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A thesis submitted to the Faculty of the Graduate College of the Oklahoma State University in 1988. It explores the expertise of community health nurses and includes a literature review, methodology, and analysis and discussion of the research findings. The author expresses gratitude to her mentors, nursing supervisors, health departments, and community health nurses who participated in the study. The document also acknowledges the author's family for their support.
Typology: Thesis
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This study was concerned with the expertise of conununity health nurses as evident in self-reported, personal examples of care which were rated by three expert judges. The study partially replicated research conducted among hospital nurses which identified expertise as the highest level of performance and also identified domains of nursing practice in that practice setting. One objective of the study was to determine whether expertise was identifiable in the narrative examples submitted by the community health nurses. A second objective was to determine whether all the domains of practice identifiable in the institutional setting could also be identified in community health nursing practice. A third objective was to examine potential relationships between the expert level of community health nursing practice, as identified by the judges in this study, and various demographic variables. In addition, the results of the two studies were compared. I wish to express my sincere appreciation to my doctoral committee: to Dr. Thomas Karman, chairman of the committee, for hie scholarly advisement and patience with my compulsive attention to detail; to Dr. Robert Kamm, for his willing assistance making evident his philosophy that students are nwnber one; to Dr. Craig Robison for his help and special friendship; to Dr. Russell Dobson for his interest and encouragement with the study methodology; and to Dr.
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Shirley Steele for her nursing expertise and generosity as a mentor
to Dr. Jim Duke for his help with the statistical treatment of the study. Gratitude is expressed to the health departments who permitted their staff nurses to participate in the study. Also, appreciation is extended to the nursing supervisors who distributed the research instruments and encouraged staff participation. Special gratitude is expressed to the community health nurses who submitted personal examples of expertise. Without them the study would not have been possible. Finally, a special appreciation is appropriate for my husband, Frank, who supported me in all my educational endeavors and commanded
five children provided immeasurable support as they saw my metamorphosis from an unemployed homemaker to a professional woman.
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- Biographical Vari~es Potential Relationship Between Skill Level and - Comparing Sunttna.ry. the• • • • Expert• • • • • • • Nurse• • I • • • in• I • Two• • • I Settings.• • • • • I • • • .• • • • • • • • • I • LIST OF TABLES Table Page I. Expertise by CUrrent Level of Education................... 72 II. Domains Identified in Examples ............................ 77 III. Experts' Rating of All ~es .....................•....• 79 IV. Scores of Expert and Non-Expert Groups .................... 80 v. Ages of Sl.Jl::)j ects......... •................................ 82 VI. Expertise by Age Groups ................................... 82 VII. Subjects by Basic Professional Program.................... 83 VIII. Expertise by Basic Nursing Education...................... 84 IX. Expertise by Additional College Credits Earned............ 85
XIII. Summary of T-Test Comparisons Between Expert and Non-Expert Nursing Groups ............................... 90 XIV. Summary of the Logistic Model Predicting Public Health
2 expertise or a breakdownin performance. She contended that as expert clinicians document their performance, new areas of clinical knowledge are made available for furtherstudy and development. While pursuing documented examples of expert community health nursing, responses were sought to the following research questions:
practice. However 1 there has been a paucity of descriptive studies which permit identification of the knowledge embedded in clinical practice and permit identifying the behaviors of the expert nurse.
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Clinical knowledge is gained over time. Because nursing is an applied discipline 1 it has been described as both an art and a science. Nurses who are in the front line of practice know intuitively which problems are important (Dick 1 19831 p. 44). What nurse clinicians learn from clinical practice enables them to make clinical judgments which vary according to the level of in-depth skill acquired. Benner ( 1984) has described what expert nurses do in specific patient care situations and has identified how beginners perform differently from experts. She also proposed that as nurses develop their careers 1 they change their intellectual orientation and refocus their decision-making on a different basis than the process-oriented one they were taught. Benner used the Dreyfus Model of Skill Acquisition as a tool for examining and understanding the differences between the experienced nurse and the novice. The model was inductively derived by two University of california 1 Berkeley 1 professors who brought together their expertise as mathematician/systems analyst and philosopher (as cited in Benner 1 1982a 1 p. 402). Although the model was developed from studies of chess players and pilots 1 Benner found that 1 when it was generalized to nursing 1 it took into account increments in skilled performance based upon experience as well as educatio~ Benner ( 1982al p. 402) used interviews and participant observations to confirm the generalizabili ty of the Dreyfus Model of Skill Acquisition to nursing. The model asserted that in the
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consideredto be holistic ratherthan fractionated, procedural, and based uponincremental steps. Byviewing performancein this way, it
meanings, and outcomes of expert nursingpractice in acute care settings ( 1984, p. 4). While Benner viewed the expert nurse's performance as holistic,
nursing literaturehad numerous examples of holis~ The holistic approach to nursing carehas included the physical, mental, and spiritual aspects of care. Holism was the unity (^) of mind and body wherein the individual is viewed as a unified biopsychosocial being. Alterations inone part affected the whole (Krauss, 1984, p. 372). Whitmore and Utz (1985, p. 147) stated that the doctrine of holism is inopposition to mechanism, reductionism, and dualism which have pervaded twentieth-century western medicine. Therefore, the doctrine of holismpertained bothto aspects of patient care as well as to the process used to view nursing performance. Martin (1986, p. 133) has stated that holistic nursing practice is a term deeply rooted innursing's past. She made reference to the holistic approach in the professional origins of nursing stating that Florence Nightingale might be called the first holistic nurse because she stressed the importance of primary prevention and health
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maintenance. Martin also stated that the community health nurse has the opportunity to practice more holistically than his/her counterpart in the hospital. Therefore, it is assumed that the expert level of skill acquisition may be identified among nurses in the community
Community health nursing practice has not received the attention for study that hospital nursing has received. Historically the term
to describe this subspecialty of nursing practice. In early accounts of home visiting, health teaching, and drawing on epidemiological concepts to determine the focus of actions, nurses were considered public health nurses (Stanhope & Lancaster, 1984, p. 123). While attempting to distinguish between community health nursing and public health nuxsing, Smith (1984, p. 179) stated that the practice of public health nursing is to some extent subsumed under the broad classification of community health nursing. However, she stated that the practice of public health nursing has traditionally focused on the health of populations by using programmatic planning techniques. Nevertheless, she stated that the goal of both those nurses considering themselves community health nurses and those who consider themselves public health nurses is the promotion of the health of populations. Gulino and LaMonica's (1986, p. 80) findings regarding the role of the public health nurse were consistent with Smith's statement that health promotion is the goal of those nurses who work in the community. They reported that seventy-nine percent of the nursing interventions in their sample of public health nursing home visits
8 Basic Assumptions The following assumptions weremade indesigning this study:
Scope and Limitations Inthe study of expert nursingpractice of community health nurses, the sample was self-selected from thepopulation of community health nurses whowere employed by three governmental agencies. Therefore, the sample was a limitation of the study as it did not include community health nurses employed inother settings. Because the studywas limited to a relatively rural, south-central state, the findings are not (^) generalizable to any otherstate or to a more urban population. Another limitation of the study was the lack of a structured instrument which might have guided the subjects in theirresponses and encouraged more detail and completeness of the examples. The
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inability of the investigator to talk with the subjects to clarify and
The influence of unconscious processes and selective recall of
therefore a limi tatio~ Also, because the study data consisted of
have occurred.
diploma preparation in nursing participated in the study. This made it impossible to generalize these results to those areas where only nurses with baccalaureate or higher degree preparation are employed as community health nurses.
number of nurses and to certain specific roles performed by those
nurses and all roles of community health nurses. The subjects were limited to those nurses who provide direct care to clients. The influence of some uncontrolled variables may be minimized in this way.
Definition of Tenns For the pw:pose of the study, the following defini tiona were used: Basic Professional Education - The education which prepares the nurse to take the licensure examination to become a registered nurse. This education may be the baccalaureate program in higher education, the associate degree program at a community college, or the diploma program at a hospital school of nursing.
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Expertise - A special skill which develope when the clinician tests and refines theoretical and practical knowledge by challenging expectations in actual clinical situations. Experience is a requisite which promotes perception of the clinical situation as a whole. Health Promotion - The prevention of illness by educating, counseling, and motivating the client toward the highest level of wellness that is achievable for the individual and his/her family. Holistic Health - The unity of mind and body in a biopsychosocial being in which alterations in one part will affect the whole. Holism - A doctrine which opposes mechanism, reductionism, and
individual by looking at the component physical or chemical units that make up the body. The focus is on the individual' s culture, environment, and physical, spiritual, and mental health. Organization of the Study
This research study is presented in five chapters. Chapter I introduces the study, explains the problem, discusses the significance of the study, assumptions, limitations, and defines terms. Chapter II presents a review of the literature related to excellence in nursing, commitment and creativity in nursing, expertise and the expert nurse, and expertise in community health nursing practice. Chapter III presents the methodology of the study including subjects, instrumentation, and collection and treatment of the data. Chapter IV describes the findings of the study. Chapter V includes a summary, conclusions, and recommendations for further research and for nursing education.
REVIEW OF SELECTED LITERATURE Introduction The movement of higher education away from the classical curriculum heralded offerings in the applied areas of study. Although the Yale Report of 1828 attempted to perpetuate the old course of
as a receptacle and a muscle with various potentialities waiting to be trained. Lindsley, an academic reformer of the nineteenth century, recognized the need for a broadly practical education, yet he was also conunitted to intellectual excellence (p. 116). Lindsley s ideas for a great educational institution made it possible for John Dewey, a later reformer, to expand the potential for excellence using a method of education based on the principles of problem solving (Levine, 1979, p. 258). The wholeness of experience, rather than compartmentalization of knowledge, represented the epitome of Dewey s vision (p. 260). By ascribing the virtue chiefly to the process rather than to the sutaect itself, experience-based education came into being. Dewey also focused on the continuity of the educational process, according to Ratner {1939, p. 627), by stating, (^11) Education is a constant reorganizing and reconstructing of