Three portraits of nursing: The good, excellent and expert nurse, voices from the field Coulon, L.1, Mok, M.2, Krause, K.2, & Anderson, M.3 1: School of Nursing and Human Movement, Australian Catholic University, NSW 2: School of Education, Macquarie University 3: School of Nursing, Avondale College INTRODUCTION Our study is a descriptive exploratory design which addresses the central question of the professional images of nurses. It arose from the authors' commitment and earlier work focusing on the meaning of nursing to nurses. There can be little doubt that a nursing philosophy embracing excellence and expertise form the espoused tenets of today's nursing profession. These virtues are acclaimed by all professions and nursing is no exception. To know what we are developing nurses toward, we need to distinguish amongst what constitutes the good, the excellent and the expert nurse. However, from pursuit of the literature, these concepts still await definition. Recently, Australian nursing has witnessed a period of transition with nursing moving from hospital based education to higher education. Outcomes from new programs have seen nurses graduate with a variety of credentials ranging from certificates, diplomas, bachelor degrees, masters and PhDs. Essentially, this has created a wide spectrum of qualified practitioners with more than 40 career path opportunities in the Australian health care system. It is therefore considered pertinent to build a prototype model which illuminates differences in concepts of expertise and excellence in nursing. Essentially, this study sought to map the terrain of nurses' work in the 1990's using the methods of qualitative critical analysis. This study was framed on the premise that while excellence and expertise are extolled, these concepts often remain elusive, complex and are constantly evolving given the changing demands of the profession. With continual flux in the context of health care delivery, it is necessary to redefine and clarify the practice standards of care administered. Thereby we hoped to contribute to important recommendations concerning strategic directions for nurse education, the goal being to enhance patient outcome. This requires a clearer understanding of differences between the good, excellent and expert nurse, which is what we shall now turn our attention to in this paper. The concept of excellence Excellence may be defined as the fact or state of excelling, it also connotes superiority and eminence. In addition, something is considered excellent if it possesses superior merit or if it represents a behaviour or attitude which is extraordinary (The Macquarie Dictionary 1989). Excellence is synonymous with terms such as exceptional, worthwhile, valuable and distinction (Bernard, 1989). Significantly, while the Medline database provided clear explications of terms such as professional nursing practice and holistic health care, it did not provide a definition of excellent nursing care. The concept of expert Expanding on the Model of Skill Acquisition developed by Dreyfus (1980), Patricia Benner (1982) posited that achieving the status of expert nurse is the highest stage of nurses' professional development. It is argued that many nurses progress through such stages of professional development as novice, through to competent practitioner. However, the question remains: do all nurses achieve what it means to be an expert practitioner? and in today's context, what does expert mean? According to the Oxford Advanced Learner's Dictionary (Crowther, 1995) an expert is someone "who has great knowledge or skill" and the Macquarie Dictionary (1989) defines an expert as, "a person who has special skill or knowledge in some particular field; a specialist; authority." METHODS Respondents This study is based on data obtained from a qualitative questionnaire administered to 156 under-graduate and post-graduate nurses. About half of the respondents reported that they were married, while the majority of the remaining nurses identified that they were single, and only a few wrote that they were divorced or widowed. The undergraduate nurses numbered 125 and were aged between 17 and 51 years of age with a mean of about 22 years. Almost a third (n=34) of these respondents were in their first year of a nursing diploma program at a large urban university, another third (n=44) were in their second year and the remainder (n=47) were in final year. Thirty-one postgraduate nurses were aged from 21 to 52 years (mean age = 33 years). These respondents cited employment in nursing for an average of about 10 years and their nursing experience ranged from 1 to 28 years. The post-graduates identified their clinical specialty areas as coronary care, medical oncology, paediatrics, orthopaedics, urology, surgery, psychiatric nursing, midwifery, obstetrics, palliative care, gynaecology and cardiology. Only one respondent described herself as a night-duty supervisor. Instrument This qualitative study wanted to capture the complexity of nursing care issues and the richness of nurses' everyday life in their world of work. It made use of an open-ended self-administered questionnaire. This questionnaire was designed specifically to elicit qualitative data by inviting respondents to provide written comment on what constituted a good, excellent and expert nurse. The nurses were consulted utilising three key questions: (1) "Someone is a good nurse when..." (2) "give an example of what you mean by excellence in nursing care", and (3) "Describe the characteristics of an expert nurse". The final section of the questionnaire sought respondent's demographic profile including: time of graduation (if appropriate), current level of nursing experience (e.g. post-graduate or 3rd year nurse), age, marital status and the respondents' area of specialty practice. Data Collection and Analysis The questionnaire was distributed in November 1992, together with (1) a covering letter explaining the aims of the study, a description of the nature of involvement and a guarantee of confidentiality and that participation was entirely voluntary; and (2) a copy of the consent form which respondents would sign when they expressed interest in taking part in the study. Thus the study was undertaken with ethical approval being received from three institutions. The written responses were content analysed. This process required direct interaction between the analyst and the written data. Initially, line by line coding was manually undertaken, for instance, this involved reading, browsing, reflecting, validation of codes and searching for emerging patterns in the data. Hand coding of the data was further analysed using the computerised software program QSR NUD.IST version 3.0 (Non numerical Unstructured Data Indexing Searching and Theorizing; Richards & Richards,1994). The process involved four analysts meeting regularly to validate codings and to derive statements of hypothetical relationships or hypotheses from the data. These hypotheses were either confirmed, modified or discarded on the basis of further discussion, conceptualisation, and empirical evidence from the data. In this way, we sought to establish intercoder reliability, consensus, and verification of emerging themes. FINDINGS Theme One: The good nurse as professional carer The predominant theme emerging from characteristics of a good nurse was that of professional caring for the patient. Caring proved to be the central tenet of the nurses' work. The following highlight significant aspects of nurses' care experience and were operationalised by the respondents in the following ways: Competent care: She/he walks into a room and the patient knows from the way you talk to him and go about caring for him that nothing is too much trouble if he needs to be given certain attention. (N144, 2nd Year Nursing student) Compassionate care: They do their best under varying conditions and treat patients with respect and dignity and yet allow some freedom of independence (N161, 2nd Year Nursing student). They are compassionate and caring enough to look after the significant others. They take into account a person's confidentiality. (N164, 2nd Year Nursing student) Holistic care: Considering the physical, psychological, social and spiritual needs of the patient. (N181, 3rd Year Nursing student) Anticipatory care: They can not only perform procedures and treatment correctly but be perceptive of feeling and concerns of the patient. (N216, 3rd Year Nursing student) Humanism care: They are genuine and show consideration towards others, put themselves in another person's place and empathise with them. Kind, loving, caring, efficient, happy, right with self and God. Listens. (N218, 3rd Year Nursing student) Advocacy care: They can pass on their knowledge in a manner appropriate to the need of the client/staff, observes and reports without giving opinions which could affect patient care. Gives patient appropriate care and is prepared to challenge orders and look for preferred alternative to best suit patient. (N254, Postgraduate Student) Equality care: They are not racist, sexist, and treats everyone equally. Cares for someone at the highest possible level not worrying if they are/not Christian or if they are in hospital for disease (AIDS) or abortion or alcohol etc. (N120, 1st Year Nursing student) Altruistic care: They go the extra mile, do things which aren't necessary but are needed as far as the patient is concerned (N204, 3rd Year Nursing student) Theme Two: The excellent nurse as the quality carer According to the respondents, nurses who deliver excellent nursing care implement the best quality nursing care. Excellent nurses demonstrate a holistic approach to caring, possess certain personal qualities which enhance practice and relate to patients, families, colleagues, and other members in the health team in a professional, competent, and co-operative manner. The sub-theme best quality care was nominated for the excellent nurse as often as 60 times (44%, or more than 2 in 5). Indeed, best quality care was uniquely utilised by respondents to portrait the excellent nurse. This was followed closely by the sub-theme of holistic, which was used 42 times (31%, or about 1 in 3) in describing an excellent nurse. The following quotations from respondents were used to illustrate how they perceived the excellent nurse. Best quality care: Doing the best at all the work we are given and having an attitude that promotes excellence (N103, 1st Year Nursing student). To always achieve for utmost proficiency (N107, 1st Year Nursing student). To achieve the highest possible care for the patients benefit and the nursing profession (N120, 1st Year Nursing student). Providing the most efficient and effective nursing care possible (N187, 3rd Year Nursing student). Aiming for the best achievements in practical and theoretical aspects in nursing so that you can provide excellence in nursing care (N250, Postgraduate Student). Holistic care: Being able to provide top quality physical care while being aware of the person's spiritual and emotional needs and relating to the person on a personal level (N142, 2nd Year Nursing student). Providing top-level (holistic) nursing care, without regard to race, age, sex, religion or condition (N161, 2nd Year Nursing student). Caring for the whole person - spiritually, physically and emotionally (N246, Postgraduate Student). Theme Three: The expert nurse as an intellectual carer The respondents perceived that expert nurses had a high intellectual component associated with their caring. There were three inter-related sub-themes to the intellectual trait of an expert nurse: (a) knowledgable, (b) efficient, and (c) interpersonal. Sub-theme One: An expert nurse as a knowledgable carer The knowledge component encompassed both the cognitive and experiential aspects of knowing. In terms of breadth of knowledge, an expert nurse was perceived to be both an authority and had deep understanding in a specialised area, as well as having acquired a broad knowledge base. An expert nurse not only was charged with responsibilities of knowledge dissemination, s/he was expected to be continually engaged in ongoing education. Credentials acquired through education proved an important source of knowledge for experts. Related to an expert's need for continual education, corrigibility, that is, the need for continual improvement, of an expert nurse, in the sense that scientific knowledge may be improved, also emerged as a sub-theme. To the respondents, a prototype expert nurse was knowledgeable, professional, skilful, competent, capable, accountable, autonomous and confident in his/her delivery of nursing care. These sub-themes were illustrated by what the respondents wrote: Cognitive and Experiential aspects of expert knowledge: Is both a practical and theoretical expert nurse (N250, Postgraduate Student). Knows every condition, symptoms and signs, treatment for caring (N115, 1st Year Nursing student). One who has attained a knowledge of nursing care through education and experience in a particular area (N114, 1st Year Nursing student). Has a good knowledge of the theory behind nursing and has plenty of experience (N128, 1st Year Nursing student). Trained by clinical practice. Has an understanding of the work involved (N188, 3rd Year Nursing student). Nursing specialist with a broad knowledge base: A nurse who has extensive training knowledge and understanding, not only of diseases and their treatments but also a deep understanding of the human being and their needs, thus carrying out their duties in the best way possible and yet taking into consideration the needs of the individual and fellow staff members. (N216, 3rd Year Nursing student) In western-style health care setting, this care demands a sound scientific base. (N241, Postgraduate Student). Excellent knowledge base (N242, Postgraduate Student). Knowledge dissemination: Can be a consultant to other nurses. (N110, 1st Year Nursing student). Knowing how to relate this knowledge to the client. Able to convey information to clients (patient education) and other health professionals (N182, 3rd Year Nursing student). Willing to impart that knowledge to junior staff and students. Able to educate patients and relatives. (N228, Postgraduate Student) 1. Ability to impart current knowledge. 2. A person who is up to date in every aspect of his specialty. 3. Teacher by example (N250, Postgraduate Student). Pursuit of knowledge through Education: Has a further education and training in a specific area (N190, 3rd Year Nursing student). Someone that continues to study and apply it to the work place (N225, Postgraduate Student) Keep up with new technology eg PCA's, TV infusion pumps. (N247, Postgraduate Student). Expert in a particular area where there has been much study with Degrees to show this (N136, 2nd Year Nursing student). Corrigibility: The expert knows his or her limitations and when to ask for help, including interdisciplinary support. The term limitations includes legal as well as skills. Nurses share their knowledge with their colleagues (N241, Postgraduate Student). To realise that being "expert" does not mean doing everything without consultation of others (N242, Postgraduate Student). Sub-theme two: The expert nurse as efficient carer The prototype view of an expert nurse was one who was also efficient in their daily practice. The word efficient was nominated as an important trait of an expert nurse by 32 (21%, or 1 in 5) of respondents. Efficiency meant an expert was able to use time wisely or organised. Efficiency also meant to be able to anticipate, evaluate, handle and solve problems, and being reflective and insightful.. Anticipation: An expert nurse is someone who can see the outcome of her/his actions (N119, 1st Year Nursing student). Anticipates possible future problems before they eventuate (N246, Postgraduate Student). An expert nurse is one who often can just anticipate things by having a 6th sense before they actually happen. (N248, Postgraduate Student). Evaluation: Can make judgements and decisions if a different situation arises (N171, 2nd Year Nursing student). Able to make decisions quickly (N172, 2nd Year Nursing student). Ability to make a critical decision (N244, Postgraduate Student). Solve Problems: Able to solve problems (N169, 2nd Year Nursing student). Deals with difficult situations in a professional manner (N158, 2nd Year Nursing student). One who has problem-solving ability (N201, 3rd Year Nursing student). Can be relied upon to make a correct decision when the pressure is on (N212, 3rd Year Nursing student). Insightful and Reflective: Hears what the patient is actually saying (N). One who is able to understand the unspoken language among the sick (N205, 3rd Year Nursing student). Reflective listening (N209, 3rd Year Nursing student). Being efficient and observant and intuitive (N243, Postgraduate Student). Sub-theme three: The expert nurse as an interpersonal carer In his/her social interactions with patients, their families, doctors, nurse colleagues, and other members of the health team, the prototype expert nurse is able to lead, educate, be a role model, obey, challenge, respect, communicate, establish rapport, and maintain autonomy. The expert nurse is assertive, organised, tactful and meek and humble, dignified, liked by administration, peers and patients alike. The following provide examples of how respondents described the interpersonal relational aspects of the expert nurse: Supporting the patient: becomes a patient's confidant (N121, 1st Year Nursing student). Reliable - both for confidential matters and in a work sense (N127, 1st Year Nursing student). Advocacy to patient (N150, 2nd Year Nursing student). Supporting the family: Is able to provide support for patient and family (N137, 2nd Year Nursing student). Show empathy toward client and relatives (N143, 2nd Year Nursing student). Sensitive to the client's feelings and those of other family, friends of the client and other health care team staff (N207, 3rd Year Nursing student). Supporting doctors: Able to follow out Doctor's orders (N186, 3rd Year Nursing student). Carries out doctor's orders as prescribed. Challenges an order or withholds treatment if seen to be inappropriate. Documents clearly and concisely. (N254, Postgraduate Student). Supporting nurse colleagues: Can be a consultant for other nurses (N110, 1st Year Nursing student). Has an excellent manner with both co-workers and patients alike (N212, 3rd Year Nursing student). Able to delegate responsibility in a balanced way. Teaching younger nurses the correct way of doing a procedure and the reason why. Be approachable and non-threatening to others on team (N243, Postgraduate Student). Supporting others in the health team: Able to convey information to clients (patient education) and other health care professionals (N182, 3rd Year Nursing student). Autonomous Practice: Ability to stand by your beliefs and tasks which have been asked to be performed (N155, 2nd Year Nursing student). Open to change and new ideas, versatile, competent, willing to stand up in a non-agitating style for what they believe to be correct (N146, 2nd Year Nursing student). REFLECTIONS In this study, essential constructs concerning the good, excellent and expert nurse were explored by discovering the qualitative meanings provided by 156 undergraduate and postgraduate nursing students. The predominant theme illustrating the characteristics of a good nurse was that of a professional carer for patients. The eight sub-themes were closely interwoven and enmeshed. Examples of these are seen in professional caring that was competent, compassionate, holistic, anticipatory, humanism, advocacy, equality, and altruistic. According to the nurses in this study, the good nurse demonstrated professionalism by communicating to patients that nothing was too much trouble and that they would go the extra mile for them. Humanism in caring was extended to others, that is, not only to the client, but also to family, other staff, self and God. The excellent nurse was more concerned with the quality of care administered to the patient. Excellence in nursing care was also delivered professionally, but importantly care was provided to the highest possible standard. That nurses were to deliver the best possible care was not highlighted by respondents when discussing the good nurse. Nurses were considered excellent when they were proficient and competent. Excellence was portrayed as possessing both knowledge and skill bases which were implemented for the patient's benefit. The excellent nurse's practice was characterised by leadership, and problem recognition leading to solution. Patient was delivered by nurses whose personal quality included confidence, commitment and tact with subtlety. Also deemed important was interpersonal relationship of the nurse with patient, family and the health team. As a result of receiving patient-centred care, optimal healing occurred worked to enhance the patient's life chances. Predominantly the Expert nurse was viewed as possessing a high intellectual capacity embracing both cognitive and experiential aspects of knowing. Being expert also meant being specialised and skilled in a particular nursing specialty, such as palliative care or mid-wifery, which was underpinned by a sound scientific base. The expert nurse also provided consultancy and teaching by example. Being expert also meant being engaged in efficient care that was intuitive and decisive. The most striking similarity was that irrespective of emergent themes, the one central unifying concept across the three major themes was that caring was the heart and foundation of nurses' work (Leininger, 1988). Perhaps the most notable difference among the three portraits of nurses was the relatively more vivid prototypic view of an expert nurse as an intellectual carer. This intellectual image of an expert nurse was significantly distinguished both from the professional carer image of a good nurse, and the quality carer portrait of an excellent nurse. Respondents were more able to describe an expert nurse than to article what made a good nurse, or what constituted excellence in nursing care. Of the three nursing images, significantly more sub-themes (almost twice in number) were derived from the portrait of the expert nurse. Further, the following concepts were used uniquely in describing an expert nurse: Experience, Specialist, Leadership, Accountability, With Dignity, Reflective, Patience, Lovable, and Intuitive. On the other hand, Challenge was the uniquely used to describe a good nurse, and Quality of Nursing Care was unique for an excellent nurse. Interestingly, whilst the nurses' involvement and empathy were often described as essential in the provision of quality care by an excellent nurse, the respondents were careful to point out that, an expert nurse has to be not too emotionally involved (N131 and N133, both 1st Year Nursing students). Of concern is an absence, or a lack of discussion, of important concepts such as nurses' role in empowering themselves, patients and families. Further, no overt reference was made to issues of budget or time limitations, political power, moral, legal and political accountability when respondents portrayed either good, excellent or expert nurse. Whilst our analysis has come a long way, we do not believe it is yet time to relax or claim a definitive portraiture. It is recognised that further research is required to refine the model. ACKNOWLEDGMENT This study was supported by a 1996 Research Discretionary Grant of the Australian Catholic University, New South Wales. REFERENCES Benner, P. (1984). From Notice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park: Addison-Wesley Publishing Company. Bernard, J.R.L. (1989). (Ed). The Macquarie Thesaurus: The Book of Words. Macquarie University, NSW: The Macquarie Library. Crowther, J. (1995) (Ed) Oxford Advanced Learner's Dictionary, 5th Edition, UK, Oxford: Oxford University Press. Leininger, M. 'Leininger's theory of nursing: cultural care diversity and universality', Nursing Science Quarterly, 1:4, 1988, pp. 152-160. Richards, T. & Richards, L. (1994). Using computers in qualitative analysis. In N. Denzin & Y. Lincoln (Eds.), Handbook of qualitative research. Thousand Oaks, CA: Sage. The Macquarie Dictionary (1989). Second Revision. Sydney, Australia: The Macquarie University, The Macquarie Library. Three portraits of nursing: The good, excellent and expert nurse, voices from the field Coulon, L.1, Mok, M.2, Krause, K.2, & Anderson, M.3 1: School of Nursing and Human Movement, Australian Catholic University, NSW 2: School of Education, Macquarie University 3: School of Nursing, Avondale College Abstract This study explores the meaning of excellence and expertise held by Australian nursing students. Qualitative data were generated by 125 undergraduate and 31 postgraduate nursing students by means of an open-ended questionnaire. Respondents were consulted concerning their perceptions of what makes: a good nurse, an excellent nurse, and an expert nurse based on their day-to-day clinical practice. Three coders independently coded the responses, utilising line-by-line coding, which led to the development of four major themes: (1) professionalism, (2) holistic care, (3) praxis, and (4) humanism. These pivotal themes provided the portrait of being a good, excellent or expert nurse in clinical practice, however, there existed differential emphasis for the three nurse images. Findings also suggested that postgraduate and undergraduate nursing students had differing perceptions of good, excellent and expert nurses. (130 words) Three portraits of nursing: The good, excellent and expert nurse, voices from the field Coulon, L., Mok, M., Krause, K., & Anderson, M. Programme Description Strand/topic:Teaching, learning and cognitive processes Key words: Nurse education, nurse image, caring Dr Lyn Coulon is a principal lecturer at School of Nursing and Human Movement, Australian Catholic University. Her main substantive interests have been in nurse education, the meaning of nursing to nurse students, research ethics, and Trauma Triage by NSW Ambulance Officers in a Regionalised Trauma System. She has made substantive contributions to the field of nursing research through her extensive publications, teaching, and services to the community. Dr Magdalena Mok is a senior lecturer at School of Education, Macquarie University. Her main substantive interests have been in the meaning of nursing to nurse students, school life of secondary students, particularly that of migrant students, in Australia. Her main interest is the application of multilevel models in educational research. Ms Kerri-Lee Krause is an associate lecturer at School of Education, Macquarie University. Her main substantive interests have been in the language development of secondary students. One of her current research is on enhancing students' composition proficiency by teaching them planning skills. Mr Malcolm Anderson is a lecturer in School of Nursing, Avondale College. His current research is on family functioning and its relationship with the psychological adjustment of carers after the spouse of the carer has had severe head injury. Three portraits of nursing: The good, excellent and expert nurse: Voices from the field Coulon, L.1, Mok, M.2, Krause, K. 2, & Anderson, M.3 1: School of Nursing and Human Movement, Australian Catholic University, NSW 2: School of Education, Macquarie University 3: School of Nursing, Avondale College Acknowledgment This study was supported by a 1996 Discretionary Research Funding from The Australian Catholic University NSW. Paper presented at the Singapore Educational Research Association (ERA) & Australian Association for Research in Education (AARE) Joint Conference, 24-29 November 1996, Singapore Polytechnic. Coulon, L. & Mok, M (1993). Learning about the meaning of nursing from nurses: a pilot study. Conference Proceedings, The Australasian and New Zealand Association for Medical Education, Annual Conference, Suva Travelodge, Fiji, 10-14 July 1993, 1-12. Coulon, L., & Mok, M. (1993). What do nurses value? Invited Paper, The Australian Nurse Teachers' Society, Glebe, August. Coulon, L., & Mok, M. (1994). How do nurses rate themselves as experts? The Bulletin, The Australian Nurse Teachers' Society, Summer 1994, 1-3. (Invited Paper). Coulon, L., & Mok, M. (1996, under review). What do nurses value in the 1990's. Paper submitted to the Australian Journal of Advanced Nursing. Coulon, L., Mok, M., Krause, K. and Anderson, M (Accepted for publication, November 1995). The pursuit of excellence in nursing care: What does it mean? Submitted to: Journal of Advanced Nursing, United Kingdom, pp 1-30. 2