Patricia Benner RN PhD Learning to nurse

October 10, 2024 -- Today I attended an excellent webinar (PDF of slides here) by Patricia Benner RN PhD and her Benner Institute and HealthImpact team at my alma mater UCSF.

I have decried the sorry state of nursing education following my nursing training fifteen years ago. I have also proposed an approach to making it better.

The good news: I am not the only one thinking about this. Benner et al too, are working on it and moving nursing education forward. Among other things, they are sponsoring a conference in Las Vegas on Jan. 13-14, 2025 and I shall attend.

It takes years to get to be good at nursing. What are the processes that get us there? How do nurses acquire our remarkable and valuable skills? There are no shortcuts. We are near-useless when we start. Nursing is learned only by doing it. As we go, Benner teaches us, we must systematically record what we learn from experience. This is essential if we are to transform our hospitals into High-Reliability Organizations.

Here is an example: early signs of sepsis. Recognizing sepsis saves lives. In the example (one of several) cited in the webinar, these methods improved one hospital's outcomes from 60% sepsis mortality to 10%. Here is that example.

Sepsis can share signs and symptoms (like fever) with other types of infections. However, in sepsis, the symptoms will get more pronounced when the infection enters the bloodstream. Symptoms may have been limited to one area of the body during the initial infection, but the symptoms of sepsis are felt throughout the entire body (systemic). Early signs may include a change in mental status and very fast breathing. Signs of sepsis include:

  • Fever or low body temperature (hypothermia)
  • Shortness of breath
  • Shivering or chills
  • Severe pain or discomfort
  • Confusion or delirium
  • Lightheadedness due to low blood pressure
  • Rapid heartbeat
  • Skin rash or mottled skin
  • Warm skin
  • Clammy or sweaty skin

Sepsis is a medical emergency. It is essential to recognize it quickly. Yet the hints are vague; sepsis is not obvious. Often, it is the nursing intuition born of experience that reveals this diagnosis.

So how does the nurse acquire this subtle skill?

situational awareness Benner et all describe the learning process as experiential and situational, a "sense of salience." It can be learned only first-hand. Precepting and coaching are essential because there is no other way to enable situational learning. They also describe it as "detective thinking" -- think back and reconstruct... e.g. why/how did this pulmonary edema happen? Also essential, they say, are accounts by engaged observers; narratives. This is the only way to convey this knowledge.

Situational awareness is a most prized skill possessed only by experienced nurses, acquired only from years of practice, termed experiential learning. Yet the headline proclaims, "The Front-line Work and Knowledge of Nurses in Direct Patient Care Still not Fully Articulated Nor Recognized." In other words, we don't know how to teach or learn this except the hard way.