From Novice to Expert

One of most-referenced and well-known nursing theories is Patricia Benner's "From Novice to Expert."  In this simple but remarkably profound model, Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through both a sound educational base as well as a multitude of experiences.  She proposed that one could gain knowledge and skills ("knowing how") without ever learning the theory ("knowing what"). 

Benner suggests five levels of nursing experience: 

1)  The Novice is a true beginner that is primarily governed by rules surrounding a very task-oriented and inflexible role in nursing

2)  The Advanced Beginner, despite acceptable performance, is a nurse that has only begun to channel experience to identify recurring meaningful components in their role

3)  The Competent Nurse is one that is able to draw on experience to apply abstract and critical thinking in order to reach a greater efficacy and organizational level

4)  The Proficient Nurse understands the "big picture" and is not only quick with decision-making but has gained the ability to predict what is next

5) The Expert is a nurse that has gained so much experience that her fluid and flexible actions are based almost entirely on intuition. 

This coveted expertise that Benner speaks of is real and is the trait every young nurse strives to attain.  The Expert is the nurse that can walk into a patient's room, look into his eyes, and know he is in trouble.  The transition from novice to expert moves away from rules and basic knowledge toward sole intuition. 

As you can imagine, this intuition can be extremely dangerous to the egos of fresh interns and some socially-obtunded residents every July.  However, this inevitably protracts the perpetual war:  experienced nurse vs. new physician.  Interns come into the hospital setting thinking they know more than nurses - and, despite what more seasoned nurses will tell you, they do.  They just don't have the experience, fluidity of reaction, and intuition of The Expert Nurse, making them untimately more dangerous to the patient.  In fact, interns are an abundance of knowledge with minimal experience while the Expert Nurse is an abundance of clinical experitise with only basic knowledge.  Now, this is undoubtably a statement that is not true of all nurses.  Proactive nurses that obtain certifications, strive to understand concepts at intricate levels, ask questions, participate in nurse-led rounds when available, and act as a sponge during clinical discussion do not fit into my earlier umbrella statement.  However, what about the nurses that just "get by" and maintain their patients?  We all work under the same license.  We all are expected to complete the mundane tasks of passing meds, washing hair, and inserting foley catheters.  We all start off with the same rudimentary knowledge base and we all inevitably gain the experience that Benner so heavily theorized about.

But, I'd like the challenge Benner's theory.  Not the theory itself, but its acceptance.

As I always point out, physicians learn to suggest treatments because they have the knowledge to diagnose on the differential.  Nurses, on the other hand, are able to suggest treatments because they recognize patterns, making experience a much more valued clinical tool than knowledge.  Why is it experience that makes a nurse valuable instead of knowledge?  Think of the potential of a nurse that had a greater knowledge base and the expertise of The Expert!  My alma mater considered itself progressive for teaching the concept of "critical thinking" as opposed to the more task-oriented education of its diploma counterparts.  Unfortunately, this tradition allows for the perpetual "dumbing down" of all nurses - from novice to expert. 

Aim Higher

Well, here I am - writing my second entry in an entire year.  I was busy, I moved, I hated my job for a while, I didn't get into a highly-ranked anesthesia school, I was on vacation, I worked too much overtime...  The excuses have an amazing potential to pile up and consume me but I need to aim higher.  And it starts today.

I'm going to begin by confessing that the focus of this blog may have been a road block to, not only my blogging, but my happiness.  Tal Ben-Shahar has a theory of the "arrival fallacy," or the belief that once you arrive at a destination, you'll be happy.  According to Gretchen Rubin in The Happiness Project, "The arrival fallacy is a fallacy because, though you may anticipate great happiness in arrival, arriving rarely makes you as happy as you anticipate."  Nothing could speak more truth to the arrival fallacy than accepting my Transplant ICU job.  Having worked in abdominal transplant for the entirety of my career, I've always had a distant love affair with the TICU.  The patients were sick, the nurses were bossy, and the locked doors to the windowless three-wing trifurcation made it appear such an elitist destination.  My friends, family, and colleagues can attest to my aspirations of working in the TICU since prior to nursing school when I worked as a nursing assistant on a transplant stepdown unit.  It wasn't until I arrived that reality became transparent to me:  this was a scary, depressing, and thankless place.

Arriving at one goal usually presents another.  I was so caught up in the power and attainment of the clinical knowledge I would inevitably absorb that I neglected the emotional consequences and repercussions that came with the territory.  I transcended from an environment of walking, talking, thankful patients with the occasional wound drain to a world of inanimate and swollen shells of people with tubes and lines in their neck, nose, wrist, groin, mouth, ass, and penis.  I wrongly looked toward the older ICU nurses, who so notoriously "eat their young," for guidance.  Having been roughly seasoned with 20+ years of this, it became apparent to me that, in their eyes, these patients were no longer people but instead a casing with no internal substance other than heart, lungs, bowel - and even those things lacked vitality, requiring vasopressors, ventilation, and tube feeds.  After a certain amount of time as an ICU nurse, patients stray from being perceived as individuals with feelings and first kisses and favorite movies toward existing as nothing more than an empty suitcase that shits.  Unfortunately, this hardness is a mere side effect of such a difficult cross to bear:  seeing people die, day in and day out.

I often liken my job to rearranging deck chairs on the Titanic.  It is hard to find purpose and positivity in doing Q2 hour mouth care, administering vitamins and supplements, and hanging blood products for a patient that is going to die, no matter what.  So perhaps I owe more to myself and this blog than telling patients' stories.  I need to also share my story.  After all, I'm the one alive to tell it.   

Some pre-op teaching...

After working at one of the world's top transplant centers for over four years now, I've had to come to the realization that, even though transplantation is mostly associated with life, it involves more death than I could have ever imagined.  Sure, we can think of an eager team of surgeons coming in and harvesting organs from some unfortunate cadaveric donor, snipping and picking kidneys, corneas, lungs, heart, liver, pancreas, skin, and bowel, leaving the OR with coolers and turning their backs on the now worthless corpse, still open and empty.  But, that scene becomes much more palatable and justified when one thinks of the lives that can be saved.  Donate life.  Put it on your drivers license.  And that's where the thinking stops. 

No one thinks of the patient that actually received a liver transplant but his portal vein keeps mysteriously clotting off and his bowel keeps spontaneously perforating, spewing shit all over his insides, requiring him to go back to the OR for surgery after surgery.  His abdomen actually needs to be kept open with only a fine layer of mesh covering his liver and intestines, exposing him to more infection in a body that already has a suppressed immune system.  His loving family that has been at the bedside for weeks with him--puffy, yellow, and sedated on mechanical ventilation--finally agreed yesterday that "comfort measures only" (or "CMO" in the industry) is the way to go.  A perfectly good liver into such a deserving candidate.  Sometimes life and death just aren't fair.  And this is an example of the stories about transplant that no ones knows. 

I am writing this blog because there is value in what a transplant nurse experiences and it indisputably deserves a voice.  While sharing stories at the bar of the grotesque aspect of transplant nursing will probably never cease, there is more to it than that.  There is beauty in being intertwined in the fine line between life and death.  There are inspiring patients and heartbreaking patients and annoying patients and patients that you want to suffocate with a pillow but can't and each and every one of them deserves to have their story told.  There are surgeons that play god and value human life above all else, even to the point where it becomes unethical.  There are nurses that give up on patients too quickly and single-handedly act as the death panel the media blew out of proportion circa 2009.  Truthfully, the possibilities for material are endless.   

Everyone always tells me I should write a blog.  So, here are my stories of transplant nursing, just for you.