The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [24]
This manual has been structured to enable nurses to develop competence, recognizing that competence is not just about knowing how to do something but also about understanding the rationale for doing it and the impact it may have on the patient.
Developing skills
Competence develops over time. Benner’s 1984 model of skill acquisition offers a framework to define the development from novice through to clinical expert. Based on the Dreyfus model (1982), which distinguishes between the level of skilled performance that can be achieved through principles and theory based in the classroom and context-dependent judgements and skill that can only be acquired in real situations, the manual is relevant to competence development at all levels.
Stage 1: Novice. As a novice, the related anatomy and physiology, related theory and preprocedural considerations will provide ‘objective attributes’ (Benner 1984), that is, knowledge of features of the task that can be gained away from the situation, for example understanding of venous anatomy of the arm. The procedures will give ‘context-free rules’ (Benner 1984) to guide actions that are not determined by the patient as an indivdual. This is the first step to technical competence (Ray 1987).
Stage 2: Advanced beginner. The advanced beginner is one who has got some clinical experience and can use the evidence-based approaches to understand what they have seen in practice and the procedures as a reminder of the steps to follow to undertake a procedure. Chapters 2 and 5 will also be important at this stage to introduce the nurse to professional aspects of care that are essential in carrying out any procedure holistically as they progress to becoming a competent practitioner.
Stage 3: Competent. At this stage, the nurse should be familiar with carrying out core procedures, but they may need to develop problem-solving skills in respect of specific procedures. The problem-solving tables and complications sections will help them to develop these skills.
Stage 4: Proficient. Proficient nurses perceive situations as a whole. They will have integrated knowledge, skills and attitudes (Benner 1984). The manual will provide a useful reference to alert them to changes in practice and using the evidence-based approaches sections will heighten their awareness of the new evidence underpinning practice.
Stage 5: Expert. The manual will be useful to the expert to highlight areas where further research needs to be done to establish the evidence underpinning practice. It will also be a useful reference to guide them as they learn those procedures that are new to their role.
Developing new roles has obvious risks attached to it and although every individual nurse is accountable for their own actions, every healthcare organization has to take vicarious liability for the care, treatment and procedures that take place. An organization will have expectations of all its nurses in respect of keeping patients, themselves and the environment safe. There are the obvious ethical and moral reasons for this: ‘Nurses have a moral obligation to protect those we serve and to provide the best care we have available’ (Wilson 2005, p.118). So there is an increasing requirement to demonstrate competencies in specific areas. This has become part of the risk management process of an NHS organization.
Evidence-based practice
The moral obligation described above extends to the evidence upon which we base our practice. Nursing now exists in a healthcare arena that routinely uses evidence to support decisions