of the institution and the

critical care unit which on they work in ( Hood & Leddy, 2003; Joseph, 2003).

According to Benner (1984), competent RNs have a feeling of mastery and the ability

to cope with and manage the contingencies of clinical nursing. Competent critical

care RNs eventually become proficient in their practice and continue to advance their

skills and knowledge. Registered nurses are able to filter through information, decide

what is important, and what can be ignored, but have not yet developed clinical

reasoning.

Proficient

Proficient is the stage of development in which RNs begin to blend personal

experience with factual and general realities in clinical practice (Kelly, 2008).

Proficient RNs learn from experience, what typical events to expect in a given

situation, and how plans must be modified in response to these events (Benner, 1984).

15

It is at this stage of learning that RNs begin to utilize experience with clinical and

theoretical knowledge simultaneously when making clinical decisions. Proficient RNs

learn and grow by recalling and reevaluating current and past clinical experiences.

When proficient, RNs know that there is more to clinical practice than technical skills

and objective data; they seek out other possible answers in flexible and innovative

patient plans of care. They begin to develop clinical reasoning (Benner, 1984; Dunn,

1992; Lindberg, 2006).

Expert

The stage ICU RNs must strive for is expert. As experts RNs are able to

perform duties while integrating knowledge, principles, and reflection; they are able

to clinically reason. As an expert, RNs are highly efficient because they now include

intuition in clinical situations and decisions (Benner, 1984). Their clinical experiences

guide practice. Expert RNs understand the process needed for clinical reasoning and

how it relies on theoretical knowledge and technical skills (Mattingly, 1991; Murphy,

2004). As experts, RNs are able to read situations and flexibly respond to the patient’s

changing condition and needs. Expert clinicians constantly learn and refine their

practices based on each patient’s responses, other medical professionals’ practices,

and advanced clinical practices in nursing (Benner et al., 1999; May et al., 2008).

They do not make assumptions and continue to seek out answers when they question

anything involved in patient care.

The categories of nursing levels should be assessed and reevaluated

throughout the learning and growing process of RNs. Through assessments and

16

reevaluation of RNs level of clinical reasoning and skills, an appropriate teaching and

learning plan must be developed to assist RNs progress from novice to expert. The

teaching and learning plan must promote experiential learning and utilize strategies

that promote advancing clinical skills and the development of clinical reasoning.

Learning Strategies

This section explores learning strategies that will aid in the RNs development

of clinical reasoning. To develop clinical reasoning, clinical practice is needed to

advance from novice to proficient and eventually to expert in practice (Benner, 1984;

Jensen & Givens, 1999). Experience may be gained in a live or virtual setting where

RNs utilize reflection and case studies. When one learning strategy is used alone,

learning may be difficult but when two or more of these strategies are utilized

together, it is powerful (Murphy & Nolan, 2006; Morris, et al., 2006).

Simulation and Case Studies

Simulation and case studies are learning strategies that can be utilized

together. When teaching in a virtual setting, simulation and case studies combined

create a realistic setting where RNs may experience specific clinical situations that

must be managed at a rapid rate to stabilize a patient. Through simulation, there is the

potential to improve the effectiveness, efficiency, and safety of patient care

(Henneman & Cunningham, 2005). It is a learning strategy that allows mistakes

without causing harm to a patient. To utilize simulation completely, it must be

combined with case studies. Registered nurses must learn about complex disease

processes, how to manage patients hemodynamically, and how to perform complex

17

procedures over a short period of time. By combining case studies with simulation,

the scenario becomes realistic causing RNs to feel the pressure that resembles the

critical care environment and prepares them to manage situations independently

(Rossier & Stefanski, 2009). By utilizing simulation and case studies together, RNs

have the opportunity to analyze various case studies and discuss what was missed,

what went wrong during simulation, and what could have been done differently to

improve the patient outcome (Henneman & Cunningham, 2005).

Simulation and case studies are strategies that can be utilized during the

novice and advanced beginner stages of nursing (Dunn, 1992; Murphy & Nolan,

2006; Morris et al., 2007). These two teaching mechanisms together promote the

application of knowledge and the performance of clinical skills at the bedside. They

provide the novice and advanced beginner with a safe environment when they

initially begin to develop their critical care skills and allow nurse educators or expert

nurses to critique novice RNs on what was performed and why. It assists with the

application of theory and technical skills in a clinical setting which is the first step

needed to develop clinical reasoning (Day, 2007; Rossier & Stefanski, 2009).

Clinical Orientation

Clinical orientation is a process where learners are introduced to the clinical

setting. It is during orientation RNs learn to understand patients, to interpret clinical

data, and to develop individual plans of care (Murphy & Nolan, 2006; Morris et al.,

2007). Registered nurses experience real life situations, complex disease processes,

appropriate treatments, and advanced nursing skills. One learns to filter through data

18

that contributed to a patient's acute condition. Without ICU orientation the

development of clinical reasoning would be delayed.

Clinical orientation is a vital teaching strategy needed for experiential

learning. It is through actual practice and application that RNs begin to advance from

novice to expert because they learn how to differentiate and treat multiple disease

processes within different populations. Nursing interventions are generated from

actual clinical situations, which involve physical, social, and psychological nursing

components (Benner et al., 1999; Murphy & Nolan, 2006). Clinical orientation is vital

in the development of clinical reasoning for a novice ICU nurse but clinical reasoning

remains a constant throughout a nurse’s professional career.

Preceptor

Preceptors teach; they educate (Webster New World Dictionary, 2003).

During clinical orientation preceptors will assist RNs in learning the knowledge and

skills needed to practice in critical care. Preceptors set the stage for application and

analysis of knowledge and data. They have the power to influence a preceptee’s

development of clinical reasoning and bedside skills (Murphy & Nolan, 2006; Morris

et al., 2007). Preceptors also possess expertise and are a resource for the preceptee.

They validate and identify levels of competency and clinical reasoning. At the novice

stage, preceptors influence RNs development of standards of practice, critical

thinking, and clinical competence at the bedside.

Reflection

Reflection is a learning strategy that aids in the development of clinical

19

reasoning by teaching RNs the process of examining assumptions while questioning

the validity of arguments, assertions, and facts of the case (Benner et al., 2008).

Through reflection RNs develop the ability to see beyond the numbers and details, to

learn to question data, and to know that other causes and outcomes are possible (Day,

2007). When RNs utilize reflection they are able to recall what worked, what did not

work, and why. In practice, to develop effective clinical reasoning RNs must be able

to reflect because it is a process that is needed to promote active learning, self-

awareness, and complex thinking in the ICU (Benner et al., 2008; Himmerick, 2011;

Murphy & Nolan, 2006). Through reflection, RNs learn to describe the patient's

situations and to use skills they have learned from specific experiences (Murphy,

2004). It helps the learner identify areas where reasoning must be improved

(Atkinson & Nixon-Cave, 2011; Rashotte & Thomas, 2002). Reflection and

evaluation are vital components of clinical reasoning.

Reflection is a developed over time and is used primarily by proficient and

expert RNs in practice. It is the process of recalling and recognizing change and

requires more than a simple transfer of knowledge or facts. It requires practice while

observing and thinking through changing situations (Benner et al., 1999). To become

an expert nurse and to have the ability to clinically reason, one must reflect because it

is how one learns and grows from previous experiences. It is through reflection that

RNs remain attuned with active learning, self, and complex situations.

Discussion

The development of clinical reasoning remains a crucial step in development

20

of proficiency and eventually expertise in critical care. RNs must become experts in

critical care with the ability to read situations while clinically evaluating processes

and outcomes (Benner, Hooper, & Stannard, 1999). By developing clinical reasoning,

a nurse is able to view the patient at a deeper level. Registered nurses learn to make

decisions through the inclusion of what they see and what they know may occur.

Clinical reasoning is a skill that is obtained through experience and action, trial and

error. It uses innovative and practical teaching strategies that promote thinking while

in action.

These strategies promote clinical reasoning as RNs form judgments, make

decisions, and perform actions. It can be thought of as an internal dialogue that occurs

before, during, and after patient care (Givens & Jensen, 1999). By using a

combination of the strategies RNs develop the ability to recognize change in a

patient's condition through observation and application in a changing situation; they

develop clinical reasoning (Benner et al., 1999). Reasoning that continues to develop

and grow as RNs shift from one level of experience to the next is the process that

continues through RNs career.

The building blocks of clinical reasoning involve knowledge and action,

gained through a combination of analytic and action strategies. Clinical reasoning is

developed through experience in a virtual and real clinical setting. The teaching and

learning strategies: simulation, case studies, clinical orientation, and reflection aid in

the development of clinical reasoning. Through these strategies, RNs progress from

novice to expert and develop clinical reasoning.

21

CHAPTER III

CRITICAL CARE PROFICIENCY

In critical care, building nursing proficiency means going beyond a basic skill base.

Health care providers have multiple specialties but the knowledge and skill base needed by

registered nurses (RNs) in each intensive care unit (ICU) is variable. Even with this variation

in clinical skills there are still commonalities among practice, knowledge, and competencies

in each unit. The purpose of this chapter is to discuss key nursing competencies needed to

build proficiency in critical care practice. The nursing competencies discussed are applicable

to each critical care specialty and are applied daily in practice. With the development of these

nursing competencies, RNs will be proficient and able to safely practice in an ICU.

Introduction

In critical care, RNs are expected to have a vast amount of knowledge and clinical

skills when making decisions and performing care. The knowledge and nursing competencies

that RNs need to become proficient are initially obtained through an orientation program in

the classroom and clinical settings. Once acquired, critical care knowledge is developed

through nursing competencies in clinical practice which leads to proficiency. Registered

nurses are able to provide adequate care to patients at any level of critical care.

Registered nurses are considered proficient when they acquire a sufficient amount of

knowledge and experience to safely practice. Proficiency is defined as being competent and

skilled (Webster New World Dictionary, 2003). When proficient, RNs have the ability to

apply theoretical and clinical knowledge independently into practice while holistically

assessing each situation. According to Benner (1984), proficient RNs are able to understand

situations overall. They are able to pinpoint the primary problem and resolve it while utilizing

22

standards of practice and following physician orders. Thus, RNs can provide adequate care to

patients and are less likely to have errors in practice.

Nursing competencies are defined as the overlap of knowledge with the performance

components of psychomotor skills and clinical problem solving; it is the application of

knowledge in the clinical setting (Clark, Crowder, Dunn, Herewane, Lawson, & Pubrison,

2000). According to the American Association of Critical Care Nursing (AACN, 2008)) and

the British Association of Critical Care Nursing (BACCN, 2008), standard nursing

competencies involve assessment, evaluation, education, teamwork, resource utilization, and

leadership. Each competency indicated by the AACN and the BACCN is applicable to all

ICU specialties because they build knowledge, clinical practice, and address professional

growth. Nursing competencies are applied during the development of novice RNs and

continue after proficiency is obtained in practice. These standard nursing competencies assist

RNs with the development of professional practice and clinical reasoning (Dunn et al., 2000;

Fordham, 2004). To build proficiency, nursing competencies are needed that allow RNs to

closely assess information that is present in the clinical situation (Lindberg, 2006; Walker,

2001). Competencies must be mastered for RNs to become proficient in practice. By

establishing standard nursing competencies in an ICU program RNs’ develop the skills and

knowledge necessary to become proficient when providing care to the critically ill.

Intensive Care Key Competencies

Nursing competencies in ICU are used to promote learning in order to advance

practice. They are measures that address the processes of thought and application in clinical

practice. The key nursing competencies that RNs must develop to become proficient in an

ICU include clinical reasoning, teamwork, leadership, cohesiveness, and reflection (Dunn,

1992; Thomas, 2006). By mastering each nursing competency during orientation, RNs will

23

develop the six Benner traits that define proficiency in an ICU (Benner, Hooper- Kyriakidis,

& Stannard, 1999).Once accomplished; RNs gain a holistic understanding of critical care

practice and are able to better care for the critically ill and their families (Benner, Hooper-

Kyriakidis, & Stannard, 1999).

Clinical reasoning.

The nursing competency that addresses skills that are needed to practice proficiently

at the bedside is clinical reasoning. This involves the process of assessment, diagnosis,

management of patients, and the development of treatment regimens (AACN, 2008; BACCN,

2008; Scribante, 1996). Clinicians are able to collect and evaluate information that is used to

diagnosis and manage patients’ problems (Atkinson & Nixon-Cave, 2011; Himmerick, 2011;

Harjai & Tiwari, 2009). Clinical reasoning improves RNs ability to make decisions with

fewer errors, to easily notice cues, and to take action when treatment is needed (Benner,

Hughes & Sutphen, 2008; Hicks, Merritt, & Elstein, 2003). According to Benner, Hooper-

Kyriakidis, and Stannard (1999), when this concept is developed, RNs are able to reason in

transition, utilize skilled know how, and apply clinical and ethical responses in practice

simultaneously. In critical care the traits are pulled together and used when detecting,

diagnosing, and treating patients’ conditions. Basically RNs develop the ability to holistically

provide bedside care to the patient and are able to make appropriate and safe decisions for

treatment.

Learning and reflection.

With clinical reasoning, there must be a competency that assists RNs with continuous

learning and growth. This is built through a continuous reflection on oneself and practice.

Registered nurses look at experiences, evaluate current meaning, and generate new meanings

through experiences at the clinical, emotional, and patient relationship levels. They develop

24

perceptual acuity and skills that aid them in making decisions for the patient (Benner, et al.,

1999; Rashotte & Thomas, 2002). They are able to assess practice and skills using past and

present experiences before making decisions about patient care. By reflecting on practice and

knowledge they are able to further develop clinical reasoning needed to practice proficiently

and to provide quality care at the bedside. With reflection, RNs understand the meaning of an

event and are able to become proficient and eventually an expert in ICU practice.

Teamwork and leadership

The last two competencies that RNs must develop to become proficient are

intertwined and include teamwork and leadership (Dunn et al., 2000). In the ICU, teamwork

plays a role in the development of each of the previous competencies (Dunn et al., 2000;

Nelsey & Brownie, 2012). Registered nurses are able to assist coworkers and advance their

knowledge through practice, clinical reasoning, and reflection. According to the AACN

(2008), RNs interact with peers and colleagues to enhance their own professional practice and

promote optimal patient outcomes. Teamwork and leadership make a difference in patient

outcomes because they promote cohesiveness and cause RNs to work as one to avoid

complication or possible death.

Teamwork leads to the development of leadership. Simply, leadership is defined as

the capacity to lead (Webster New World Dictionary, 2003). When further defined in nursing,

it emphasizes ethical and clinical decision-making, working relationships, respectful

communication, collaboration, delegation, and the ability to resolve conflicts with other

healthcare professionals (AACN, 2008). Through leadership at the clinical and management

level, young RNs move towards proficiency, which improves retention in the critical care

area (AACN, 2008; Alberto, Schmollgruber, & Williams, 2006). When RNs become leaders

they have the ability to assess the situation, practice in action, advocate, and make appropriate

25

clinical and ethical decisions while providing care. To develop leadership, continuous

learning must be used to advance nursing practice, improve oneself, and promote positive

patient outcomes (Nelsey & Brownie, 2012).

Clinical reasoning, reflection, teamwork and leadership are important for the

development of proficiency. When used together nursing competencies promote positive

outcomes. Teamwork, and leadership develop RNs understanding of nursing standards that

address the cooperation and understanding of coworkers, patients, and families (Scribante,

Muller, & Lipman, 1996). Without leadership and teamwork, RNs are ineffective in practice

because nursing competencies are used when advocating for needed changes in practice and

to improve patient outcomes (AACN, 2008). Clinical reasoning and reflection address how

RNs perform at the bedside. They are needed when assessing and making decisions that

address current conditions and needed treatments. They allow RNs to be able to detect subtle

changes that improve patient outcomes. Registered nurses utilize reflection to assess their

own skills in clinical practice. Each nursing competency promotes understanding of change,

personal growth, and professional accountability in practice; when the nursing competencies

are combined, proficiency is achieved (Lindberg, 2006).

A Proficient Intensive Care Registered Nurse

Registered nurses that are proficient understand how theory and clinical skills are

applied in practice. According to Benner (1984), proficient RNs understand situations

holistically and their perspectives are based on practice. When proficient in critical care, RNs

begin to have a deeper understanding of the specialty, its courses and responsibilities.

Proficient ICU RNs are able to perform efficiently at the bedside and behind the scenes. The

BACCN define proficient RNs as follows:

26

A proficient critical care nurse utilizes: advanced problem solving, decision

making, and communicative skills to provide proactive, safe, and effective

care when undertaking continuous complex monitoring and assessment,

administering, coordinating, and evaluating high intensity therapies,

responding promptly to sudden change(s) in patients’ condition, and in

providing information and emotional support to patients’ and relatives (p.11)

These ICU RNs understand their specialized nursing practice and are able to utilize multiple

thinking and clinical processes while providing care. There are specific traits that proficient

RNs must develop and master. According to Benner et al. (1999), the six specific components

needed to become proficient include 1) reasoning in transaction and thinking in action; 2)

skilled know-how; 3) response based practice; 4) agency; 5) perceptual acuity and skill of

involvement; and 6) links between clinical and ethical reasoning. When the components are

mastered, RNs become proficient because they holistically understand nursing practice.

Through proficiency RNs improve patient outcomes and family satisfaction (Dunn, 1992).

Reasoning in transition and thinking in action.

The initial nursing components in Benner’s critical care theory are known as

“reasoning in transition” and “thinking in action”. Through these components, RNs develop a

clear understanding of the current clinical situation. They are able to assess for losses or gains

in a patient’s situation and condition (Benner et al., 1999). Registered nurses evaluate and

question practice in an ongoing process through experiential learning (AACN, 2008;

BACCN, 2009). These two traits of this component assist RNs in developing an

understanding of clinical skills and how to apply skills into practice.

Skilled know-how.

27

Another component that proficient RNs have is the ability to safely perform in a

clinical setting. This component is known as “skilled know-how”; it is the performance of

intervention sets in practice that include assessments, charting, and complex clinical tasks

(Benner, Hooper-Kyriakidis, & Stannard, 1999). When RNs develop this component they are

able to make judgments, perform clinical assessments, and interpret patient data while

making a clinical decision (AACN, 2008; EFCCNA, 2004; BACCN, 2009; WFCCN, 2005).

It is more than mimicking skills; it is accomplished only after the skill becomes fluent and

second nature. By developing skilled know-how and understanding specialized skills through

theory and clinical practice RNs are able to provide a higher and more adequate level of care

for critically ill patients.

Response-based practice.

Once “skilled know-how” is developed, RNs’ begin to develop a response-based

practice; allowing them to be able to read current situations and flexibly respond to the

changing situation and patients needs (Benner et al., 1999). Registered nurses integrate

knowledge and experience when making a clinical decision. They initially choose the least

evasive treatment for patients to limit body stress and reduce patient anxiety. By developing

response-based practices, RNs become proficient because they have established the ability to

make rapid decisions, evaluate responses, and adjust treatments when appropriate (Dunn,

1992). With the development of this trait, RNs may prevent complications and improve

outcomes in the ICU.

Agency.

The next trait, which involves the ability to act for another, is known as agency.

According to Benner et al. (1999), agency is one’s ability to act upon or influence a situation.

Registered nurses become attuned with practice through experiential learning and

28

engagement in situations. When agency is developed RNs are proficient in practice because

they are able to acknowledge a change in a situation and alter previous plans to improve

outcomes (Benner et al., 2008). Proficient RNs move from task oriented care towards patient

specific care. Through agency, RNs become fully involved in their patient and the family

situations.

Perceptual acuity and skill of involvement.

Perceptual acuity and skill of involvement focuses on problem identification and is

linked to a RNs emotional engagement with the current problem and the interpersonal

relationship with the patient and family (Benner et al., 1999). When proficient in ICU, RNs

have the ability to think broadly and identify the patient’s current problem. They must have

the ability to manage the emotions of patients, families, and self when making a clinical

decision. Perceptual acuity and skill of involvement are vital in ICU nursing because when

they are underutilized, RNs are not able to see beyond basic knowledge in the clinical setting

and lack the ability to empathize with patients and their families (Benner et al., 1999) When

achieved, they have the ability to engage in the clinical and human situation. It is the skill of

involvement that requires RNs to balance clinical practice and emotions in order to be

proficient in practice.

The links between clinical and ethical reasoning.

The last trait is obtaining a link between clinical and ethical reasoning; when RNs

make clinical judgments in practice. When they clinically and ethically reason, RNs are

proficient practitioners because of their ongoing experiential learning, reflection, and

dialogue with patients and their families (Benner, Hughes, & Sutphen, 2008; Hicks, Merritt,

& Elstein, 2003). To clinically and ethically reason RNs must apply cognitive and

psychomotor skills that are based on theory and evidence as well as reflective thought

29

processes that direct change in patient situations (Atkinson and Nixon-Cave, 2011; Dunn,

1992). Registered nurses use clinical and ethical reasoning each day in practice through daily

plans of care and ongoing assessment. When RNs are able to clinically and ethically reason,

they become proficient in practice. They develop the ability to understand what the best

outcome is for the patient and their families (Benner et al., 1999). Clinical and ethical

reasoning cannot be developed overnight; it is achieved with time and through experience.

Proficiency in an ICU involves nursing theory and clinical skills that grow and

develop over time and through experiential learning. When proficient, RNs perform complex

skills fluently with quick responses to change and the knowledge to make appropriate

decisions when treating individual patients. When RNs transition into an ICU, proficiency is

accomplished when they are able to adequately assess, identify, and manage situations safely

and effectively at both the clinical and emotional level of the patient and their families

(ACCN, 2008; BACCN, 2009; Benner et al., 2008). A registered nurses development of

proficiency in ICU may determine a negative or positive outcome of a patient. Proficiency

must be obtained to improve patient outcomes in the ICU.

Discussion

Proficiency in critical care is not achieved through a single competency or clinically

based skill alone. It requires competencies that promote the processes of understanding

clinical practice and professional growth. The key nursing competencies: clinical reasoning,

reflection, teamwork and leadership are needed for RNs to become proficient (Nelsey &

Brownie, 2012). When they are used together appropriate care is provided, fewer errors

occur, and patient outcomes improve (Nelsey & Brownie, 2012; Scribante, Muller, &

Lipman, 1996). When achieved, RNs have developed Benner’s six critical care components

and are able to provide care holistically (Benner et al., 1999). They realize that nursing

30

competencies are not independent of one another and need to be used daily to solve patient

problems and improve outcomes. Ultimately, the goal is that RNs will understand critical care

practice clinically and theoretically, therefore enhancing positive patient outcomes. When

proficient, RNs value knowledge and learning; they continuously strive to become an expert

in critical care practice.

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CHAPTER IV

CRITICAL CARE ORIENTATION

Critical care registered nurses (RNs) require advanced knowledge, clinical skills, and

clinical reasoning to effectively care for critically ill patients. Due to the growing complexity

of critical care traditional orientation programs are no longer adequate enough to build

proficiency. Current orientations programs vary in structure and in length of time spent in the

clinical setting. The structure and length of a program will determine the success rate of

orientation and improve retention of RNs in critical care (Nelsey & Brownie, 2012;

Thomason, 2006). This chapter investigates what length of orientation and program structure

are required to adequately prepare RNs to gain clinical reasoning, apply technical appropriate

skills, and communicate safely in practice.

Introduction

When RNs transition into critical care, they must obtain advanced theory and clinical

skills that are needed to care for the critically ill. These skills include advanced problem

solving, decision making, communication, complex monitoring, and high intensity therapies

(American Association of Critical Care Nursing (AACN), 2008; British Association of

Critical Care Nursing (BACCN), 2009; European Federation of Critical Care Nursing

Association (EFCNNA), 2004). Advanced theory and skills are developed initially in the

classroom setting; then, eventually, they are applied in the artificial and live clinical setting

through experiential learning. Through orientation, RNs learn how to physiologically manage

patients, assimilate and prioritize information sources, and manage patient and technology.

Knowledge and skills are learned and developed through an orientation program with the

desired outcome of transcending an RN from basic knowledge to a holistic understanding of

complex disease processes, treatments, and desired outcomes (Derham, 2007; Dunn et al.,

32

2000; Murphy & Nolan, 2006). It is during orientation that RNs will gain a true

understanding of the art of critical care.

Traditional

Traditionally, orientation in the intensive care unit (ICU) consists of two settings: the

classroom and the clinical setting. Each setting is utilized separately when educating RNs’

about critical care practice. According to Alspach (1984), traditional ICU programs are a

form of “ivory tower nursing”, which means the curriculum is based more on the theory of

the clinical practice versus the reality of it. Due to the ICU’s growing complexity, traditional

orientation programs are inadequate because they do not promote the application of

knowledge into practice (Morris et al., 2007; Murphy & Nolan, 2006; Proulx & Bourcier,

2008) According to Benner, Hooper-Kyriakidis and Stannard (1999), nurses come away from

traditional programs with mere mastery and classifying of information but that is not the

same as being able to actively think about issues and clinical situations. A greater

understanding of critical care theory and its application into practice is obtained by through

an emphasis on teaching and learning strategies that adopt a philosophy of androgogy; adult

centered learning (AACN, 2008; EFCCNA, 2004). The teaching and learning strategies of

case studies, simulation, clinical orientation, and reflection promote adult centered education

through experiential learning in the classroom and the clinical setting. When each strategy is

utilized through the duration of a critical care orientation program, the nursing competencies:

clinical reasoning, reflection, teamwork, and leadership, with the application of clinical skills,

begin to develop and carry over into phase two of the clinical orientation; preceptorship.

Preceptor Role

Nursing competencies are promoted through experiential learning that is obtained in

the clinical setting with the guidance of a preceptor, and eventually, a mentor. It is in this

33

setting that RNs transitioning into ICU will set the initial stage for learning nursing

competencies (Clough, 1982; Johantgen, 2001; Murphy & Nolan, 2006). It is through a

preceptor that RNs enhance their technical skills and clinical knowledge (Cavanaugh & Huse,

2004). When a preceptorship is complete, RNs gain independence in practice and the

preceptor becomes the mentor who will continue to assist with the development of clinical

reasoning and nursing competencies (Murphy & Nolan, 2006). Through a program that

includes a preceptorship and a mentorship, RNs transitioning into ICU will have ample time

and resources with guidance to advance from novice to proficient and eventually become an

expert in practice.

Length of Orientation

With the extensive knowledge and advanced skills needed to practice in the ICU,

there must be an adequate length of time for orientation. Orientation programs on average are

12 to 28 weeks in length and are often determined by the amount of experience RNs have had

before they begin clinical orientation (Thomason, 2006). The amount of time needed to orient

in the ICU is variable from hospital-to-hospital and person-to-person. The program should be

composed of three segments: theory, preceptorship, and mentorship. The length of

mentorship ideally should be extended for all nurses because even RNs’ practicing

independently still need an experienced RN to guide, assist, and aid them in becoming

proficient and eventually an expert.

For RNs to successfully transition into ICU, a broad amount of advanced knowledge,

clinical skills, and clinical reasoning must be developed (Scribante, Muller, & Lipman, 1996).

Success is determined by the orientation programs’ standards, structure, content, and length

of orientation (Dunn, 1992; Nelsey & Brownie, 2012). Each carries a significant weight in the

development of an ICU RNs ability to be clinically proficient. A program that is unstructured

34

and does not promote the development of critical care skills and clinical reasoning will

produce RNs that are walking, talking encyclopedias, but lack the ability to effectively care

for the critically ill.

Program Structure

The structure of a traditional critical care program consists of two components:

theory learned in the classroom and skills learned and developed in the clinical setting.

Traditional education programs were organized around a content expert. Objectives were

identified and solely based on a theoretical notion of the field of practice (Alspach, 1984). By

dividing theory and practice, traditional programs failed to begin the development of clinical

reasoning. Registered nurses would have theoretical knowledge but lack an understanding of

what they learned or how to apply it in practice. To become proficient in critical care,

experiential learning must be a piece of the program’s foundation (Derham, 2007; Walker,

2001). It must promote multiple forms of experiential learning for RNs to develop an

understanding on how theory is applied into practice and to begin to develop clinical

reasoning.

Assessment.

When transitioning into an ICU, RNs come from various specialties and have

individual levels of knowledge and nursing skills. To determine the needs of RNs prior to

beginning the orientation program, nurse educators and clinical nurse specialists assess the

knowledge and skills of RNs by giving a written examination and conducting skills

assessment in the learning lab. First, the RNs knowledge level is evaluated through the use of

a comprehensive written examination. The examination covers a variety of ICU topics:

cardiovascular, pulmonary, neurology, nephrology, endocrinology, hemodynamics, and the

significance of basic lab/diagnostic results (Morris et al., 2007; Murphy & Nolan, 2006;

35

Proulx & Bourcier, 2008). After the examination is complete, the RNs’ clinical skills are

assessed in the learning lab. While in the learning lab, nurse educators assess the RNs’ level

of technical skills, situational understanding, and clinical reasoning. Technical skills are

evaluated through RNs demonstrating the skill on a mannequin in the lab. Situational

understanding and clinical reasoning are evaluated through case scenarios that are given in a

simulation lab. During the simulation, nurse educators will evaluate the depth of RNs’ level

of clinical reasoning and ability to apply technical skills when various situations arise.

Through simulation and lab assessment, nurse educators note the RNs’ strengths and

weaknesses in clinical practice and thinking process. The assessment of knowledge and

clinical skills prior to beginning the orientation program aids in the development of

individualized learning plans for transitioning RNs and also allows the educator and

preceptor to prioritize specific needs and goals in the classroom and clinical setting (Clough,

1982, Morris et al., 2009; Proulx & Bourcier, 2008).

Classroom.

The orientation program begins in the classroom setting when theory is introduced to

the RNs and it provides a broader understanding of complex disease processes and treatment.

To be beneficial, learning must go beyond chalk and blackboard. Learning must be enhanced

by utilizing: case studies, role playing, learning labs, and learning modules (Dunn, 1992).

These methods take into consideration the various learning styles of RNs and help develop a

clearer understanding of critical care theory and how it is applied in clinical practice. By

using multiple learning mechanisms, material is presented in a manner that promotes and

encourages RNs to learn and grow (Murphy & Nolan, 2006). Once the advanced knowledge

of ICU theory is obtained, RNs begin to develop the ability to apply it in practice. This is

accomplished through experiential learning in the clinical setting.

36

Clinical orientation.

Orientation programs must provide critical care theory but place a primary emphasis

on applying theory into practice in the clinical setting (AACN, 2008; BACCN, 2008;

EFCCNA, 2004; WFCCN, 2005). Each is vital to the success of an ICU program; theory

offers what is explicit and formalized, while clinical practice is complex and provides many

more realities than can be captured in theory alone (Benner, 1984). Registered nurses are able

to practice complex skills and to develop a greater understanding of how it is applied in

critical care before performing at actual bedsides with live patients. Complex ICU skills that

are learned and practiced in a learning lab and through simulation include ventilator

management, hemodynamic monitoring, managing complex medications, and intravenous

drips, lab interpretations, and code blue scenarios. It is in the simulation lab that RNs are

exposed to multiple ICU scenarios that will assist them with the application of clinical skills

and the development of clinical reasoning (Henneman & Cunningham, 2005; Morris et al.,

2007). It is in the actual clinical setting that a majority of the RNs’ learning will occur.

Initially RNs are assigned an individual preceptor. A preceptor is defined as an

experienced staff nurse who serves as a resource and a guide to transitioning RNs as they

learn to adapt to the ICU clinical setting (Johantgen, 2001). Preceptors set the stage for

learning because they are the teacher, demonstrator, validater, and evaluator throughout the

clinical orientation. As peers they command a tremendous amount of power and influence

that encourages the preceptee to follow standards, to think critically, and to be clinically

competent at the bedside (Johantgen, 2001; Murphy & Nolan, 2006). During this level of

clinical orientation, RNs are exposed to the multiple situations, different treatments, and

outcomes. The preceptor evaluates and assesses the RNs clinical reasoning and critical care

skills by utilizing question/answer format, demonstration, and reflexion. When preceptors are

37

able to confidently state that an individual RN has developed a greater understanding of

nursing skills, critical care theory, and the application of both into practice, the RN is ready to

advance to the next level of the clinical orientation, known as mentorship.

During this phase, the preceptee transitions into mentorship. As a mentee, they are

able to function more independently with occasional guidance (Murphy & Nolan, 2006;

Proulx & Bourcier, 2008) The preceptor shifts from a parent role to the counselor and teacher

role; a mentor (Murphy & Nolan, 2006). During mentorship, the mentee is scheduled on the

same shifts and days as their mentor to maintain comfort and continuity in the

teaching/learning process. Through mentorship, more patient care responsibility, clinical

practice, and clinical reasoning are placed on the mentee and the mentor becomes less and

less involved with the patient care (Morris et al, 2007; Murphy & Nolan, 2006). In this more

independent role, the mentee is able to further develop technical skills and clinical reasoning

through experiential learning. The mentor is always available for the mentee and continues to

evaluate and assess the progression through observing the demonstration of skills, reflection

of situations, and through the use of question/answer formats. Mentorship is complete when

the mentee has proficiently demonstrated clinical reasoning, teamwork, leadership, and the

application of advanced clinical skills.

Length of Orientation Program

The initial portion of orientation occurs in the classroom and learning lab setting

where simulation and case studies are utilized. The average classroom and learning lab

segment of critical care programs is 75 hours (Dunn, 1992; Thomason, 2006). With this in

mind, the theory segment of the program would occur over the first four weeks and

simultaneously correlates theory and the learning lab. This is where the process of knowing

and applying to practice begins. It is during this transition that RNs will apply advanced

38

knowledge and practice complex skills so that when they begin clinical orientation, they will

be familiar with the equipment and the advanced tasks critical care RNs manage daily.

The clinical levels of orientation vary in length. The preceptorship segment is an

average of 12 weeks for RNs transitioning from another specialty. This segment of

orientation provides the basics of critical care practice and experience. During this time RNs

begin to master technical skills and begin to develop clinical reasoning, teamwork, and

leadership while in the ICU setting (Boyle, Butcher, & Kenney, 1998; Dunn et al., 2000). The

last level of clinical orientation would be mentorship, this segment of orientation is different

for each RN and its length is indeterminate. Mentorship further develops the skills of RNs

and their ability to utilize experiential learning by reflecting on previous experiences and

actions taken when caring for similar patients. Registered nurses transcend from knowing to

understanding when mentorship is complete.

Each RN learns in a different way while grasping ICU content and skills; some may

have a short learning curve while others may have a long learning curve. According to

Benner, Tanner, and Chesla (1996) practitioners at different levels of skill and knowledge

live in different worlds, noticing and responding to different directives for action. The length

of an ICU orientation program should not be set in stone; it must be based on the RNs

individual level of knowledge and preferred learning modalities. By individualizing RNs’

learning needs for transitioning into an ICU, nurse educators, preceptors, and mentors are

better able to determine the primary focus points and specific learning styles. When learning

needs at the clinical level are individualized, program completion and retention of RNs in

ICU may increase.

Program Outcome

39

The ICU orientation is stressful emotionally, mentally, and physically to transitioning

RNs because they may become overwhelmed with nursing theory and the need to master

critical care skills. Traditionally, when the critical care orientation is complete, RNs begin

practicing with limited resources and support. Due to this lack of support, in 2012 the

turnover rate for critical care RNs was 12.6 percent. (Nursing Solutions, 2012). Even a small

percentage of ICU turnovers make a difference in the quality of care and patient outcomes.

With this in mind, steps must be taken that will provide adequate support during and post

critical care orientation.

According to Thomason (2006), a structured program with support has shown to be

an integral component to retention in critical care. Retention is dependent on a program that

is comprehensive and supportive versus staggered with limited support. A staggered program

is composed of theory and clinical but is limited in continuity and support during and post

orientation. In a staggered program, RNs begin practice unprepared and ill equipped. In a

comprehensive program, RNs are better prepared for their new role as a critical care provider

(Thomason, 2006). If adequate orientation, resources, and support are not provided,

transitioning RNs will become frustrated and burnout causing them to leave ICU practice

(Nelsey & Brownie, 2012; Williams, Schmollgruber, & Albertson, 2006). With appropriate

support and resources, RNs transitioning into ICU have a greater chance of success because

they know that if any difficulty arises or complications occur they will not be alone or

isolated. For RNs to be successful in ICU, retention strategies must be considered with the

focus on providing a positive, supportive orientation through each segment of the program

(Nelsey & Brownie, 2011; Nursing Solutions, 2012).

The desired outcome of an orientation program is the successful development of

proficient critical care RNs that surpass knowing theory to understanding how it is applied

40

daily in ICU practice. By using the Benner’s novice to expert model, RNs will be successful

in the ICU because the program is individualized to meet RNs learning needs and

preferences. Registered nurses will move from understanding abstract principles to

understanding experiences and will have the ability to holistically understand various

situations, and transcend from observer to an involved performer (Morris et al. 2007; Murphy

& Nolan, 2006). Simply, they transcend from novice to expert.

Discussion

Intensive care unit orientation programs can no longer continue to use the traditional

model for orientation because of the need for advanced knowledge and complex skills that

RNs must have to effectively provide care to the critically ill patients. Registered Nurses must

not only have the knowledge and clinical concepts of the ICU, they must holistically

understand each patient’s individual situation. This can only be accomplished through a

program that embraces Benner’s novice to expert theory and promotes experiential learning

which is developed in a clinical orientation that moves from a preceptorship to mentorship

and eventually independence (Benner, 1984; Morris et al. 2007; Murphy & Nolan, 2006). By

utilizing Benner’s model, an orientation program produces RNs who have developed clinical

reasoning, teamwork, leadership, and advanced skills; thus becoming proficient in critical

care practice.

41

CHAPTER V

DISCUSSION

Critical care continues to grow complex as new research, technology, and treatments

add to the knowledge that registered nurses (RNs) need to acquire in order to work in these

specialty units. Registered nurses that transition into critical care must be proficient in

advanced skills to provide safe and adequate care to the critically ill. Proficiency is

accomplished when RNs are able to apply knowledge with experiences together in practice

while making a clinical decision. Clinical reasoning is holistically visualizing and adapting to

the situation, while applying treatment when appropriate (Benner, Hughes, & Sutphen, 2008).

Critical care programs develop proficient practitioners with established competencies

through experiential learning. Competencies include: clinical reasoning, teamwork,

leadership, and reflection (Dunn et al., 2000). Vital to developing established critical care

competencies are Benner’s six critical care traits: 1) reasoning in transition and thinking in

action; 2) skilled know how; 3) response based practice; 4) agency; 5) perceptual acuity and

skill of involvement; and 6) links between clinical and ethical reasoning (Benner, Hooper-

Kyriakidis, & Stannard, 1999). As competencies and traits are achieved RNs begin to

transition through developmental phases starting with novice and moving through advanced

beginner, competent, and proficient with the ultimate goal of expert. When the competencies

are mastered and the RNs display Benner’s six critical care traits, they are considered

proficient to practice alone in an Intensive Care Unit (ICU) (1999).

To achieve the competencies and acquire the six critical care components, the

orientation program is set up into four separate levels that transitioning RNs will need to

progress through in order to develop proficiency. The initial levels include learning nursing

theory in the classroom and the initial technical skills in a learning lab. Most importantly,

42

preceptorship and mentorship take place in the clinical arena and promote experiential

learning and aid in the development of competencies that are needed to be proficient in the

ICU. Each level of the program develops a deeper understanding of critical care theory and

complex skills. It moves RNs from comprehending theory alone to looking at the whole

situation. Experiential learning requires RNs to participate and interact through the

teaching/learning strategies: case studies, simulation, clinical orientation, and reflection. Each

strategy is utilized in the classroom and skills lab then carried into the clinical setting where

RNs apply acquired knowledge in practice; they gain understanding, and begin to develop

clinical reasoning, build proficiency, and achieve expert.

It is important to keep in mind that RNs travel at their own pace through this process

since each comes to the table with different levels of knowledge. They will have different

starting points and it is important to tailor the learning experience to meet individual needs.

With each learning strategy, RNs gain a deeper understanding of critical care theory and its

application in practice; they begin to grasp the competencies with the goal of eventually

progressing towards proficiency.

To develop proficient critical care RNs, orientation programs need to provide more

than theoretical knowledge and successfully passed tests; an effective program promotes the

development of clinical reasoning, leadership, teamwork, and reflection through experiential

learning. Critical care orientation programs need to promote learning in both the classroom

and clinical settings. Murphy & Nolan (2006) stated that in order to develop proficiency in

the ICU, RNs take an examination every day, every shift, with every patient and pass that

examination. In addition, they are applying and utilizing knowledge in a way that exemplifies

not only the science but also the art of critical care nursing (Murphy & Nolan, 2006).

Orientation programs for ICU settings not only need to produce RNs with book knowledge,

43

but RNs with the ability to holistically understand situations and provide safe and effective

care to critically ill patients. Strategies outlined in these chapters will accomplish this goal.

44

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