Understanding skill acquisition among registered nurses: the ‘perpetual novice’ phenomenon

Probably not a substantial claim: may not pass S3 (load-bearing).

A study of 46 allied health professionals in Australia identified heavy workload and inadequate staffing as key barriers to workplace learning.

“A recently published study specific to the identification of barriers and enablers to learning among a sample of 46 allied health professionals in Australia identified heavy workload and inadequate staffing as key barriers to workplace learning (Lloyd et al. 2014).”

• cites Lloyd et al. 2014 sourceSupported

May combine two claims.

Respondents provided examples of infrequently used skills including venipuncture, setup or use of pain pumps, NG or feeding tube insertion or maintenance, and chest tube care or removal, and this varied by clinical area.

“On the open-ended questions, respondents provided examples of infrequently used skills in their respective areas including venipuncture (n = 12), setup and/or use of pain pumps (n = 8), NG/feeding tube insertion and/or maintenance (n = 7) and chest tube care/removal (n = 7) and this appeared to vary by clinical area.”

May combine two claims.

Nurses performed non-nursing tasks required to keep their unit functioning, and these tasks took priority over learning.

“They described nurses performing a number of non-nursing tasks (i.e.laundry, delivering meal trays, making coffee, cleaning) required to keep their unit functioning and these tasks took priority over learning:”

May combine two claims.

There was wide variation in how nursing units responded to new staff members, from very accepting to senior nurses appearing frustrated.

“One example was the wide variation in how some nursing units responded to the new staff members from those very accepting to other areas were senior nurses appeared frustrated.”

May combine two claims.

Respondents identified individual registered nurse qualities perceived to impact learning: motivation to learn, lack of personal responsibility, lack of time or will to learn, attitude, fear of failing, and burnout or compassion fatigue.

“In terms of RN qualities, participants identified motivation to learn (n = 19), lack of personal responsibility (n = 13), lack of time or will to learn (n = 12), attitude (n = 11), fear of failing (n = 10) and burnout/compassion fatigue (n = 8).”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was recognition among participants that unit culture is hard to change.

“There was also recognition among participants that unit culture is hard to change as summarised by one participant:”

Probably not a substantial claim: may not pass S3 (load-bearing).

The final sample consisted of 17 Clinical Educators, 15 Nurse Practitioners, 7 Clinical Nurse Specialists, and 2 Advanced Practice Nurses.

“The final sample consisted of 17 (41Á5%) Clinical Educators, 15 (36Á6%) NPs, 7 (17%) CNSs and 2 (4Á9%) APNs (See Table 1).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

A number of nursing units had undergone amalgamation within months of study participation, and this may have impacted participants' views.

“A number of nursing units had undergone amalgamation within months of study participation and this may have impacted the participants' views.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Of 129 surveys distributed, 42 were returned, for a response rate of 32.5%.

“Of the 129 surveys distributed, 42 were returned for a response rate of 32Á5%.”

May combine two claims.

Participants described orientation programmes that were comprehensive and well-developed, and in most cases included some sort of preceptorship or mentorship component.

“Participants described orientation programmes that were comprehensive and well-developed, and in most cases these included some sort of preceptorship/mentorship component.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Data collection took place during the summer when many take vacations, which may have affected the lower survey response rate.

“Finally, data collection took place during the summer when many take vacations which may have affected the lower survey response rate.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The highest level of nursing-related education achieved was Diploma for 2.4%, Baccalaureate for 35.7%, Masters for 54.7%, and other for 7.2%.

“The highest level of nursing-related education achieved was the following: Diploma (2Á4%), Baccalaureate (35Á7%), Masters (54Á7%) and other (7Á2%).”

May combine two claims.

More time appeared devoted to orientation programmes than ongoing education, and this varied by clinical area.

“More time appeared to be devoted to orientation programmes than for ongoing education and this, too, varied by clinical area.”

May combine two claims.

Environmental influences most frequently reported included workload or staffing issues, infrequent opportunity to practice skills, high staff turnover, and support or funding to attend learning events.

“Environmental influences most frequently reported included workload/ staffing issues (n = 22), infrequent opportunity to practice skills (n = 11), high staff turnover (n = 7) and support/ funding to attend learning events (n = 6).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Participants saw themselves as a resource to staff, being readily available to answer questions and monitor staff members' progress in learning.

“Participants saw themselves as a resource to staff, being readily available to answer questions and monitor staff members' progress in learning.”

Classified as probably not a substantial claim.

Personal motivation to learn ranges on a continuum from 'go-getters' who seek out learning opportunities to 'avoiders' who dodge learning opportunities.

“In fact, they described personal motivation on a continuum from the 'go-getters' at one end who seek out and attend available learning opportunities, to the 'avoiders' who become expert at dodging learning opportunities altogether.”

May combine two claims.

How learning occurred and the challenges faced varied by nursing unit.

“How learning occurred and the challenges faced also varied by nursing unit.”

May combine two claims.

Skill acquisition and maintenance appeared highly valued, and in many clinical areas nurses were praised for skill performance.

“Skill acquisition and maintenance appeared highly valued and in many clinical areas, nurses were praised for their skill performance.”

May combine two claims.

Participants, who were clinical nurse leaders and clinical educators, reported having some direct role in educating registered nurses, and all could identify a number and wide range of educational opportunities available for their staff members.

“Participants, who were clinical nurse leaders and clinical educators, reported having some direct role in educating RNs and all could identify a number and wide range of educational opportunities available for their staff members and these existed in various forms.”

Probably not a substantial claim: may not pass S1 (asserted).

Not knowing how to perform a particular skill would mean not being asked to do it, thereby preventing an increase in workload.

“Participants even suggested that not knowing how to perform a particular skill would mean not being asked to do it, thereby preventing an increase in workload.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Study participants were employed an average of 25.6 years in nursing and had worked a mean of 9.2 years in their current position.

“Study participants were employed an average of 25Á6 years in nursing (range 4-35 years) and had worked a mean of 9Á2 years (range 1-25 years) in their current position.”

May combine two claims.

Respondents described extensive opportunities for learning during orientation with little or no opportunity for new hires to hide or avoid learning.

“Respondents described extensive opportunities for learning during orientation with little or no opportunity for new hires to hide or avoid learning.”

May combine two claims.

Some units valued skill development and RNs 'stepping up to the plate', while individuals in other areas would be criticised or bullied for showing initiative.

“Some units valued skill development and RNs 'stepping up to the plate', while individuals in other areas would be highly criticised, even bullied by their peers for showing initiative.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Approximately two-thirds of respondents worked with inpatients and most worked with adult patient populations.

“Approximately twothirds (65Á3%) of the respondents worked with inpatients and most (92Á5%) worked with adult patient populations.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Available education allowed for both passive learning and pro-active education.

“Available education allowed for both passive learning (i.e.weekly didactic inservices) as well as pro-active education.”

May combine two claims.

A wide variation in skill level among registered nurses was reported, with a mean score of 4.1 out of 5.

“Respondents indicated they could identify perpetual novices in their clinical areas (mean score 4Á2 out of 5) and a wide variation in skill level among the RNs was also reported (mean score 4Á1 out of 5).”

May combine two claims.

Learning in many areas was described as dynamic, supportive, and collegial.

“On a positive note, they described learning in many of their areas as dynamic, supportive, and collegial.”

May combine two claims.

Chronic avoidance of learning occurred only with experienced staff members, as new RNs in orientation were monitored and skill development was a priority and primarily mandatory.

“This only occurred with experienced staff members as new RNs in orientation were monitored and skill development was a priority and primarily mandatory.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Participants offered explanations for avoidance including personal problems, burnout, lack of interest, differences in attitude, and lack of confidence.

“Participants offered a number of explanations for their observations including nurses' personal problems, burnout, a lack of interest in learning, differences in personal attitude(s) towards learning and/or lack of confidence to learn.”

May combine two claims.

Four contributing factors emerged from the interviews: opportunities for education, the context of learning, personal motivation and initiative to learn, and the culture of the units where nurses worked.

“Four contributing factors, both personal and structural in nature, emerged from the interviews: (1) opportunities for education, (2) the context of learning, (3) personal motivation and initiative to learn and (4) the culture of the units where nurses worked.”

• Also stated in: § Qualitative interviews · plain

  “Four contributing factors, both personal and structural in nature, emerged from the interviews: (1) opportunities for education, (2) the context of learning, (3) personal factors, motivation and initiative to learn and (4) the culture of the unit.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Often education might not be related to the skill or skills needing to be developed.

“The downside was that often this education might not be related to the skill(s) needing to be developed.”

May combine two claims.

The perpetual novice has had theoretical and real-life situational experience in regard to cannulation, which should be sufficient for progression of skill acquisition, yet it proves not to be so.

“The perpetual novice has had theoretical and real-life situational experience in regard to cannulation, which should be sufficient for progression of skill acquisition, yet it proves to not be so.”

• cites Wilson et al. 2013Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Content and face validity of the survey was conducted.

“Content and face validity of the survey was conducted and is described previously.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Commensurability legitimation, the back and forth interpretation of quantitative and qualitative data, was used during the analysis phase.

“Commensurability legitimation refers to the back and forth interpretation of quantitative and qualitative forms of data and this process was used during the analysis phase of the study.”

May combine two claims.

Skill acquisition appears more complex than a series of stages, including both structural influences such as unit culture and workload and personal attributes such as attitude and motivation.

“Rather than a series of stages through which RNs progress, skill acquisition appears more complex including both structural influences such as unit culture and workload in addition to personal attributes such as attitude, motivation or lack thereof.”

• cites Wilson et al. 2013Not checked — no full text of the source

Classified as probably not a substantial claim.

This creates a negative feedback loop, or perverse disincentive to being identified as an expert in a task where many colleagues are perpetual novices.

“This creates a negative feedback loop, or perverse disincentive to being identified as an expert in a task where many colleagues are perpetual novices:”

May combine two claims.

Some registered nurses continue to experience ongoing difficulty with essential clinical skills, are unable to advance their skill from novice to expert, and remain in a state of perpetual novice.

“However, research has demonstrated that some RNs continue to experience ongoing difficulty with essential clinical skills, and are unable to advance their skill from novice to expert and remain in a state of perpetual novice (Wilson et al. 2010(Wilson et al. , 2013)).”

• cites Wilson et al. 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Wilson et al. 2013Not checked — no full text of the source

Classified as probably not a substantial claim.

To understand behaviours such as nurses' skill development and decisions towards acquiring skills, both agency and context must be explored.

“Therefore, to understand behaviours, in this case nurses' skill development and decisions towards acquiring these skills, both the agency and the context must be explored.”

Classified as probably not a substantial claim.

Kolb's (1984) theory is based on the notion that learning occurs when individuals progress through a four stage learning cycle.

“Kolb's (1984) theory is based on the notion that learning occurs when individuals progress through a four stage learning cycle (concrete experience, reflective observation, abstract conceptualisation and active experimentation).”

• cites Kolb's (1984)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Preliminary analysis was discussed by the co-investigators and the research assistant and served as a form of memberchecking.

“Preliminary analysis was discussed by the co-investigators and the research assistant and served as a form of memberchecking (Creswell & Plano Clark 2011).”

• cites Creswell & Plano Clark 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Synthesis of researcher data was reviewed with an in-hospital expert or consultant in organisational psychology and adult learning to ensure accurate interpretation.

“For this study, synthesis of researcher data was reviewed with an in-hospital expert/ consultant in organisational psychology and adult learning to ensure accurate interpretation.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

The findings of this study shed light on various challenges that can impact skill acquisition and help explain why some RNs never advance their clinical skills.

“The findings of this study shed light on the various challenges that can impact on skill acquisition and help to explain why some RNs never advance their clinical skills.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Bahn (2007) reported that nurses were motivated to take part in continuing education for fear of being left behind by more highly educated nurses, a belief that continuing education would enhance patient care, and personal and professional satisfaction.

“Bahn (2007) reported that nurses were motivated to take part in continuing education for fear of being left behind by the more highly educated nurses entering the profession, a belief that continuing education would enhance patient care, as well as personal and professional satisfaction.”

• cites Bahn (2007)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Results reflect the views and opinions of a sample from one Canadian city and may not necessarily be generalisable to hospitals in Canada or internationally.

“First, results reflect the views and opinions of a sample from one Canadian city and may not necessarily be generalisable to the hospitals in Canada or internationally given the differences in the work environments, education and scope of practice for the role.”

Classified as probably not a substantial claim.

Benner argues that even seasoned nurses entering a clinical area where they have no prior clinical experience with a particular patient population may be limited to novice level performance if the goals and tools of patient care are unfamiliar to them.

“For the latter group, Benner (2001) argues that even seasoned nurses entering a clinical area where they have no prior clinical experience with a particular patient population may be limited to novice level performance if the goals and tools of patient care are unfamiliar to them.”

• cites Benner 2001Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Previous research identified personal and contextual barriers to attending professional development activities, including inability to leave the unit due to patient care responsibilities, cost of conferences, difficulty getting time off, lack of managerial support, and child care or home responsibilities.

“Previous research has identified a number of personal and contextual barriers to attending professional development activities including the inability to leave their unit(s) due to patient care responsibilities (Dealy & Bass 1995), the cost of conferences (Dealy & Bass 1995, Harper 2000, Schweitzer & Krassa 2010), difficulty getting time off from work to attend (Schweitzer & Krassa 2010), lack of”

• cites Dealy & Bass 1995 sourceNot checked — no full text of the source
• cites Harper 2000 sourceNot checked — no full text of the source
• cites Schweitzer & Krassa 2010 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Positive deviance occurs in organisations when certain individuals (or groups) demonstrate practices outside the established 'norm' and results positive outcomes despite having access to the same resources as others in the same group.

“Positive deviance occurs in organisations when certain individuals (or groups) demonstrate practices that are outside the established 'norm' (deviance) and results positive outcomes despite having access to the same resources as other individuals in the same group (Garg 2013).”

• cites Garg 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Personal factors motivated some hemodialysis nurses to improve their cannulation skills or became a stimulus to avoid cannulation, preventing further skill development.

“Personal factors appeared to motivate some to improve their cannulation skills or became a stimulus to avoid cannulation altogether, thus preventing further skill development.”

• cites Wilson et al. 2013Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Spivak et al. (2011) suggested that developing expert clinical nurses requires significant time and investment on the part of nursing leaders.

“Spivak et al. (2011) have suggested that developing expert clinical nurses requires significant time and investment on the part of nursing leaders.”

• cites Spivak et al. (2011)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable).

If quality care is to be maintained, perpetual novices will need to become competent and able to perform essential clinical skills in their respective patient care areas.

“If quality care is to be maintained, perpetual novices will need to become competent and able to perform essential clinical skills in their respective patient care areas.”

• AssumptionRests on an assumption: Progression from novice to expert is desirable and necessary for quality patient care.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Given the number of environmental barriers identified, nursing leaders can play a significant role in promoting skill development and affecting the culture of a unit.

“Given the number of environmental barriers identified, nursing leaders can play a significant role in promoting skill development and affecting the culture of a unit.”

May combine two claims.

Survey questions were derived from two previous studies on the topic, contributing to both content and face validity.

“Questions were derived from the two previous studies on the topic (Wilson et al. 2010(Wilson et al. , 2013)), thus contributing to both content and face validity (DeVon et al. 2007).”

• cites Wilson et al. 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Wilson et al. 2013Not checked — no full text of the source
• cites DeVon et al. 2007 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Laschinger (1990) proposed that Kolb's (1984) model of experiential learning may be useful in the design and implementation of educational programmes in a variety of learning environments.

“Laschinger (1990) has proposed that Kolb's (1984) model of experiential learning may be useful in the design and implementation of educational programmes in a variety of learning environments.”

• cites Laschinger (1990) sourceNot checked — no full text of the source
• cites Kolb's (1984)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable).

At the unit level, nursing leaders are in a position to influence change through the elimination of barriers.

“At the unit level, nursing leaders are in a position to influence change through the elimination of barriers.”

Classified as probably not a substantial claim.

Maintaining skill competency for RNs can be challenging, regardless of the clinical setting.

“Maintaining skill competency for RNs can be challenging, irregardless of the clinical setting.”

Classified as probably not a substantial claim.

Registered nurses entering an unfamiliar clinical area can advance their skills if given sufficient theoretical education and real-life experience.

“However, these RNs can advance their skills if given sufficient theoretical education and real-life experience.”

• cites Benner 2001Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the qualitative data, the investigators each did their coding separately and then met to discuss their findings and emerging themes.

“In terms of the qualitative data, the investigators each did their coding separately and then met to discuss their findings and emerging themes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Throughout the interviews, participants were asked additional probes for clarification, which reduces misinterpretation and contributes to the study's credibility and confirmability.

“Throughout the interviews, participants were asked additional probes for clarification regarding their comments.This reduces misinterpretation and contributes to the study's credibility and confirmability (Lincoln & Guba 1985).”

• cites Lincoln & Guba 1985 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

A second study on nursing skill acquisition in nephrology challenged the taken-for-granted assumption of progression in Benner's theory.

“A second study on nursing skill acquisition in nephrology (Wilson et al. 2013) challenged the taken-for-granted assumption of progression in Benner's (2001) theory.”

• cites Wilson et al. 2013Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

An epidemiologist was consulted to provide expertise around tool development.

“An epidemiologist was also consulted to provide expertise around tool development.”

Classified as probably not a substantial claim.

Benner's model suggests that skill development occurs on a continuum as the learner passes through five levels of proficiency from novice to expert.

“Benner's model suggests that skill development occurs on a continuum as the learner passes through five levels of proficiency from novice to expert.”

• cites Benner 2001Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

Benner's theory has been previously critiqued for a simplistic positive view of progress that recommends retraining without attention to place or social knowledge and structure.

“Benner's (2001) theory has been previously critiqued for a simplistic positive view of progress that recommends retraining without attention to place (Purkis 1994) or social knowledge/structure (Thompson 1990).”

• cites Purkis 1994 sourceNot checked — no full text of the source
• cites Thompson 1990Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Effective clinical leadership has been identified as essential to maintaining quality patient care and building healthy workplaces.

“Effective clinical leadership has been identified as essential to maintaining quality patient care and building healthy workplaces (Cummings et al. 2010, Gilmartin 2014).”

• cites Cummings et al. 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Gilmartin 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The survey was developed by the research team using principles of good survey design as described by Dillman.

“The survey was developed by the research team using principles of good survey design as described by Dill-man (2007).”

• cites Dillman 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

In this study, Onwuegbuzie and Johnson's criteria for inside-outside legitimation and commensurability legitimation were specifically addressed.

“In this study, Onwuegbuzie and Johnson's (2006) criteria for inside-outside legitimation and commensurability legitimation were specifically addressed.”

• cites Onwuegbuzie and Johnson (2006)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Critical realists are cautious to accept claims solely from personal accounts, so the perspectives of advanced practice nurses were sought.

“It is due to this lack of awareness that critical realists are cautious to accept claims solely from personal accounts (i.e.staff nurses experience) and, thus, the perspectives of advanced practice nurses was sought.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Positive deviance may be playing a role in how some individuals respond to contextual challenges.

“At some level positive deviance may be playing a role.”

May combine two claims.

The perpetual novice as described in this study appears to be the antithesis of the clinical nurse leader and is not able to develop clinical skills to his/her fullest potential due to personal and structural barriers.

“The perpetual novice as described in this study appears to be the antithesis of the clinical nurse leader and is not able to develop clinical skills to his/her fullest potential due to a number of personal and structural barriers.”

Classified as probably not a substantial claim. May combine two claims.

Kolb's (1984) theory outlines four distinct learning styles and that educational opportunities be designed to allow each learner-type to participate in the learning style that suits them best.

“Kolb's (1984) theory also outlines four distinct learning styles (diverging, assimilating, converging, accommodating) and that educational opportunities be designed and implemented to allow each learner-type the opportunity to participate in the learning style that suits them best.”

• cites Kolb's (1984)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These individuals practice differently and display behaviours that are innovative, creative and highly adaptable.

“These individuals practice differently and display behaviours that are innovative, creative and highly adaptable (Garg 2013).”

• cites Garg 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

In nephrology nursing, the perpetual novice was conceptualised as the state in which nurses are unable to progress from novice to expert in cannulation of the arteriovenous fistula even after working in hemodialysis for a number of years.

“In nephrology nursing, the concept of perpetual novice was conceptualised as the state in which nurses are unable to progress from novice to expert in the skill of cannulation of the arteriovenous fistula (AVF) even after working in hemodialysis (HD) for a number of years (Wilson et al. 2010(Wilson et al. , 2013)).”

• cites Wilson et al. 2010Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Wilson et al. 2013Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Results reflect the opinions of those working in one of four advanced nursing roles, not the RNs working in their respective clinical area(s), which may have yielded a different perspective.

“Furthermore, results reflect the opinions of those working in one of four advanced nursing roles, not the RNs working in their respective clinical area(s) which may have yielded a different perspective.”

Probably not a substantial claim: may not pass S4 (based).

It is even more challenging for RNs to maintain competency performing clinical skills not used routinely.

“It is even more challenging for RNs to maintain their competency performing clinical skills not used routinely.”