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Understanding skill acquisition among registered nurses: The 'perpetual novice' phenomenon

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Aims and objectivesTo determine whether the perpetual novice phenomenon exists beyond nephrology nursing where it was first described.Background The perpetual novice is a state in which nurses are unable to progress from a novice to an expert in one or more essential clinical skills which are used in their practice area. Maintaining clinical competence is essential to quality patient care outcomes.DesignAn exploratory, sequential, mixed methods design was used, comprised of a quantitative component followed by in-depth interviews.Methods Registered nurses employed in one of four roles were recruited from two university-affiliated hospitals in London, Ontario, Canada: Clinical Educator, Clinical Nurse Specialist, Advanced Practice Nurse and Nurse Practitioner. Participants were first asked to complete and return a survey and demographic questionnaire. Following the return of the completed surveys, ten participants were interviewed to enhance the results of the surveys.ResultsThe results of the surveys confirmed that the perpetual novice phenomenon exists across multiple nursing care areas. Four contributing factors, both personal and structural in nature, emerged from the interviews: (1) opportunities for education, (2) the context of learning, (3) personal motivation and initiative to learn and (4) the culture of the units where nurses worked.Conclusion The perpetual novice phenomenon exists due to a combination of both personal factors as well as contextual factors in the work environment.Relevance to clinical practiceThe results assist in directing future educational interventions and provide nursing leaders with the information necessary to create work environments that best enable practicing nurses to acquire and maintain clinical competence.
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ORIGINAL ARTICLE
Understanding skill acquisition among registered nurses: the
‘perpetual novice’ phenomenon
Barbara Wilson, Lori Harwood and Abe Oudshoorn
Aims and objectives. To determine whether the perpetual novice phenomenon
exists beyond nephrology nursing where it was first described.
Background. The perpetual novice is a state in which nurses are unable to pro-
gress from a novice to an expert in one or more essential clinical skills which are
used in their practice area. Maintaining clinical competence is essential to quality
patient care outcomes.
Design. An exploratory, sequential, mixed methods design was used, comprised
of a quantitative component followed by in-depth interviews.
Methods. Registered nurses employed in one of four roles were recruited from
two university-affiliated hospitals in London, Ontario, Canada: Clinical Educator,
Clinical Nurse Specialist, Advanced Practice Nurse and Nurse Practitioner. Partic-
ipants were first asked to complete and return a survey and demographic ques-
tionnaire. Following the return of the completed surveys, ten participants were
interviewed to enhance the results of the surveys.
Results. The results of the surveys confirmed that the perpetual novice phe-
nomenon exists across multiple nursing care areas. Four contributing factors, both
personal and structural in nature, emerged from the interviews: (1) opportunities
for education, (2) the context of learning, (3) personal motivation and initiative
to learn and (4) the culture of the units where nurses worked.
Conclusion. The perpetual novice phenomenon exists due to a combination of
both personal factors as well as contextual factors in the work environment.
Relevance to clinical practice. The results assist in directing future educational
interventions and provide nursing leaders with the information necessary to create
work environments that best enable practicing nurses to acquire and maintain
clinical competence.
Key words: clinical nurse leaders, nursing skill acquisition, nursing work environ-
ments, perpetual novice, skill competency
What does this study contribute to
the wider global clinical
community?
The perpetual novice phe-
nomenon does appear to exist
across nursing units and results
in the failure of some nurses to
become experts or advance their
skills towards expert in one or
more nursing skills.
Results of this study reinforce
that a nurse’s ability to acquire
and maintain skill competency is
the result of both personal factors
as well as contributing factors in
his/her work environment.
There are opportunities for bed-
side nurses, clinical nurse leaders
and administrators to foster a
positive culture for continued
learning in their work areas.
There are opportunities for fur-
ther research investigating which
interventions are most successful
at improving clinical skills, par-
ticularly for those skills not used
frequently enough to maintain
clinical competence.
Accepted for publication: 10 July 2015
Authors: Barbara Wilson, RN(EC), MScN, CNeph(C), Nurse Prac-
titioner, London Health Sciences Centre, London, Ontario; Lori
Harwood, RN(EC), PhD, CNeph(C), Nurse Practitioner, London
Health Sciences Centre London, Ontario; Abe Oudshoorn, RN,
PhD, Assistant Professor, Arthur Labatt Family School of Nursing,
Western University, London, ON, Canada
Correspondence: Barbara Wilson, Nurse Practitioner, London
Health Sciences Centre, Room A2-335, 800 Commissioner’s
Road East, London, ON, Canada, N6A 5W9. Telephone:
+1 519 685 8500 ext. 57240.
E-mail: barb.wilson@lhsc.on.ca
©2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, doi: 10.1111/jocn.12978 1
Introduction
Registered nurses (RNs) are vital to the delivery of health
care services globally and require specific knowledge and
skills to function effectively in their role. In Canada, RNs
are members of a self-regulating profession and are respon-
sible for lifelong learning to ensure their competencies are
relevant and up-to-date (Canadian Nurses Association
2004). A prevailing approach to skill acquisition/mainte-
nance in the clinical setting occurs by providing RNs with
education, resources and opportunities to practice the skill.
Many are familiar with the progression of development
from novice to expert. However, research has demon-
strated that some RNs continue to experience ongoing dif-
ficulty with essential clinical skills, and are unable to
advance their skill from novice to expert and remain in a
state of perpetual novice (Wilson et al. 2010, 2013).
Research on clinical nurse leaders or nurse educators has
elucidated several factors associated with skill development
but has been limited in terms of addressing situations in
which skill development does not occur (i.e. perpetual
novices) (Khomerian et al. 2006, Spivak et al. 2011).
Therefore, the purpose of this study is to explore the
extent to which the perpetual novice phenomenon is found
within nursing workplaces, and to begin to unpack how it
might be addressed through nursing skill development and
maintenance.
Background
Competency in nursing is difficult to define and there is a
lack of consensus regarding its definition and ongoing mea-
surement in nursing (Scott Tilley 2008). It involves nurses’
personal reflection and self-assessment of knowledge and/or
skills and a plan for ongoing improvement in the area(s)
identified (CNA 2004). While clinical nurse leaders and
clinical educators play important roles in facilitating nurs-
ing knowledge and skill development in their respective
clinical areas, there must also be a balance of responsibility
placed on individual nurses to identify and remediate gaps
in their own practice.
Maintaining skill competency often requires that RNs
attend continuing professional development activities that
are relevant to their practice. Previous research has identi-
fied a number of personal and contextual barriers to attend-
ing professional development activities including the
inability to leave their unit(s) due to patient care responsi-
bilities (Dealy & Bass 1995), the cost of conferences (Dealy
& Bass 1995, Harper 2000, Schweitzer & Krassa 2010),
difficulty getting time off from work to attend (Schweitzer
& Krassa 2010), lack of managerial support for continuing
education (Bahn 2007), as well as child care and/or home
responsibilities (Harper 2000, Schweitzer & Krassa 2010).
The RNs working the night-shift have an added challenge
as the availability of educational opportunities during work
time is considerably reduced (Mayes & Schott-Baer 2010).
A recently published study specific to the identification of
barriers and enablers to learning among a sample of 46
allied health professionals in Australia identified heavy
workload and inadequate staffing as key barriers to work-
place learning (Lloyd et al. 2014). Unfortunately in this
study, only one of the 46 individuals in the sample had a
nursing background.
Maintaining skill competency can also be a challenge in
patient care areas where there are few opportunities to
practice and become proficient in a particular skill. In
nephrology nursing, the concept of perpetual novice was
conceptualised as the state in which nurses are unable to
progress from novice to expert in the skill of cannulation of
the arteriovenous fistula (AVF) even after working in hemo-
dialysis (HD) for a number of years (Wilson et al. 2010,
2013). Our research reported the interplay between per-
sonal attributes of the individual HD nurse as well as a
number of contextual factors in the work environment that
hinder skill development around cannulation resulting in a
wide variation in the skill level between nurses (Wilson
et al. 2013). Barriers such as attitudes and demands from
patients, unit flow and time pressures, and limitations
imposed by the current model of nursing care were also
identified as contributing factors within the environment
that prevented adequate learning opportunities. Personal
factors appeared to motivate some to improve their cannu-
lation skills or became a stimulus to avoid cannulation alto-
gether, thus preventing further skill development. These
findings raise the question of whether this same challenge
to advance from novice to expert exists across other nurs-
ing areas?
Benner’s (2001) widely adopted work on skill acquisition
was used as the framework to examine the development of
HD nurses’ skill development around cannulation. Benner’s
model suggests that skill development occurs on a contin-
uum as the learner passes through five levels of proficiency
from novice to expert. The concepts embedded in Benner’s
(2001) model are deemed widely applicable to both newly
graduated nurses as well as seasoned RNs transferring to
another practice area. For the latter group, Benner (2001)
argues that even seasoned nurses entering a clinical area
where they have no prior clinical experience with a particu-
lar patient population may be limited to novice level perfor-
mance if the goals and tools of patient care are unfamiliar
©2015 John Wiley & Sons Ltd
2Journal of Clinical Nursing
B Wilson et al.
to them. However, these RNs can advance their skills if
given sufficient theoretical education and real-life experi-
ence.
A second study on nursing skill acquisition in nephrology
(Wilson et al. 2013) challenged the taken-for-granted
assumption of progression in Benner’s (2001) theory. Rather
than a series of stages through which RNs progress, skill
acquisition appears more complex including both structural
influences such as unit culture and workload in addition to
personal attributes such as attitude, motivation or lack
thereof. The perpetual novice has had theoretical and real-life
situational experience in regard to cannulation, which should
be sufficient for progression of skill acquisition, yet it proves
to not be so. Benner’s (2001) theory has been previously cri-
tiqued for a simplistic positive view of progress that recom-
mends retraining without attention to place (Purkis 1994) or
social knowledge/structure (Thompson 1990).
To the best of our knowledge, there is no research
available that examines the perpetual novice phenomenon
apart from what has been described in relation to cannu-
lation in dialysis. Nephrology nursing is one of the many
areas of nursing practice. As a practice profession, we
hypothesise that most, if not all, areas of nursing would
have certain essential skills on which RNs are unable to
move along the continuum of expertise. Further investiga-
tion of this concept and the extent to which this phe-
nomenon exists in other areas of nursing practice is
essential to understand the factors that hinder nursing
skill development.
Theoretical/conceptual framework
Critical realism based upon Roy Bhaskar’s writings (Bhas-
kar 1975, 1989) is used as the theoretical framework for
this study. Critical realism is a worldview which is particu-
larly suited to explaining complex problems (Pawson &
Tilley 1997, Sayer 2000) by allowing for the investigation
of wide determinants of a personal and structural nature
(Harwood & Clark 2012). Therefore, to understand beha-
viours, in this case nurses’ skill development and decisions
towards acquiring these skills, both the agency and the con-
text must be explored. At the individual level, a person’s
successes or failures may have little to do with their own
reasons and intentions but may have everything to do with
the structure-agent interaction over which they have limited
control or awareness (Sayer 2000, Harwood & Clark
2012). It is due to this lack of awareness that critical real-
ists are cautious to accept claims solely from personal
accounts (i.e. staff nurses experience) and, thus, the per-
spectives of advanced practice nurses was sought.
Aim
The perpetual novice is a state in which nurses are unable
to progress from novice to expert in one or more essential
clinical skills which are used in their practice area. The aim
of this study was to further explore this concept and deter-
mine whether this phenomenon exists beyond nephrology
nursing to other clinical areas where RNs practice, and if
so, with which particular skills. Secondarily, if participants
do identify the phenomenon as present in their work envi-
ronment, qualitative interviews will begin to unpack barri-
ers preventing the progression from novice to expert.
Methods
An explanatory sequential mixed methods research design
was used consisting of quantitative then qualitative method-
ology. This is a type of design in which quantitative and
qualitative data are collected sequentially, analysed sepa-
rately and then the results are combined (Creswell & Plano
Clark 2011). Mixed methods studies are consistent with the
tenets of critical realism (Lipscomb 2008, Creswell & Plano
Clark 2011). The reason for collecting both quantitative
and qualitative data was to corroborate results from both
forms of data to bring greater insight into the problem of
interest (Creswell & Plano Clark 2011). The quantitative
results, which entailed the first phase of the study, were
used to identify the extent to which the participants
believed that the perpetual novice phenomenon existed
within the hospital setting and their beliefs about the con-
cept. The qualitative component, which was the second
phase of the study, was used to further explore the com-
plexities around this phenomenon in greater detail, particu-
larly barriers to progression from novice to expert.
Sample
Subjects were recruited from two university-affiliated hospi-
tals in London Ontario, Canada. Combined, these centres
provide both in- and outpatient services for the city and
region. The sample consisted of RNs employed in one of
the four roles: Clinical Educator, Clinical Nurse Specialist
(CNS), Advanced Practice Nurse (APN) and Nurse Practi-
tioner (NP). These job categories were selected believing
they would provide broader knowledge about skill acquisi-
tion across all clinical areas. Furthermore, individuals in
these advanced nursing roles are responsible for providing
and supporting clinical education to front-line staff. This is
consistent with critical realism where in this case, nurses in
advanced roles from their experience observing many
©2015 John Wiley & Sons Ltd
Journal of Clinical Nursing 3
Original article Perpetual novice phenomenon
nurses would be familiar with the skill sets of their col-
leagues, formed beliefs and are likely to have a working
hypothesis of skill development (Pawson & Tilley 1997).
Inclusion criteria consisted of individuals employed in
one of these four roles, either inpatient or outpatient, acute
or chronic setting, adult or paediatric patient population,
for at least one year. Subjects were excluded if they were
not working at the time of data collection or were
employed in community-affiliated settings (i.e. family medi-
cal centre, home support services). In total, 129 individuals
were eligible to participate. Participants who completed the
survey were invited to express interest in the second phase
of the study, a qualitative interview.
Quantitative
Following ethics approval in 2013 by the local university-
affiliated research board, participants fitting the inclusion
criteria were mailed an information letter about the study,
which included a description of the perpetual novice phe-
nomenon, a three page survey, a weblink for optional
online completion and a short demographic questionnaire
to allow for sample description. The purpose of the survey
was fivefold: (1) to introduce participants to the perpetual
novice concept; (2) to request their feedback about the con-
cept; (3) to identify essential but infrequently used nursing
skills in their practice area(s) that may not be performed
regularly enough for the nurses to become expert, (4) to
identify strategies they have used to move nurses from
novice to expert for the nursing skills they identified and
(5) identify aspects of perpetual novices which are context
dependent and need to be further explored qualitatively.
The survey provided an introduction and detailed
description of the perpetual novice phenomenon, the partic-
ipants were then asked to what extent they agreed/dis-
agreed with 12 statements about the phenomenon on a
five-point likert scale (strongly disagree, disagree, neutral,
agree, strongly agree). These statements asked for the
respondents’ opinions about the skill competency of nurses
in their respective work areas and reflect on the extent to
which opportunities to maintain skill competency are avail-
able. Specific survey items are reported in Table 2. The sur-
vey also included a number of open-ended questions to
allow respondents the opportunity to provide detailed
description(s) of the number and types of clinical skills
infrequently performed on their respective units, the num-
ber of RNs working on their respective units and the num-
ber of RNs on their unit they would describe as a perpetual
novice. The survey was developed by the research team
using principles of good survey design as described by Dill-
man (2007). In particular, consistency in likert scale direc-
tion was used throughout the survey, important but easy to
miss changes in the wording of some questions were under-
lined and use of dark print and shading for questions and
no shading behind answer choices was also used. Questions
were derived from the two previous studies on the topic
(Wilson et al. 2010, 2013), thus contributing to both con-
tent and face validity (DeVon et al. 2007). An epidemiolo-
gist was also consulted to provide expertise around tool
development. Return of the survey denoted willing partici-
pation. A reminder postcard was sent two weeks after the
initial survey to maximise response rate (Dillman 2007).
Qualitative
Nurses who completed the survey were asked if they would
participate in a face-to-face follow-up interview. The pur-
pose of the interview was to explore the concept of perpet-
ual novice in more depth from the participant’s perspective.
Informed consent was obtained at the time of each inter-
view by the research assistant. Ten individuals participated
in one 4560 minute interview occurring at a mutually
acceptable location. A semi-structured interview tool was
used with questions derived from survey data and previous
research. In particular, interviewees were asked to provide
feedback about the perpetual novice phenomenon and
whether it made sense to them. Did they see it in their prac-
tice area(s)? Participants were also asked to identify factors
they believe fostered skill development, barriers to learning,
as well as strategies they have used to assist RNs in their
respective area(s) to become expert in a particular clinical
skill. Throughout the interviews, participants were asked
additional probes for clarification regarding their comments.
This reduces misinterpretation and contributes to the study’s
credibility and confirmability (Lincoln & Guba 1985). All
interviews were audiotaped and transcribed verbatim.
Data analysis
Data analysis occurred in two stages. First, mean scores
were calculated for each survey statement and responses
from the open-ended questions were collated. All data were
grouped to ensure anonymity and confidentiality. As the
primary aim of the study was simply to determine the exis-
tence of the phenomenon, only descriptive statistics were
required. The investigators met to discuss the quantitative
results and refine the qualitative interview guide based on
the areas that needed more explanation. Data analysis for
the interviews was ongoing during the data collection phase
and began once the first three interviews were transcribed.
©2015 John Wiley & Sons Ltd
4Journal of Clinical Nursing
B Wilson et al.
While 10 interviews were completed, one interview focused
more on self-reflection of the respondent’s clinical skills
rather than the skills of the RNs in their clinical area. This
interview was subsequently removed from the analysis.
Content analysis was used for the remaining nine interviews
which allowed for interpretations of the context of data
through a systematic process of coding, classification and
identifying themes and patterns (Hsieh & Shannon 2005).
Validity and reliability/rigour
Rigour was addressed in the quantitative and qualitative
components separately and then assessed on the integration
of the two types of data. Content and face validity of the
survey was conducted and is described previously. In terms
of the qualitative data, the investigators each did their cod-
ing separately and then met to discuss their findings and
emerging themes. Negative cases were also sought out,
which increases certainty and confidence that the analysis
and conclusions are reliable (Richards & Morse 2007). Pre-
liminary analysis was discussed by the co-investigators and
the research assistant and served as a form of member-
checking (Creswell & Plano Clark 2011).
Onwuegbuzie and Johnson (2006) have proposed criteria
that are consistent for mixed methods approaches with a
focus on the quality of the research, which they refer to as
legitimation. The authors have proposed nine areas of legit-
imation for mixed methods research that should be consid-
ered and used to guide rigour in the final synthesis of data.
In this study, Onwuegbuzie and Johnson’s (2006) criteria
for insideoutside legitimation and commensurability legiti-
mation were specifically addressed. Insideoutside legitima-
tion occurs when the researcher integrates the analysis of
data from the researcher(s) standpoint (i.e. insider) with
external analysis (i.e. outsider). For this study, synthesis of
researcher data was reviewed with an in-hospital expert/
consultant in organisational psychology and adult learning
to ensure accurate interpretation. Commensurability legiti-
mation refers to the back and forth interpretation of quan-
titative and qualitative forms of data and this process was
used during the analysis phase of the study.
Results/Findings
Demographics
Of the 129 surveys distributed, 42 were returned for a
response rate of 325%. The final sample consisted of 17
(415%) Clinical Educators, 15 (366%) NPs, 7 (17%)
CNSs and 2 (49%) APNs (See Table 1). Study participants
were employed an average of 256 years in nursing (range
435 years) and had worked a mean of 92 years (range
125 years) in their current position. Approximately two-
thirds (653%) of the respondents worked with inpatients
and most (925%) worked with adult patient populations.
The highest level of nursing-related education achieved was
the following: Diploma (24%), Baccalaureate (357%),
Masters (547%) and other (72%).
Survey results
Survey statements and their respective mean and range of
scores are presented in Table 2. Results supported our
hypothesis of the ubiquitous nature of the perpetual novice
phenomenon. Not surprisingly, highest mean scores were
obtained for statements 1 and 2 recognising the importance
of maintaining skill competency for practicing RNs in their
clinical areas (mean scores 49 and 45 out of 5). Concern
about the ongoing ability of the RNs to maintain compe-
tency for infrequently used but important skills (statement
4) was also ranked high (mean score 42 out of 5). Respon-
dents indicated they could identify perpetual novices in
their clinical areas (mean score 42 out of 5) and a wide
variation in skill level among the RNs was also reported
(mean score 41 out of 5).
Table 1 Demographic characteristics of survey respondents
(n=42)
Characteristic n(%)
Mean years
(range)
Highest education in nursing
Diploma 1 (24)
Baccalaureate 15 (357)
Masters 23 (547)
Other 3 (72)
Highest non-nursing education received
Diploma 6 (40)
Baccalaureate 5 (333)
Masters 1 (67)
Other 3 (20)
Current position in the organisation
Clinical Educator 17 (415)
Clinical Nurse Specialist 7 (17)
Advanced Practice Nurse 2 (49)
Nurse Practitioner 15 (366)
Years employed as a registered nurse 256(435)
Years employed in current position 92(125)
Type of work setting
Inpatient 27 (653)
Outpatient 15 (357)
Patient population
Adults 37 (925)
Paediatrics 3 (75)
©2015 John Wiley & Sons Ltd
Journal of Clinical Nursing 5
Original article Perpetual novice phenomenon
On the open-ended questions, respondents provided
examples of infrequently used skills in their respective areas
including venipuncture (n=12), setup and/or use of pain
pumps (n=8), NG/feeding tube insertion and/or mainte-
nance (n=7) and chest tube care/removal (n=7) and this
appeared to vary by clinical area. When asked to identify
the percentage of nurses in their units who could be
described as a perpetual novice, a mean of 33% was
reported, suggesting as many as one-third of nurses could
be described as a perpetual novice in their work setting(s).
Respondents were also asked in the open-ended questions
to identify individual RN qualities and environmental influ-
ences that they perceived had an impact on learning in
their respective work areas. In terms of RN qualities, par-
ticipants identified motivation to learn (n=19), lack of
personal responsibility (n=13), lack of time or will to
learn (n=12), attitude (n=11), fear of failing (n=10)
and burnout/compassion fatigue (n=8). Environmental
influences most frequently reported included workload/
staffing issues (n=22), infrequent opportunity to practice
skills (n=11), high staff turnover (n=7) and support/
funding to attend learning events (n=6). Further explo-
ration of the number and types of infrequently used clinical
skills, as well as personal and environmental influences on
learning were further explored qualitatively through the
interviews.
Qualitative interviews
Analysis of interview data was consistent with the descrip-
tive data from the surveys suggesting that the perpetual
novice phenomenon does exist across most, if not all, clini-
cal areas. Four contributing factors, both personal and
structural in nature, emerged from the interviews: (1)
opportunities for education, (2) the context of learning, (3)
personal factors, motivation and initiative to learn and (4)
the culture of the unit.
Opportunities for education
Participants, who were clinical nurse leaders and clinical
educators, reported having some direct role in educating
RNs and all could identify a number and wide range of
educational opportunities available for their staff members
and these existed in various forms. Available education
allowed for both passive learning (i.e. weekly didactic inser-
vices) as well as pro-active education. The downside was
that often this education might not be related to the skill(s)
needing to be developed.
Participants described orientation programmes that were
comprehensive and well-developed, and in most cases these
included some sort of preceptorship/mentorship component.
Participants saw themselves as a resource to staff, being
readily available to answer questions and monitor staff
Table 2 Survey statement results (n=42)
Statement Mean score/5 Range of scores
1. I believe that maintaining skill competency among RNs in my clinical area is important 4915
2. I believe that maintaining skill competency for infrequently used but important skills
among RNs in my clinical area is important
4515
3. I am concerned about the ongoing ability of RNs to maintain competency in all
clinical skills in my area
415
4. I am concerned about the ongoing ability of RNs to maintain competency for
infrequently used but important skills in my clinical area
4215
5. The RNs in my clinical area are concerned about their ongoing ability to maintain
skill competency
3925
6. The RNs in my clinical area are concerned about their ongoing ability to maintain skill
competency for infrequently used but important clinical skills
3715
7. I feel that RNs in my clinical area lack sufficient opportunities to practice one or
more essential clinical skills to maintain their clinical competence
3215
8. I feel there is wide variation in skill level among practicing RNs in my clinical setting 4125
9. The concept of perpetual novice as described makes sense to me 4035
10. I feel that there are one or more RNs in my clinical setting that could be described
as a perpetual novice, meaning they are not able to transition from novice to
expert in an essential skill (or skills)
4225
11. I feel that there are environmental influences (i.e. workload, staffing etc.) in my work setting
that hinder skill development for practicing RNs
3915
12. I feel that there are personal RN qualities (i.e. motivation, attitude etc.) that may impede
or hinder their skill development
3825
Ranking of responses where: 1 =Strongly Disagree, 2 =Disagree, 3 =Neutral, 4 =Agree, 5 =Strongly Agree.
©2015 John Wiley & Sons Ltd
6Journal of Clinical Nursing
B Wilson et al.
members’ progress in learning. Respondents described
extensive opportunities for learning during orientation with
little or no opportunity for new hires to hide or avoid
learning. However, it was often noted that those tasks on
which staff members found themselves to be perpetually
novice, although well covered in orientation, became prob-
lematic due to lack of practice postorientation. All partici-
pants identified personal challenges in their own workload
such as covering multiple patient care areas, feeling
stretched in multiple directions, especially when corporate
learning initiatives were forced to take precedence. The fol-
lowing is a comment by one participant in reference to
workload:
Iam... covering both units and I have so many other responsibili-
ties, it is difficult for me to take time to spend one-on-one with a
nurse if she is faced with a particular challenge...part of that
though is that they don’t always ask for help, but I think if I was a
little less busy, I would be able to spend more time just checking in
on nurses to see. Because if I do make myself present then they are
more likely to ask for help. (Participant #5)
The context of learning
How learning occurred and the challenges faced also varied
by nursing unit. Participants reported a number of chal-
lenges to delivering unit-based education requiring them to
be creative and innovative in design and implementation.
Most of these challenges were resource-based including time
constraints to organise and deliver education, availability of
staff member coverage, funding to develop programmes
and/or pay staff members to attend. Clinical areas with fre-
quent patient turnover created additional challenges:
Patients are constantly coming through their doors being admitted
to their beds and being discharged within, usually, a 24-hour per-
iod. So there is so much of that patient turnover that they [nurses]
are just so overwhelmed by that piece and often just don’t have the
time to focus [on education]...inservices are often cancelled or
rescheduled if the demands of the unit do not allow staff to be
freed up to attend.... (Participant #5)
Areas with high RN turnover created environments of
constant change requiring orientation programmes for new
staff members to take precedence over continuing education
for the existing staff members. Experienced staff members
were frequently required to function as mentors for the
new staff members at the expense of fewer opportunities
for their own skill development. The situation was further
compounded in areas with large numbers of health profes-
sional staff and/or students as this resulted in competition
for opportunity to practice designated skills beyond orienta-
tion. As described by one participant with respect to the
skill of vaginal exams in labour/delivery:
We have an awful lot of nursing students... medical stu-
dents...mid-wifery students...paramedic students...the expectation
is that the nurse at the bedside is to function and help them...they
[nurses] are competing with the residents in our area, but at the
same time we are also faced with another unique situation because
we have at least two-thirds of our staff are new and the physicians
are not trusting. And because of that then, the residents are doing
more and more vag exams and the nurses aren’t able to do it.
(Participant #4)
Participants described the lack of support services in
some clinical areas as an additional barrier to learning.
They described nurses performing a number of non-nursing
tasks (i.e. laundry, delivering meal trays, making coffee,
cleaning) required to keep their unit functioning and these
tasks took priority over learning:
We don’t have a lot of support services here that other clinical
areas have so there is a lot of work that is really non-nursing work
that gets downloaded to nursing because nursing is always here-
...which take away from their clinical time and it also takes away
from the time they have for education...it also takes some of the
value out of their role because they are seen as being the task-
workers who can get this, this, and this done. (Participant #3)
Personal factors, motivation and initiative to learn
Participants identified the individual differences they
observed in nurses’ personal motivation to learn as a signifi-
cant hindrance to skill development. In fact, they described
personal motivation on a continuum from the ‘go-getters’
at one end who seek out and attend available learning
opportunities, to the ‘avoiders’ who become expert at dodg-
ing learning opportunities altogether. Avoidance was obvi-
ous or more subtle:
...we would notice when a code-4 ambulance was coming in, we
would get some notice when they were coming, and there was
always certain people that would kind of take off to the back of
the room because they really had to go to the bathroom, you know
whatever...there would be some people who would, kind of scat-
ter, because they just didn’t want to deal with whatever might be
coming through the door. (Participant #7)
Participants identified individuals fitting both of these
extremes and voiced frustration towards those who chroni-
cally avoided the learning made available. This only
occurred with experienced staff members as new RNs in
orientation were monitored and skill development was a
priority and primarily mandatory. Participants offered a
©2015 John Wiley & Sons Ltd
Journal of Clinical Nursing 7
Original article Perpetual novice phenomenon
number of explanations for their observations including
nurses’ personal problems, burnout, a lack of interest in
learning, differences in personal attitude(s) towards learning
and/or lack of confidence to learn. Participants even sug-
gested that not knowing how to perform a particular skill
would mean not being asked to do it, thereby preventing an
increase in workload. This creates a negative feedback loop,
or perverse disincentive to being identified as an expert in a
task where many colleagues are perpetual novices:
There is a subset of people that like to hang back at the back of
the room if you are doing a teaching thing. They don’t make eye
contact, don’t want to be asked a question, don’t step for-
ward...just kind of hang back. So if I just kind of pretend that it’s
all new and it’s not my accountability and I don’t have to know
anything outside of this little, you know, set of skills...then I am
not going to be asked to do it. And if I am, then, I have an excuse,
“no, no, I’m not comfortable to do that”, or, “I’m not competent
to do that”. (Participant #7)
The culture of the unit
Respondents were forthcoming in their descriptions of unit
culture and its influence on learning. On a positive note, they
described learning in many of their areas as dynamic, sup-
portive, and collegial. Skill acquisition and maintenance
appeared highly valued and in many clinical areas, nurses
were praised for their skill performance. Participants could
identify clinical experts in their respective areas. On many
units, staff members were more likely to be respected by their
peers if they demonstrated a desire and willingness to learn.
The unfortunate downside to a supportive culture is the ten-
dency to cover for one another such that the skills get done
in the absence of transferring learning to the less-skilled.
A number of negative aspects of unit culture were also
described. One example was the wide variation in how some
nursing units responded to the new staff members from those
very accepting to other areas were senior nurses appeared
frustrated. Differences were noted in the value placed on skill
development. Some units valued skill development and RNs
‘stepping up to the plate’, while individuals in other areas
would be highly criticised, even bullied by their peers for
showing initiative. Behaviours consistent with intimidation
were described by one participant within the context of his/
her own previous skill development as a staff nurse:
I think back to when I first learned how to .... the person that
mentored me was really good, but she was also extremely intimi-
dating and I think somewhat controlling as well. So unless I did it
exactly her way she was right on my rear, so I was afraid to learn
new things because how would I .... because she is watching and
hovering over me. I certainly don’t want to lose my job because
she has been here forever and she’s got that power. So I felt power-
less to move on until finally it happened to the point I had to blow
up and say, “hey, enough”, and that’s what I am hearing is hap-
pening to some people here. But those people don’t really want to
go forward and have the discussion with that person that is doing
that to them and they don’t really want to go forward to say any-
thing about it either. (Participant #1)
Participants appeared highly aware of the factors, both
positive and negative, that were contributing to the culture
on their respective units. There was also recognition among
participants that unit culture is hard to change as sum-
marised by one participant:
I think having adequate mentors, having nurses that we look up to
that can support our learning, and there has to be a culture on the
unit for that too. It’s kind of interesting, we have one unit where
people will call me and say, “Hey.....I’m on today and I can’t get
to one of those inservices on seizure management can you come up
and do a special for us?”...So they are always eager to learn. And
I have another unit that, it’s almost embarassing, if I have knowl-
edge so I am going to dumb it down. There are times what I would
love to do is just blow that unit up and self-select a dozen nurses
to start it up again and build a new culture on that unit. Maybe it
comes from leadership but culture is very hard to change. If you
have a culture of learning and good role models and people that
are keen, they really can support the learning of the rest of the
unit. (Participant #9)
Discussion
This study aimed to explore the concept of perpetual novice
using critical realism as a lens to question the presence of
this phenomenon beyond nephrology nursing where it was
first described, and to understand the personal and struc-
tural factors influencing the lack of progression from novice
to expert. Results of this mixed methods study suggest that
it does indeed exist beyond nephrology nursing, affecting
most, if not all, nursing practice settings. Specifically,
results reaffirm that there are few opportunities to perform
some skills with enough regularity to become expert and
the extent of the phenomenon varies depending on the clini-
cal area. What this study has added to our knowledge is
both the confirmation of the ubiquitous nature of the per-
petual novice phenomenon, as well as a refined understand-
ing of the internal motivators and contextual factors that
can either promote or hinder skill acquisition. Personal
factors such as the nurse’s motivation to learn, burnout,
lack of interest, lack of confidence to learn, self-regulation,
©2015 John Wiley & Sons Ltd
8Journal of Clinical Nursing
B Wilson et al.
negative attitude, reluctancy to ask for help and excuses of
not knowing or being able to decline to do the skill were
all identified as being components of the perpetual novice.
Structural factors identified in this research that contributed
to the perpetual novice were providing opportunities to
learn, orientation programmes, mentoring programmes,
educator availability and workload, lack of funding for
education, doing non-nursing tasks and a culture on the
unit where nurses were bullied and intimidated for showing
initiative rather than one which was dynamic, supportive
and valued skill development for clinical leadership.
Participants were all heavily involved in the design and
conduct of educational programmes for RNs. They appeared
to take ownership of the learning that occurred and made
significant efforts to be a resource for staff members despite
feeling stretched in multiple directions. All could identify a
number of challenges/barriers to delivering unit-based edu-
cation. Frequently, corporate education took priority at the
unit level. More time appeared to be devoted to orientation
programmes than for ongoing education and this, too, var-
ied by clinical area. When skill-based education was pro-
vided, these sessions were not always relevant to the skill(s)
with which a particular nurse may be struggling. All of these
factors, combined with opportunities to avoid learning, have
the propensity to result in a group of individuals that could
fall through the cracks with respect to skill acquisition.
Consistent with previous research specific to the perpet-
ual novice, participants reported a number of factors, both
personal and structural in nature, which would appear to
influence/hinder RN learning. At the personal level, partici-
pants described nurses’ personal motivation as a major con-
tributor to learning but reasons behind this are unclear.
Bahn (2007) reported that nurses were motivated to take
part in continuing education for fear of being left behind
by the more highly educated nurses entering the profession,
a belief that continuing education would enhance patient
care, as well as personal and professional satisfaction.
Whether these motives were contributing factors in this
study is unknown but certainly interesting to consider.
At the unit level, results highlight the importance of unit
culture as a factor that can promote or hinder learning.
Even clinical areas with a supportive culture may have lim-
ited learning opportunities, especially when staff members
cover for one another rather than encouraging skill acquisi-
tion across the board. These so called ‘go-getters’ who seek
out learning opportunities can either be praised or criticised
by their peers. Furthermore, many units appeared more
accepting of newly graduated nurses with novice skills than
towards senior nurses with defined skills but limited skill
acquisition within a new clinical area.
Peer pressure to maintain skill competency was brought
forth by several participants as an issue. In some clinical
areas, this appeared to result in an environment of shame
and intimidation with the potential to negatively affect the
RNs’ confidence to learn, thus compounding the problem.
In contrast, what we heard during other interviews were
examples of RNs overcoming this culture of shame, becom-
ing highly skilled despite significant adversity. It is interest-
ing to consider how these individuals responded to the
contextual challenges in their work environment. At some
level positive deviance may be playing a role. Positive
deviance occurs in organisations when certain individuals
(or groups) demonstrate practices that are outside the estab-
lished ‘norm’ (deviance) and results positive outcomes
despite having access to the same resources as other individ-
uals in the same group (Garg 2013). These individuals prac-
tice differently and display behaviours that are innovative,
creative and highly adaptable (Garg 2013). At the mini-
mum, it suggests that some sort of internal motivation and
initiative provides a strong influence in learning for some,
irregardless of the contextual barriers in their work envi-
ronment. Further exploration of positive deviance as it
relates to skill acquisition and the relationship between per-
sonal motivation and unit culture, would seem essential.
How to create learning opportunities for nurses in the
clinical setting that best enables skill acquisition is impor-
tant to consider. Laschinger (1990) has proposed that Kolb’s
(1984) model of experiential learning may be useful in the
design and implementation of educational programmes in a
variety of learning environments. Its use as the foundation
for baccalaureate nursing education has been previously
reviewed (Lisko & O’Dell 2010). Kolb’s (1984) theory is
based on the notion that learning occurs when individuals
progress through a four stage learning cycle (concrete expe-
rience, reflective observation, abstract conceptualisation and
active experimentation). Kolb’s (1984) theory also outlines
four distinct learning styles (diverging, assimilating, con-
verging, accommodating) and that educational opportunities
be designed and implemented to allow each learner-type the
opportunity to participate in the learning style that suits
them best. If this theory holds true, then perhaps skill-based
education sessions previously offered on some nursing units
were not varied enough to accommodate participants with
different learning style preferences. At the minimum, it
would seem essential that those providing skill-based educa-
tion have an understanding of Kolb’s (1984) theory and
consider its use in the design and implementation of future
skill-based learning.
The perpetual novice as described in this study appears to
be the antithesis of the clinical nurse leader and is not able to
©2015 John Wiley & Sons Ltd
Journal of Clinical Nursing 9
Original article Perpetual novice phenomenon
develop clinical skills to his/her fullest potential due to a num-
ber of personal and structural barriers. Effective clinical lead-
ership has been identified as essential to maintaining quality
patient care and building healthy workplaces (Cummings
et al. 2010, Gilmartin 2014). Spivak et al. (2011) have sug-
gested that developing expert clinical nurses requires signifi-
cant time and investment on the part of nursing leaders. If
quality care is to be maintained, perpetual novices will need to
become competent and able to perform essential clinical skills
in their respective patient care areas. This will require moni-
toring by nurse educators and unit administrators who, unfor-
tunately, have significant workload concerns of their own.
Noticeably absent from all of the interviews were com-
ments pertaining to the role(s) of nursing leadership (i.e.
adminstration) in skill acquisition. This seemed unusual
given the number and variety of resource issues identified
as barriers. In essence, there seemed to be a disconnection
between nursing managements’ role in supporting skill
development and creating a culture where it is valued and
the individuals organising and providing nursing education.
Given the number of environmental barriers identified,
nursing leaders can play a significant role in promoting skill
development and affecting the culture of a unit. Pool et al.
(2013) reported that nurse manager leadership style and
responsiveness to change can have a positive influence on
the nurses’ attitudes towards continuing professional devel-
opment. At the unit level, nursing leaders are in a position
to influence change through the elimination of barriers.
This might include the creation of flexible staffing schedules
to facilitate attendance at education, hiring RNs with high
personal motivation to learn, examining workload issues,
downloading of non-nursing duties to unregulated staff and
setting expectations for skill acquisition through regular
performance evaluation.
Limitations
This study has some possible limitations. First, results
reflect the views and opinions of a sample from one Cana-
dian city and may not necessarily be generalisable to the
hospitals in Canada or internationally given the differences
in the work environments, education and scope of practice
for the role. Furthermore, results reflect the opinions of
those working in one of four advanced nursing roles, not
the RNs working in their respective clinical area(s) which
may have yielded a different perspective. A number of nurs-
ing units had undergone amalgamation within months of
study participation and this may have impacted the partici-
pants’ views. Finally, data collection took place during the
summer when many take vacations which may have
affected the lower survey response rate.
Opportunities for future nursing research
Further research specific to the perpetual novice phe-
nomenon would be helpful with particular attention to a
couple of areas. First, in what manner does this concept
exist beyond the environment of this study? Specifically, on
a larger scale there are opportunities to examine which nurs-
ing skill sets work well on units and further identify contex-
tual factors that positively impact on skill acquisition. Much
focus has been given to new nurses with orientation/mentor-
ing programmes, however, interventional studies that assist
the perpetual novices (which were estimated to be approxi-
mately one-third of respondents’ staff) are needed. Research
may suggest that efforts to increase self-efficacy in perform-
ing their skills may be helpful and, as well, build resilience
to counteract the negative culture and intimidation. Second,
focused study of clinical nurse leaders would assist to iden-
tify what these individuals do to become experts, then seek
to determine how to embed these qualities in other nurses
and if not, can they be cultivated. Both of these areas would
assist in developing a positive culture of learning in the long
term.
Conclusion
The perpetual novice phenomenon would appear to exist
across nursing care areas and this is due to a combination of
personal and contextual factors. Education alone is not the
answer. The challenge to nurse educators and those working
in advanced roles will be to create a culture whereby nurses
can learn and not feel shame. Results will assist in directing
future educational interventions and provide nursing leaders
with the information necessary to create work environments
that best enable nurses to acquire and maintain clinical com-
petence, regardless of the work setting.
Relevance to clinical practice
Maintaining skill competency for RNs can be challenging,
irregardless of the clinical setting. It is even more challeng-
ing for RNs to maintain their competency performing clini-
cal skills not used routinely. The findings of this study shed
light on the various challenges that can impact on skill
acquisition and help to explain why some RNs never
advance their clinical skills. Individual nurses have a role to
play in identifying their learning needs and developing a
©2015 John Wiley & Sons Ltd
10 Journal of Clinical Nursing
B Wilson et al.
plan to ensure they are competent in their skill performance.
At the same time, clinical nurse leaders, administrators and
clinical educators need to be attuned to the fact that in addi-
tion to simply providing learning opportunities, they have a
role to play in creating learning cultures that motivate all
nurses to engage in ongoing education. Creating more
awareness of the perpetual novice may assist those nurses
who self-identify with this phenomenon in understanding
their own professional development.
Acknowledgements
The authors thank Brooke McCutcheon RN, research assis-
tant, for her help with this project.
Contributions
Study design: BW, LH, AO; Data collection and analysis:
BW, LH, AO; Manuscript preparation: BW, LH.
Funding
This study was funded by the Sigma Theta Tau Interna-
tional/Canadian Nurses Foundation 2013 Research Grant.
Conflict of interest
No conflict of interest has been declared by the authors.
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... Previous research conducted by Harwood et al. 17 and Wilson et al. 18 have identified that some HD nurses are in a state of "perpetual novice" and are unable to move on a continuum from novice to expert with their cannulation skills for AVFs. This results in cannulation misses and complications such as increased bruising, pain, fear and, if this persists, a need for insertion or reliance on a CVC. ...
... This results in cannulation misses and complications such as increased bruising, pain, fear and, if this persists, a need for insertion or reliance on a CVC. 17,18 Probably this can be understood as justification to results obtained by Parisotto et al. 19 in the performed international observational study (n = 7058; 171 HD units) demonstrating that area puncture was the dominant technique in use (65.8% of patients), which had a greater association with VA failure (Hazard ratio (HR): 0.78 (0.61-1.00) buttonhole and rope ladder vs area). 19,20 The nursing recommendations for the management for VA in adult HD patients from the Canadian Association of Nephrology Nurses and Technologists (CANNT) enhances that cannulation competency is best determined by the vascular access coordinator or vascular access nurse, and that they should develop local strategies to improve cannulation skills leading to fewer missed cannulations and, ultimately, improve patients and nurses experiences. ...
... This further contributes to the problem, creating a vicious cycle: fewer AVFs, less opportunity for skill development, more unsuccessful attempts, fewer patients wanting AVFs and so forth. 17,18 Improving outcomes through behavior change appears to be much more complex than providing nursing education on proper needle insertion technique and patient education on the benefits of an AVF. A successful cannulation for new or difficult AVF needs to be planned ahead of time with a requiring quiet environment in the HD unit and appropriate equipment available to enable a thorough assessment based on defined decision models that can support the HD nurse counseling to the patient needing HD. 17 Managing Access by Generating Improvement in Cannulation (MAGIC) is a joint Vascular Access Society of Britain and Ireland (VASBI) and British Renal Society Vascular Access Special Interest Group (BRS VA SIG) quality improvement project supported by Kidney Quality Improvement Partnership (KQuIP) in the UK. ...
Article
Full-text available
The cannulation of an arteriovenous fistula (AVF) by the hemodialysis (HD) nurse is challenging. Despite it being the focus of extensive research, it is still one of the majors causes of damage making it prone to failure. A considerable number of Clinical Practice Guidelines (CPGs) for the management of vascular access (VA) have been published worldwide over the past two decades. This review aimed to assess all information available in the selected CPG regarding AVF cannulation for HD providing a comprehensive analysis in order to interpret possible future cannulation approaches. A total of seven CPGs were described in a coding table separated in seven subthemes: Initiation of cannulation, preparation, technique, needle selection, surveillance, pain, and education. Our analysis outlines current CPGs for HD VA cannulation with lack of good evidence support for the majority of the recommendations, showing that, there is an urgent need for international collaboration and coordination to ensure relevant and high-quality evidence. Future CPGs must consider recommendations with better grading of evidence aiming patient-centered care and nurse decision models that can potentially represent better AVF cannulation outcomes.
... Other learning strategies included access to training, supervision, practical experience over time and collective reflections, which are known to facilitate a positive implementation climate [76]. Discontinuity in practicing newly acquired skills inhibited the development of competence, in line with the perpetual novice syndrome described by Wilson et al. [77]. Orchestration and translation was essential for the development of absorptive capacity, including communication with external organisations, between actors in the consortium and within internal subunits [35]. ...
... Orchestration and translation was essential for the development of absorptive capacity, including communication with external organisations, between actors in the consortium and within internal subunits [35]. As HCPs, the middle managers are expected to be able to take key roles in the implementation [78], with the capability to mediate between the innovation strategy and day-to-day activities, and translate and facilitate implementation processes [77]. Their delegation of responsibility for implementation activities to project managers and professional practice advisors without delegation of authority over the nursing staff impeded the problem-solving capacity at times when it was difficult to maintain momentum during the implementation [28]. ...
Thesis
Full-text available
Norwegian authorities emphasize use of welfare technology in order to meet the increasing demand for healthcare services to the population of older persons. Implementation of welfare technology is considered beneficial to increase the quality of municipal care services, support the independence of persons receiving care services and improve the care providers’ workflow. However, welfare technologies challenge established workflows and competence, as well as perceptions of good care. Furthermore, recommended implementation strategies such as co-creation of services and outcome measurements such as benefit - and value realization represent novelties in the care services. Digital transformation of the care services thus calls for innovative approaches, as well as research. This thesis had a longitudinal mixed-methods design, and explored and evaluated implementation of digital monitoring services based on welfare technologies that promoted safety in municipal residential care facilities. The thesis belonged to a person-centred healthcare PhD program, and theories on innovation, implementation, co-creation, resistance and networks guided the research. Three sub-studies were included, presented by four research papers. In the first sub-study, paper 1 aimed to identify and describe forms of resistance that emerged during the first year (2013-2014) of the digital monitoring implementation in five residential care facilities. Paper 2 aimed to identify the facilitators and barriers during the full four-year (2013-2017) implementation of digital monitoring in eight residential care facilities, and to explore co-creation as implementation strategy and practice. Both were longitudinal qualitative case studies where we observed and elicited the experiences of care providers, healthcare managers and vendors. Paper 2 also included managers and staff in information technology (IT) support services. Data analyses in paper 2 started with a deductive analysis based on a determinants of innovation framework, and both papers included inductive content analysis of interviews, process- and observation data. Four main categories of resistance could be identified in paper 1: Organizational, cultural, technological and ethical. Each included several subcategories, which emerged as the participants perceived threats to stability and predictability in their workflow; to their role and group identity; and to their basic healthcare values. The resistance was primarily subtle, and changed over time. IT infrastructure and –support was identified as the most prominent resisting factor. Importantly, resistance contributed as a productive force during co-creation processes. Paper 2 identified five categories of facilitators and barriers: Pre-implementation preparations, implementation strategy, technology stability and usability, building competence and organisational learning, and service transformation and quality management. Each category encompassed several subcategories that affected the early-, mid and late phases of the implementation to varying degrees. The implementation resulted in a sustained digital monitoring service in all the residential care facilities, indicating success. The co-creation methodology was in itself identified as the most prominent facilitator. The reluctance of the IT support service to contribute in the co-creation activities, in combination with persistent IT infrastructure instability, was the principle barrier. In the second sub-study, paper 3 aimed to describe how a measurement instrument for determinants of innovation could be contextually adapted to evaluate welfare technology implementation in municipal care services. We performed an iterative evaluation of our adaptations of the instrument (questionnaire) during 2013-2019 and identified the chronological order of the most relevant informants and settings to adapt and verify the instrument. We described the operationalization of items detailing the 29 instrument determinants and linked the determinants to a sequence of welfare technology implementation strategies used in municipal care services. In the third sub-study, paper 4 aimed to evaluate facilitators for and barriers to implementation of wireless nurse call systems as measured by the adapted determinant instrument. Paper 4 had a quantitative cross-sectional descriptive design and we collected questionnaire data from care providers (n=98) during the first year of wireless nurse call system implementations in five residential care facilities (2017-2019). The greatest facilitators were the normative belief of unit managers and the care providers’ perceptions of the nurse call systems contributing to prompter call responses and increased safety for residents and families. The care providers’ lack of prior knowledge, and how they initially found the systems difficult to learn, constituted the most prominent barriers, rapidly solved through training and skill acquisition. The major finding of the thesis is that digital transformation in the form of successful implementation of digital monitoring is a complex, resource intensive and time-consuming process in municipal residential care facilities, and more so when it represents radical innovation with respect to technology novelty, disruption of care relationships and workflows, moral values, and the need for competency. All the implementations studied were successful in establishing new services that are still sustained, even though the implementations represented a high degree of complexity. Alignment of actors and agencies’ self-efficacy, their trust in the technology, and in other actors’ competence and support represented a tipping-point in the implementation processes, where the resistance decreased and safe, person-centred practices were established. Co-creation had a strong facilitating effect on resource-integration between actors, as well as on the development of competency and new workflows. However, both the implementations and co-creation represented novelty and depended on facilitation. The findings point to the importance of how the implementation of digital monitoring was conceptualized; as a straightforward “just do it” process, or as a complex and innovative endeavor. The thesis contributed with substantial empirical evidence for digital monitoring implementations, including resistance, co-creation, facilitators and barriers, implementation strategies, complexity, conceptualization of digital monitoring implementation, and development of competency, capacity and capability for digital monitoring in residential care facilities. Further, it contributed methodologically with detailed descriptions of co-creation practices for dual implementation and research projects, as well as an adapted version of a measurement instrument for determinants of innovation for welfare technology implementation. Clinical implications are in line with the major findings: Digital monitoring implementation will be safer if conceptualized as digital transformation, rather than incremental change. The implementations benefit from good planning and persistent management focus. The prior level of digital competency among care managers and care providers needs to be addressed appropriately. Practical training and co-creation processes facilitate implementation efforts and contribute to competence building and an implementation climate characterized by benevolence. The measurement instrument offers valuable means to evaluate welfare technology implementation. Moreover, digital transformation of care services challenges the current silo organization of municipal IT support services. This is ultimately a threat to patient safety and will need to change over time. More research is needed into patients’ perspectives, safety aspects and organizational capacity building as more welfare technologies are introduced into the care services, either as new entities or as new parts and functionalities expanding such innovative digital systems as described in this thesis. A compilation of welfare technology implementation strategies has been suggested, and more research is needed into the differentiation and cause effect relationship between barriers, facilitators, implementation strategies, intermediate implementation outcomes and long term service- and patient outcomes, in order to realize benefits and a sustainable digital care service.
... Other learning strategies included access to training, supervision, practical experience over time and collective reflections, which are known to facilitate a positive implementation climate [76]. Discontinuity in practicing newly acquired skills inhibited the development of competence, in line with the perpetual novice syndrome described by Wilson et al. [77]. ...
... Orchestration and translation was essential for the development of absorptive capacity, including communication with external organisations, between actors in the consortium and within internal subunits [35]. As HCPs, the middle managers are expected to be able to take key roles in the implementation [78], with the capability to mediate between the innovation strategy and day-to-day activities, and translate and facilitate implementation processes [77]. Their delegation of responsibility for implementation activities to project managers and professional practice advisors without delegation of authority over the nursing staff impeded the problem-solving capacity at times when it was difficult to maintain momentum during the implementation [28]. ...
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Background Implementation of digital monitoring technology systems is considered beneficial for increasing the safety and quality of care for residents in nursing homes and simultaneously improving care providers’ workflow. Co-creation is a suitable approach for developing and implementing digital technologies and transforming the service accordingly. This study aimed to identify the facilitators and barriers for implementation of digital monitoring technology in residential care for persons with dementia and wandering behaviour, and explore co-creation as an implementation strategy and practice. Methods In this longitudinal case study, we observed and elicited the experiences of care providers and healthcare managers in eight nursing homes, in addition to those of the information technology (IT) support services and technology vendors, during a four-year implementation process. We were guided by theories on innovation, implementation and learning, as well as co-creation and design. The data were analysed deductively using a determinants of innovation framework, followed by an inductive content analysis of interview and observation data. Results The implementation represented radical innovation and required far more resources than the incremental changes anticipated by the participants. Five categories of facilitators and barriers were identified, including several subcategories for each category: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The combination of IT infrastructure instability and the reluctance of the IT support service to contribute in co-creating value with the healthcare services was the most persistent barrier. Overall, the co-creation methodology was the most prominent facilitator, resulting in a safer night monitoring service. Conclusion Successful implementation of novel digital monitoring technologies in the care service is a complex and time-consuming process and even more so when the technology allows care providers to radically transform clinical practices at the point of care, which offers new affordances in the co-creation of value with their residents. From a long-term perspective, the digital transformation of municipal healthcare services requires more advanced IT competence to be integrated directly into the management and provision of healthcare and value co-creation with service users and their relatives.
... learning strategies that assist nursing students in attaining clinical skills proficiency in the clinical learning laboratory environment (Ball et al., 2015;Chicca & Shellenbarger, 2018;Gregory et al., 2014;Wilson et al., 2015;Young et al., 2014). The importance of skills competence is becoming more crucial as limited clinical placements and fewer nursing faculty shift the skills learning process from the healthcare environment to the clinical learning laboratory (Bensfield et al., 2012;Bloomfield et al., 2010). ...
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Introduction The quality of care for patients is linked to the performance and competence of nurses. Nurse educators are challenged to prepare graduates to deliver safe, competent, patient-centered care. Nursing skills video “selfie” is an innovative teaching and learning strategy in which nursing students use technology to create videos of themselves (video selfie) performing psychomotor skills. Method The instructional exercise of creating the video selfie was administered to a group of nursing students in a medical–surgical class. The laboratory instructors identified three psychomotor nursing skills. In the skills lab, the instructors showed videos to demonstrate how the skills were performed. The students returned demonstration in the lab and were asked to return to the lab independently to practice the skills and to create a video selfie. Results The exercise encouraged students to increase the quality and length of practice and master the skill. Students demonstrated confidence to perform the skills and to accurately list each step required to perform the skills. The video selfie was used as a peer evaluation tool and as a faculty assessment tool to guide individual students’ instruction, learning, and remediation. Conclusion The exercise had some shortcomings. Future quantitative research using survey instruments to collect data from a larger group of nursing students is needed to validate the utility of this innovative teaching and learning strategy in nursing programs.
... Even though the WNCSs were perceived as difficult to learn and the prior level of knowledge was somewhat low, the care providers rated themselves and their colleagues as competent users of the WNCS within the first year of implementation. The ability to acquire and maintain clinical competency is the result of both personal factors as well as contributing factors in the work environment (62). Within the window of time from the outset of the implementation until the survey was undertaken, the care providers had gained experience from using the WNCS devices. ...
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Background: Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities. Methods: The study had a cross-sectional descriptive design. We collected data from care providers (n=98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores (D1-29). MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation. Results: More facilitators (n=22) than barriers (n=6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety (D9 expected outcomes), and the normative belief of unit managers (D15 subjective norm). During the implementation process, 87% became familiar with the systems (D18 awareness of content), and 86% and 90%, respectively regarded themselves (D17 knowledge) and their colleagues (D14 descriptive norm) as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge (D17 knowledge) and that they found the WNCS difficult to learn (D8 personal drawback). No features of the technology were identified as barriers. Conclusions: Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.
... Even though the WNCSs were perceived as difficult to learn and the prior level of knowledge was somewhat low, the care providers rated themselves and their colleagues as competent users of the WNCS within the first year of implementation. The ability to acquire and maintain clinical competency is the result of both personal factors as well as contributing factors in the work environment (62). Within the window of time from the outset of the implementation until the survey was undertaken, the care providers had gained experience from using the WNCS devices. ...
Preprint
Full-text available
Background: Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities. Methods: The study had a cross-sectional descriptive design. We collected data from care providers (n=98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation. Results: More facilitators (n=22) than barriers (n=6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86% and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers. Conclusions: Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.
... Even though the WNCSs were perceived as difficult to learn and the prior level of knowledge was somewhat low, the care providers rated themselves and their colleagues as competent users of the WNCS within the first year of implementation. The ability to acquire and maintain clinical competency is the result of both personal factors as well as contributing factors in the work environment [61]. Within the window of time from the outset of the implementation until the survey was undertaken, the care providers had gained experience from using the WNCS devices. ...
Article
Full-text available
Background: Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities. Methods: The study had a cross-sectional descriptive design. We collected data from care providers (n = 98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation. Results: More facilitators (n = 22) than barriers (n = 6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86 and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers. Conclusions: Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.
... The possibility of a decline in clinical competency and the problems inherent in maintaining it were studied by Wilson, Harwood, and Oudshoorn (2015). They concluded that the perpetual novice phenomenon existed, and described it as a "failure of some nurses to become experts or advance their skills towards expert in one or more nursing skills" (p. ...
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Background: The most recent nursing home regulations indicate that nurses must possess the skills sets needed to properly provide residents’ care (“Reform of Requirements,” 2016). Nursing home directors of nursing (DONs) frequently meet the requirement to train their nurses using online continuing education programs. However, the hands-on practice of fundamental clinical nursing skills necessary to maintain proficiency cannot be accomplished with this method. Purpose: This study aimed to determine whether an educational intervention including hands-on practice of two clinical skills would improve the skills proficiency of nursing home nurses. Method: The study used a pretest-posttest design with skills fair-style educational intervention for nursing home nurses recruited from two nursing homes. The pretest and posttest each included a multiple-choice quiz and hands-on demonstrations of two different clinical skills. Statistical analysis using paired t-tests showed significantly improved skills proficiency for the participating nurses following the educational intervention with hands-on practice of the two clinical skills. Findings: The findings suggest that nursing home DONs should consider educational interventions that include hands-on practice to maintain clinical skills proficiency.
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Workplace learning refers to continuing professional development that is stimulated by and occurs through participation in workplace activities. Workplace learning is essential for staff development and high quality clinical care. The purpose of this study was to explore the barriers to and enablers of workplace learning for allied health professionals within NSW Health. A qualitative study was conducted with a purposively selected maximum variation sample (n = 46) including 19 managers, 19 clinicians and eight educators from 10 allied health professions. Seven semi-structured interviews and nine focus groups were audio-recorded and transcribed. The 'framework approach' was used to guide the interviews and analysis. Textual data were coded and charted using an evolving thematic framework. Key enablers of workplace learning included having access to peers, expertise and 'learning networks', protected learning time, supportive management and positive staff attitudes. The absence of these key enablers including heavy workload and insufficient staffing were important barriers to workplace learning. Attention to these barriers and enablers may help organisations to more effectively optimise allied health workplace learning. Ultimately better workplace learning may lead to improved patient, staff and organisational outcomes.
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PART ONE: INTRODUCING CRITICAL REALISM Introduction Key Features of Critical Realism in Practice A Brief Introduction PART TWO: POSTMODERN-REALIST ENCOUNTERS Introduction Realism for Sceptics Postmodernism and the Three 'PoMo' Flips Essentialism, Social Constructionism and Beyond PART THREE: Social Science and Space Introduction Space and Social Theory Geohistorical Explanation and Problems of Narrative PART FOUR: CRITICAL REALISM: FROM CRITIQUE TO NORMATIVE THEORY Introduction Critical Realism and the Limits to Critical Social Science Ethics Unbound For a Normative Turn in Social Theory