Nursing Today
Objectives
• Discuss the development of professional nursing roles.
• Describe educational programs available for professional registered nurse education.
• Describe the roles and career opportunities for nurses.
• Discuss the influence of social, political, and economic changes on nursing practices.
Key Terms
Advanced practice registered nurse (APRN), p. 7
American Nurses Association (ANA), p. 1
Caregiver, p. 7
Certified nurse-midwife (CNM), p. 8
Certified registered nurse anesthetist (CRNA), p. 8
Clinical nurse specialist (CNS), p. 8
Code of ethics, p. 4
Continuing education, p. 5
Genomics, p. 10
In-service education, p. 5
International Council of Nurses (ICN), p. 9
National League for Nursing (NLN), p. 9
Nurse administrator, p. 8
Nurse educator, p. 8
Nurse practitioner (NP), p. 8
Nurse researcher, p. 8
Nursing, p. 1
Patient advocate, p. 7
Professional organization, p. 9
Quality and Safety Education for Nurses (QSEN), p. 9
Registered nurse (RN), p. 5
Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully with compassion, caring, and respect for each patient’s dignity and personhood. As a science nursing practice is based on a body of knowledge that is continually changing with new discoveries and innovations. When you integrate the science and art of nursing into your practice, the quality of care you provide to your patients is at a level of excellence that benefits patients and their families.
Your opportunities for a nursing career are limitless. There are a variety of career paths, including clinical practice, education, research, management, administration, and even entrepreneurship. As a student it is important for you to understand the scope of nursing practice and how nursing influences the lives of your patients.
The patient is the center of your practice. The patient includes the individual, family, and/or community. Patients have a wide variety of health care needs, experiences, vulnerabilities, and expectations; but this is what makes nursing both challenging and rewarding. Making a difference in your patients’ lives is fulfilling (e.g., helping a dying patient find relief from pain, helping a young mother learn parenting skills, and finding ways for older adults to remain independent in their homes). Nursing offers personal and professional rewards every day. This chapter presents a contemporary view of the evolution of nursing and nursing practice and the historical, practical, social, and political influences on the discipline of nursing.
When giving care, it is essential to provide a specified service according to standards of practice and to follow a code of ethics (American Nurses Association [ANA], 2008, 2010b). Professional practice includes knowledge from social and behavioral sciences, biological and physiological sciences, and nursing theories. In addition, nursing practice incorporates ethical and social values, professional autonomy, and a sense of commitment and community. The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations (ANA, 2010b). The International Council of Nurses (ICN, 2010) has another definition: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. Both of these definitions support the prominence and importance that nursing holds in providing safe, patient-centered health care to the global community.
Expert clinical nursing practice is a commitment to the application of knowledge, ethics, aesthetics, and clinical experience. Your ability to interpret clinical situations and make complex decisions is the foundation for your nursing care and the basis for the advancement of nursing practice and the development of nursing science (Benner, 1984; Benner, Tanner, and Chesla, 1997; Benner et al., 2010). Critical thinking skills are essential to nursing (see Chapter 15). When providing nursing care, you need to make clinical judgments and decisions about your patients’ health care needs based on knowledge, experience, and standards of care. Use critical thinking skills and reflections to help you gain and interpret scientific knowledge, integrate knowledge from clinical experiences, and become a lifelong learner (Benner et al., 2010).
Historical Highlights
Nursing has responded and always will respond to the needs of its patients. In times of war the nursing response was to meet the needs of the wounded in combat zones and military hospitals in the United States and abroad. When communities face health care crises such as disease outbreaks or insufficient health care resources, nurses establish community-based immunization and screening programs, treatment clinics, and health promotion activities. Our patients are most vulnerable when they are injured, sick, or dying.
Since the beginning of the profession, nurses have studied and tested new and better ways to help their patients. A classic article described Florence Nightingale’s work during the Crimean War. She studied and implemented methods to improve battlefield sanitation, which ultimately reduced illness, infection, and mortality (Cohen, 1984). Take time to reflect about Nightingale’s actions centuries ago and think about the impact of her actions. She set the stage for using evidence to direct practice.
Today nurses are active in determining the best practices for skin care management, pain control, nutritional management, and care of older adults, to cite just a few examples. Nurse researchers are leaders in expanding knowledge in nursing and other health care disciplines. Their work provides evidence for practice to ensure that nurses have the best available evidence to support their practices (see Chapter 5).
Nursing is a combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies needed for safe, quality patient-centered care (Gugliemi, 2010). It continuously responds and adapts to new challenges. Nurses are in a unique position to refine and shape the future of health care.
Nurses are active in social policy and political arenas. Nurses and their professional organizations lobby for health care legislation to meet the needs of patients, particularly the medically underserved. For example, nurses in communities provide home visits to newborns of high-risk mothers (e.g., adolescent, poorly educated mothers or medically underserved). These visits result in fewer emergency department visits, fewer newborn infections, and reduced infant mortality (Mason et al., 2012).
Knowledge of the history of our profession increases your ability to understand the social and intellectual origins of the discipline. Although it is not practical to describe all of the historical aspects of professional nursing, some of the more significant milestones are described in the following paragraphs.
Florence Nightingale
In Notes on Nursing: What It Is and What It Is Not, Florence Nightingale established the first nursing philosophy based on health maintenance and restoration (Nightingale, 1860). She saw the role of nursing as having “charge of somebody’s health” based on the knowledge of “how to put the body in such a state to be free of disease or to recover from disease” (Nightingale, 1860). During the same year she developed the first organized program for training nurses, the Nightingale Training School for Nurses at St. Thomas’ Hospital in London.
Nightingale was the first practicing nurse epidemiologist (Cohen, 1984). Her statistical analyses connected poor sanitation with cholera and dysentery. She volunteered during the Crimean War in 1853 and traveled the battlefield hospitals at night carrying her lamp; thus she was known as the “lady with the lamp.” The sanitary, nutrition, and basic facilities in the battlefield hospitals were poor at best. Eventually she was given the task to organize and improve the quality of the sanitation facilities. As a result, the mortality rate at the Barracks Hospital in Scutari, Turkey, was reduced from 42.7% to 2.2% in 6 months (Donahue, 2011).
The Civil War to the Beginning of the Twentieth Century
The Civil War (1860 to 1865) stimulated the growth of nursing in the United States. Clara Barton, founder of the American Red Cross, tended soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death. The U.S. Congress ratified the American Red Cross in 1882 after 10 years of lobbying by Barton. Dorothea Lynde Dix, Mary Ann Ball (Mother Bickerdyke), and Harriet Tubman also influenced nursing during the Civil War (Donahue, 2011). As superintendent of the female nurses of the Union Army, Dix organized hospitals, appointed nurses, and oversaw and regulated supplies to the troops. Mother Bickerdyke organized ambulance services and walked abandoned battlefields at night, looking for wounded soldiers. Harriet Tubman was active in the Underground Railroad movement and assisted in leading over 300 slaves to freedom (Donahue, 2011).
The first professionally trained African American nurse was Mary Mahoney. She was concerned with relationships between cultures and races; and as a noted nursing leader she brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color, or religion.
Isabel Hampton Robb helped found the Nurses’ Associated Alumnae of the United States and Canada in 1896. This organization became the ANA in 1911. She authored many nursing textbooks, including Nursing: Its Principles and Practice for Hospital and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907) and was one of the original founders of the American Journal of Nursing (AJN) (Donahue, 2011).
Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City (Donahue, 2011). Nurses working in this settlement were some of the first to demonstrate autonomy in practice because they frequently encountered situations that required quick and innovative problem solving and critical thinking without the supervision or direction of a health care provider.
Twentieth Century
In the early twentieth century a movement toward developing a scientific, research-based defined body of nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities. She became the first professor of nursing at Columbia University Teachers College in 1906 (Donahue, 2011). In addition, the Goldmark Report concluded that nursing education needed increased financial support and suggested that university schools of nursing receive the money.
As nursing education developed, nursing practice also expanded, and the Army and Navy Nurse Corps were established. By the 1920s nursing specialization was developing. Graduate nurse-midwifery programs began; in the last half of the century specialty-nursing organizations were created. Examples of these specialty organizations include the American Association of Critical Care Nurses; Association of Operating Room Nurses (AORN); Emergency Nurses Association (ENA); Infusion Nurses Society (INS); Oncology Nursing Society (ONS); and Wound, Ostomy, Continence Nurses Society (WOCN).
Twenty-First Century
Nursing practice and education continue to evolve to meet the needs of society. In 1990 the ANA established the Center for Ethics and Human Rights (see Chapter 22). The Center provides a forum to address the complex ethical and human rights issues confronting nurses and designs activities and programs to increase ethical competence in nurses (ANA, 2010c).
Today the profession faces multiple challenges. Nurses and nurse educators are revising nursing practice and school curricula to meet the ever-changing needs of society, including bioterrorism, emerging infections, and disaster management. Advances in technology and informatics (see Chapter 26), the high acuity level of care of hospitalized patients, and early discharge from health care institutions require nurses in all settings to have a strong and current knowledge base from which to practice. In addition, nursing and the Robert Wood Johnson Foundation are taking a leadership role in developing standards and policies for end-of-life care through the Last Acts Campaign (see Chapter 36). The End-of-Life Nursing Education Consortium (ELNEC) offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center has brought end-of-life care and practices into nursing curricula and professional continuing-education programs for practicing nurses (Tilden and Thompson, 2009).
Influences on Nursing
Multiple external forces affect nursing, including demographic changes of the population, human rights, increasing numbers of medically underserved, and the threat of bioterrorism.
Health Care Reform
Health care reform not only affects how health care is paid for but how it is delivered. There will be greater emphasis on health promotion, disease prevention, and illness management in the future. This model impacts the delivery of nursing care. More services will be in community-based care settings. As a result, more nurses will be needed to practice in community care centers, schools, and senior centers. This will require nurses to be more adept at assessing for resources, service gaps, and how the patient adapts to returning to the community. Nursing must respond to such changes by exploring new methods to provide care, changing nursing education, and revising practice standards (O’Neil, 2009).
Demographic Changes
The U.S. Census Bureau (2008a) predicts that between 2010 and 2050 there will be a steady rise in the population. This change alone requires expanded health care resources. Add to the population change a steady increase in the population of people 65 years and older (U.S. Census Bureau, 2008b). To effectively meet all the health care needs of the expanding and aging population, changes need to occur as to how care is provided, especially in the area of public health, to address health care reform and meet the needs of the changing population. The population is still shifting from rural areas to urban centers, and more people are living with chronic and long-term illness (Presley, 2010). Not only are there expansions of outpatient settings, but more and more people want to receive outpatient and community-based care and remain in their homes or community (see Chapters 2 and 3).
Medically Underserved
The rising rates of unemployment, underemployment and low-paying jobs, mental illness, and homelessness and rising health care costs all contribute to increases in the medically underserved population. Caring for the medically underserved population is a global issue; the social, political, and economic factors of a country affect both access to care and resources to provide and pay for these services (Huicho et al., 2010). In the United States some of the medically underserved population are poor and on Medicaid. Others are part of the working poor (i.e., they cannot afford their own insurance, but they make too much money to qualify for Medicaid and as a result do not receive any health care). In addition, the number of underserved patients who require home-based palliative care services is increasing. This is a group of patients whose physical status does not improve and heath care needs increase. As a result, the cost for home-based care continues to rise, to the point that some patients opt out of all palliative services because of costs (Fernandes et al., 2010). Today nurses and schools of nursing are developing partnerships to improve health outcomes in underserved communities. Nurses work in these community-based settings providing health promotion and disease prevention to the homeless, mentally ill, and others who have limited access to health care or who lack health care insurance (McCann, 2010).
Threat of Bioterrorism
The world is a changing place; the threats of bioterrorism are continuous. Many health care agencies, schools, and communities have educational programs to prepare for nuclear, chemical, or biological attack. Nurses are active in disaster preparedness. The ICN works alongside national nursing associations to determine how to best educate and prepare nurses for future disasters (Robinson, 2010). For example, public health emergency simulation exercises allow nurses and students to work with community disaster-preparedness groups and hospitals to determine what specific nursing activities are needed (Morrison and Catanzaro, 2010). These activities sometimes range from participation in vaccine research, decontamination in the event of biological attack, and triage for mass casualty to crisis response units. If a disaster were to occur, nurses would be essential in evaluating the strengths and weaknesses of any disaster plan.
Rising Health Care Costs
Skyrocketing health care costs present challenges to the profession, consumer, and the health care delivery system. As a nurse you are responsible for providing the patient with the best-quality care in an efficient and economically sound manner. The challenge is to use health care and patient resources wisely. Chapter 2 summarizes reasons for the rise in health care costs and its implications for nursing.
Nursing Shortage
There is an ongoing global nursing shortage, which results from insufficient qualified registered nurses (RNs) to fill vacant positions and the loss of qualified RNs to other professions (Flinkman et al., 2010). This shortage affects all aspects of nursing such as patient care, administration, and nursing education (Tanner and Bellack, 2010), but it also represents challenges and opportunities for the profession. Many health care dollars are invested in strategies aimed at recruiting a well-educated, critically thinking, motivated, and dedicated nursing workforce (Benner et al., 2010). There is a direct link between registered nurses’ care and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status (Aiken, 2010; Lucero et al., 2009).
Professional nursing organizations predict that there will continue to be a diminishing pipeline of RNs in the future (AACN, 2008b; Aiken, 2010). Like it or not, the nursing shortage affects the needs of the consumer (Block and Sredl, 2006). With fewer nurses in the workplace, it is important for you to learn to use your patient contact time efficiently and professionally. Time management, therapeutic communication, patient education, and compassionate implementation of psychomotor skills are just a few of the essential skills you need. Most important, your patients leave the health care setting with a positive image of nursing and a feeling that they received quality care. In a rapid-discharge and high-tech health care environment nurses need to relate to their patients on a human, caring level (Manthey, 2008). Your patient should never feel rushed or that he or she was unimportant. If a certain aspect of patient care requires 15 minutes of contact, it will take the same time to deliver the care in an organized manner as it would in a rushed, harried manner.
Nursing as a Profession
Nursing is not simply a collection of specific skills, and you are not simply a person trained to perform specific tasks. Nursing is a profession. No one factor absolutely differentiates a job from a profession, but the difference is important in terms of how you practice. To act professionally you administer quality patient-centered care in a safe, conscientious, and knowledgeable manner. You are responsible and accountable to yourself and your patients and peers. A profession has the following primary characteristics:
• It requires a basic liberal foundation and an extended education of its members.
• It has a theoretical body of knowledge leading to defined skills, abilities, and norms.
• It provides a specific service.
• Members of a profession have autonomy in decision making and practice.
• The profession as a whole has a code of ethics for practice.
Scope and Standards of Practice
Since 1960 the ANA has engaged in documenting the scope of nursing and developing standards of practice (ANA, 2010b). Within this document are the Standards of Practice and Standards of Professional Performance. It is important that you know and apply these standards in your practice. The document is usually available in most schools of nursing and practice settings. The goal of this document is to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standard-based practice (ANA, 2010b).
Standards of Practice
The Standards of Practice describe a competent level of nursing care (Box 1-1). The levels of care are demonstrated by the critical thinking model known as the nursing process: assessment, diagnosis, outcomes identification and planning, implementation, and evaluation (ANA, 2010b). The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to patients (see Unit 3).
Standards of Professional Performance
The ANA Standards of Professional Performance (Box 1-2) describe a competent level of behavior in the professional role (ANA, 2010b). These standards provide objective guidelines for nurses to be accountable for their actions, their patients, and their peers. The standards provide a method to assure patients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measures are in place to determine whether care meets the standards.
Code of Ethics
The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It is important for you to also incorporate your own values and ethics into your practice. As you incorporate these values, you explore what type of nurse you will be and how you will function within the discipline (ANA, 2008, 2010c). Ask yourself: how do your ethics, values, and practice compare with established standards? The ANA has a number of publications that address ethics and human rights in nursing. The Code of Ethics for Nurses with Interpretive Statements is a guide for carrying out nursing responsibilities that provide quality nursing care; it also outlines the ethical obligations of the profession (ANA, 2008). Chapter 22 provides a review of the nursing code of ethics and ethical principles for everyday practice.
Nursing Education
Nursing requires a significant amount of formal education. The issues of standardization of nursing education and entry into practice remain a major controversy. In 1965 the ANA published a position paper on nursing education that emphasizes the role of education for the advancement of the science of the profession (ANA, 1965). Most nurses agree that nursing education is important to practice and that education needs to respond to changes in health care created by scientific and technological advances. There are various education preparations for an individual intending to be an RN. In addition, there is graduate nurse education and continuing and in-service education for practicing nurses.
Professional Registered Nurse Education
Currently in the United States the most frequent way to become a registered nurse (RN) is either through completion of an associate or baccalaureate degree program. Graduates of both programs are eligible to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) to become RNs in the state in which they will practice.
The associate degree program in the United States is a 2-year program that is usually offered by a university or community college. This program focuses on the basic sciences and theoretical and clinical courses related to the practice of nursing.
The baccalaureate degree program usually includes 4 years of study in a college or university. The program focuses on the basic sciences; theoretical and clinical courses; and courses in the social sciences, arts, and humanities to support nursing theory. In Canada the degree of Bachelor of Science in Nursing (BScN) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Science in Nursing (BSN) in the United States. The Essentials of Baccalaureate Education for Professional Nursing (AACN, 2008a) delineates essential knowledge, practice and values, attitudes, personal qualities, and professional behavior for the baccalaureate-prepared nurse and guides faculty on the structure and evaluation of the curriculum. The National League for Nursing Accreditation Council (NLNAC) published the NLNAC Standards and Criteria Baccalaureate Programs in Nursing—2008. This document identifies core competencies for the professional nurse and supports the Pew Health Commission and the competencies of the Institute of Medicine (IOM) for health professionals (NLNAC, 2008). In addition, one of the IOM’s recommendations is that 80% of nurses be prepared with a baccalaureate in nursing by 2020 (IOM, 2010) (see Chapter 2).
Graduate Education
After obtaining a baccalaureate degree in nursing, you can pursue graduate education leading to a master’s or doctoral degree in any number of graduate fields, including nursing. A nurse completing a graduate program can receive a master’s degree in nursing. The graduate degree provides the advanced clinician with strong skills in nursing science and theory, with emphasis on the basic sciences and research-based clinical practice. A master’s degree in nursing is important for the roles of nurse educator and nurse administrator, and it is required for an advanced practice registered nurse (APRN).
Doctoral Preparation
Professional doctoral programs in nursing (DSN or DNSc) prepare graduates to apply research findings to clinical nursing. Other doctoral programs emphasize more basic research and theory and award the research-oriented Doctor of Philosophy (PhD) in nursing. Recently the AACN recommended the Doctor of Nursing Practice (DNP) as the terminal practice degree and required preparation for all APRNs by 2015 (Chase and Pruitt, 2006). The DNP is a practice-focused doctorate. It provides skills in obtaining expanded knowledge through the formulation and interpretations of evidence-based practice (Chism, 2010).
The need for nurses with doctoral degrees is increasing. Expanding clinical roles and continuing demand for well-educated nursing faculty, nurse administrators, and APRNs in the clinical settings and new areas of nursing specialties such as nursing informatics are just a few reasons for increasing the number of doctorally prepared nurses.
Continuing and In-Service Education
Nursing is a knowledge-based profession, and technological expertise and clinical decision making are qualities that our health care consumers demand and expect. Continuing education programs are one way to promote and maintain current nursing skills, gain new knowledge and theory, and obtain new skills reflecting the changes in the health care delivery system (Hale et al., 2010). Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. An example is a program on caring for older adults with dementia offered by a university or a program on safe medication practices offered by a hospital. Continuing education updates your knowledge about the latest research and practice developments, helps you to specialize in a particular area of practice, and teaches you new skills and techniques (Hale et al., 2010).
In-service education programs are instruction or training provided by a health care agency or institution. An in-service program is held in the institution and is designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Often in-service programs are focused on new technologies such as how to correctly use the newest safety syringes. Many in-service programs are designed to fulfill required competencies of an organization. For example, a hospital might offer an in-service program on safe principles for administering chemotherapy or a program on cultural sensitivity.
Nursing Practice
You will have an opportunity to practice in a variety of settings, in many roles within those settings, and with caregivers in other related health professions. Administrators in health care agencies and institutions guide the practice of nursing only in part. State and provincial Nurse Practice Acts (NPAs) establish specific legal regulations for practice, and professional organizations establish standards of practice as criteria for nursing care. The ANA is concerned with legal aspects of nursing practice, public recognition of the significance of nursing practice to health care, and implications for nursing practice regarding trends in health care. The ANA definition of nursing illustrates the consistent orientation of nurses to providing care to promote the well-being of their patients individually or in groups and communities (ANA, 2010a).
Nurse Practice Acts
In the United States the State Boards of Nursing oversee NPAs. NPAs regulate the scope of nursing practice and protect public health, safety, and welfare. This protection includes shielding the public from unqualified and unsafe nurses. Although each state defines for itself the scope of nursing practice, most have similar NPAs. The definition of nursing practice published by the ANA is representative of the scope of nursing practice as defined in most states. However, in the last decade many states have revised their NPAs to reflect the growing autonomy of nursing and the expanded roles of nurses in practice. For example, NPAs expanded their scope to include minimum education requirements, required certifications, and practice guidelines for APRNs such as nurse practitioners and certified RN anesthetists. The expansion of scope of practice includes skills unique to the advanced practice role (e.g., advanced assessment, prescriptive authority for certain medications and diagnostic procedures, and some invasive procedures).
Licensure and Certification
Licensure
In the United States RN candidates must pass the NCLEX-RN® examination administered by the individual State Boards of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States. This provides a standardized minimum knowledge base for nurses.
Certification
Beyond the NCLEX-RN®, the nurse may choose to work toward certification in a specific area of nursing practice. Minimum practice requirements are set, based on the certification the nurse seeks. National nursing organizations such as the ANA have many types of certification to enhance your career such as certification in medical surgical or geriatric nursing. After passing the initial examination, you maintain your certification by ongoing continuing education and clinical or administrative practice.
Science and Art of Nursing Practice
Because nursing is both an art and a science, nursing practice requires a blend of the most current knowledge and practice standards with an insightful and compassionate approach to patient care. Your patients’ health care needs are multidimensional. Thus your care will reflect the needs and values of society and professional standards of care and performance, meet the needs of each patient, and integrate evidence-based findings to provide the highest level of care. Nursing has a specific body of knowledge; however, it is essential that you socialize within the profession and practice to fully understand and apply the nursing knowledge base and develop professional expertise. Clinical expertise takes time and commitment. According to Benner et al. (2010), an expert nurse passes through five levels of proficiency when acquiring and developing generalist or specialized nursing skills (Box 1-3).
Box 1-3
Benner: From Novice to Expert
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