Copyright May 8, 2019

Patricia Benner, R.N., Ph.D., FAAN

We continue to examine the teaching and learning required by all new graduate nurses; how preceptors transmit local knowledge, engage in situated coaching, and role model nurse-patient caring relationships that are respectful, discerning, and attuned. Here we focus on preceptor Marye Fuqua, who is a relatively new nurse herself.  She loves the curiosity, fresh perspectives, and engagement typical of new graduates. Rather than an added chore, she says precepting new graduates is energizing, inspiring and refreshes her own practice and growth. She is keenly aware of the learning needs of new graduates, having recently been one, herself. She remembers the challenges of learning to be a team member with as much initiative and independence as possible. All preceptors would do well to make a note of Marye Fuqua’s keen awareness of the almost universal learning needs of newly graduated nurses.

Coaching for Autonomy

Marye Fuqua hits some of the major highpoints of precepting. Her practice focuses on encouraging independence and autonomy rather than over-supervising, or what she calls being a “helicopter” preceptor. Coaching for autonomy is an art and a skill!  Judgment is required for an accurate reading of the situation and a good knowledge of the preceptee’s readiness to perform in that particular situation. For example, a key to effective precepting is discerning when a preceptee is ready to perform in a clinical situation so that the patient’s safety is not at risk, yet does not erode self-confidence of the preceptee.  It is tempting for the preceptor to try to protect the orientee from feeling the anxiety of performing a skill for the first time in front of others, yet over-protectiveness can impede learning.

Marye Fuqua encourages autonomy; she doesn’t encourage the orientee to be a clone by doing things exactly as she does. She recognizes the importance of preserving diversity, allowing each nurse to develop her own style and identity as a nurse. This goes along with one of Marye’s central values of being a “real person” as a nurse. Being real, or authentic, makes a human connection and involves putting the patient at ease as much as possible.  One cannot truly meet the other from a stance of distance, pretense, distraction, façade, or any other stance that is less than genuine, or authentic.

Coaching for Good Nurse-Patient Relationships

Marye Fuqua strives to be a good role model for being authentic with patients.  She demonstrates attention to patient comfort and preserving their personhood in the midst of vulnerability and breakdowns that come with illness. For example, assisting with grooming prior to a family visit makes the patient feel better and more like themselves. Marye acknowledges that fitting in these non-urgent tasks takes planning and valuing patient comfort.  Marye reports her own early difficulties meeting and being with patients to her preceptees; for example, entering a patient’s room, waking a patient up, and remembering to provide everyday comfort care. These are early struggles typical for new graduate nurses, that more experienced nurses take for granted and therefore, may forget to teach.

Being a real person, for Marye, means being approachable and open to patient’s needs and questions. It means taking enough time with the patient so that they do not feel rushed, anxious or devalued, by her preoccupation with other tasks or concerns that might crowd out her ability to be present. Her concerns are admirable for a nurse with two and a half years experience. Her awareness of her own struggles of just starting one’s nursing career is no doubt useful in understanding where newly graduated nurses need to learn and receive encouragement.

Developing Clinical Imagination

Being a role model, demonstrating what it means to be authentic with patients (preserving their dignity and personhood) requires clinical imagination. Marye Fuqua wants her preceptees to be approachable and real.  She demonstrates this by the way she approaches and relates to patients and to new graduates. Planning for the patient’s specific care, and managing to carry out what is needed requires clinical imagination. Discerning what would be helpful is learned in specific clinical situations and added to one’s awareness for future situations.  For example, Marye helps her orientees figure out what clinical signs and symptoms, changes in EKG’s or other lab work have real immediate clinical implications for action, bears watching, or are not immediately clinically relevant. It takes time and experiential learning to recognize and understand when a test result or clinical sign or symptom has clinical relevance for immediate attention. As a relatively new nurse herself, Marye Fuqua continues to learn firsthand the relevance of patient changes. As a preceptor, Marye is aware of the difficulty of experientially learning a sense of salience or relevance of patient clinical changes, signs and symptoms, tests and lab reports. This is a good example of the centrality and importance of contextualized clinical learning from particular patients in order to advance in one’s skill level.

All clinicians, regardless of their particular practice (e.g., medicine, law, teaching, social work, etc.) must learn to create a dialogue between the particular and the general, and narrative accounts of particular clinical situations as they unfold provides a way of capturing the particular, transitions across time, interactions and inter-relationships between co-morbidities, clinical interventions and so on (Taylor, 2016). In this preceptor series, we have provided a number of first-person-experience-near accounts in the form of narratives about particular clinical situations by the preceptors. It is useful to consider what these narrative accounts add to clinical understanding that can’t be provided by ‘patient guidelines’ or statistical generalizations about signs and symptoms about a particular disease or injury.  In any clinical practice, explanation and generalization are necessary but not sufficient for excellent practice.

Much of ongoing clinical learning, particularly in the first five years of practice, has to do with matching particular clinical situations to textbook accounts or formal guidelines. However, the need for understanding the particular in relation to the general never goes away in any practice. “Knowing that” and “knowing about” (i.e., facts, theories, formal concepts, and generalizations) are not sufficient for understanding their relevance or use in particular situations in any particular situation in any practice discipline. All clinicians must learn over time, how particular clinical situations relate to and vary in relation to the general.

“Knowing how” and “knowing when” clinical changes in patients occur, and when interventions are needed are central to understanding any particular clinical situation. Perceiving relevance of patient changes, and knowing how and when to act are all forms of higher order thinking. They go beyond mere template matching, rational calculation, or application of technical and procedural knowledge. In practice, nurses encounter variability and particularity and not generalizations about patient population statistics. This is why every patient situation is rife with the need for experiential learning, and the need for understanding the particular patient’s clinical situation in relation to the general. The following table contrasts knowing in general, and knowing in a particular clinical situation:

Logic of Clinical Practice is different than the Logic of a Narrow Rational Technical Model:

The clinician in any practice discipline must bridge the gap between explanation, generalizations, and perceptual grasp, i.e., understanding and recognizing the actual occurrence and particular variations in clinical situations.  The logic of understanding the particular is different than the logic of acting on generalizations alone. While understanding the particular is greatly influenced by explanation and generalizations, it has a different logic and requires perceptual acuity and understanding of the whole case with all its particular variations.  In addition to perceptual acuity and understanding the whole case, changes across time, or transitions in the patient’s condition, and/or the clinician’s understanding of those particular changes are essential to clinical reasoning and judgment (Taylor, 2016, p.291-337).

Clinical reasoning across time about the particular and knowledge of the typical or generalizations about clinical conditions are both essential.  “Across time” refers to the particular transitions/changes in a particular clinical situation, with all its co-morbidities, patient sensitivities, drug interactions, and so on. Variability can only be captured in the particular clinical situation as it unfolds, and requires the clinician’s clinical judgment based on past concrete comparable cases and on knowledge of generalized norms and expectations. Patient guidelines and generalizations are necessary, but never sufficient for sound clinical reasoning in particular clinical situations.

As noted above, in clinical practice generalizations are made more problematic, due to patient co-morbidities, idiosyncratic reactions, interactions between medications and treatments and so on.  Situated thinking and learning practical knowledge directly from practice requires thinking-in-action and reflection on the particular clinical situation at hand and the transitions or evolution of that unfolding of the particular case. Clinical reasoning and thinking come both from theory and practice, from an explanation of the general, understanding of the particular and a clinician’s dialogue between the two in particular clinical situations.

Time Management

A major challenge for the new nurse is time management, i.e., attending to patient needs, completing required interventions in a timely manner, while not forgetting essential items in a care plan. New graduates have to learn to integrate their activities with the team and take responsibility for total patient care, for a number of patients. The complexity of patient care requires learning how to manage one’s limited time to accomplish all that is required. Marye Fuqua encourages her preceptees to develop a “brain sheet” for each patient in order to make sure that all required tests, medications, treatments, patient education, discharge planning and so on, are accomplished. Such a paper and pencil approach is needed to prompt the nurse’s memory (writing things down helps one mentally organize and using the brain sheet makes sure that nothing is left out). And since computer systems fail, the nurse needs a written back up of essential interventions for particular patients. Also, the brain sheet is readily available in the pocket to keep track of what is needed for each patient as the day progresses. Marye Fuqua encourages her preceptees to individualize their brain sheet according to their own learning needs, e.g., what they have trouble remembering or checking. The brain sheet and the need for one is a great example of the kind of practical knowledge that the preceptor needs to impart to the new graduate orientee, and actually to every nurse.

Teamwork and Curiosity

Marye Fuqua encourages her preceptees to ask questions and prompts questions that she suspects the preceptee needs to ask but doesn’t.  She worries about silence and unasked questions because she knows that silence may be an indication of feeling alone and intimidated as a new member of a team, or a result of secondary ignorance, not knowing what one does not know. She vigorously engages in team building, insisting that the nurse should never feel alone.  She empowers and entitles her preceptees to ask questions of all team members. Curiosity is essential for all experiential learning. Asking questions has to be encouraged by preceptors and all team members.  Exemplary questions are useful to the new graduate, who may lack the clinical imagination to ask certain kinds of questions or who simply can’t know what he or she does not know (secondary ignorance).

Marye coaches her preceptees about which team members are best for specific areas of specialized and practical knowledge. This is the kind of practical local knowledge that cannot be found in procedure books or orientation manuals, and it is specific to each clinical unit.  Marye encourages the preceptee to rely on others as coaches, and not just her as a preceptor. She encourages the preceptee to seek out the wisdom and coaching of all the health care team members, e.g., other nurses more skilled in specific areas, like neurological assessments, respiratory, as well as physicians. Marye’s message is that no nurse should ever feel alone or isolated, and she goes further, to teach the orientee how to achieve this sense of team membership and belonging.  She encourages curiosity, asking questions, asking for help, and helping others so that the orientee’s citizenship and membership on the team are built from the very beginning.

Summary

• Preceptors, like Marye Fuqua, daily help bridge the education-practice gap. They help the orientee move from knowing “that and about” to also knowing “how and when” and for the purpose of “achieving what goals”. Moving to understand how and when to act in particular situations requires the higher order thinking of using knowledge in particular situations. Understanding how and when to use knowledge and for what purpose or end, in a particular clinical situation, goes beyond the mere application of knowledge (e.g.,  pre-determined invariable following of procedures, such as how to take blood pressure, versus interpreting the implications of blood pressure for a particular patient). While it is essential to know generalizations and explanatory systems for physiology, pathophysiology, pharmacology and so on, it is equally essential to know when and how, and to what end to use this knowledge in particular clinical situations. One can only imagine that as a preceptor such as Marye Fuqua gains more expertise, her precepting will be enriched, and her situated coaching even more attuned due to her own experience as a preceptor and nurse.  We also hope that she will hold on to her current understanding and grasp of the early learning needs of the new graduate nurse.  Those learning needs include being a real person, learning how to meet and be with patients, managing time, staying curious and asking questions, being an effective team member, while developing independence and identity as a nurse. As Joseph Dunne (1993) points out:

A practice is not just a surface on which one can display instant virtuosity.  It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners (pp. 378-380).

References

Dunne, J. (1993)Back to the Rough Ground. Practical Judgment and the Lure of  Technique.  Notre Dame, Ind.: Notre Dame University Press. (p. 378-380)

Taylor, C. (2016) the Language Animal. The Full Shape of the Human Linguistic  Capacity. Cambridge, Mass.: The Belknap Press of Harvard University press.

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