STUDENT PROGRESSION:
FROM NOVICE TO EXPERT
Laurie Heline CRNA, MS
Clinical Coordinator Oakland UniversityBeaumont Graduate Program of Nurse Anesthesia
OBJECTIVES
 At
the conclusion of this presentation, the
learner will:
1. Discuss the five stages of progression an RN
takes to become a CRNA in clinical education.
 2. Identify the clinical instructor's role in each
of these five stages of development.

CLINICAL INSTRUCTION IMPORTANCE
A profession that is not growing is
dying.
CLINICAL INSTRUCTOR
 Fill



many different roles:
Anesthesia provider
Employee
Clinical teacher
NOVICE TO EXPERT THEORY
 Developed
by Dr. Patricia Benner
 Develop skills over time through a sound
educational base as well as a multitude of
experiences
 Difference between “knowing that” versus
“knowing how”
5 STEPS AN RN TAKES TO BECOME A
CRNA
 Novice




learner
Advanced Beginner
Competent Student
Proficient Student
Expert Practitioner
Graduate students are exposed to more
facts in one year than their grandparents
were in a lifetime
The sum of all that is known is doubling
every seven years.
Think of a student at each stage
 Anesthesia is both a science and an art

NOVICE LEARNER
Enter as successful ICU nurses
 Unfamiliar with the OR
 Process of anesthesia is mysterious
 No anesthesia experience, little
knowledge

NOVICE LEARNER
Learning must begin somewhere
 Learn from didactic work theories to guide
actions
 Theories and rules provide general rules
but do not cover all possible situations
 Task-oriented
 Vary greatly in abilities

NOVICE LEARNER









Eager
Enthusiastic
Motivated
Lack of Flexibility
Anxious
Afraid
Uncertain
Frustrated
Overwhelmed
NOVICE LEARNER
 Anesthesia
students in the first months
 Average cases:


27 cases at end of first semester
155 at end of second semester
NOVICELEARNER
WHAT CAN WE DO?
Set clear, detailed expectations
 Provide as much consistency as possible
 Remind to focus on patient
 Guide in organizing tasks



Checklists
Mnemonics
Care plans
 Recognize that students need to gain
confidence

THE ADVANCED BEGINNER
 Generally
sometime within second semester
to beginning of third semester
 Marginally acceptable performance
 Acquired enough knowledge and experience
to:



Recognize important aspects
Begin to feel comfortable
Make some interventions based on experience
THE ADVANCED BEGINNER
 Students
have:
Limited knowledge
 Misunderstood concepts
 May apply knowledge incorrectly

 Still
focused on tasks but not as
overwhelmed by the environment
 Small deviations from routine may
derail
THE ADVANCED BEGINNER
 Perform
routine preparation in 30 minutes
 Can plan for successive case
 Skills improving but can continue to
struggle with mask ventilation, poor body
mechanics, intubation
 Still need constant supervision, should be
able to recognize when to ask for help
THE ADVANCED BEGINNER
 Quickly
doubt own ability leading to a
viscous cycle of:
performance anxiety
 self-flagellation
 further failure

 Feel
responsibility for decision making lies
with those who have superior knowledge
and experience
THE ADVANCED BEGINNER
WHAT CAN WE DO?
Help student with psychomotor skills
 Recognize that:

Dependent on instructor’s knowledge
 Hesitant to voice opinions
 Still task focused
 Need help with prioritization
 Don’t always have good rationale


Allow students to make good and bad
decisions
THE ADVANCED BEGINNER
WHAT CAN WE DO?
 Instructors
hesitant to ask questions because
think student may have more theory
knowledge than them
Develop stock questions
 Ask student to explain concept to them

 Help
identify distinctions of common
anesthesia events and share rationale for
decision making
THE COMPETENT STUDENT

After 150-200 anesthetics

3rd semester end with 271 cases
 Able
to manage an ASA 1-2 patient
undergoing a simple surgical procedure with
minimal assistance
THE COMPETENT STUDENT
 Demonstrate:
Familiarity with variety of basic anesthesia
situations
 Identify significant aspects of a situation
 Anticipate events that may occur
 Improved organizational skills
 Can integrate sensory input from numerous
sources
 Ownership, becoming patient advocate
 Trust in self and comfort with knowledge,
skills, and abilities

THE COMPETENT STUDENT
 Must
still analyze possibilities of each situation
and think through options
 Challenge
this stage
instructor’s knowledge and authority at
 Demonstrate
competency in some areas and
“novice” behavior in others
 Complacent
THE COMPETENT STUDENT
WHAT CAN WE DO?



Suggest alternatives
Ask the student to teach the instructor
something
When challenged by a student, understand
this may be part of growth process

When time is right, discuss with the student and
attempt to elicit rationale for behavior
THE PROFICIENT STUDENT
 Not
necessarily related to the number of months
the student has been in the program
 Students soon to graduate exemplify proficient
level behavior, an entry-level practitioner
 Can see the big picture
 Beginning to show signs of intuitive decision
making
 Some technical skills excellent, others may need
more practice
THE PROFICIENT STUDENT
 May
feel overly responsible OR become overly
confident


Believe their knowledge is more current than
instructors
Results in the potential for humbling errors
 No
longer concerned with merely performing
tasks

Seek to prevent common problems and
minimize adverse events
THE PROFICIENT STUDENT
WHAT CAN WE DO?
 Encourage
the independence
 Remind them even seasoned
practitioners:
Seek help
 Share tasks
 Request consultation when needed

 Complacence,
so continue to challenge
 “Senioritis” behaviors
THE EXPERT PRACTITIONER
 Unusual
for students to reach
 Not all CRNAs reach
 No longer rely on principles, rules, or
guidelines
 Have difficulty verbalizing how they make
decisions or respond to certain events
 Can deal with various possibilities and
quickly switch plan of action
THE EXPERT PRACTITIONER
 Even
expert can revert to novice role
when confronted with:




New drug
New technique
Unfamiliar situation
Can still make wrong decisions
NOVICE TO EXPERT MODEL
 Way
to examine SRNAs clinical growth and
development
 Some grow rapidly, while others take longer
to achieve milestones
 We must recognize impact we have on
facilitating or hindering learning as we are
held in high esteem by students
CLINICAL INSTRUCTORS
Thank you for all you do
for our students and the
profession of Nurse
Anesthesia!
BIBLIOGRAPHY
Benner PA. From Novice to Expert: Excellence
and Power in Clinical Nursing Practice.
Commemorative Ed Upper Saddle River, NJ:
Prentice-hall, Inc, 2001.
 Benner PA, Tanner PA, Chesla CA. Expertise in
Nursing Practice: Caring, Clinical Judgment,
and Ethics. New York, NY: Springer Publishing
Company, Inc; 1996.
 Hendrichs B, Thompson J. A Resource for Nurse
Anesthesia Educators. Park Ridge, Ill: AANA
Publishing, Inc; 2009.
 http://currentnursing.com accessed 6/15/2011
 http://typhongroup.net accessed 9/15/2011
