I am very lucky. I am six months into a developmental tissue viability nurse (TVN) post in an experienced team, led by a nationally recognised leader in tissue viability, in a Care Quality Commission (CQC) rated ‘outstanding’ hospital.  I hold degree and masters level accreditations in tissue viability and dermatology care and I have 12 years of nursing experience – including five years focused on wound care and four years as a Band 6. One would imagine that the transition from experienced nurse to that of tissue viability nurse specialist would be smooth and seamless but, in reality, it is not. 
 
My role as a TVN is to provide expert care and management of inpatients with wounds; to develop and deliver education to nursing staff and allied health professionals and to shape service development, with the aim of improving efficiency and patient outcomes. Increased experience and mastery in these areas is supported for me throughout by the tissue viability nurse specialist and the Tissue Viability Lead and ultimately the aim is to transition to ‘fully fledged’ clinical nurse specialist.  

In order to better understand, and so overcome, some of the personal challenges I have faced in the role, I turned to the literature on advanced practitioners, including nurse specialists, and the transition from experienced staff nurse to these roles. Although a great deal of the research is several decades old it has been included here because of its seminal nature and because it continues to aid understanding and so preparation for the role. This article will briefly explore some of the more personally salient aspects of the literature to provide insight into my transition so far and the strategies that can be used mitigate some of the difficulties when transitioning from novice to expert nurse specialist. 

The perpetual novice

I first worked in the Trust as a newly qualified nurse before leaving to work in the community. As I had retained my interest in oncology, I rejoined the Trust many years later and, with my community-acquired tissue viability experience, worked in the surgical outpatient team, assisting with minor surgeries and managing post-operative wound complications.  The developmental tissue viability nurse role was an exciting opportunity and applying for it seemed a natural extension of my wound management experience.

Despite all my previous experience, however, I was unprepared for the sheer diversity of the wounds encountered in my role which spans the prevention and management of pressure ulcers to the management of surgical wound complications, fungating tumours, radiotherapy-induced skin reactions and cutaneous manifestations of graft versus host disease.  With a background predominantly based in the community, the management of oncological wounds and the acuity of patients in my setting poses a steep learning curve and requires a level of resilience not necessitated in my previous posts. I may have been an expert in my previous role but in my new setting it has been apparent from day one that I have a lot to learn. 
 

The extent to which a nurse’s knowledge is embedded within the clinical situation is attested to in Benner’s (1984) model of nursing skill acquisition. The model utilises Dreyfus and Dreyfus’ model (1980) to describe the five levels of proficiency developed by a nurse as he or she progress from novice, to advanced beginner, to competent, then proficient and finally to expert (Figure 1). Research shows that as job roles or situations change, all nurses may transition back and forth between the levels of proficiency, from novice to expert and back again (Brykcynski, 2014).  



 Figure 1. Benner's Model.

The imposter phenomenon

For the new tissue viability nurse specialist the expectation of expertise applies not only to tissue viability but to all the role components – be it consultant, practice educator, manager or researcher (Arena and Page, 1992). This pressure to be an expert across so many new roles places even the most confident of nurse specialists at an ‘inherent’ risk of experiencing the imposter phenomenon (Arena and Page, 1992).

The imposter phenomenon (Clance and Imes, 1978) typically occurs in high-achievers and does not appear to be contingent on competence, attainment or preparation (Ares, 2018). The phenomenon results in a state of chronic anxiety and lack of self-confidence resulting from an inability to meet expectations set by oneself or others and feelings of constantly being tested (Arena and Page, 1992). To cope, individuals increase effort and labour and try to conceal their fear (Brykczynski, 2014). The resulting high performance and recognition unfortunately serves only to perpetuate the cycle (Clance and Imes, 1978).
 
Brykczynski (2014) highlighted that the imposter phenomenon is most likely to occur during the frustration phase of the transition to nurse specialist. This is congruent with Arena and Page’s (1992) assertion that it results from unrealistic expectations of the novice specialist to be an expert in all the various nurse specialist sub-roles. A more recent study, however, suggested that the prevalence and incidence of imposter phenomenon in nurse specialists may be similar to those found in nurses in other roles (Ares, 2018).   

I am acutely aware of the limitations in my knowledge and recognise that it simply isn’t possible to become an expert in all the roles entailed by my position immediately. Despite my best efforts to accrue as much knowledge and experience as I can in the coming months, it is inevitable that in many situations I will lack the knowledge and expertise that others may ascribe to me. Regardless of whether it’s a product of role incongruity (Hardy and Hardy, 1988) or punitive self-criticism, the resulting anxiety and self-doubt will need to be managed and overcome.

Understanding the imposter phenomenon helps me personally to guard against excessive self-doubt and scrutiny and has paved the way for a more positive approach instead.  Seizing every opportunity to read, practicing within my sphere of competence, identifying a ‘one positive impact’ on a daily basis (Bath et al, 2017) and adopting a growth mindset (Dweck, 2012) whereby mistakes are accepted as requisite components of learning, are additional strategies that have helped me mitigate the imposter phenomenon.

I have also indubitably benefitted from the freedom to share anxieties and concerns with the more senior members of my team, who have been unstinting in their advice and support. Hamric and Taylor (1989) argued that feedback from a senior nurse specialist is essential to the development of the new nurse specialist, helping them structure their work more effectively, set realistic goals and manage difficult situations. To support this my team include fortnightly meetings to review progress and provide performance feedback. The benefits of peer networks for novice nurse specialists are manifold and well documented (Hamric and Taylor, 1989; Glenn and Waddington, 1998; Kelly and Mathews, 2001; Brykcynski, 2014; Bath et al, 2017) and the advent of social media has meant that access to an ever-widening network of peer support is now possible.

 

Establishing credibility while managing time

Although feeling personally credible is essential for personal well-being, recognition by others as competent is equally critical to building relationships, attaining goals or achieving change (Bath et al, 2017). Establishing credibility can take more time across large organisations or new organisations as stakeholders are unlikely to possess sufficient knowledge of the new nurse specialist’ clinical abilities (Bath et al, 2017).

Having worked in another organisation for eight years previously, I had grown accustomed to colleagues there ‘knowing’ that I was diligent and competent.  With a circumscribed clinical area it was also possible to become an expert quite rapidly and so my credibility was unproblematic to establish and was easily maintained. In my new role I have had to start the process afresh: establish relationships, demonstrate competence and build credibility with each clinical decision, each interaction and each piece of work I produce.

Studying hard and engaging in a large number of projects and activities are ways in which the new nurse specialist can seek to gain credibility, however it is at the risk of overcommitment (Bath et al, 2017).  In my case this risk is likely amplified by my transition from a structured clinic-based role, to the flexible and broad nurse specialist regime, where activity occurs across the system and multiple projects and activities run in parallel.

This over-commitment can result in underachievement or burn-out as the workload increases to an unmanageable level, tasks are left incomplete (Bath et al 2017) and the novice nurse specialist can become overwhelmed with the requirements of their new role and exhausted by their efforts to master them (Brykczynski, 2014). Prioritisation difficulties and the need to establish credibility in their new role can lead to new clinical nurse specialists working long hours and insufficient time and time management problems are frequently cited concerns (Kelly and Mathews, 2001; Brykczynski, 2014; Bath et al, 2017).
 

I have personally found the transition from a structured environment to multiple projects running in parallel, and alongside direct patient care, a challenge. In my clinic role I had structured time, albeit small, for management duties and a cap to the caseload in terms of clinic slot availability. In my new role there is no cap on caseload and alongside this I have been responsible for the creation of an online referral form, creation of virtual clinics to capture the team’s activity and the formation of a skin integrity group comprised of clinical nurse specialists tasked with improving skin integrity within the Trust.  

Trying to achieve all this, while providing excellent patient care has been made more difficult by my inexperience.  I soon discovered, for example, that each patient review took longer than I had anticipated and that, as a result, I would routinely be starting the day’s documentation when I was due to finish. As well as regularly eating into my own time this also meant that my service development commitments were being sidelined. Simply allocating myself more time for each visit, as recommended by Brykczynski (2014), when diarising my visits would have highlighted the unmanageability of my diary in advance. Imposing a structure by allocating time within the diary for designated weekly tasks and triaging more effectively are additional simple steps that I also now employ to ensure that the workload remains manageable and all my responsibilities are met.

Conclusion

Although relatively simple to achieve, understanding what to expect in itself can help with role transition (Hamric and Taylor, 1989; Kelly and Mathews, 2001; Bath et al, 2017). Knowing that you will be operating at best as an advanced beginner and are likely to feel overwhelmed, face time management issues and feel inadequate is made easier by the knowledge that this is typical and time limited (Hamric and Taylor, 1989; Kelly and Mathews, 2001).

I am also very fortunate in that many of the strategies for facilitating role transition are already established ways of working in my team and will undoubtedly smooth my personal transition to nurse specialist. These steps would likely be enhanced by the establishment of national competencies for tissue viability nurses in England: having a knowledge and skills framework would not only standardise key competencies for the role — making role progression for the tissue viability nurse specialist clearer and easier to attain — but would also ensure equity in the provision of high quality care (Maylor, 2012; Ousey et al, 2014).

Although the literature and my personal experience highlight some of the universal challenges nurses transitioning to a specialist role may face, once achieved the end state is ideally one of greater stability, clinical mastery, increased autonomy and considerable job satisfaction (Kelly and Mathews, 2001). Being a tissue viability nurse specialist has been heralded by those in the role as the ‘best job in the world’ - my journey to this end may be long and rocky, but I am already enjoying it and I am definitely looking forward to getting there.