Learning begins early in our existence. It is unclear when learning starts whether it be in utero or after birth nonetheless one learns. As time goes by and with each passing moment there are opportunities to learn and increase our knowledge. Every occupational and professional group has a knowledge base from which occupational behaviour is governed. In nursing, this base is broad yet specific as we have
borrowed and adapted knowledge from other disciplines and modified this for our needs. A professional nurse cannot nurse without nursing knowledge. That is, a typical person off the street cannot walk into a hospital and recognise the specific clinical manifestations of raised intracranial pressure or know how guide a person to a good death. The participants acknowledged the underlying significance of
knowledge. A common thought was:
[I didn’t know that] this is what could be happening here [relating to a clinical situation] until I had gained a lot more knowledge.
This comment was describing the participant’s first encounter with an emergency situation. The developmental nature of knowledge is reflected in the next comment;
… I think I was always confident in my assessment abilities – fairly confident that is – however I tended to be cautious early on and needed to rule out a few things first.
Here Elise was acknowledging her early behaviour and also recognising that there had been a change. Knowledge was implicit in the interviews and as Stephen said:
I just couldn’t come from the general area and expect to cope in A & E – there was so much to learn you couldn’t just amble along and hope to pick it up. That’s why I did the A & E course so I would know what the hell I was suppose to do.
This need for specific knowledge was continually commented on by each participant. Each had at least one emergency post basic qualification. Julia was completing two emergency courses simultaneously (at different institutions).
I am getting towards the end of a Masters, doing research in the ED and I’m also doing this Graduate Certificate [in emergency] here.
The extent of post registration credentialing is evidence of the importance place on specific emergency knowledge. Knowledge tended to pail into the background when the relevance of experience was discussed in the interviews. The participants
recognised that without experience knowledge was ineffectual:
You know they come in straight from uni thinking they know everything there is to know – they may know the A & P etc but what use is that when faced with a dart in the head.
In practice I continually hear words similar to those used by Gayle below. She too was relating a story when she was working with a new graduate. It sounds a little harsh on the surface but it also acknowledges the integrated role of knowledge and experience:
I worked with those, you know the ones that can rattle every sign and symptom off but couldn’t recognise it in a real person if it whacked them
in the face ……it will take time and seeing these things and all the variations that come in before she will be of any use in the department.
Benner (1984) and Dreyfus and Dreyfus (1986) support the importance of experience in practice development however experience from the participants perspective is more than a mere component of practice development. Also knowledge does not need to be an active process. Cheryl recalled,
especially traumas you know their mechanism but you get a sense about the survival of the patient. I once predicted that this trauma patient would crash which he did and this student nurse just said to me, the same thing that I’d said to my senior many years ago, like how on earth do you know that? And I sat there and I thought hmmm I do know. I think that learn so very gradually and you don’t even know you’re learning it.
The understanding that knowledge is only one component of practice was expressed as a paradox in one interview,
……these things all seem very paradoxical but the more I live the more I realise that everything is just a paradox, you know, there is no right or wrong, it’s just an interpretation of the facts at any given time.
It is this complex range of understandings that create our knowledge; it is partly formative and partly tacit. There is that knowledge that is unable to be articulated, unacknowledged knowledge. Knowledge is formative, as knowing that and applied knowing how.
Nonetheless knowledge alone is unable to have singular relevance to emergency nursing as it needs to be matured, developed and nurtured to be useful. The catalyst for this maturity is experience; emergency practice becomes a marriage of
knowledge and experience. Such a union can be seen when I asked Melissa the question how can you describe your practice. She described her practice as one that is all encompassing, all knowing and experiential:
Everything. I’m using my experience, stuff I know about, you know that I’ve learnt. The main thing I use initially is my eyes and just looking at the person. I mean you can’t treat someone just based on their
observations – can you?
Melissa brings the person into her vision, she uses all tools she has available, she sees the person and uses her all encompassing knowledge.
Kaye attempts to bring together her perception of knowledge as more than the sum of its parts:
It’s not just the text stuff it more, I think there is learning to be had in every situation both good and bad learning. Sometimes we need to unlearn. It is really I suppose the word is encompassing yes, all
encompassing knowledge that means that everything is included, do you understand what I mean.
In the context of expert intuitive practice knowledge is more than its component parts. The participants spoke of traditional knowledge in terms of what they learn from time-honoured sources such as courses or textbooks. Tacit knowledge falls outside of the traditional paradigm a participant called this a paradox. The participants also recognized the understandings that come from non-traditional knowledge which support their practice. The relationship and utility between knowledge and experience was clearly articulated by the participants. One of the participants interestingly looked at the suppression of knowledge when using judgement as though there are times when knowledge may hinder our practice. This she related to experience. Knowledge is a pre-understanding necessary for practice development and necessary for professional experience to shape the expert nurse.