Assessing patients’ needs: does the same information guide expert and novice nurses?

© 2002 International Council of Nurses

Keywords

Expert/Novice

Differences, Handover,

Patient

Documentation,

Pre-Encounter Data

Qualitative Research

Assessing patients’ needs: does the sameinformation guide expert and novice nurses?

C.Taylor RN, RCNT, DipCNE, BappSc(adv nurs), MEd Pol&Admin, PhD, FRCNA

Senior Consultant, ACT NOW SERVICES, Business, Education and Research Consultants, Melbourne,Victoria, Australia

Abstract

The difficulties experienced by nurses in assessing patients before providing care

have been the subject of enquiry for many years. Much has been written about the

nursing process and, in particular, the data-collection component, where the nurse

gathers information before deciding on a diagnosis and nursing intervention.

There is, however, very little published on the differences between expert and

novice nurses, in either the way they gather information or the emphasis placed

on the different data sources accessed when preparing to carry out a nursing

procedure. Communication between nurses is essential in the provision of safe,

competent care, and yet we have minimal understanding of how experts use data

sources to plan procedural care giving. This article reports on the findings of one

component (the differences between expert and novice nurses in accessing data

before implementing a nursing procedure) of a larger study into the identification

of problem-solving strategies adopted by nurses during procedural care giving.

The study was conducted in clinical settings and used a qualitative research

methodology of observation followed by an in-depth semistructured interview.

The study results indicate that expert and novice nurses accessed four similar

information sources before meeting a patient. However, there were differences

noted between the two groups in the amount of information accessed, as well as

in the interpretation and use of that information. This is an important issue for

nurse educators.

Correspondence address: Dr Catherine Taylor, SeniorConsultant, ACT NOWSERVICES, Business, Educationand Research Consultants, 82Fulton Road, Mount Eliza,Melbourne, Victoria 3930,AustraliaTel.: +61 39787 9367Fax: +61 39787 9367E-mail:[email protected]

11

Original article

Introduction

Nursing is a unique profession ‘because of its broad

focus on understanding and managing a persons

health’ (Potter 1999). It is essential therefore that

nurses are educated and are able to assess the health

needs of patients before delivering care, including

those care practices commonly referred to as

nursing procedures. The nursing process, which

emphasizes the collection of data prior to making a

nursing judgement, has been written about exten-

sively, to enable nurses to share a common approach

to the provision of care. Senior nurses in clinical sit-

uations are frequently role models for less experi-

enced nurses, both in the preparation and delivery

of nursing care. Investigators of expertise in nursing

12 C.Taylor

practice in their respective seminal works (Benner

1984; Carnevali et al. 1984) endeavoured to expose

the essence of why some individuals perform at a

higher level than others. To date, there is still no

common set of theoretical principles that appear to

cross professional disciplines. According to Van

Lehn (1989), however, having a highly developed

level of skill is recognized as essential in all expert

practice.

Why compare experts andnovices?

Differences between expert and novice nurses are

of considerable interest to practitioners and re-

searchers for a number of reasons. Educators, for

example, believe that if the differences between

expert and novice nurses (in different situations)

can be identified, then application of evidence-

based practice will provide improved education for

novices and safer care provision for patients. Com-

paring the performance of experts and novices as a

method of understanding how expertise develops is

supported by a number of researchers (Benner

1984; Corcoran 1986; Westfall et al. 1986; Tanner

et al. 1993; Benner et al. 1996) because it contributes

to the body of nursing knowledge.

The literature suggests that the development of

expertise depends on the availability of relevant

experience in order to expand a clinician’s knowl-

edge base. Ericsson & Smith conducted studies in

1991 to determine whether expert performance is

an inherited trait in individuals or if it is acquired.

They concluded that ‘superior performance is pre-

dominantly acquired’and to understand it properly,

expert practice should be studied whenever possible

in real-life settings. Chenitz & Swanson (1986)

argue more vigorously and suggest that ‘scientific

discovery is based on the judicious use of induction,

deduction and intuition’, and that analysis of clini-

cal practice through inductive logic will generate

appropriate research questions that will ultimately

lead to the discovery of nursing theory.

According to Dowie & Elstein (1988), clinicians

hold expert clinical judgement in high regard. It is

therefore an important professional responsibility

to help novices to acquire competency in clinical

practice, without causing distress to themselves and

their patients during the learning process. In order

to educate and support novices effectively, we must

understand how clinical knowledge is acquired and

used.

Although adequate preparation to give care is

essential for safe practice, and much nursing work is

carried out through routine procedures, very little

has been written on the differences between expert

and novice nurses in how they gather information

about patients before they implement a procedure,

or what emphasis is placed on different data sources

accessed.

This article reports on the findings of one com-

ponent (expert/novice differences in accessing data

before implementing a nursing procedure) of a

larger study by Taylor (1997) into the identification

of problem-solving strategies adopted by nurses

during procedural care giving.

Methods

The literature-retrieval approach used for the study

included electronic searches of MEDLINE and

CINHAL databases, manual searches of nursing

indexes in both University and Hospital libraries,

examination of PhD theses related to clinical deci-

sion making and reasoning, as well as review of ref-

erence lists in the retrieved literature. Many of the

studies reviewed were valuable in helping to identify

approaches used by other researchers to gain an

understanding of how nurses problem-solve.

However, no articles were identified which dealt

with the cognitive strategies used by novice and

expert practitioners in carrying out basic nursing

procedures.

Assumptions

Taylor’s (1997) study into the identification of

problem-solving strategies adopted by nurses

during procedural care giving was shaped by her

understanding of nursing practice, plus insights

gained from the literature (Taylor 2000) and, as

such, directly influenced the methodological ap-

proach to the study. The following assumptions

were made:

© 2002 International Council of Nurses, International Nursing Review, 49, 11–19

Assessing patients’ needs 13

• nurses collect information related to patients

before carrying out procedures on them,

• knowledge and experience empower the nurse to

be able to make decisions in clinical situations,

• during nursing procedures, the nurse becomes

aware of individual patient differences, which may

require changes in routine,

• the ‘becoming aware’ stage requires problem

recognition and action by the nurse and, as a result,

a change in procedural routine occurs. This change

in routine can be observed. Questions can then be

asked that relate to the thinking behind the decision

to change the routine,

• as a result of observing a nurse’s practice and

asking related questions, it is possible to identify the

cognitive strategies used by the nurse in deciding to

change the routine,

• nurses use the information gained while carrying

out procedures to plan future care for patients,

• nurses concentrate on the patient receiving care

during a procedure,

• nurses consider their own safety during

procedures and as a result of this may choose to

modify the way they provide care to the patient,

and

• problem-solving occurs when procedures are

carried out.

Design

The design of the study was influenced by a concern

to access nurses’ thinking processes when providing

routine care-giving procedures. Additional con-

cerns related to the ability to access practice situa-

tions that allowed comparisons to be made between

novice and expert nurses when carrying out similar

procedures. The contextual intricacies of the clini-

cal environment were therefore deemed to be the

best setting for examining nurses’ problem-solving

strategies. Given the complexity of the investiga-

tion, a qualitative methodology was employed to

capture the required data. Qualitative research,

according to Burns & Grove (1987) enlightens

nursing practice by allowing exploration of ‘the

depth, richness and complexity inherent in holistic

nursing care’. Sherman & Webb (1988) also support

the qualitative approach to nursing research and

additionally state that ‘events can be understood

adequately only if they are seen in context’.

Setting for the study

Acute medical-surgical and rehabilitation hospitals

were selected for data collection.

Participants

Undergraduate students from years 1 and 3

(novices) in a Bachelor of Nursing course leading to

registration were identified at random from the uni-

versity database. Registered nurses (RNs) (experts)

were identified from hospital personnel records

relating to having had 5 or more years of postgradu-

ate experience. Five years was accepted as an appro-

priate time frame for the clinicians to have devel-

oped expertise in the basic procedures chosen, as

Patel & Groen (1991) suggest that the development

of expertise requires opportunities for repetitive

practice. The procedures chosen (discussed below)

are carried out daily or more frequently by RNs.

Letters of invitation to participate, including an

explanatory statement of the study and a consent-

to-participate form, were sent out. Eighty sets of

data were collected from the participants and 33 sets

were used in the final analysis.

Procedures chosen for the study

The procedures chosen were: showering a patient;

taking blood pressure; testing a urine sample; carry-

ing out a complex dressing; and taking a blood

glucose measurement. These procedures were

chosen because undergraduate students are intro-

duced to them at different stages of the education

process. In the programme that the students were

enrolled in, year 1 students were taught to shower

patients, to test urine and to measure and record

blood pressure. Students were taught to take blood

samples for glucose monitoring and carry out

complex dressings in year 3. As these procedures are

carried out daily in wards, depending on patients’

needs, there are numerous opportunities for stu-

dents to practice and for postgraduate nurses to

develop expertise.


14 C.Taylor

Table 1 represents the sample distribution and

indicates participant experience across procedures.

Sample distribution (see Table 1)

Three novices (year-1 students), three intermediate

participants (year-3 students) and three experts

(RNs) were observed when conducting a showering

procedure. This was the only procedure for which

an intermediate group was observed.

Six participants – three novices (year-1 students)

and three experts (RNs) – were observed when con-

ducting the blood pressure recording procedure.


and three experts (RNs) – were observed testing

urine samples.


and three experts (RNs) – were observed conduct-

ing a complex dressing procedure.

Six participants – three novices (year 3 students)

and three experts (RNs) – were also observed con-

ducting a blood glucose measurement.

Data-collection methods

Observation of participants carrying out the

selected procedures, followed by in-depth, semi-

structured interview, was the method used for data

collection.

A schedule was developed and used during the

observation phase to assist with the systematic recall

of events. A semistructured open-ended interview

format using the same questions as starting points

enabled in-depth probing of replies during the

interviews. This technique allowed an in-depth

analysis of the thinking process for each participant.

Questions related to the notes made on the observa-

tion schedule during the procedure were also asked.

Interviews were taped and lasted for ª 20–45 min.

A transcript of each was made later to assist with

the analysis process.

A field log was also maintained to assist with any

ongoing issues that were encountered.

Ethics approval

Application to conduct the study was made to the

research and ethics committees in each hospital and

the university. As the study did not directly involve

patients as active participants, the most important

issue considered by the committees was confiden-

tiality. All participants were given a code number

known only to the researcher.

Analysis process

A large volume of data was generated by the study

and a complete record was kept of all aspects of the

research. Several different methods of retention of

data were used. The interviews were taped and tran-

scribed to ensure that an accurate and comprehen-

sive record of the discussions was available for

future reference. A separate file, which included a

transcript of the interview, a field log, an observa-

tion schedule and a copy of the interview format,

was maintained for each subject in the study.


Table 1 Sample distribution indicating participant experience across procedures

Procedure

Blood Blood Complex Showers Urine

glucose pressure dressing testing

RNs (more than 5 years of experience) 3 3 3 3 3

Year-1 students (first experience) 3 3 3

Year-3 students (first experience, except for showers 3 3 3

where year-3 students had previous experience)

RNs, registered nurses.


The processes described by Miles & Huberman

(1984; 1994) were used to manage the data for

analysis.

A preliminary analysis was made concurrently

with collection of the data. Before proceeding with

the formal analysis, the immense volume of data

produced by the study had to be categorized and

reduced. Reduction involved selecting, focusing,

simplifying, abstracting and transforming the raw

data from the written-up field notes and transcrip-

tions. From the initial sample of 80 data sets, care

was taken when transcribing the recorded inter-

views into written text. This process comprised lis-

tening to each of the 80 tapes and typing the verba-

tim statements. When this process was complete,

each tape was listened to again and checked for

errors in the transcribed text. Shifts in meaning that

might have been introduced by small errors in tran-

scription were eliminated. Tapes that were difficult

to hear owing to background noise or technical

problems, were, at this stage, regarded as not yield-

ing a complete record of the interview and were

discarded.

The remaining 33 transcripts, observation sched-

ules and field notes were read and reread. An inter-

pretive summary of each participant’s clinical

episode was prepared and used to develop the start-

ing description of recurring themes. The data were

coded according to major themes. The transcripts

were entered into a computer software package

called NUDIST (Non-numerical Unstructured Data

Indexing, Searching, Theorizing). This programme

allowed data to be sorted and coded into specific

themes, identified by the researcher and supervisor,

to be retrieved during the analysis process.

Rigour

Credibility is essential in all research; however,

validity and reliability measures are not so obvious

in qualitative research. According to Lo Biondo-

Wood & Haber (1990), rigour applied to the data-

collection process is the best check of validity and

may be enhanced by describing the exact process

of data collection. The data-collection process in

this study is referred to above. Displaying partici-

pants’ verbatim statements according to Miles &

Huberman (1984; 1994) assists with internal reli-

ability. Selected participant statements are provided

below, in the Results.

Reliance on the participants behaving honestly

(as direct observation of individuals can change

their behaviour) during the observed procedure,

and reporting their thoughts during the interview

process, was an important factor in this study. In

an attempt to minimize altered behaviours, the

researcher’s role during each procedure was one of

observer without concealment and without inter-

vention. According to Lo Biondo-Wood & Haber

(1990), when ‘the observer makes no attempt to

change the subjects’ behaviour and informs them

that they are to be observed, then this type of obser-

vation allows a greater depth of material to be

studied than if the observer is separated from the

subjects by an artificial barrier’. This frank approach

allowed the researcher to collect data openly and to

ask related questions later during the interview

phase.

Limitations of the study

The limitations of this study relate mainly to the

methodology chosen. The sample size, the settings

and the procedures chosen were specific to the

conduct of this research and are therefore represen-

tative of this group at a specific point in time.

Results

The results identified that a similar problem-solving

process to that of diagnostic reasoning described in

the seminal work of Carnevali et al. (1984) and later

by Carnevali & Thomas (1993), was being used in

this study.

The nurses accessed four main data sources when

preparing to carry out a procedure. These were:

nursing handover; patient documentation; previ-

ous knowledge of the patient; and a selection of

other sources grouped as a miscellaneous category.

These categories are briefly discussed below.

The nursing handover

Much has been written on the types, duration

and rituals involved in handovers (Taylor 1993;


16 C.Taylor

Wise 1994; Prouse 1995; Parker 1996; Strange

1996). However, there was nothing in the literature

that discussed differences between expert and

novice nurses in the perceived value of handover

information.

Seven of the 18 novices in the study mentioned

the nursing handover as a source of data used to

prepare for implementing a procedure. All were in

the year-3 sample group. The comments made were

varied, as some found value in them but colleagues

did not. When asked how they knew about the

patient, two of the replies (Taylor 1997; p. 332) were:

[From the handover] She’s got a thrombosis,

I think. She hasn’t got exacerbated COAD

(chronic obstructive airways disease) . . . she has

a nebuliser.

Handover, yes, I always have trouble remem-

bering from the handover and I like the nursing

notes.

It was noted that there was an obvious reliance of

some participants on written notes taken during the

handover. In some instances, the nurse in charge

handed preprepared notes to the nursing staff

coming on duty before the handover. When this

approach was taken, it was noted that the partici-

pants recorded very little additional information,

even though the written information generally only

provided the patient’s name, bed number and

medical diagnosis. It was also noted that the novice

group tended to be silent during the handover.

Ten of the 15 experts used nursing handover

information as pre-entry guidance to the patient

care situation and expected the handover to be a

major source of patient information both on com-

mencing a shift and throughout a patient’s stay. It

was frequently the main source of information used

for maintaining and updating their general and spe-

cific knowledge of patients. When asked how they

knew about the patient, two of the replies were:

First I was aware of [the patient] was at handover.

The handover sheet is three computer print-

outs long and you get a bit of history on that.

It was noted that the experts frequently asked ques-

tions during handover to clarify issues. This behav-

iour appeared to require ‘in-depth knowledge of

patient care issues and good cue recognition, as well

as the ability to store, link and retrieve information

quickly from long-term memory’ (Taylor 1997).

Patient documentation

The two most significant sets of documents used by

the nursing staff were the patient’s history (often

referred to as progress notes) and the nursing care

plan.

The patient’s history is a very comprehensive

document containing the past medical information

of the patient, notations from all health professional

groups who provide care management, and all

pathology and test results.

The nursing care plan is intended to communi-

cate, to the nursing staff who provide care, the

specific nursing measures to be implemented.

However, many of the nursing care plans reviewed

in this study did not convey the specific information

necessary to carry out the required procedures.

Seven out of 18 novices mentioned accessing

written documentation but did not express a prefer-

ence for patients’ histories or nursing care plans as

an information source:

I got information from a lot of different things,

his nursing history, his admission notes and the

doctor’s notes . . . and the nursing care plan.

I read his care plan so I knew about his cyto-

toxic drugs . . . the bit I got through the history

told me he was from New Zealand.

The novices who reviewed the patients’documenta-

tion tended to look at a variety of documents and

relied heavily on the written orders for the patient:

The nursing care plan, that’s how we knew to put

him on the toilet, even if he didn’t really have to

go . . . (Taylor 1997).

Eleven out of 15 experts used the patient’s docu-

ments to obtain comprehensive information. Most

of this group showed a preference for the patient’s

history as the major source.The group who accessed

the patient’s documents showed a tendency to read

sections of the patient’s history document to answer

any queries they had. Very few comments were

made about the use of the care plan:



Reading it myself in the history [that the dressing

had to be done].

It appeared that not one participant read a complete

set of documents. The comment below was a typical

response to the question, ‘how do you know about

this patient?’

I just read her past observations for the night

before and I haven’t actually read her history

completely.

Previous contact with the patient

There are a variety of ways in which a nurse may

have had previous contact with patients. For

example, patients may return to the same ward

weeks, months or even years after an initial admis-

sion and be cared for by the same nurse. When a

patient is admitted to hospital, the same nurse may

look after him/her for several shifts. Such continu-

ous interaction allows the nurse to develop a bank of

current knowledge about the patient. It was noted in

this study that previous knowledge seemed to

obviate in some way the need to read the patient’s

progress notes before performing some care activi-

ties. This may or may not be appropriate, depending

on what information has been added to the notes by

other members of the health care team and what

information (if any) may have been missed by the

nurse or omitted at handover.

Four out of 18 novices indicated that prior per-

sonal contact with the patient influenced their

approach to working with patients:

I had already seen the wound before, so I knew

what to expect.

I’d watched the dressing the night before, so I

got out all the materials that I needed (to do the

dressing).

Of the expert group, only two of the 15 participants

mentioned previous knowledge of the patient as an

information source influencing daily care. They

inferred that they used this previous knowledge as

the basis of continual assessment and judgement of

the patient’s current health status:

I’ve known him from before . . . he’s had quite a

lot of admissions for haematoma.

The experts who reflected on previous patient

knowledge indicated that assessment of the patient

was taking place, whereas the novices did not.

Miscellaneous other sources

There are a number of sources of information avail-

able to nurses. Examples of these are families and

other members of the health care team. The data

analysis suggested that novices looked at different

sources of information from expert nurses.

In the novice group, eight out of 18 reported

accessing other sources of information to assist in

understanding their patients:

Her daughter, I spoke to her . . . she was just

saying . . . she’s deteriorating and things.

I just probably asked her [the patient] . . . the

nurse told me when I got in what things she likes,

the cold water and all that.

Eight out of 15 experts accessed other data sources

of patient information. Characteristically, the

doctor or the charge nurse was a frequent source:

From the charge nurse who mentioned it earlier

in the day.

From the charge nurse who had actually done

the round with the doctor.

The type of person from whom the nurse obtained

extra information on the patient’s condition

seemed to reflect the practitioner’s confidence level

and knowledge base. Novices reported feeling more

comfortable asking the patient’s relatives and RNs

for information. The experienced nurses, on the

other hand, appeared to select the person most

likely to supply the information they required.

Discussion

It was found that all 33 participants had accessed at

least one source of preparatory data, suggesting that

before attempting each procedure, some form of

problem framing had taken place to assist the nurses

to enter the patient environment. This is consistent

with the theory of Carnevali et al. (1984) on the

nurses’ use of pre-encounter data. It was noted that

the experts in the study were more likely to access


18 C.Taylor

multiple sources of preparatory information

than the novices. The ability of the RNs to link the

information gathered from a variety of sources is

characteristic of expert performers in a variety of

disciplines and is reliant on the components of

memory. According to Van Lehn (1989), ‘experts

seem better at monitoring the progress of their

problem-solving and allocating their effort appro-

priately’. Novices, on the other hand, tend to

solve problems on the ‘basis of literal, superficial

features of a specific problem’ (Van Lehn 1989).

Of the four categories identified as sources of

information, two seemed to be more important for

both experts and novices; these were the nursing

handover and the miscellaneous category. As dis-

cussed previously, handover information was

important to the experts in the study, but meant

very little, and in some cases nothing at all, to the

novices. It is also worth noting that only the year-3

novices referred to handover information, even

though the year-1 group attended handover daily

whilst on clinical placement. A combination of

information overload, lack of clinical experience

and little or no understanding of medical terminol-

ogy, may all have contributed to the novices’ appar-

ent inability to recognize or absorb meaningful

information during handover. As there is such a

reliance on the handover as a vehicle for communi-

cating patient information, the contrast between

the experts and the novices in this study is signifi-

cant enough to warrant further investigation.

Authors such as Wise (1994) and Strange (1996)

suggest that the traditional handovers offer a chance

for experienced nurses to pass on information to

inexperienced nurses.

This can only be possible if novices are capable of

understanding and, as this study suggests, there

seems to be a gap between what we think novices

recognize from attending handovers and what they

really do.

The miscellaneous category of information

sources gave the impression that there was an infor-

mal hierarchy of professional relationships in the

hospital wards. Novices asked those whom they

apparently regarded as less authoritarian, for infor-

mation to help them. Although the information

gained about patients by the novices was frequently

of a personal nature and, as such, is important, the

RNs’ use of more senior people to provide care

instructions needs to be acknowledged and in-

corporated into the education process, perhaps

through mentoring programmes. Nothing in the

literature discusses this particular topic.

While patient documentation was widely ac-

cessed, particularly by the experts, it was disquieting

to note that none of the participants reviewed a

patient’s documents comprehensively. ‘Documen-

tation is a vital aspect of nursing practice’ according

to Elkin (1999) and the result of inadequate com-

munication for whatever reason can affect patient

care and recovery. Although novices are taught the

importance of reading and writing patient care

information, once in the care environment they

often rely on copying the practices of more senior

nurses. This type of role modelling seems to help

them fit into the nursing team. However, it appears

from this study that the expert RNs selected discrete

information, as required, to help them solve clinical

problems, and the novices had very little under-

standing of the information selection process of the

RNs. The novices often only saw the RNs flicking

through patient documents. More research needs to

be carried out on expert practice in the use of docu-

mentation in order to identify the major principles

and practices involved.

A difference was also noted between experts and

novices in how they used previous contact with the

patient to influence their practice, although insuffi-

cient information was provided by the RNs for any

conclusions to be drawn. However, the novices’

comments of basing their care on previous patient

contact and, as a result, copying what they did or

witnessed previously, is congruent with a descrip-

tion of the novice by Benner (1984), where she sug-

gests that novices use rules to guide their behaviour.

Conclusion

The results presented in this study indicate that

expert and novice nurses accessed four information

sources before meeting a patient. However, there

were differences between the two groups in the

amount of information accessed as well as the inter-

pretation and use of that information. If accessing



data prior to carrying out procedures influences

nursing actions, then further study into expert

behaviour is required to determine the relationship

between the thinking processes (problem framing)

that drive the selection and the use of information.

In advance of available research on this topic, the

employment of expert mentors should be consid-

ered to help novices develop clinical reasoning

skills, especially in the use of clinical communica-

tion pathways.

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Assessing patients’ needs: does the same information guide expert and novice nurses?

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