Objective: This study aims to develop a valid, reliable survey measure of clinical nursing expertise that can be used in hospital outcomes research to study the contribution of nursing expertise to the quality of care and patient outcomes and to identify work environments that cultivate nurses' expertise. Presently, there are no measures to distinguish differences across nurses in their clinical expertise. Many researchers calculate the absolute numbers of hospital registered nurses in relation to the number of patients cared for or as a proportion of all nursing staff, but these statistics tell us nothing about the expertise levels of nursing staff. When we study the contribution of nurse staffing to patient outcomes across hospitals, we make the implicit assumption that all registered nurses are equivalent. Hospital administrators who consider ratios of nurses to patients make the same assumption. Thus, the inability to distinguish differing levels of nursing expertise is problematic for theoretical, empirical, and policy reasons. This instrument development effort builds on the work of Patricia Benner and her colleagues, who have been using qualitative methodologies for two decades to describe and explain variability in clinical expertise among staff nurses.
Design: A multi-item instrument comprising 35 nursing roles or functions was developed from Benner's From Novice to Expert (1984). For each item, respondents reported their level of ability using a five-point scale. Sample items were "Establishing trust and good communication with patients and families," "Creating and implementing wound care strategies that foster healing and comfort," and "Setting priorities to effectively coordinate and meet multiple patient needs and requests." Based on a pretest by 95 staff nurses, item wording and sequence were refined. The instrument's psychometric properties were evaluated in a sample of staff nurses. As part of the sampling procedure, each nurse's level of expertise was rated by their clinical director and an advanced practice nurse in their clinical area. Each nurse completed the multi-item self-assessment and named three nurse colleagues who "know my practice well" to complete independent assessments.
Population, Sample, Setting, Years: A purposive sample of 83 staff nurses from one teaching hospital was generated by clinical directors and advanced practice nurses in four clinical areas: medical, surgical, obstetrical, and psychiatric. Within each area, equal proportions of nurses across four expertise levels were chosen: advanced beginner, competent, proficient, and expert. The staff nurse response rate was 76% (n=63). Colleagues completed 140 out of 186 assessments (75% response rate). Data were collected in 1999-2000.
Concept: clinical nursing expertise
Methods: A scale created from all 35 items was assessed for internal consistency using Cronbach's alpha. The three sources of expertise assessment (nurse, colleagues, director/APN) were used to evaluate construct validity. Concurrent validity was evaluated using seven indicators of clinical advancement and professional activity. The concurrent validity indicators were years of staff nurse experience, nursing specialty certification, membership in a professional organization, subscription to a professional journal, and participation in nursing committees and projects. Validity was explored by correlation analysis, chi-square analysis, and analysis of variance.
Findings: The scale was highly reliable (alpha=.97). The scale's hypothetical range of 1 (beginning level of expertise) to 5 (highest level of expertise) suggests that the mean score of 4.1 for this sample corresponds to a "proficient" level of expertise. Construct and concurrent validity of the expertise instrument were supported by strong (ranging from .69 to .81) and statistically significant correlations between the nurse's scale score and the director/APN's and colleagues' assessments, as well as strong associations with other validity indicators.
Conclusion: The new survey measure shows promise for use in research on clinical expertise and its association with the quality of patient care and patient outcomes.
Implications: Clinical nursing expertise could be included in a theoretical framework linking the organization of hospital nursing to patient outcomes. A growing body of literature shows that nurse staffing levels are important to patient outcomes. The focus on numbers of nurses, however, can obscure what may be a key component of the nurse staffing dimension that has yet to be factored into outcomes research: clinical nursing expertise. Expertise may be the single, most powerful influence on the technical quality of nurses' clinical interventions. Moreover, expertise is critical to nurses' non-clinical functions, such as coordination within a therapeutic team of providers. The concept of nursing expertise could be added to the theoretical framework to help delineate the effect of hospital nursing organization on patient outcomes.
Reference Benner P. From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, 1984.
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