Changing how the world thinks about nursing

Join our Facebook group

Expert and novice

March 10, 2008 -- One cover story in this week's issue of TIME was John Cloud's "The Science of Experience." Its basic idea is that we should not conclude John McCain or Hillary Clinton would be better presidents than Barack Obama simply on the basis of their longer experience, because research indicates that even far greater experience does not necessarily lead to better results. The piece uses examples from different fields, but by far the most prominent is its account of simulations in which both a new nurse and a veteran nurse failed to save a crashing "patient." Some have faulted the piece for this seemingly negative view of nurses. And it might have been helpful for the report to note whether any nurses would be capable of saving the patient. But the piece's physician example is also impliedly negative, suggesting experienced attendings are "no more accurate" than interns at predicting end-of-life preferences, even when they've known the elderly patients in question far longer. The piece seems to confuse true novices with less experienced experts, and it arguably suggests that experts are no better than novices in such fields generally, which is plainly wrong. However, the piece clearly conveys that experienced nurses are experts, that nursing is a field in which humans can reach high levels of skill. It places nursing alongside medicine, chess, and Nobel-worthy endeavors. Even the description of the simulation the two nurses failed shows how complex, exciting, and consequential nursing is--lives are at stake.

The teaser material below the headline reads:

Would you prefer a doctor who has practiced medicine for 30 years or just 10? Research into expert performance shows that the choice isn't simple.

The piece then starts, oddly, with a 500-word description of the nursing simulations. They are reportedly conducted by James Whyte IV, an assistant professor at Florida State's School of Nursing, as part of a study comparing the performance of nurses at different levels of experience. First the piece describes how a new nursing grad, "Thomas," confronted a robot "patient" whose blood pressure was dropping quickly.

The piece gives significant detail about the patient's complaints, and Thomas's nervous reactions. Thomas checked the chart but panicked, and missed the "simple" solution of increasing the dopamine the patient was already getting. He gave epinephrine instead, spiking the patient's heart rate, which would have killed him if the simulation had not ended. Then 25-year nursing veteran "Monica" did the simulation. She "coolheadedly" identified possible responses and quickly saw that dopamine was the answer, but when the patient's pressure dropped even faster, she too panicked and went for the epi, which sent the patient into v-tach. Monica quickly shocked the patient with the defibrillator, but he died even more quickly than in the novice Thomas' simulation. A photo accompanying the piece has a scene from the simulation, and a caption notes that "[b]oth nurses failed."

The piece goes on to note that at a time when Obama's rivals are pointing to his lack of experience, research like the Florida State simulation shows experience does not always help, and can actually hurt. Though it is "widely accepted that mastering most complex human endeavors requires a minimum of 10 years' experience," even that "doesn't guarantee success" because, in essence, it can lead to less attentiveness and overconfidence.

The piece notes that the "10-year-rule" explained Thomas' failure, but not Monica's. It asks why Monica also failed, but never directly answers. In fact, it's not clear that its discussions of distraction and overconfidence really apply to her, since it sounded like she simply panicked as Thomas did.

The piece relies mainly on Anders Ericsson, "the world's leading expert on experts" and the head of the Florida State lab that ran the simulations. Ericsson argues that (in the piece's words) "rather than mere experience or even raw talent, it is dedicated, slogging, generally solitary exertion--repeatedly practicing the most difficult physical tasks for an athlete, repeatedly performing new and highly intricate computations for a mathematician -- that leads to first-rate performance."

Examples in the piece include chess grand masters, figure skaters, and expert drivers. The piece cautions that it is not saying this means any of the leading presidential candidates would necessarily perform better, but that it does indicate that "the more seasoned candidates wouldn't automatically outperform Obama"--though "Ericsson's conclusion that deliberate practice leads to better performance might favor the punctilious, famously diligent Clinton." The piece does not say whether it regards Obama as a novice or a 10-year expert.

The piece concludes by noting that the Cambridge Handbook on experts says another key factor in great performance is "regularly obtaining accurate feedback." It cites a 1997 study that found attending physicians who had known a group of elderly patients for more than six months "were no more accurate" at predicting the patients' "end-of-life preferences" than interns who had generally known the patients for no more than a week. What mattered in assessing this

crucial factor in determining whether a patient has a good death...was attention to the patients' feelings and values [], not having more knowledge of their diseases. And in the end, determining which of the presidential candidates pays more attention to your concerns requires not adding up their years of experience but a far more complex calculation: deciding what their experiences have led them to truly value.

The piece's treatment of the overall expertise issues is confused and arguably misleading. It fails to adequately distinguish the novice-expert comparison from the 10-year expert / 30-year expert comparison. There is a risk that readers will come away with the impression that there's no meaningful difference between a new health professional and one with 20 years of experience, since the "at least 10 years" idea is explained well into the piece. The teaser headline suggests it's talking about the 10/30 year comparison for physicians, but the textual physician example is a novice/expert comparison.

The kind of rescue task performed by Thomas and Monica is a huge focus of ED nursing, and it's hard to believe experts would not be better than novices overall. The piece also fails to note that in many key clinical tasks, there would be simply no comparison--the veteran would generally save you, and the novice would often kill you. And it is odd that the piece's subhead asks whether readers would prefer a physician with 10 or 30 years experience when the physician example is far less prominent--did editors sense that they needed a physician example to catch readers' eyes?

But however flawed the piece is in general, and conceding that some readers might grasp only that "nurses failed," the piece does place nurses squarely in the category of "expert." Here nursing, like the other fields above, is a "complex human endeavor" requiring at least 10 years to master. The piece repeatedly refers to Thomas and Monica in this context. And yes, both failed. But consider what the simulation tells people about nursing. It says that nurses must be able to respond instantly and independently to critical patient emergencies--there is no hint that the answer would be relying on physicians. It says that nurses have to master complex procedures and treatments, including defibrillation and giving dangerous drugs, again with real autonomy. The dramatic way the piece presents the simulation will engage readers: nurses hold lives in their hands. This focus is especially notable because TIME is generally in thrall to the heroic physician narrative; it's amazing nurses appeared in this piece at all. And although it might have been nice if Professor Whyte was identified as a nurse (readers might assume otherwise) and if there was any indication of his credential (he has a doctorate in nursing), at least the piece tells us there is such a thing as a nursing professor.

The piece has flaws, but we commend Cloud and TIME for presenting nursing as one of the complex, important fields in which humans can become "experts."

See the article "The Science of Experience" in the March 10, 2008 edition of TIME.

 

‚Äč