Just like any other profession, a perioperative nurse must strive to become an expert. The ability to master perioperative care will undoubtedly increase patient satisfaction and at the same time minimize the risk of error. A Zen master was able to put it succinctly when he said, “In the beginner’s mind there are many possibilities, but in the expert’s mind there are few” (Suzuki, 2009). In other words, an expert will be able to make the right decision much quicker than others. It is a skill necessary in the operating room where the lives of patients are at stake. In order to develop a novice into an expert, mentoring and a systematic orientation process are just a few of the suggested solutions. In order for this strategy to work, the proponents must first understand how human beings think and learn.
The baby boom generation is entering the latter stages of life. In other words, many of them will begin to feel the effect of old age and as a result they will need medical care – f exerting pressure on an already thinly stretched U.S. healthcare system. In addition, more and more people are being added to the American society as a natural outcome of increasing population growth and radical changes in immigration patterns. Thus, medical centers are in need of more nurses. But the pressures of the job, as well as rising expectations about modern-day nurses, are two factors that add to the increasing frustration of novice nurses. Many of them will quit on their first year unless medical centers learn appropriate strategies to significantly reduce turnover rate. This is especially true for novice nurses who are thrust into the perioperative care.
Nurses that are new graduates and are tasked to work in the operating room are required to have a higher level of competency than regular nurses. Even if they are new to their profession, it can be argued that perioperative nurses face more daunting challenges than new nurses who are assigned to less demanding roles. This is due to two reasons. Firstly, they have not yet acquired the experiences required to become a competent nurse. Secondly, their work in the operating room requires focus and competence because mistakes can lead to very serious consequences. This is the reason why many nurses, especially those who work in a high-pressure environment chose to quit on their first year – a staggering 29.5% turnover rate (Halfer, 2007). If regular nurses are overwhelmed by the pressure of the new job then one can easily understand the kind of strain that perioperative nurses are experiencing on a regular basis.
It should not be surprising to find out that the turnover rate is also very high in this type of specialization. Something has to be done to ease the transition and strategies must be developed to help new nurses cope with the reality of their profession, especially those assigned to the operating room. Many are in agreement that one of the best ways to deal with this problem is through mentoring (Halfer, 2007). This is achieved through the pairing of a novice with an expert or by creating small groups, mixing rookies and veterans so that they can help each other. But before going any further it is important to first understand the theoretical basis of mentoring and the types of learning that a novice will have to undergo in order to grow and mature as a perioperative nurse.
Knowing and Thinking
New graduates must be trained to think and learn from observing the activities inside the operating room. This view is not new and according to one study, “Mastery of psychomotor, cognitive, and affective skills necessary for nursing practice must be acquired through experience in the work situation (Anderson, 1975). The process of emotional maturity and intellectual growth can be enhanced by realizing that there are at least three types of thinking:
- reflective; and
- through the power of networking.
Moreover, the novice nurse assigned to perioperative care will do well to understand the multiple ways of knowing:
- empiric, the science of nursing;
- personal knowledge;
- ethics, the component of moral knowledge; and
- aesthetics, the art of nursing (Diem & Moyer, 2004). It is interesting to note that learning goes beyond the empirical level.
Critical thinking is a skill that is very important in perioperative care because new technology and higher standards in health care require nurses working within perioperative care to make an assessment, diagnosis, planning, implementation and evaluation (Kimmel, 2009). This is because perioperative nurses are required to carefully identify specific problems and physiological and psychological factors “…that affect the client’s position on the health and wellness continuum” (Kimmel, 2009). This means that the critical thinker is not chained to the rule book but able to see the whole picture (Halfer, 2007). Critical thinking can be acquired through the application with experience (Kimmel, 2009).
Reflective thinking is the opposite of critical thinking because instead of looking to the outside world, the person will try to look within himself. The mind is actively engaged but this time the intellect is used to examine the thoughts and feelings of the person (Granqvist, 2000). Reflective thinking is not only about self-knowledge, it is also about “…being open-minded to other’s thoughts, views and perspectives” (Granqvist, 2000). This kind of knowledge acquisition can help nurses perceive the needs of patients even if they are unable or not yet comfortable in the presence of strangers.
Critical and reflective thinking is highly dependent on the action of the individual. Learning can be done through observing others and by studying a body of knowledge prepared by teachers and various experts. In the latter part of the 20th century, management gurus like Stephen Covey developed another method of learning and this is via networking (Hickman et al., 1996). Instead of trying to be a “lone ranger” novice nurses in perioperative care must learn to work in a group and their leaders must also learn how to unify the group’s talents and abilities to create collective competence (Hickman et al., 1996). A good Networker is someone who is not afraid to form relationships with others who seem more intelligent, more experienced, or more perceptive than themselves (Hickman et al., 1996). This is the correct attitude in order to enhance the nurse’s personal and professional development.
The most popular means of knowledge acquisition is through empiricism. Schools and textbooks are created based on this idea. But in recent times it has been made clear that men and women should not limit themselves with empirical learning (Chinn & Kramer, 2004). There are researchers in the field of nursing research who asserted that “What is expressed in a nurse’s actions conveys a simultaneous wholeness that textbooks and theories can never portray” (Chinn & Kramer, 2004). This insight is very helpful in developing a strategy to train novice nurses and turn them into experts.
When it comes to knowledge acquisition one of the most important is ethical knowing (Polifroni, 2007). This kind of knowledge can be acquired when new graduates will go out of their way to clarify issues on an individual and community level (Polifroni, 2007). There are at least two major forms the first one is professional ethics and the second one is clinical ethics. Professional ethics deals with integrity, confidentiality, behavior, privacy and professionalism while clinical ethics deals with care decisions, stakeholder involvement, and personal philosophies that can be consistent or in conflict with planned action (Polifroni, 2007). These are things that a novice nurse needed to learn but this type of knowledge can only be acquired through interaction with the hospital’s staff and other health workers.
Personal knowledge is also the discovery of self, values, morals, and lived experience (Diem & Moyer, 2004). This is linked to reflective thinking (Granqvist, 2000). Personal knowledge will allow nurses to use interpersonal relationships and intuition to evaluate, adapt and enhance practice (Diem & Moyer, 2004). This type of knowledge can be integrated with the other aforementioned forms of knowledge. One example is to combine it with aesthetics or the art of nursing. In this way, a nurse can adapt to different types of situations. A nurse can therefore become sensitive to what the community needs and be flexible enough to recognize that some policies and practices require re-evaluation. Finally, the nurse can go one step further by looking into a fifth pattern which is similar to emancipatory knowledge or the knowledge required to question the status quo and remove barriers preventing people from accessing healthcare (Diem & Moyer, 2004).
Based on the preceding discussion regarding learning and developing skills and talents, it can be argued that mentoring is one strategy that can help new nurses assigned to perioperative care. In order to begin the discussion on mentoring it is important to first unpack what Benner described as the Dreyfuss Model of skill acquisition and this model will help understand the learning curve that new nurses must negotiate and the reason why many are dropping out on the first year:
- Stage 1 – Novice
- Stage 2 – Advanced Beginner
- Stage 3 – Competent
- Stage 4 – Proficient
- Stage 5 – The Expert
After graduation, the nursing student will attempt to overcome the final hurdle – the licensure exams. After passing this final test the registered nurse will now have the credentials needed to work in a medical facility. But work has just begun. The school was all about theory and a little bit of training and yet the nursing student has never been tested. The first few months at work can be very crucial and many will soon realize that classes and written exams have not adequately prepared them for actuality.
They must go through the first level regardless of whether they went to the best school and regardless if they completed nursing school with flying colors. The most difficult aspect of the novice level according to Benner is the fact that new nurses are sustained by rules. They have had no experience and they cannot look back on a particular incident that they can use to solve a given problem. They cannot refer to a single memory in the past that can give them the wisdom and the knowledge to go about their task. According to Benner, their situation is made more difficult by rules that are context-free and independent of specific cases (2007). Thus, if the situation that they are in is not fully described in their rule book then they are paralyzed and unable to contribute, they will need the help of a more experienced nurse to help them deal with the current problem at hand.
The novice stage is a painful process. It is also a humbling experience for many and yet after working so hard for a period of time, the novice does not automatically jump to higher levels. He or she must still go through the next one which is called advanced beginner. The length of time spent at this level is dependent on the discipline, determination, and resources available for the new nurse. This is a much better position because the new worker will learn to adjust to the reality of being a nurse. It is also a good place to be in because at this point the new nurse is beginning to formulate principles that will help him or she make correct decisions later on.
It would do well for the advanced beginner to quickly transition to the next level which is definitely much better than the earlier stages of learning and skill acquisition. The next rung in the ladder is the competent level. Those who are fortunate enough to reach this point are now standing on a more solid foundation. They are not yet out of the woods yet but one can argue that it may take longer for them to succumb to the pressures of their work. They have more confidence, more knowledge and they can now experience a sense of satisfaction from their work because they are no longer a burden, they actually are contributors to the medical world.
Helping new nurses in perioperative care to get oriented with the challenges and reality of working in the operating room is well-grounded on theory. The idea of providing a helping hand and creating a mentoring program is supported by insights gleaned from studying knowledge and skill acquisition. It has been made clear that empirical-type of learning is not enough to teach all that is needed to become a highly proficient nurse. There are things that can only be learned through hands-on learning and by observing an expert at work.
The mentoring program will allow perioperative nurses to understand other aspects of learning such as the ethical way of doing their job. More importantly, the new trends in learning also indicated that a person’s development can be enhanced if he learns to work with others who are more experienced, more knowledgeable and more competent than the novice nurse. Mentoring if done properly can reduce the rate of turnover as well as increase the competency of new graduates to grow from being a novice to an expert.
Anderson, S. et al. (1975). The new graduate in the operating room.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Web.
Chinn, P. & M. Kramer. (2004). Integrated Knowledge Development in Nursing. MI: Mosby.
Diem, E.& A. Moyer. (2004). Community Health Nursing Projects: Making a Difference. New York: PA.
Granqvist, A. (2000). Reflective thinking in nursing education. Web.
Halfer, D. (2007). A magnetic strategy for new graduate nurses. Web.
Hickman, C. et al. (1996). The Fourth Dimension: The Next Level of Personal and Organizational Achievement. New Jersey: John Wiley & Sons, Inc.
Kimmel, N. (2009). Nursing Education – The Importance of Critical Thinking.
Polifroni, E. (2007). Ethical Knowing and Nursing Education. Web.
Suzuki, S. (2009). Shunryu Suzuki quotes a Japanese Zen priest. Web.