Journal of Gerontological Nursing

Guest Editorial 

Sharing the Evidence, Adding Our Clinical Wisdom

Wanda Bonnel, PhD, RN

Abstract

© iStockphoto.com/ Miroslaw Pieprzyk

Sharing clinical wisdom with our new and future gerontological nurses is a key professional responsibility. Even when clinicians and students are interested in becoming gerontological nurses, they often lack the evidence base and a context for applying this information. Although efforts are being made in preparing gerontological nurses, further work is needed (Institute of Medicine, 2008). No textbook or manual provides all of the needed clinical practice tips to accompany the evidence. The clinical wisdom of our nurse clinicians needs to be considered in mentoring our future nursing workforce.

Consistent with the aging of the broader nursing population, expert gerontological nurses are also aging (Institute of Medicine, 2008). With this aging workforce, the potential exists for “brain drain,” or loss of clinical wisdom. Gerontological nurses have unique practice perspectives to share; reflecting on clinical practices and communicating these reflections to students and staff is key so our wisdom continues on. Knowledge transfer has been described as an important practice for clinical nurses (Robert Wood Johnson Foundation, 2006).

Gerontological clinicians bring unique experiences in applying gerontological evidence, whether for the specialty care of patients with selected diagnoses or patient functional deficits related to physical frailty or dementia. All clinicians are aware of the importance of evidence-based practice, but simple application of the evidence with older adults rarely exists. In gerontological nursing, evidence-based protocols often are applied with older adult patients with multiple diagnoses and residing in unique or complex settings. Evidence-based protocols such as fall prevention will vary from assisted living to acute care settings. Sharing case experiences that incorporate these diverse variables, a kind of clinical wisdom, benefits future gerontological nurses.

Clinical wisdom is based on evidence, but more than evidence-based protocols, it is the application of the protocols tied to clinical practice reality. Clinical wisdom adds context to lists of factual data, creating a bridge between the written protocol, the classroom, and clinical settings. Benner, Hooper-Kyriakidis, and Stannard (1999) described clinical narratives as one way to show how and why an evidence base is implemented. Wisdom is conveyed via these clinical narratives, adding color via the broad “who, what, when, and where” of case experiences. Authenticity is added to learning as clinical data become illustrative narrative.

Consistent with adult education principles (Knowles, 1984), clinical narratives can help engage learners and make content relevant. Students gain an evidence base, and they may better understand and remember the real-world applications. Functional approaches in working with patients in varying stages of Parkinson’s disease might be conveyed. For example, approaches to assisting with eating difficulties in varying disease stages can be described via narratives, helping students understand the best “fit” for particular clinical evidence and protocols.

Students gain a variety of perspectives from clinicians’ narrative experiences, including how clinicians situate the evidence in reality, how they frame clinical problems, and how they reflect on their clinical decisions. Concepts such as anticipatory guidance or selected cues to prompt action can also be conveyed. Without clinical narratives from advanced clinicians, students might miss the existence of start and end points for specific evidence-based protocols when working with patients with changing prognoses. This may include, for example, when patients change from receiving acute to palliative care in diseases such as congestive heart failure. The clinical grasp and forethought of experienced clinicians (Benner et al., 1999) is conveyed to students, helping them see via narratives how experts use context and pattern.

Written evidence-based teaching narratives can be developed, serving as tools for synthesizing clinical knowledge and sharing gerontological wisdom with others. For example, one university online staff educational program shared an evidence base…

© iStockphoto.com/ Miroslaw Pieprzyk

© iStockphoto.com/ Miroslaw Pieprzyk

Sharing clinical wisdom with our new and future gerontological nurses is a key professional responsibility. Even when clinicians and students are interested in becoming gerontological nurses, they often lack the evidence base and a context for applying this information. Although efforts are being made in preparing gerontological nurses, further work is needed (Institute of Medicine, 2008). No textbook or manual provides all of the needed clinical practice tips to accompany the evidence. The clinical wisdom of our nurse clinicians needs to be considered in mentoring our future nursing workforce.

Consistent with the aging of the broader nursing population, expert gerontological nurses are also aging (Institute of Medicine, 2008). With this aging workforce, the potential exists for “brain drain,” or loss of clinical wisdom. Gerontological nurses have unique practice perspectives to share; reflecting on clinical practices and communicating these reflections to students and staff is key so our wisdom continues on. Knowledge transfer has been described as an important practice for clinical nurses (Robert Wood Johnson Foundation, 2006).

Gerontological clinicians bring unique experiences in applying gerontological evidence, whether for the specialty care of patients with selected diagnoses or patient functional deficits related to physical frailty or dementia. All clinicians are aware of the importance of evidence-based practice, but simple application of the evidence with older adults rarely exists. In gerontological nursing, evidence-based protocols often are applied with older adult patients with multiple diagnoses and residing in unique or complex settings. Evidence-based protocols such as fall prevention will vary from assisted living to acute care settings. Sharing case experiences that incorporate these diverse variables, a kind of clinical wisdom, benefits future gerontological nurses.

Clinical wisdom is based on evidence, but more than evidence-based protocols, it is the application of the protocols tied to clinical practice reality. Clinical wisdom adds context to lists of factual data, creating a bridge between the written protocol, the classroom, and clinical settings. Benner, Hooper-Kyriakidis, and Stannard (1999) described clinical narratives as one way to show how and why an evidence base is implemented. Wisdom is conveyed via these clinical narratives, adding color via the broad “who, what, when, and where” of case experiences. Authenticity is added to learning as clinical data become illustrative narrative.

Consistent with adult education principles (Knowles, 1984), clinical narratives can help engage learners and make content relevant. Students gain an evidence base, and they may better understand and remember the real-world applications. Functional approaches in working with patients in varying stages of Parkinson’s disease might be conveyed. For example, approaches to assisting with eating difficulties in varying disease stages can be described via narratives, helping students understand the best “fit” for particular clinical evidence and protocols.

Students gain a variety of perspectives from clinicians’ narrative experiences, including how clinicians situate the evidence in reality, how they frame clinical problems, and how they reflect on their clinical decisions. Concepts such as anticipatory guidance or selected cues to prompt action can also be conveyed. Without clinical narratives from advanced clinicians, students might miss the existence of start and end points for specific evidence-based protocols when working with patients with changing prognoses. This may include, for example, when patients change from receiving acute to palliative care in diseases such as congestive heart failure. The clinical grasp and forethought of experienced clinicians (Benner et al., 1999) is conveyed to students, helping them see via narratives how experts use context and pattern.

Written evidence-based teaching narratives can be developed, serving as tools for synthesizing clinical knowledge and sharing gerontological wisdom with others. For example, one university online staff educational program shared an evidence base for various problem behaviors in dementia, including bathing and dressing difficulties; relevant narratives helped students visualize the concepts and allowed for further thought and questions (Bonnel, 1999). A collection of written narratives can frame and focus specific topics, helping summarize areas of clinical expertise.

Reflective and narrative approaches to sharing wisdom benefit clinicians as well as students. In addition to clarifying information for others, narratives provide self-assessment opportunities for clinicians. The case reflection used in developing narratives can provide a form of quality improvement, demonstrating thoughtful attention to clinical practices. Clinical practice becomes more visible via narratives, opportunities are gained for documenting practice successes, and questions for further study can be generated.

This is an important time for sharing gerontological information. Particularly with an aging population, there is need to provide wisdom specific to gerontological specialty care. Sharing clinical narratives can help students see clinical possibilities and potential, perhaps even serving as a way to encourage gerontological interests.

As nurses emerge from their basic and continuing education programs, it is important they have access to gerontological clinicians’ wisdom in combining evidence and practice narratives. Geriatric clinicians have the opportunity to influence students’ learning and their future clinical practice. Sharing clinical wisdom has implications for future generations of nurses, as well as for quality care for older adults. There is a high cost to society if we lose this wisdom.

Wanda Bonnel, PhD, RN
Associate Professor
University of Kansas School of Nursing
Kansas City, Kansas

References

  • Benner, P., Hooper-Kyriakidis, P. & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Philadelphia: Saunders.
  • Bonnel, W. (1999). Nursing management of behavioral disturbances in dementia. Unpublished manuscript, University of Kansas City, Kansas City, KS.
  • Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Retrieved March 3, 2009, from the National Academies Press Web site: http://www.nap.edu/catalog.php?record_id=12089
  • Knowles, M. (1984). The adult learner: A neglected species. Houston, TX: Gulf Publishing.
  • Robert Wood Johnson Foundation. (2006, June). Wisdom at work: The importance of the older and experienced nurse in the workplace. Retrieved March 3, 2009, from http://www.rwjf.org/files/publications/other/wisdomatwork.pdf
Authors

Wanda Bonnel, PhD, RN
Associate Professor
University of Kansas School of Nursing
Kansas City, Kansas

10.3928/00989134-20090331-07

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