Expertise in nursing practice : caring, clinical judgment - Springer ...

Introduction xvii
recognize that this clinical situation is a situation of heart “pump” failure
or fluid depletion and then proceed to clarify the nature of the situation
by further assessment.
The skillful practitioner learns to hold his background understandings
in a fluid or semipermeable way so that he can recognize when these
tacit expectations are not being met. Like Bourdieu (1990), we found
that responding to the situation as an “instance of particular concerns” is
central to the logic of excellent practice. Clinical practice occurs within a
health care team. Whereas in some skill situations, such as playing chess
or driving a car, experts would not need to articulate their perspectives
before taking action, in the nursing profession, a case must be made that
includes articulating the nurse’s perspective and evidence in order to get
the appropriate physician intervention. However, both physicians and
nurses are required to make a case about their clinical interpretations
to other clinicians. In emergencies, when there may be no physician
available, the nurse must be able to articulate clearly the reason for using
a standing order or protocol or going beyond the usual boundaries of
usual nursing practice. This is expected and defensible when it is critical
for the patient’s survival. Recognizing the unexpected—that is, when tacit
global expectations of patients’ recovery are not met—is also a hallmark
of expert practice. This background is essential situating information for
reading this research that extends and examines the previous 1984 From
Novice to Expert study.
We insert a condensed account of the novice stage of skill acquisition,
which typically occurs in the first year of the nursing student’s
clinical education. We want to clear up any mislabeling and misconceptions
that a nursing student can graduate and remain at a novice
level of skill acquisition. No one can get through nursing school and take
the NCLEX–RN (National Council Licensure Examination–Registered
Nurse) while remaining a novice! We did not study undergraduate students
in the 1996 study reported here. In the 1996 study, we studied only
practicing, licensed nurses. Therefore, we include the novice stage here
for contrast to the advanced beginner—the newly graduated nurse in the
first job:
NOVICE: FIRST YEAR OF EDUCATION
The novice stage of skill acquisition occurs in areas where the student
has no experiential background to base approach or understanding of the