How do we define nursing care expert witnesses?

By Frances W. (Billie) Sills, RN, MSN, ARNP

© 2007 The Medical-Legal News

The need for expert witnesses in the area of nursing care continues to grow at a rapid pace. It brings to mind two questions, “Just who is a nursing expert, and when does the nurse transition from ‘novice’ to ‘expert?’” This CE presentation will begin a series of issues that face the nursing expert witness in today’s litigious society.

As nurses we acknowledge the fact that a new nursing graduate is indeed a “novice.” A novice is an individual lacking experience in a particular domain — here the art and science of nursing. The terms “novice” and “beginner” stir the emotions. The fact is all of us are novices in most fields no matter how experienced we are. Nursing was very straight-forward in the days of Florence Nightingale. The nurse took physical care of the patient, ensuring that the environment was such that it allowed nature to heal the patient. As the years went on, nurses took on more and more responsibilities and now in the 21st century we find nurses in a variety of settings, functioning in multiple roles and becoming specialists in diverse clinical settings. Because of this, it is imperative that nurses who wish to explore the idea of being an expert witness identify their area of expertise. The assumption that a “nurse is a nurse is a nurse” could not be further from the truth. Every individual who holds a license to practice nursing is not an expert in the art and science of nursing. A nurse with ten years experience in OB nursing is not an expert in neuroscience nursing. The neuroscience nurse is in fact a “novice” in the area of OB. That being said, let us explore further this concept of “nursing expert.”

Webster defines the word “expert” as “one who has acquired special skill in or knowledge of a particular subject: having, involving or displaying special skill or knowledge from training or experience.” Witness is defined “as one who gives evidence; testifies in a cause or before a judicial tribunal.” The term “expert witness” has been defined in numerous legal writings as “any person who has the special knowledge, skill, experience, training or education necessary to become an expert in a field may be qualified to testify as an expert.”

Therefore, anyone who is to serve as an expert witness must prove on request that he or she possesses the necessary abilities.

“Expertise literature from a variety of domains provides a fairly consistent definition of what an expert is. There are certain qualities that can be accepted as characteristics of an expert: Someone who is very knowledgeable of his particular area, one who can engage in skillful practice, make accurate diagnoses, insightful analysis and can make decisions usually very quickly.” (Tsui, 2003).

Experts vs. non-experts

When we review the research literature, we find that over the years research has taken many different approaches — some studies have compared experts and novices, others have looked at factors or differences between what we know as the “experienced individual” and the “expert.” This has led to more studies to try and determine why some individuals become “experts” while others remain simply experienced non-experts.

One of the differences that has been a thread in the research findings is that of “having the right mind-set.” That means being fully engaged in doing the job, commitment to doing the job correctly, being disciplined, and understanding that there is no quick way of becoming an expert. In her landmark work From Novice to Expert: Excellence and Power in Clinical Nursing, Dr. Patricia Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences. Her premise is that the development of knowledge in the applied disciplines such as medicine and nursing is composed of the extension of practical knowledge (know-how) through research and the characterization and understanding of the “know-how” of clinical experience. Simply stated, experience is a prerequisite to becoming an expert.

Five levels

In her studies, Benner used the model proposed by professor Hubert Dreyfus and described nurses as passing through five levels of development: novice, advanced beginner, competent, proficient and expert. Each step builds on the previous one, as abstract principles are refined and expanded by experience and as the learner gains expertise. Patient care shifts from pieces of unrelated information and a series of tasks to the integration of various aspects of patient care as a whole. In order to understand how the novice moves to expert, it is important to examine each level of development and the characteristics of the level:

Novice

• No experience of situations where one is expected to perform; can take in little of the situation that is new and strange.

• Governed by context-free rules (in order to enter situations to gain experience); little understanding of contextual meaning of textbook concepts.

• Extremely limited and inflexible.

• Requires support in clinical practice from someone at least at “competent” level.

• Most new graduates are at this level.

Advanced beginner

• Limited experience of situations in which one is expected to perform.

• Recognizes overall global characteristics of situations that can only be identified through prior experience.

• Requires support in clinical practice from someone at the “competent” level.

Competent

• On the job with same or similar situations for 2-3 years.

• A plan for work or care establishes only a perspective; no rigid rules to follow, but is most organized and efficient with conscious, deliberate planning.

• Recognizes contextual aspects of situations.

• Has a feeling of mastery and ability to manage.

• Still lacks speed and flexibility characteristics of the next level.

Note: A significant difference in expertise occurs between these next two levels. Skills are transformed at the proficient and expert levels, and adhering to formal rules or models may actually deteriorate performance.

Proficient

• Three to five years experience in same or similar situations.

• Perceives situations as a contextual whole and recognizes most significant aspects of a situation.

• Knows from experience what typical events to expect in given situations; has a “web of perspectives” from which to operate.

• Considers fewer options and hones in on accurate regions of problems.

• Performs with flexibility.

Expert

• Five to ten years in same or similar situations; enormous background of expertise.

• Operates from a deep understanding of the total situation as a contextual whole without relying on rules, guidelines or maxims.

• Intuitive grasp of situations: rapidly zeroes in on accurate regions of problems without wasting time considering a large range of options.

• Performs with great flexibility.

How do they learn?

To further understand this transition from novice to expert we must ask, “How do nurses learn?” In various studies with pilots and nurses it was found that novice professionals tend to govern their practice with rule-oriented behavior (Dreyfus & Dreyfus, 1985; Benner, 1982, 1984; Benner & Tabber, 1987).

Since novices have little experience in real situations, they must rely on the rules from their preparatory education in order to function.

In contrast, the expert professional “has an intuitive grasp of the situation and zeros in on the accurate region of the problem without wasteful consideration of a larger range of unfruitful possible problem situations.” (Benner, 1982). With the perceptual ability to recognize patterns in clinical situations, the nursing expert can determine that the standard of care was not met, for instance.

The path followed in using one’s knowledge and experience while serving a client in the legal arena contains many rewards in personal and professional satisfaction and remuneration, but keep in mind that it is fraught with pitfalls. Serving as an expert witness is a combination of application of knowledge, a good memory and the ability to deal with the emotions of others. •

Frances W. (Billie) Sills, RN, MSN, ARNP, is an assistant professor at ETSU College of Nursing in Tennessee; dewars3@aol.com.