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Evidence-Based Practice, Rule-Following, and Nursing Expertise

2009; American Association of Critical-Care Nurses; Volume: 18; Issue: 5 Linguagem: Inglês

10.4037/ajcc2009147

1937-710X

Lisa Day,

Ethics in medical practice

While it still has critics, the evidence-based practice movement has made great headway in medicine and nursing. Nurses are encouraged to use the best available evidence to guide their practice and to form the foundation for institutional policies and procedures.Evidence-based practice standards developed by professional organizations are implemented as sets of rules for nurses to follow as they care for populations of patients. For example, ventilated patients must have the heads of their beds raised to 30° and receive oral care at least every 4 hours in order to prevent pneumonia; patients with central venous catheters must be bathed daily with a chlorhexidine gluconate body wash in order to prevent line-related bloodstream infection. These kinds of evidence-based rules are put into place and then rates of ventilator–associated pneumonia, central venous catheter–associated blood stream infection, and nurses’ compliance with the rules are measured against institutional and national benchmarks.Standardized practice and habituated rule-following are vitally important to certain areas of nursing practice, and following procedures to the letter is sometimes the only way to ensure safe patient care. But as more nursing practice comes to fall under rules generated by research evidence and more emphasis is placed on strict adherence to procedure regardless of the situation, we risk losing touch with expertise.In this column, I will discuss the novice to expert model of skills acquisition as described by Dreyfus and Dreyfus1 and applied to nursing by Benner.2 I will argue that, as a form of rule-following, practice based on research evidence is limited in its ability to capture essential domains of nursing practice and that reducing the practice to sets of rules to be followed precludes expertise. There is a place for rule-following in expert practice but we must be careful not to let rules take over to the point that existing experts are deskilled and expertise is no longer fostered.In 1984, Benner publisher her groundbreaking work From Novice to Expert: Excellence and Power in Clinical Nursing Practice.2 In this book, Benner describes the Dreyfus and Dreyful model of skill acquisition and how it applies to nursing practice. She also describes 7 domains of nursing practice and argues for the importance of developing and sustaining experts in the practice as the only way to fully sustain these domains. Benner, Tanner, and Chesla3 followed Benner’s original work with Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics, published in 1996, which further explicates skill acquisition and expands on the domains. Benner, Hooper-Kyriakidis, and Stannard4 followed with Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach. Published in 1999, this book describes expertise and the domains of practice specific to critical care nursing.My understanding of skill acquisition comes essentially from these 3 highly influential books, as well as from the critique of artificial intelligence offered by Stuart and Hubert Dreyfus,1 and the continued work of Hubert Dreyfus in cognitive science, including his critique of artificial intelligence5,6 and his commentary on the work of Heidegger.7Although Benner’s work is known throughout the world, and the phrase “novice to expert” is often used by nurses to describe the process of learning the practice, the nature of expert practice, as described by Dreyfus and Benner, is often misconstrued. It is difficult to appreciate the nonreflective, noncognitive, responsive nature of expert performance and how hugely different this is from the rule-following of beginners and competent-level performers. Dreyfus describes expert performance as “arational”—not irrational but also not analytic or calculative6 ; experts live in a world of affordances and solicitations that “[call] forth a flexible response to the significance of the current situation”6(p1144) and afford the possibility of a certain response.Heidegger has referred to this embodied, situated, smooth coping with one’s environment as “readiness to hand.”7,8 In the ready-to-hand mode of coping, the expert nurse is completely familiar with the situation, draws on past similar experiences and, “When things are proceeding normally, experts don’t solve problems and don’t make decisions; they do what normally works.”1(p31)In contrast to expert practice, the practice of a novice, advanced beginner, and competent nurse consists of the “analytic behavior of a detached subject, consciously decomposing his environment into recognizable elements, and following abstract rules.”1(p35) The expert engages in “involved skilled behavior based on an accumulation of concrete experiences and the unconscious recognition of new situations as similar to whole remembered ones.”1(p35)The move away from reliance on abstract rules and consciously rational decision-making to an ara-tional1 grasp of whole situations that characterizes expert practice depends on experience and engaged experiential learning. Sustaining expert practice requires that the expert engage in the care of familiar patients without resorting to “critical thinking” or any other kind of analytic, decomposing of the clinical situation or effortful cognition. It is only when she is thrown out of the familiar clinical world that the expert moves out of ready-to-hand coping into an analytic mode. This move signals a breakdown of smooth coping and, while she is occupied with disengaged examination, the expert is no longer performing as an expert; she has been brought back to a competent or even advanced beginner level of performance.Following rules is a necessary part of nursing practice. In the acute care setting, nurses are expected to follow generic sets of rules in the form of institution-specific procedures based on the best evidence. Yet expert nursing practice is responsive to the particular patient care situation as it changes over time. This kind of responsiveness, what Benner calls “thinking in action” or “reasoning in transitions”4 demands flexibility, attentiveness, and constant readjustment.Asking nurses to rely on abstract rules brings the expert’s practice to competent level at best and makes expert-level performance impossible. Therefore, standards of practice or standardized nursing procedures that take the form of algorithms or lists of steps can create an impediment to expert performance in the areas of practice to which they refer. That these standards might be based on the best research evidence makes no difference; expert practice does not come from detached analysis of abstract theory and cannot be rule-bound regardless of the quality of the theory or source of the rules.Expertise is gained and maintained experientially as the nurse engages in context-rich practice. Developing along the novice to expert trajectory requires involvement in clinical situations where there is something important at stake and reflection on one’s performance after the fact. Did my response to the patient make the situation better or worse?The advanced beginner must rely on rules for much of his practice since he has little practical experience. But the domains of nursing practice Benner describes consist primarily of nursing responses that cannot be formed into empirical questions to be answered by randomized controlled trials and that cannot be completely rule-driven. For example, within the domain “the helping role” there is a competency “maximizing the patient’s participation and control in his or her own recovery.”2(p50) The nurse’s ability to engage a patient as a participant in his or her own recovery is necessarily dependent on the nurse-patient relationship and the situation and context. The beginner can follow certain general rules to help him identify when a patient might be ready to participate in his or her recovery. These rules will be right sometimes for some patients but wrong for others. The ability to discern when the rules can be applied and when they should be set aside is beyond the skill of the advanced beginner. With the achievement of competence, the rules recede to the background, allowing the nurse to focus attention on those situations in which the rules did not work and ask, “What should I have done differently? How can I adjust the rules to take this situation into account?” In this way, the competent nurse makes up new rules and makes contingency plans for each situation: “If plan A doesn’t work, I’ll use plan B.”The practice of the expert nurse provides a jarring contrast to the rule-following behavior of the advanced beginner and competent nurse. The practical reasoning and practice-based knowledge of the expert nurse draws attention to the limits of formalism: constructing sets of abstract rules for nurses to use in all or even most situations they might encounter is an impossible task. Eventually the competent nurse runs out of room to store all the sets of rules it takes to respond intelligently to every situation. This precipitates the move to proficiency and expertise. By not relying on rules at all, the expert is free to respond to what each situation demands. It is impossible to achieve this kind of flexibility with rule following.That expert nurses are able to respond appropriately to a huge variety of patient care situations points to clinical practice as an important source of knowledge. Clinical knowledge is often overlooked in favor of science-based, disengaged critical reasoning.3 The emphasis on critical thinking in nursing education points to this bias. Whereas it is true that the beginner is dependent on rules and maxims and does not yet have the experience required to give up the guidance of standardized procedures, beginning nurses are also encouraged to analyze patient care situations in a disengaged, objective manner by applying abstract theory and using problem solving skills. The clinical situation becomes a problem to solve rather than a relationship in which to become emotionally engaged. In order to progress toward expertise, beginning and competent nurses need rules to follow and analytic skills; they also need guidance in developing the right kind of emotional engagement in order to determine if their response to the patient was good or if they somehow got it wrong. An overemphasis on rules and disengaged reasoning that neglects the importance of involvement in the situation impedes the competent nurse’s progress toward expertise.After extensive study of artificial intelligence, Dreyfus and Dreyfus1 claim that the only situation in which computer reasoning is better than human judgment is the situation where no human experts exist. The same can be said of rule-following. There may never be experts in certain technical tasks required of nurses, such as preparing medications. In this case the best the nurse can do is follow the rules for checking the drug, dose, route, time, and patient identification. The judgment as to whether giving a specific drug to a specific patient at a specific time will make the patient’s situation better or worse is an area in which human experts do exist, and in this case it is better to rely on expert intuition than on abstract rules.As evidence-based practice expands and takes on more areas of nursing practice, and as the patient safety movement demands more standardization of nursing interventions, nurses find fewer situations in which they are called on to use clinical judgment. The situations in which nursing judgment resulted in a worsening of the patient’s situation often create a new set of institutional rules to be followed in the next, similar situation. By following the rules next time, the nurse does not gain from her experience, and if the system response to getting it wrong is always to make new rules, the development of clinical expertise is impeded.There is a tension in nursing practice. A wrong judgment can cause harm to a patient, but the move toward standardized, evidence-based practice threatens to rob us of experts. Sticking to the rules and rigidly adhering to protocol does not allow for the kind of engagement with the practical situation that is required to move from competence to proficiency to expertise. It is hoped that standardization, solid rule sets and algorithms, and good computer programs to support decision-making will compensate for the absence of experts. But expert nurses are infinitely adaptable in their responses to unfolding situations at hand because they are able to engage in situated, context-driven reasoning that shifts between the general and the particular, and draws on similar past experiences. The ability to step safely outside of abstract, general rules and respond to the particular in each situation is a skill that is essential to a relational practice that operates in rapidly changing situations. If we don’t support expert practice and foster the development of expertise, we risk losing what is fundamentally important to nursing practice.The author wishes to thank Patricia Benner for her invaluable assistance in preparing this column.