Many of you are familiar with Patricia Benner’s book From Novice to Expert. It describes Benner’s application to nursing of the Dreyfus model of skill acquisition. The model posits that in the acquisition and development of a skill, a learner passes through five stages of proficiency: novice, advanced beginner, competent, proficient, and expert.
These stages reflect three different aspects of skilled performance. One is a transition from relying on abstract principles to the use of past concrete experiences as paradigms. The second is the change in your perception of a situation, which is seen less as a collection of equally relevant pieces and more as a complete whole in which only certain pieces are relevant. The third is a journey from being a detached observer to an involved participant. You no longer stand outside the situation—you’re now an integral part of it.
Nursing is a field with many different practice settings and specialties. Some nurses choose to stay in one setting and advance to the expert stage in that field. This takes many years and many experiences. Others choose to move into new areas, initiating a reverse expert-to-novice transition. I am one of those nurses.
I started my career as a geriatric nurse practitioner in a nursing home care unit at a VA medical center. I worked there for seven years. I went through Benner’s five stages and achieved expert status. I then decided it was time for a change and started a new journey on the inpatient hospice and palliative care unit at the same facility.
I chose to make this move for various reasons. Having been in foster homes as a child and having served in the army for four years, I was used to a life where change and growth were expected. I’m not afraid of change—to me, change is good. An opportunity for growth and new experiences and the challenges that come with them are rewarding to me.
But it wasn’t an easy move to make. As an expert in one area, you have confidence in what you’re doing. Some decisions are made quickly and instinctively—and they’re the right decisions. Becoming a novice again changes all of that. The confidence is no longer there; decisions take more thought, time, and effort.
This made me feel inefficient and uncomfortable at first in my new position. Instead of being able to act autonomously, I was once again dependent on others for guidance and direction. I had to open up to new ways of approaching things.
Having to “unlearn” things is a must when making a change like this. The examples I could cite are numerous, ranging from simple nursing concepts to important medical decisions. All levels of staff are involved in this expert-to-novice process. I learned important hospice and palliative care concepts from the housekeeper, the doctors, and every team member in between.
The director on my new unit would leave me notes, reminding me of certain key concepts to consider in palliative care and hospice cases. One very important note was “Cast a large net,” a reminder to ask open-ended questions when first approaching a patient and family, to get a feel for where they stood in their understanding of the diagnosis and prognosis. An example would be “Tell me what you know about your illness. And how do you feel about that?”
When presenting a statement or a question to dying patients, it’s important to let them guide the interaction rather than guiding it for them. These patients are no longer looking for treatment options in the hope of a cure or a longer life. They are now seeking peace, love, and acceptance. It’s not appropriate anymore to try to teach them about their illness and how to achieve a positive outcome. You must now have empathy for them and their death experience. You are seeking to help them accept death rather than fight it.
The unit provides not only hospice care but also palliative care. I didn’t fully realize or appreciate the differences between these two types of care until I started working on this unit. Palliative care focuses on reducing the severity of disease symptoms rather than providing a cure. The goals are to prevent and relieve suffering and to improve the patient’s quality of life. Nonhospice palliative care is offered along with curative and all other appropriate forms of medical management. It should not be confused with hospice care, which is palliative care delivered to those at the end of life.
When I worked in the nursing home setting, I often encountered palliative care and end-of-life situations. We did our best to meet these patients’ needs. We thought we were doing a good job, and I took exception to those who claimed otherwise. I now have a new level of understanding.
The mindset and milieu in a nursing home are quite different from those on my new unit. The nursing home environment is often very noisy and busy; the focus is usually on subacute conditions and rehabilitation. There are activities, therapies, lab and diagnostic tests, consults, rounds, and meetings.
On the hospice and palliative care unit, it is much quieter, and the pace is slower. We do quality-of-life meetings daily, spend time with families, and educate everyone involved on how to help the hospice patients achieve a more dignified and peaceful death.
One way to encourage this is by providing the patients and families with the pamphlet “Live and Die Healed.” It encourages the family to consider the following statements: Forgive me, I forgive you, I love you, Thank you, Goodbye, Let go, and Open up to what comes next. (The first five were written by Ira Byock, MD, former president of the American Academy of Hospice and Palliative Medicine. The last two were added by our hospice director, Deborah Grassman, ARNP.)
Death, I realize now, is a sacred event, and I am very happy that I decided to make this change in my nursing career. Not only is my mind more open, but my heart and soul are open as well. “If you don’t love yourself, then how can you love others?” is a question you’ve undoubtedly heard before. My new question is “If you don’t heal your own heart, then how can you help others heal their hearts?”
My heart was broken. Seven years ago, my sister died tragically, a victim of domestic violence. She was murdered—strangled in her bed by a jealous boyfriend—leaving behind four beautiful children. My hospice experience has helped me heal some of those wounds, and that is helping me heal others.
It has only been about 10 months since I started on this unit, but already I am no longer the rehab NP who would say “You’re a diabetic or cardiac patient—put that doughnut down” or “You’re an alcoholic. If you go out on pass and drink, we will do drug and alcohol testing when you return, and if the results are positive, we will discharge you.”
I now say instead, “I know you’re a diabetic and have heart disease, but you can have that doughnut” or “I know you’re an alcoholic, but would you like a beer or a glass of wine or anything else? You can have anything you want.”
It is very fulfilling to give people what they desire and need in their last days. I have never had so many people say “Thank you” and “God bless you.”
I still laugh and smile. I am still alive—and I actually feel more alive in this place. I treasure my life, my family, and my health much more now. I cry, too. There is no holding back. As a result of my expert-to-novice experience, I see and feel the human condition in a new light.
Ellen Thatcher is a Geriatric Nurse Practitioner on the Inpatient Hospice and Palliative Care Unit at Bay Pines VA Healthcare System in Bay Pines, Florida.