Philosophy of Caring and Expert Nursing Practice: Patricia Benner

Philosophy of Caring and Expert Nursing Practice: Patricia Benner

Patricia Benner was born in Hampton, Virginia. Her childhood was spent in California, where she obtained both her early and her advanced education (Brykczynski, 2006). Benner received both her associate’s degree in nursing and her bachelor’s degree in nursing from Pasadena College in 1964. Her master’s degree in medical-surgical nursing was received from the University of California, San Francisco, in 1970. Her Ph.D. was received from the University of California, Berkeley, in 1982, where she was an interdivisional student in education. Benner’s doctoral work focused on stress, coping, and health in mid-career men (P. Benner, personal communication, October 24, 2006). During this time, she became heavily influenced by the work of Hubert Dreyfus and Richard Lazarus. She has nursing practice experience, as both a staff nurse and in management, in medical-surgical, emergency room, coronary care, intensive care, and home care nursing (Benner Associates, 2002).

Benner is currently director of the National Nursing Education Study for the Carnegie Foundation for the Advancement of Teaching. In addition, she is a professor in the Department of Social and Behavioral Sciences at the University of California, San Francisco, and holds the Thelma Shobe Endowed Chair in Ethics and Spirituality (P. Benner, personal communication, October 24, 2006).

Benner has authored numerous books, chapters, and articles. She has published in a number of international forums and has received several Book-of-the-Year awards from the American Journal of Nursing and other organizations. Her books have been translated into many languages and are influential worldwide on nursing practice and education. Benner’s work has had a significant impact within the United States, Great Britain, Australia, and New Zealand. Among her many honors are induction as a fellow of the American Academy of Nursing in 1985 and as an honorary fellow of the Royal College of Nursing in the United Kingdom in 1994. Benner has received numerous awards in nursing for publications, research, leadership, education, and service (Benner Associates, 2002; P. Benner, personal communication, October 24, 2006; University of California, San Francisco Faculty Profiles, 2006).

Benner’s recent projects include director of a National Nursing Education Research Project sponsored by the Carnegie Foundation for the Advancement of Teaching. This study is the first national study in 30 years to examine nursing education and is part of a larger project that is investigating the preparation for professionals. Other recent projects include a taxonomy of nursing errors for the National Council of State Boards of Nursing, development of a program to educate advanced practice nurses in genomics, a study of clinical knowledge development of nurses in combat operations environments, and a study of skill acquisition and clinical and ethical reasoning in critical care nurses (P. Benner, personal communication, October 24, 2006).

Development of Benner’s Philosophy of Expert Nursing Practice

Benner identifies Virginia Henderson as a significant early influence on her nursing career (Benner & Wrubel, 1989). Benner’s earlier work relating to expert nursing practice investigated the progression of skill acquisition for nurses based on the skill acquisition theory developed by philosopher Hubert Dreyfus and his brother, mathematician and systems analyst Stuart Dreyfus (Dreyfus & Dreyfus, 1980). It is important to clarify that Benner has consistently referred to this model as the “Dreyfus Model of Skill Acquisition.” Benner, rather than developing a model of skill acquisition, merely validated and extended the existing Dreyfus model to exemplify the process of skill acquisition in nursing. In addition, much of Benner’s writing is the result of collegial effort. For the sake of preventing redundancy, general references contained in this chapter to Benner’s work must be assumed to refer to Benner and colleagues.

Benner served as project director for the Achieving Methods of Intrapersonal Consensus, Assessment and Evaluation project from 1979 through 1981. This project was designed to identify differences between beginning and expert nurses’ clinical performance and situational appraisals (Benner, 1984/2001). A sample of 21 pairs of nurses in a preceptor relationship (newly graduated nurse and expert) was examined using an interpretive phenomenological method and structured using the Dreyfus Skill Acquisition Model (Dreyfus & Dreyfus, 1980). The pairs were interviewed separately and asked to describe a clinical incident that they had in common to determine if there were differences in the descriptions, indicating differing perceptions and approaches. In addition to the 21 pairs, 51 experienced nurses selected by administrators as being highly skilled, 11 new graduates, and five senior nursing students were interviewed (individual and small group) and/or observed to identify characteristics of performance in other skill levels of nurses. Six hospitals were represented. The results of this study are reported in From Novice to Expert: Excellence and Power in Clinical Nursing Practice (FNE). Findings indicated discernable differences in skill level between novices, advanced beginners, and competent, proficient, and expert nurses. Narrative descriptions were interpreted, and 31 nursing competencies were identified. These competencies were further examined and classified into seven domains of nursing practice. The information presented in FNE regarding skill acquisition domains of nursing practice provides a structure for later works in that frequent reference is made to the differences between inexperienced and expert nursing in terms of concepts such as critical thinking, intuition, and ethical agency.

While the levels of skill acquisition along with the related competencies and domains of nursing practice identified in FNE are frequently used as a framework for practice and education, Benner did not state an intent to develop an interpretive theory until the publication of Primacy of Caring (Benner & Wrubel, 1989). Here, Benner and Wrubel comment on the limitations of existing nursing theories in capturing the essential human issues that are central to nursing. They state, “A theory is needed that describes, interprets, and explains not an imagined ideal of nursing, but actual expert nursing as it is practiced day by day” (p. 5) with a goal to “make visible the hidden significant work of nursing as a caring practice” (p. xi). Benner and Wrubel note, “This book is devoted to an interpretive theory of nursing practice as it is concerned with helping people to cope with the stress of illness” (p. 7).

Primacy of Caring (Benner & Wrubel, 1989) contains further development of the distinguishing features of expert nurses begun in FNE as well as a description of the primary role of caring in nursing practice. Expert nursing practice, as presented in that work, is based on caring at multiple levels of practice. Caring is defined as a “basic way of being in the world” (p. xi) and nursing as a “caring practice whose science is guided by the moral art and ethics of care and responsibility” (p. xi). The descriptions contained in Primacy of Caring relate to the primacy of caring as a significant factor in stress and coping, nursing practice, and illness outcome. Expert nursing care is described related to specific situations such as chronic illness, cancer, and neurological illness. In addition, Benner discusses caregiving from a feminist perspective in her chapter on coping with caregiving.

Benner, Tanner, and Chesla (1996) present the findings of a study conducted between 1990 and 1996 in Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (ENP). This work extended the original data of earlier studies. An additional 130 critical care nurses representing eight hospitals were interviewed in small groups, with 48 of those nurses individually interviewed and observed in practice. Benner states, “From this original study, we developed an ethnography of the practice of critical care nurses” (Benner, Hooper-Kyriakides, & Stannard, 1999, p. 6). ENP devotes several chapters to application of this information for improvement of nurse–physician relationships and implications for nursing education and administration.

Benner et al. (1999) published Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach (CWICC) based on the findings of Phase 2 of the previously described study. Conducted between 1996 and 1997, Phase 2 extended the critical care focus to an additional 75 nurses working in a wide variety of critical care areas as well as advanced practice nurses. This book gives insight into the development of expert critical care nurses’ ability to grasp a problem intuitively and plan ahead when in familiar clinical situations as well as excellent examples of Benner’s nonlinear concept of nursing process. The work identified two habits of thought and actions of expert critical care nurses: (a) clinical grasp and clinical inquiry and (b) clinical forethought. In addition, nine domains of critical care nursing practice with nursing competencies specific to the critical care setting were delineated. Implications for the educational strategies to foster development of expertise are presented in CWICC.

Philosophy of Expert Nursing Practice

The exemplification of caring as primary in expert nursing practice differs according to the skill acquisition level of the nurse. It is therefore necessary to understand not only the nature of nursing care but also how that care differs according the individual nurse’s professional development. In order to do this, Benner departs from the typical Cartesian cognitive-rationality that splits the mind and body of the person. Benner cites Kuhn’s (1970) and Polanyi’s (1958) views that there is a difference between “knowing that” stemming from theoretical knowledge and “knowing how” stemming from practical knowledge. In order to discover how nurses “know how” to practice expertly, Benner adopted an interpretive or hermeneutic phenomenological approach. While nurses with a variety of experience levels and clinical focuses were included, the accumulated exemplars reported tend to be from narratives of expert nurses working in critical care units.

Use of the interpretive phenomenological approach enabled the researchers to identify numerous nursing competencies, which were then inductively grouped into a number of domains of nursing care. Benner explicitly states in a number of her writings that her work must be clearly understood to be useful. She cautions against “deifying” the domains of nursing described and the competencies attributed to those domains (Benner, 1984/2001, pp. xxii, xxv). She emphasizes the need to avoid trying to use her work as a template or set of rules, stating that it is a way of thinking or a method (Benner & Wrubel, 1989). Readers of Benner’s work are cautioned to carefully consider the focus of the study from which the domains and competencies were derived. Thorough reading of Benner’s body of work, as well as similar studies based on Benner’s framework, reveals both expansions and contractions of the originally identified domains and varying competencies subsumed under those domains. Indeed, as an interpretive theory rather than an explanatory theory, those who wish to apply Benner’s framework must first validate the domains and competencies for their unique clinical and staff situations.

Benner (1984/2001) divides nursing skill acquisition into five stages: novice, advanced beginner, competent, proficient, and expert. Novices are generally conceptualized as students. Advanced beginners are newly graduated nurses. Competent nurses have worked in a specialty for somewhere between one and a half and two years. Proficient nurses begin to rely less on theory and more on experientially learned knowledge. Expert nurses rely heavily on experientially learned knowledge and fall back on theory when the clinical picture is unclear.

Additional concepts were introduced in the books that followed. In Primacy of Caring, Benner and Wrubel (1989) discuss the importance of understanding the human in terms of the role of embodied intelligence, background meaning, human concern, situatedness, and temporality. Concepts such as stress, coping, life cycle, and health promotion are addressed. The stages of professional skill acquisition were further explicated in ENP (Benner et al., 1996), where the concepts and relationships among caring, clinical knowledge, clinical and ethical judgment, and social embeddeness are expanded. Benner et al. (1999) discussed clinical grasp, clinical inquiry, clinical forethought, expert nursing judgment, thinking, and clinical comportment in CWICC. In addition, the concepts of thinking and reasoning-in-action were discussed as well as skilled know-how, response-based practice, agency, perceptual acuity, ethical reasoning, and the role of emotions in nursing.

Key Concepts

Benner’s work contains reference to a large number of significant concepts, as described next.

Agency refers to one’s ability to influence the situation (Benner & Wrubel, 1989). Agency is affected by one’s ability to see the possibilities within the situation based on one’s experience level. New nurses feel little ability to impact the situation, whereas expert nurses have a realistic awareness of their ability to impact the situation (Benner & Wrubel; Benner et al., 1996).

Assumptions, expectations, and sets are beliefs generated from past experiences that orient and influence the nurse’s perception of the patient situation. Sets are subtle and may not be completely explicit. These sets predispose the nurse to act in certain ways when involved in certain situations (Benner, 1984/2001).

Background meaning is part of context and is the culturally acquired set of meanings the person accumulates from birth. Background meaning is how the world is understood to “be” and influences one’s perception of the factual world (Benner & Wrubel, 1989).

Caring is an essential skill of nurses and is “a basic way of being in the world” (Benner & Wrubel, 1989, p. xi). Caring means that “things,” such as other people, events, and so on, matter. Some “things” matter more than others because we live in a differentiated world where priorities are evident. Caring is required to create personal concern.

Clinical forethought, or “future think,” is anticipation of likely events and the actions required to prepare for those eventualities based on context. Clinical forethought allows the clinician to plan ahead based on the immediate situation, to anticipate and quickly prevent potential problems (Benner et al., 1999).

Clinical judgment implies recognizing salient, or important, aspects of the situation as they unfold and acting appropriately on that knowledge. The novice uses learned rules to make clinical judgments, whereas the expert nurse uses a more refined, engaged, practical reasoning based on subtle changes that are unseen by nurses functioning at a lower level. Clinical judgment in the expert nurse is based on experiential learning, moral agency, knowing the patient, emotional response to the situation, and intuition (Benner et al., 1996, 1999). Benner identifies six aspects of clinical judgment and skillful comportment: reasoning-in-transition, skilled know-how, response-based practice, agency, perceptual acuity and involvement, and links between clinical and ethical reasoning (Benner et al., 1999).

Clinical knowledge is practical knowledge. Benner (1984/2001) identifies six areas of practical knowledge: “(1) graded qualitative distinctions; (2) common meanings; (3) assumptions, expectations, and sets; (4) paradigm cases and personal knowledge; (5) maxims; and (6) unplanned practices” (p. 4).

Clinical reasoning is a process of understanding a particular patient’s condition at a particular time based on the changes or transitions observed for that patient (Benner, 2003; Benner et al., 1996).

Clinical transitions are recognized when the clinician detects subtle or not-so-subtle changes in the patient’s condition that require the clinician to reconsider the needs of the emerging situation (Benner et al., 1999).

Common meanings occur because nurses work within a health and illness situation. Nurses form common meanings with other nurses in their perspective on health-and illness-related issues commonly encountered. Nurses also learn what to expect from the situation by experience with patient and family responses. These meanings form a tradition that is used to compare specific patient situations and theory and further define the common meanings (Benner, 1984/2001).

Concern refers to a human way of being in the world, or being involved in one’s world, which engages the person with the salient aspects of the world. This ability to be engaged in one’s world is an essentially human aspect that allows one to determine what is “at stake” for the person. It explains why things matter to humans. Concern is situational, and the health care provider must be able to determine the concerns of persons within their culturally held meaning. Concern also has a temporal aspect as concerns change across time and situations (Benner & Wrubel, 1989).

Coping is defined consistently with Lazarus’s beliefs that coping is reflected in the emotional and behavioral responses one has to stress (Benner & Wrubel, 1989; Lazarus & Folkman, 1984).

The Dreyfus Model of Skill Acquisition serves as the theoretical basis of Benner’s work on identifying the professional development of nurses. This model identifies “five stages of qualitatively different perceptions of their [nurse’s] task as skill improves” (Dreyfus & Dreyfus, 1996). These stages have been labeled novice, advanced beginner, competent, proficient, and expert. Dreyfus and Dreyfus caution, “There are, perhaps, no expert nurses, but certainly many nurses achieve expertise in the area of their specialization” (p. 35). This statement points to the situational and experiential aspects of expertise. Nurses may function as an expert in a situation where they have sufficient experience to intuitively grasp the nuances of the situation. However, if a nurse is confronted by a new situation, a new type of patient, or a new nursing unit, he or she will function at a lower level of expertise (Benner, 1984/2001). Dreyfus and Dreyfus also point out that closer examination of the stages may reveal substages; however, the five-stage model has been sufficient for their purposes. See Table 22-1 for a breakdown of the characteristics of each of the five stages of skill development for nurses.

Table 22-1 Benner’s Descriptors of Nurses Based on the Dreyfus and Dreyfus Model of Skill Acquisition

Novice

A complete beginner with no experience in that specialty area.1 Practices using theoretical knowledge acquired through formal learning.2 Relies on use of context-free rules for drawing conclusions based on recognizable, objective features of the situation.1,2 Behavior is extremely limited and inflexible, as learned rules cannot differentiate relevant versus nonrelevant aspects of the situation.1

Advanced Beginner

The newly graduated nurse or the experienced nurse who has transferred to another specialty or dissimilar unit.3 Performs at a marginally acceptable level after having gained experience coping with real situations.2 Begins to notice situational elements in addition to the objective elements learned in formal situations.2 Begins to see structure in the clinical setting.3 Begins to realize the complexity of situations and feels overwhelmed, anxious, and exhausted in trying to identify all the relevant elements.2,3 Sees breakdowns in ability to provide care as lack of knowledge or poor organization.3 Begins constructing more and more complex rules developed from actual practice to help guide actions.2 Remains very task oriented with a physical/technological focus.3 Goal orientation is the accomplishing of tasks in a timely fashion with elaborate organizational plans, often at the expense of not noticing what is occurring within the situation.3 Sees clinical practice as a test of personal abilities, with a focus on personal goals rather than patient-centered goals.3 Clinical agency has an external focus, with reliance on standards of care and orders for direction.3 Decision making is referred up the clinical ladder, with extraordinary faith in the expertise of others.3 Often makes decisions based on what has been done for the patient by other nurses on previous shifts.3 Oriented to the present moment with little ability to see applicability of patient’s past and future expectations on present care needs.3 Begins to recognize changes in clinical state but lacks the experience to identify how to manage those changes.3

Competent

The nurse who has about one and a half to two years of experience on a specific unit.3 Differs from the advanced beginner primarily related to improved “clinical understanding, technical skills, organizational ability, and ability to anticipate the likely course of events” (p. 78).3 Exemplifies “standard” nursing care.3 A pivotal stage for progression to proficiency where pattern recognition begins to become established.3 The overwhelming number of potentially relevant elements now recognized force the nurse to begin sorting the elements into a hierarchy of importance based on a conscious selection plan.2 New rules are established to facilitate choice of plan.2 The unlimited variety of potential plans of actions presents a frightening list of possibilities, which generates an exaggerated sense of responsibility in the nurse.2 Goals remain predominantly focused on personal organization rather than immediate patient outcomes.3 Emotional involvement increases and begins to be used as screening or alerting mechanism.2,3 There is a gradual shift to a focus on clinical issues rather than self-performance.3 The nurse begins to discriminate between skill levels of others involved in the clinical setting and recognizes the fallibility of others.3 Extensive reading identifies the limits of theoretical knowledge, precipitating a crisis in the trust in that knowledge.3 Clinical knowledge becomes integrated with theoretical knowledge to allow the nurse to begin to see the “big picture.”3 The temporal orientation increasingly shifts to the near future.3 Ethical and clinical concerns may remain unaddressed due to lack of experiential wisdom.3 Improved recognition of salient signs and symptoms and variations between patients develops.3 Begins to deviate from standardized patient care practices to individualize to current demands.3 Becomes more adept at presenting a clinical case for physician action.3

Proficient

A transition stage that usually leads to expertise.2,3 There is a qualitative, rather than incremental, leap in perceptual acuity and relational skills that shapes actions.3 Experience results in development of synaptic pathways in the brain that alter the rule-and-principle-based responses to a more situationally associated response set of behaviors referred to as intuition.2 This ability to intuitively discriminate between a variety of situations stems from a growing concern and involvement that helps differentiate important aspects of the situation.2 There is improved reasoning-in-transition, sense of salience, and recognition of relevant changes.3 Stress levels decrease as required actions becomes more clear and require less recourse to calculative reasoning.2 Experience is still short of that required for expertise; thus, the proficient nurse still does not respond intuitively to situations without first giving conscious thought to the possible options.2 The past becomes more critical to understanding the present and possibilities for the future.3 The nurse exhibits a practical grasp and practical reasoning.3 Practical grasp, emotional attunement, and involvement allow the nurse to develop an ethic of responsiveness to the current situation that allows the nurse to differentiate self from others.3 The “big picture” now guides the nurse’s care.3 Actions demonstrate a smooth response-based approach and are situationally appropriate.3 The nurse is able to read the situation and determine when changes have occurred but still lacks some skill in determining the correct course of action to take in response to changes.3 The nurse begins to function as a change agent as sense of agency grows.3 Responsibility is realistically examined, with a growing balanced awareness of the impact others have in the care given.3 The focus shifts from self to patient outcomes.3 Communication and negotiation skills increase in order to meet the situated needs of the patient and family.3 Maxims, or rules based on subtle nuances within the situation, can now be developed and used. However, once the maxim is developed and the skill mastered, it is difficult for the nurse to remember the learning process that produced that maxim.1,3

Expert There is an ability to notice both the unexpected and features that are absent in the situation, which alerts the expert nurses to give more detailed attention to the patient who fails to follow the expected trajectory.4 The skill to discriminate when to act and when to wait becomes evident. This skill is based on “vigilant monitoring.”4 Expert nurses situate themselves within an observational distance of the patient in order to stay attuned to the changing needs and condition of the patient.4 Attuning to changes and awareness of salient aspects of the situation are accomplished without conscious deliberation.3 Discrimination between similar situations becomes more refined, allowing for ease of discrimination between courses of action.3 An intuitive grasp of the situation based on extensive experience leads to a focus on actions rather than problems.3 Expert nurses use “deliberative rationality” to reflect on goals and actions to achieve those goals rather than on formal rules and formulas.3 Theory is understood at a deeper, applied level.3 Moral agency is highly developed in expert nurses, as demonstrated by a highly developed concern for the personhood of the patient, protecting them in their vulnerability and helping them in ways that preserve the integrity of the person.3 The “big picture” is future oriented for the patient and includes an awareness of people and activities occurring on the unit that add or detract from care. This future orientation is specific and contextually based.1,3 Expert nurses can take strong positions based on their experience and not only communicate effectively with other professionals, but use this communication to advocate for patients and to help redesign the system in caring ways.3 Organizational expertise is evident as the expert nurse facilitates and directs care on multiple levels simultaneously within complex and sometimes rapidly changing environments.1 Expert nurses are confident and able to keep their composure in the face of rapid shifts in patient change or system breakdown.1 Experts develop sophisticated maxims for practice that are difficult to relate verbally to others.1

Note:

¹Benner (1984/2001);

²Dreyfus and Dreyfus (1989);

³Benner, Tanner, and Chesla (1996);

⁴Benner, Hooper-Kyriakidis, and Stannard (1999).

Benner (1984/2001) states that the five levels reflect changes occurring in three aspects of skilled performance: (a) a movement from reliance on rules and abstract principles to the use of concrete past experiences as the basis of decision making, (b) increasing ability to see the situation as a whole or the “big picture,” and (c) increasing involvement within the situation.

There are nurses who do not follow the trajectory outlined by the Dreyfus model. Aspects relevant to these nurses have been addressed by Rubin (1996). Rubin states that these nurses fail to follow the typical trajectory from the very beginning of their practice. She also makes clear that this failure to follow the typical trajectory is not an issue of personality differences. These nurses exhibit common patterns of behavior that cannot be attributed to common personality types or common psychological conditions. Classic narratives, or exemplars, derived from discussions with these nurses revealed: (a) a lack of ability to remember salient aspects of patient care situations; that is, seeing all patients as stereotypes; (b) perceiving that they do not use clinical knowledge and ethical judgment to make clinical decisions; (c) fuzzy boundaries between “patient” and “self,” that is, assuming that the patient’s thoughts and feelings are the same as one’s own; (d) inability to see nuances in the situation; (e) confusion of the ethical and legal foundations of care; (f) shifting responsibility for decision making to others; and (g) feeling unimportant in the care of patients. Rubin states, “Whatever the psychological difficulties or moral shortcomings of these nurses, their fundamental problem is their lack of knowledge of the qualitative distinctions that are embodied in expert nursing practice” (p. 191).

Domains of practice are thematic groupings of clinical competencies identified in the narrative accounts of nurses. These domains of practice were not designed to be exhaustive or comprehensive (Benner, 1984/2001) but reflect the thoughts and actions of the nurses who participated in the study. Activity related to the domains of practice is not exclusive; that is, the nurse may be practicing in several domains simultaneously. The situation determines which domains take precedence, by necessity, over others (Benner et al., 1999).

The domains of practice identified in FNE have a somewhat broader applicability, as the nurses involved in that study represented a wider range of abilities and clinical specialties than in Benner’s other studies. From that study, Benner (1984/2001) identified 31 competencies that lead to the inductive derivation of seven domains. These domains include “the helping role, the teaching-coaching function, the diagnostic and patient monitoring function, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of health care practices, and organizational and work role competencies” (Benner, 1984/2001, p. 46) (see Table 22-2).

Table 22-2 Domains of Nursing Practice and Related Competencies

The helping role
“The healing relationship: Creating a climate for and establishing a commitment to healing Providing comfort measures and preserving personhood in the face of pain and extreme breakdown Presencing: Being with a patient Maximizing the patient’s participation and control in his own recovery Interpreting kinds of pain and selecting appropriate strategies for pain management and control Providing comfort and communication through touch Providing emotional and informational support to patient’s families Guiding a patient through emotional and developmental change: Providing new options, closing off old ones: Channeling, teaching, mediating Acting as a psychological and cultural mediator Using goals therapeutically Working to build and maintain a therapeutic community” (Benner, 1984/2001, p. 50)
The teaching-coaching role “Timing: Capturing a patient’s readiness to learn Assisting patients to integrate the implications of illness and recovery into their lifestyles Eliciting and understanding the patient’s interpretation of his illness Providing an interpretation of the patient’s condition and giving a rationale for procedures The coaching function: Making culturally avoided aspects of an illness approachable and understandable” (Benner, p. 79)
The diagnostic and patient-monitoring function “Detection and documentation of significant changes in a patient’s condition Providing an early warning signal: Anticipating breakdown and deterioration prior to explicit confirming diagnostic signs Anticipating problems: Future think Understanding the particular demands and experiences of an illness: Anticipating patient care needs Assessing the patient’s potential for wellness and for responding to various treatment strategies” (Benner, p. 97)
Effective management of rapidly changing situations “Skilled performance in extreme life-threatening emergencies: Rapid grasp of a problem Contingency management: Rapid matching of demands and resources in emergency situations Identifying and managing a patient crisis until physician assistance is available” (Benner, p. 111)
Administering and monitoring therapeutic interventions and regimes
“Starting and maintaining intravenous therapy with minimal risks and complications Administering medications accurately and safely: Monitoring untoward effects, reactions, therapeutic responses, toxicity, and incompatibilities Combating the hazards of immobility: Preventing and intervening with skin breakdown, ambulating and exercising patients to maximize mobility and rehabilitation, preventing respiratory complications Creating a wound management strategy that fosters healing, comfort, and appropriate drainage” (Benner, p. 123)
Monitoring and ensuring the quality of health care practices
“Providing a backup system to ensure safe medical and nursing care Assessing what can be safely omitted from or added to medical orders Getting appropriate and timely responses from physicians” (Benner, p. 137)
Organizational and work-role competencies
“Coordinating, ordering, and meeting multiple patient needs and requests: Setting priorities Building and maintaining a therapeutic team to provide optimum therapy Coping with staff shortages and high turnover: Contingency planning Anticipating and preventing periods of extreme work overload within a shift Using and maintaining team spirit; gaining social support from other nurses Maintaining caring attitude toward patients even in absence of close and frequent contact Maintaining a flexible stance toward patients, technology, and bureaucracy” (Benner, p. 147)

Domains of practice are also identified in the narrative accounts of critical care nurses presented in CWICC (Benner et al., 1999). In that text, nine domains were identified from 46 competencies: “(1) diagnosing and managing life-sustaining physiologic functions in unstable patients; (2) the skilled know-how of managing a crisis; (3) providing comfort measures for the critically ill; (4) caring for patient’s families; (5) preventing hazards in a technological environment; (6) facing death: end-of-life care and decision making; (7) communicating and negotiating multiple perspectives; (8) monitoring quality and managing breakdown; and (9) the skilled know-how of clinical leadership and the coaching and mentoring of others” (Benner et al., 1999, p. 3). As can be seen, the terminology differs to some extent and new domains were added. This points to the importance of identifying the domains present within the particular situation on a particular unit within a particular hospital before adopting these domains as anything other than suggested areas of competency.

Embodied knowledge is information that is learned and “known” by the body (Benner & Wrubel, 1989). Embodied knowledge affects the habits one develops related to attentiveness, thinking, and acting and is a method of learning and reasoning. Benner cites Merleau-Ponty’s (1962) five dimensions of the ontological or “knowing” capacity of the body to be (a) the inborn skills of knowing (inborn complex); (b) the culturally and socially learned postures, gestures, and customs (habitual skilled body); (c) the way one normally acts in skilled comportment (projective body); (d) one’s actual projection at the current time (actual projected body); and (e) the body’s awareness of self (the existential body). Embodied knowledge allows us to grasp how humans make rapid, unconscious and seemingly reflex understandings of the significance of the world around them.

Emotions are recognized to play a key role in the nurse’s ability to respond to situations in a engaged fashion and take morally sound action (Benner et al., 1999). Emotions give voice to the embodied knowledge and are useful to the nurse in terms of their qualitative content in understanding the meaning related to the particular situation (Benner & Wrubel, 1989).

Ethical judgment is the nurse’s “fundamental disposition toward what is good and right” (Benner et al., 1996, p. 15). This disposition is shaped, or socially constructed, by both the discipline of nursing and the norms of the particular unit. Ethical judgment, as used by Benner, speaks to skillful and compassionate moral decisions and action on behalf of the patient and his or her family based on a specific situation (Benner et al., 1999).

Experience is an active rather than passive process. It does not depend on the passage of time but, rather, the transformation of expectations and perceptions (Benner et al., 1989). Preconceived notions and theory are refined in light of actual encounters, with many clinical situations adding a new richness to the theoretical basis. While theory can help guide the practitioner to the appropriate questions, experience adds to the necessarily limited and skeletal view provided by that theory (Benner, 1984/2001).

Graded qualitative distinctions are the subtle, context-dependent physiologic changes experienced by the patient that are recognizable to the expert nurse based on direct patient observation (Benner, 1984/2001). This recognition corresponds to Polanyi’s (1958) concept of “connoisseurship,” which is instrumental in uncovering clinical knowledge.

Intuition is a concept that has been much debated in the literature and is, perhaps, the most contentious of Benner’s concepts (Bradshaw, 1995; Darbyshire, 1994; English, 1993; Paley, 1996; Thompson, 1999). Intuition, as used by Benner, is based on experiential learning and caring. Expert intuition involves pattern recognition of the salient aspects of a situation. This heightens the nurse’s attentiveness to the situation (Benner & Tanner, 1987). This results in a sense of knowing without necessarily having a specific rationale (Benner et al., 1999). Benner et al. (1996) further clarify intuition in stating,

To respond by intuition is not the same as thoughtless and automatic response–quite the contrary. We have found that while intuition is clearly possible when nurses don’t know the patient, based on experiences with similar patients, knowing the patient and involvement with him supports the direct apprehension and understanding that we describe as intuition. (p. 10)

Knowing the patient implies knowledge of the patient’s typical responses and enables the nurse to have a good clinical grasp and use expert clinical judgment even when the patient is in a transition phase. Benner et al. (1996) identify five aspects of knowing the patient: “(1) responses to therapeutic measures; (2) routines and habits; (3) coping resources; (4) physical capacities and endurance; and (5) body topology and characteristics” (p. 22). The importance of knowing the patient as a person assists to avoid stereotypes when making clinical decisions (Benner, 2003).

Maxims are described by Polanyi (1958) as instructions experts use to pass on explanations of their actions to others. However, these maxims are cryptic in nature, as one must have extensive experience in the situation to understand the subtle meanings and distinctions required to effectively interpret these instructions. The use of maxims makes it difficult for expert nurses to pass along their clinical wisdom to minimally experienced nurses (Benner, 1984/2001).

Paradigm cases and personal knowledge are past situations that stand out in the nurse’s memory that allow for rapid perceptual grasp of the situation (Benner, 1984/2001, p. 7). This is an advanced type of clinical knowledge that provides a more comprehensive view of the situation than simple reliance on theory. Paradigm cases contain transferable knowledge that is useful in other situations (Benner, 1984/2001).

Reasoning-in-transition is habitually based thinking as situations change and unfold that takes into account past and present knowledge of the situation. Knowledge is gained or lost based on the unfolding situation, and the expert nurse develops the ability to recognize those gains and losses in knowledge in order to prevent errors (Benner et al., 1996, 1999).

Social embeddedness gives context to caring. Benner et al. (1996) state, “Caring for one another is social through and through. Both clinical and caring knowledge require the identification of salient situations and knowing how and when to act” (p. 194). This ability to identify salient aspects of a situation depends on the value systems within which professional development has occurred. The social mores and teaching style of the work unit help shape aspects the nurse will learn to see as valuable and salient to the situation.

Stress is viewed from a phenomenological standpoint as “the disruption of meanings, understanding, and smooth functioning so that harm, loss, or challenge is experienced, and sorrow, interpretation, or new skill acquisition is required” (Benner & Wrubel, 1989, p. 59).

Temporality refers to the relational events of past, present, and anticipated future. One never has the same experience twice because between those experiences lies other experiences that impact the “past” of any given situation (Benner & Wrubel, 1996).

Thinking-in-action is based on a pattern of thought learned initially through prototypical situations and expanded upon through experience and is directly tied to responding to patient and family needs (Benner et al., 1999).

Unplanned practices are practices that have been given to nurses by default. Many unplanned practices are the result of taking on more roles that were once the domain of other health care professionals. These practices are often unrecognized by others as skills performed by nurses. As these new skills are acquired, they influence nurse perceptions and add to clinical knowledge and thus impact clinical judgments (Benner, 1984/2001).

Relationships

In examining Benner’s writing, many relationships are described in the exemplars derived from the discussions with nurses in various research studies. These relationships are complex and do not conform to the typical linear logic evident in cognitive-rationalist theories. The ability to draw a pictorial structure is neither feasible nor appropriate when describing this body of work as it is derived from phenomenological research. The themes and competencies identified must be appreciated within the context from which they are derived. Researchers using phenomenological methods do not seek to generalize their findings to the population at large. Narrative evidence within Benner’s work lends support for many potential relationships among the variables. See Table 22-3 for a selection of relationships suggested to exist among concepts.

Table 22-3 Selected Relationships Among Concepts Identified by Benner

Experience within a supportive environment fosters progression of skill acquisition1,2 Experience allows for the development of caring, which is the basis of nursing practice3 Experience fosters the intuitive grasp of the situation found in expert nurses3,4 Experience impacts agency2,3 Caring is socially embedded2,3 Caring allows for personal concern about the patient2 Concern allows for the identification of stressors and potential coping options2 Attending to the embodied knowledge and emotions elicited by the situation is required for ethical judgment to occur2,3 Expert-level nursing care is achieved through caring and concerned involvement; knowing the patient; awareness of temporal issues; ability to make clinical and ethical judgments; and use of intuitive clinical reasoning, reasoning-in-transition, and thinking-in-action2,3,4

Note:

¹Benner (1984/2001);

²Benner and Wrubel (1989);

³Benner, Tanner, and Chesla (1996);

⁴Benner, Hooper-Kyriakidis, and Stannard (1999).

Assumptions

Benner bases her assumptions on the existential and phenomenological works of Merleau-Ponty, Kierkegaard, Heidegger, Charles Taylor, and Hubert Dreyfus. These assumptions are set forth in Primacy of Caring (Benner & Wrubel, 1989) and deal with the concept of person from an existential viewpoint. These assumptions are evident in Benner’s discussions related to the metaparadigm. Selected assumptions are presented in Table 22-4.

Table 22-4 Selected Assumptions of Benner’s Work

“Human wisdom is taken to be more than rational calculation” (p. 7).1 “Theory is derived from practice” (p. 19).1 Theory is a simplification of reality, and thus presents a limited picture of reality.1 “Theory frames the issues and guides the practitioner in where to look and what to ask” (p. 21).1 “Nursing practice is a systematic whole with a notion of excellence inherent in the practice itself (MacIntyre, 1981)” (p. 19).1 Nurses can and do make a difference in the well-being of patients.1 Caring is the core of nursing practice.2 Caring is primary to nursing practice because: (a) caring creates possibility and is, therefore, essential for coping; (b) caring allows for concern, which is required for connectedness; (c) through caring, the possibility of giving and receiving care becomes possible.1 Caring is always specific and is understood only in context.1 “Caring is the basis of altruism” (p. 367).1 “Caring is the essential requisite for all coping” (p. 1).1 “Caring and interdependence are the ultimate goals of adult development” (p. 368).1 “Concern is essential for the nurse to be situated.” (p. 92).1 Increased experience and mastery of the skill bring about a transforming improvement in performance.3 Clinical performance cannot be understood in terms of “formal structural models, decision analysis, or process models” (p. 38).3 “Regardless of the stage, no practitioner can practice beyond her experience, despite necessary attempts to make the practice as clear and explicit as possible.”2

Note:

¹Benner and Wrubel (1989);

²Benner (2000);

³Benner (1984/2001).

Expert Nursing Practice and Nursing’s Four-Concept Metaparadigm

Person (or Being)

Benner draws from the phenomenological views of Heidegger (1962) in her interpretation of the person with additional references to Dreyfus and Dreyfus (1980) and Merleau-Ponty (1962). The human is to be viewed holistically. However, this view is not the typical “layered-on” holism described in nursing literature (Benner & Wrubel, 1989). The term “bio-psycho-social-spiritual being” frequently used in nursing breaks the human into four pieces that, when layered together, do not adequately represent the wholeness of the person. The question of “being” is extensively debated in the literature, with questions regarding whether Benner is, in fact, using a Heideggarian definition (Benner, 1996; Benner & Wrubel, 2001; Bradshaw, 1995; Cash, 1995; Darbyshire, 1994; Edwards, 2001; Horrocks, 2000, 2002, 2004). However, regardless of the validity or lack of validity of those arguments, Benner makes important observations about the humanness of persons. The person is a whole who cannot be reduced to mind–body dualism (Benner & Wrubel, 1989). The person’s way of being in the world affects his or her thoughts and understandings of the world because “a person is a self-interpreting being, that is, a person does not come into the world predefined but becomes defined in the course of living a life” (Benner & Wrubel, 1989, p. 41). This person is situated in a world that has a personal meaning. The situatedness of the person allows him or her to grasp the world through embodied knowledge, background meanings, concern about things that matter, and the ability to participate in the environment and world. The person cannot be understood out of context (Benner & Wrubel, 1989).

Well-Being

The term “well-being” is preferred by Benner over the term “health” because “health” has typically been associated with physiological and psychological measures. She takes a phenomenological view, selecting the term “well-being” as it “reflects the lived experience of health, just as the term illness reflects the lived experience of disease” (Benner & Wrubel, 1989, p. 160). Benner goes on to define well-being as “congruence between one’s possibilities and one’s actual practices and lived meanings as is based on caring and feeling cared for” (p. 160). Well-being is both contextual and relational. She goes on to say, “Health, as well-being, comes when one engages in sound self-care, cares, and feels cared for–when one trusts the self, the body, and others” (p. 161). In addition, health or well-being can be promoted by effective use of the patient’s formal beliefs, deliberate choices and planning, understanding and being guided by emotional responses, awareness and use of embodied intelligence, investigating meanings and concerns, and identifying and understanding the situational aspects impacting well-being.

Benner and Wrubel (1989) differentiate health, illness, and disease by stating, “Health is not the absence of illness, and illness is not identical with disease. Illness is the human experience of loss or dysfunction, whereas disease is the manifestation of aberration at the cellular, tissue, or organ level” (p. 8). Disease and illness have a bidirectional flow, with each impacting the other. The human experience of illness impacts disease since humans assign meaning to the disease and respond emotionally to that meaning. Disease, in turn, affects illness from a biophysical standpoint, giving rise to signs and symptoms that are then perceived by the person as an interruption, an inconvenience, or a worry.

Situation

People are situated in a world that gives meaning to their being. Benner and Wrubel (1989) state, “The term situation is used as a subset of the more common nursing term environment because the former term connotes a peopled environment. Environment is a broader more neutral term, whereas situation implies a social definition and meaningfulness” (p. 80). The ways in which people experience “being” in a situated world impacts how they understand that world, which impacts their experience of the world. This experience is shaped by context and influenced by the background meanings given to that context. Context implies the many ways in which people are connected to the world. Temporality is part of context. People understand themselves and the world in relation to past and present with possibilities for the future.

Benner and Wrubel (1989) note that people can feel “situationless” when placed in a new and unfamiliar situation. There is a lack or loss of meaning to draw upon. Nurses often work with people who are experiencing new, unfamiliar situations and are instrumental in helping the person to regain a feeling of situatedness. The nurse, situated in a familiar world, informs and coaches the patient through active involvement with that person.

Nursing

Benner and Wrubel (1989) define nursing as “a caring practice whose science is guided by the moral art and ethics of care and responsibility” (p. xi). Further, they state that “nursing is concerned with health promotion and treatment of illness and disease” (p. 303). In addition, nursing is a

science that studies the relationships between mind, body, and human worlds…. Nursing is concerned with the social sentient body that dwells in finite human worlds: that gets sick and recovers; that is altered during illness, pain, and suffering; and that engages with the world differently upon recovery. (Benner, 1999, p. 315)

Nurses are knowledgeable practitioners who are central to the promotion of health and well-being of patients. Expert nurses understand the theoretical basis of health, illness, and disease as well as have experientially based, practical understanding of the typical patterned responses of humans to situations of well-being and illness. Cognitive, relational, and technical skills and understanding are acquired through experience with real patients in real situations over extended periods of time (see earlier description of novice to expert levels). These skill competencies comprise the domains of nursing (Benner, 1984/2001; Benner & Wrubel, 1989).

Expert Nursing Practice and the Nursing Process

The linear nursing process is viewed by Benner as insufficient to meet the needs of expert nursing practice. Benner (1984/2001) states that this view oversimplifies nursing transactions because it leaves out context and content. As an oversimplification, the formal steps do not capture all of the expert nurse’s thought processes as he or she interacts in a therapeutic manner with the patient and family. As stated by Benner et al. (1999), “Classification systems may work for information management and record retrieval, but they do not present an accurate account of the habits of thought, thinking-in-action, or reasoning-in-transition involved in actual clinical practice” (p. 66). The linear process does not allow for the intuitive grasp and flexibility required of the nurse in rapidly changing situations, nor does it not account for the interrelatedness of the steps. When expert nurses recognize a problem, it is already diagnosed with treatment options already selected and implementation begun.

However, given the criticisms noted, the nursing process is viewed as a sound method for the development of patterns of thought for novices and advanced beginners. In addition, when faced with a new or unique situation, it is a tool that can be effectively used by the more advanced nurse (Benner et al., 1999).

Assessment. Benner (1984/2001) maintains that assessment “is so central and contains so much content and skill in its own right that much of the skill and content are overlooked if this domain is seen solely as the first step of a linear process” (p. 107). Symptoms are to be viewed in terms of the patient’s past and present context and are never experienced in isolation. Thus, the nurse must learn to utilize the patient’s embodied knowledge to assist with assessment. Benner and Wrubel (1989) caution that patients become experts in the assessment of their own state of well-being. A great fear of these “expert patients” is that their expertise will be discounted, and practitioners will intervene in less-than-expert ways. Thus, the nurse must learn to know the patient in terms of his typical response patterns and be able to make qualitative distinctions between the patient’s typical state and the current state.

Learning these assessment skills is not an easy task. Inexperienced practitioners have not yet developed the skill of differentiating the most salient symptoms within a situation. They therefore try to interpret every symptom demonstrated in terms of their understanding of disease (Benner & Wrubel, 1989). Observational, or monitoring, skills are primary to assessment. In learning to be a skilled observer, the nurse must gain experience and expertise in distinguishing changes from the patient’s typical pattern and the expected pattern given the situation as well as understanding the meanings inherent in that change.

Diagnosis. The concept of nursing diagnosis is meant to serve a wide variety of purposes within the framework of nursing process. Benner et al. (1996) state that the purposes espoused by nursing for nursing diagnoses are many and varied and that “no single dimension of a professional practice can achieve all that nursing diagnosis as a concept and as a taxonomic effort was intended to do” (pp. 27–28).

The use of an established taxonomy for diagnosis can have the negative effect of putting the nurse into a mind-set where diagnosis leads to focus on certain symptoms at the expense of others that may be present within the situation (Benner & Wrubel, 1989). Symptoms, by nature, are ambiguous and present an unclear picture. However, attending to these vague symptoms can occur because of embodied knowledge. For example, a nurse may encounter a patient, sense an odor, and understand that the patient has an infection. The question of where and what organism is then left to be determined through skilled observation and technology. The simplistic label “potential for infection” lacks specificity because of an unknown etiology and gives little direction to determine which signs and symptoms may be salient in that situation. Thus, the partial diagnosis does not convey enough information for the experienced nurse to respond to the patient and family’s needs. The experienced nurse relies on other means.

Prioritization of diagnoses is an additional problem exemplified by the traditional view of nursing process. Salience of symptoms and diagnoses is situated in time and place. Consequently, priorities may change rapidly, or two diagnoses may have comparable weight at any given time. Lack of observational skills or problem solving on the part of the nurse can compromise prioritization. Benner et al. (1999) state that “being a good problem solver is not sufficient if the most critical problem is overlooked or the problem is framed or defined in misguided ways” (pp. 14–15).

Expert nurses, rather than relying on labels, base clinical judgments on experience, knowing the typical trajectory of disease states within their specialty, knowing the patient as a temporally situated being, and making observations guided by theoretical, practical, and embodied knowledge (Benner et al., 1996, 1999).

Planning, implementation, and evaluation. Benner and colleagues have established through their qualitative study of nurses that while the less experienced nurse attempts to follow the structured nursing process, the more expert nurse engages in an intuitively based process of interpreting care needs that is not well captured by the steps labeled planning, implementation, and evaluation. Expert nurses engage in essentially response-based action based on experience and individualization to the specific patient at that specific time and place (Benner et al., 1996). These actions are intuitively based and imply a simultaneous, multidirectional, and multidimensional grasp of what needs to be done at any given time (Benner, 1999; Benner et al., 1996).

Nursing action is goal directed. For the expert nurse, goals are patient focused, whereas less experienced nurses focus extensively on personal goals to be accomplished during their shift, and these personal goals inhibit them from focusing on the goals of the patient (Benner et al., 1996). Experienced nurses understand the importance of realistic, individualized goals in establishing and maintaining the patient’s commitment for, perhaps, long periods of time (Benner, 1984/2001). Goals are established through knowing the patient. This allows goals to be congruent with the person’s view of what is possible and desirable (Benner et al., 1999).

Expert nurses intuitively design interventions to avoid known hazards. They are vigilant to safety needs of the patient and are assertive in changing the plan as needed should circumstances change. Plans are seen as flexible and evolving and are subject to ongoing review and questioning. Priorities shift as the patient situation changes. Thus, needs may be conflicting at times. Benner speaks of the “fuzzy recognition” of changes in clinical status. Intervention may well be delayed until additional information is acquired to have sufficient understanding to guide intervention. One feature of the expert nurse is that he or she is willing to wait before taking action (Benner et al., 1996).

In evaluation of the effectiveness of care, the nurse is sometimes required to determine which of conflicting interventions is the most salient to the current situation. Evaluation based on situated knowledge enables the nurse to determine when to reprioritize, when to change interventions, and when to discontinue orders that are no longer relevant (Benner, 1984/2001).

An example of care given by an advanced beginner and an expert can be found in the story of Sara.

Sara’s Story

Sara is 24-year-old gravida 1 para 1 who delivered late yesterday evening. She has an unremarkable medical history and had an uneventful pregnancy, although she did just recently move to this area, resulting in a need to change her primary care provider in the 8th month of her pregnancy. Sara is an elementary school teacher. Her husband is a sculptor and painter who just accepted a position at the local college as an art instructor.

Maria R.N. is caring for Sara from 7 A.M. to 11 A.M. Maria has been working on postpartum since graduation from nursing school seven months ago. The night nurse reports that Sara is in stable condition with no outstanding problems other than having a hard time getting the baby to latch on for breastfeeding. Following report, Maria organizes her day according to the nursing needs she identified from night shift’s report. Around 8:15, Maria stops by Sara’s room and notes that Sara is nursing the baby. Maria introduces herself and asks how Sara is feeling this morning. Other than a few aches and some pain from the third-degree episiotomy, Sara says she is feeling fine. Maria then proceeds to inquire about breastfeeding problems. Sara indicates that she has finally been able to get the baby to latch on and that the baby seems to be sucking effectively. Maria checks the latch, mentally going over her growing list of “tips and tricks for proper breastfeeding,” and assures Sara that the baby is well latched. She instructs the new mother on how to assess for a proper latch-on. Maria then asks if Sara would mind delaying the rest of the baby’s feeding until she finishes her morning assessments. Sara agrees, unlatches the baby, and Maria efficiently finishes her postpartum and neonatal assessments. During this time, Maria notes that Sara seems to have been crying recently, as her eyes are puffy. Maria gives positive reinforcement for Sara’s good breastfeeding technique and assures her that the initial frustrations of breastfeeding are well worth the final results. She then makes a mental note to have the lactation consultant stop by to in order to identify any breastfeeding issues that she may have missed in her inexperience. Maria asks Sara if she would like some pain medication for her episiotomy pain. After providing the medication and making sure that the baby is again well latched, Maria leaves Sara’s room confident that she has performed good nursing care.

At 11 A.M., Maria gives report to Jessie R.N. Jessie, an energetic nurse who has worked on postpartum for 15 years, is well known for her insight into clinical situations and her ability to manage even the most unexpected events. Shortly after report, Jessie stops by Sara’s room. Again, Sara is breastfeeding her baby. Jessie smiles warmly and looks Sara in the eyes as she introduces herself and asks how things are going. Sara looks tired and somewhat withdrawn as she remarks that the baby is feeding well and her stitches are still sore. Jessie notes that there are a number of used tissues accumulated on the bedside table. She sits down on the chair next to Sara’s bed, leans forward, and gently asks her about the tissues.

Sara looks grateful that someone seems interested in her “real” pain. She tearfully begins her story by saying that she wasn’t happy about moving to this town a few weeks ago. However, the fall semester was starting and her husband had to start work. She didn’t want to stay in her old home because it was a six-hour trip and she was afraid her husband wouldn’t be able to be present for the birth. In her home town, she had been planning a natural birth in the home-like birthing suite. Unfortunately, only one obstetrician in the new town was accepting patients. She had gone into labor, been sentenced to continuous fetal monitoring, and was restrained in the labor bed with monitor belts. She couldn’t walk or use a whirlpool, so her labor pattern became sluggish and oxytocin was started to augment the contractions. The oxytocin worked well, and labor became very painful since Sara couldn’t change positions easily in bed without causing problems with the labor tracing. She finally asked for an epidural. When it came time to deliver, Sara couldn’t push effectively. After a failed vacuum extraction, forceps were used to deliver the baby. Her episiotomy had ripped into a third-degree tear. Sara hadn’t slept well following the delivery, as there were seven times during the night when staff members came into her room. Sara stated that she wanted to go home right now, but she was told that the pediatrician wouldn’t release the baby in less than 48 hours post-birth and she wasn’t going home alone. She stated that she felt very lonely, as the baby had spent so much time in the nursery and her husband would be at work until 4 P.M.

Jessie recognized the acute grieving Sara was experiencing for her lost dreams and plans of a fulfilling labor. She recognized that Sara was feeling overwhelmed with the imposed power structure in the hospital and was feeling out of control. After listening to the story, Jessie expressed her sorrow that things had worked out so differently than Sara had planned. Jessie suggested that Sara had a number of options that they could implement to give Sara a better sense of control over the hospitalization. Sara was encouraged to get dressed into her normal daywear. Jessie suggested that Sara call her husband and ask him to bring in her favorite takeout food for dinner and Sara’s favorite bedtime snack. Jessie gave Sara several nonpharmacological options for pain control as well as informing her about the variety of pain medications Sara could request. Noting the small cross on Sara’s necklace, Jessie inquired whether Sara would like to speak with her clergy or whether she would like to speak to one of the hospital clergy representatives. A sign was put onto Sara’s door instructing staff to not bother Sara except at 4, 8, and 12 so that Sara could get uninterrupted time for proper sleep. The nursery was informed that the baby would be rooming-in, per Sara’s request, for the remainder of the stay and that all infant assessments and procedures should be done in the mother’s room only at 4, 8, or 12 if possible. Noting that Sara was smiling and her eyes were now brighter, Jessie asked if Sara could think of anything else that would make the rest of her stay more pleasant. Jessie left the room stating that she would check with the pediatrician about an earlier discharge for the baby. As Jessie walked to the nurses’ station, she reflected on Sara’s experience and what the unit could learn from Sara’s story. Identifying several points of concern, Jessie planned to speak with the policies committee to be sure that evidence-based care and national standards for family-centered maternity care were truly reflected in the unit’s policies and orientation plan.

Expert Nursing Practice and the Characteristics of A Theory

1. What is the historical context of the theory?Predominantly female occupations such as nursing and teaching were striving to be recognized as professions despite their historical deviation from the generally accepted professional development pathways. Feminist theory was being applied to understand aspects of these typically female professions. Traditional views of science, as laid down by Socrates, Descartes, and other early philosophers, were viewed with dissatisfaction by professions where cognitive-rational deductive theory did not take into account the human element. The mechanistic view of people as orderly, predictable, measurable entities did not reflect the day-to-day reality experienced by professions such as nursing. Academic discussions on science offered by Kuhn (1970) and Polanyi (1962) appeared in nursing literature as well as nursing classrooms. The question of “knowing-how” without being clearly aware of the reasoning behind that “know-how” left unsettling questions for nurse theorists. Alternative perspectives were sought in the philosophy of other disciplines.Benner’s work takes the stand that theory arises from practice and practice subsequently uses theory to change practice. Theory, according to Heidegger (1962), either confirms or disconfirms practice. As such, theory is then subject to modification based on the new possibilities within the situation that extend practice knowledge. An understanding of the writing of Heidegger and phenomenology is useful for understanding many of the concepts discussed by Benner. In addition, an appreciation of feminist theory can assist the reader to grasp the fundamental importance of this body of work. The ability to give voice to nurses in order to articulate their knowledge and wisdom is, perhaps, the most significant achievement of Benner.
2. Benner’s work reflects the search for a more congruent philosophical stance on the profession of nursing. Influenced by the feminist movement and the phenomenological philosophy of Heidegger (1962), Merleau-Ponty (1962), Taylor (1985), and others, as well as by Hubert and Stuart Dreyfus and Richard Lazarus’s views on stress and coping, Benner sought to discover the knowledge and wisdom embedded in the practice of nursing in order to address the many contextual issues challenging nurses of the time. Accounts of nursing shortages, the rising impact of technology and resulting dehumanizing of the health care environment, poor caregiving practices, and devaluation of nurses within the health care system plagued the formative professional years of Benner (Benner & Wrubel, 1989). These issues continue today. New challenges have occurred during the years since the first publication of Benner’s work. The increasing existence of large conglomerates controlling numerous health institutions, insurance company control of health care availability, mushrooming new categories of health care workers seeking licensure, and rising standards in education level for advanced practice nurses make articulating the basis of quality nursing care imperative for the continued development of the profession. The work of Benner, then, continues to be relevant today.
3. According to Benner, understanding the historical context of her work requires a return to the mind-set of the late 1970s and early 1980s. During this time, the grand theories of nursing were extensively taught and debated in nursing schools. Nursing theory was espoused in nursing education programs as a way of structuring and understanding the science and practice of nursing. Most nursing theorists focused on the science of nursing and building a scientific basis to legitimize nurse’s existence as a distinct profession. These grand theories were hoped to be templates that could be used to guide nursing science development as well as nursing practice. However, restrained by traditional views of theory development, these theorists encountered difficulties in capturing aspects of the lived experience of nursing. Attempts to use the theories as templates resulted in devaluing of the clinical knowledge possessed by the individual nurse (Benner & Wrubel, 1989).
4. What are the basic concepts and relationships presented by the theory?Benner discusses a large number of concepts in her works. The concepts are defined in terms that are continually expanded. Relationships between concepts are well explicated through the use of exemplars and demonstrate a complex fabric to nursing expertise. Few assumptions are explicitly stated. The reader can hypothesize a number of assumptions, however, based on the recurrence of thoughts throughout the works.
5. Benner’s efforts were aimed at developing a scientific basis for nursing based on the lived experience of the nurse that encompassed the lived experience of the person experiencing illness (Benner & Wrubel, 1989). Caring became the pivotal concept. Although caring had been addressed by other nurse theorists such as Lydia Hall, Madeleine Leininger, and Jean Watson, Benner sought a phenomenological understanding of how caring develops and is exemplified by expert nurses. Thus, differentiating between the thoughts and actions of nurses as different skill levels becomes a necessary foundation.
6. What major phenomena of concern to nursing are presented? (These phenomena may include but are not limited to human beings, environment, health, interpersonal relations, caring, goal attainment, adaptation, and energy fields.)Benner’s work does provide insight into critical thinking as an evolutionary process that becomes more intuitive as experience is gained. Elements of this critical thinking are identified as clinical reasoning, clinical judgment, clinical forethought, reasoning-in-transition, and thinking-in-action. Development of critical thinking skills can be fostered or hindered by the unit culture where this experience is gained. Thus, administrators have responsibility to demonstrate positive leadership and assist the system to develop into professionally nurturing environments.
7. This is not to imply that Benner finds no place for traditional models of critical thinking. Benner et al. (1996) note, “Calculative reasoning, requiring analysis of particular situations, consulting research and theoretical literature for possible interpretations and solutions, and explicitly weighing of possible outcomes and consequences of each potential action, does and should figure prominently in the practice of experienced clinicians” (p. 12).
8. Benner clearly discusses the four concepts of the metaparadigm although she does make changes to the terminology to person, well-being, situation, and nursing. These concepts are covered extensively and consistently. As stated previously, caring is a primary focus and differs in approach from the works of other nursing theorists.
9. To whom does this theory apply? In what situations? In what ways?Benner’s work focuses on the question of how nurses intervene as they do rather than the questions of what nurses need to do in any given situation. Nurses intervene as they do because they are beings who care. The novice nurse’s focus of care is on how he or she, the nurse, performs. This self-focus gradually shifts as experience is gained to a mature ability to care about the patient. Expert caring leads to concern, and concern allows the nurse to identify salient aspects of the situation. Concern is influenced by the nurse’s background meanings, embodied intelligence, reasoning processes, and future focus. These factors lead to an intuitive grasp that allows the nurse to first start with interventions that have worked most of the time for patients in similar circumstances. Vigilant monitoring then dictates whether changes are made to the intervention plan based on expert observational skills.
10. Over 175 research based articles citing Benner’s work as the framework were identified in a recent CINAHL search. Benner’s work is applicable in nursing education, nursing practice, nursing administration, and nursing research. There is extensive information contained in her books suggesting appropriate education methods for nurses at different levels of skill acquisition. Benner’s descriptions of professional development and domains of practice have been used to guide nursing curricula and to give direction to staff development programs (Carlson, Crawford, & Contrades, 1989; Gatley, 1992). Nurse administrators are given direction in how to create an environment that fosters expertise. In addition, an understanding of how to individualize the domains of nursing practice to a particular institution fostered the development of Clinical Practice Development Model (Haag-Heitman, 1999) and similar models used within a number of hospital systems across the country. Researchers have further investigated Benner’s domains of nursing skill acquisition and competencies in other settings (Brykczynski, 1998; Noyes, 1995; Urs, Van Rhyn, Gwele, McInerney, & Tanga, 2004).
11. By what method or methods can this theory be tested?
12. Benner’s conclusions have been tested, for the most part, using qualitative methods to determine whether the domains of nursing practice, as identified by Benner, are evident in other settings. Qualitative methods are most appropriate as the concepts are most amenable to analysis of narrative information and observation. Quantitative attempts have been made to design and validate competency assessment forms (Meretoja, Erickson, & Leino-Kilpi, 2002; Meretoja, Isoaho, & Leino-Kilpi, 2004).
13. Does this theory direct nursing actions that lead to favorable outcomes?
14. Benner did not investigate client outcomes except that many of the exemplars from the nurses focused on a significant occasion when the nurse believed she made a difference. The domains of nursing practice can, however, give direction to nursing actions. The competencies identified with a particular domain of practice gives guidance to the nurse in terms of what is expected of her within that practice setting. In addition, important aspects emphasized in Benner’s work that direct attention to a means for favorable outcomes include the concepts of ethical judgment and moral agency.
15. How contagious is this theory?
16. A CINHAL search in mid-2006 using the keywords “Benner,” and “Novice to Expert” yielded just over 1,500 publications either citing Benner or having a major focus on Benner’s work. These citations include a number in international journals. Benner’s work has been translated into many languages and has been the source of many nursing conferences. Nursing curricula receive guidance from Benner’s work. In addition, many hospital systems have instituted clinical ladders based on the Dreyfus model as applied to nursing. Internationally, Benner’s work has been influential at national levels in countries such as the United Kingdom, New Zealand, and Australia in structuring nursing education and practice guidelines.

Strengths and Limitations of the Theory

The narrative detail evident in Benner’s work makes it easy for nurses to validate whether Benner’s conclusions seem reasonable. While there are a large number of concepts, they complement each other to tell the story of expert nursing practice. Benner’s work can be understood in a simple form, such as skill levels of novice to expert, or can be applied in a more expanded form in terms of understanding critical thinking and caring practices.

Benner’s work has been tremendously influential in nursing in several areas. Her work has drawn renewed attention to the pivotal role played by caring in nursing practice. Nursing practice is, in essence, caring. In a society that values a rational, logical, positivistic view of science, Benner reawakened the desire to examine the profession from a more humanist view in order to see nursing’s wisdom in a fresh new light.

Benner repeatedly cautions the reader to question the representativeness of her works and to carefully examine the applicability of her ideas to the specific situation (Benner, 1984/2001). A limitation noted repeatedly in the literature is the inappropriate use of Benner’s work as a template in situations where the framework has not been validated (Benner & Benner, 1999). Institutions that are truly interested in effectively using Benner’s ideas must assess their own situation to see if modifications to her domains are in order.

Other concerns have been noted in the literature. An excellent review is provided by Padgett (2000), who notes questions regarding the appropriate interpretation of her philosophical foundations, the limitation of the majority of her work to the examination of expert nurses without equal focus on the other levels of practice, the practice of selection of expert research participants by administrators, and the methodological limitations of using a predetermined framework to structure her qualitative, phenomenological studies.

Summary

The work of Benner and colleagues has had a significant impact on nursing within the United States and abroad. The questions of what is a nurse and what is nursing have been debated and described for decades. The question of what is an expert practitioner requires an examination of the day-to-day activity of nurses in real situations. Here, one needs to begin to step back to fundamentals that can be supplied only by the nurses themselves. Thus, practice generates knowledge and knowledge contributes to practice.

Thought Questions

1.	In Sara’s story, identify examples of how the practice of the advanced beginner and the expert nurse varied.

2.	Given Benner’s conceptualization of the competent nurse, what is the impact of mandatory annual “competency” testing on the motivation of nurses to attain proficient or expert levels of practice?

3.

Benner cautions against using her qualitatively identified domains of practice and competencies as a template. How can staff development nurses examine the appropriateness of Benner’s work for the development of a clinical advancement model for a particular hospital? Would factors within particular units of the hospital require variations of the proposed model?

4.	Benner focuses extensively on the concept of caring as a basic concept in the development of nursing expertise. What are the implications of role conflict between a desire to care and the economic considerations of time and resource management on the professional development of nurses?

5.

Benner states that expert nurses use maxims to explain the rationale for their nursing actions. These maxims are cryptic instructions based on subtle experiential learning that are difficult to verbalize; thus, it is difficult to pass along clinical wisdom to newer nurses. What implications does this have for the orientation of advanced beginners as they enter the work environment?

6.	Given that Benner states that the clinical reasoning and decision making of expert nurses does not follow the traditional nursing process taught to novices, what modifications may be in order for the teaching of critical thinking skills in nursing education programs?

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References

Benner, P. (1996). A response by P. Benner to K. Cash (1995), Benner and expertise in nursing: A critique. International Journal of Nursing Studies, 33(6), 669–674.

Benner, P. (1999). New leadership for the new millennium: Claiming the wisdom and worth of clinical practice. Nursing and Health Care Perspectives, 20(6), 312–319.

Benner, P. (2000). The wisdom of our practice. American Journal of Nursing, 100(10), 99–105.

Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice (com. ed.). Upper Saddle River, NJ: Prentice Hall. [Original work published 1984, Menlo Park, CA: Addison-Wesley]

Benner, P. (2003). Beware of technological imperatives and commercial interests that prevent best practices. American Journal of Critical Care, 12(5), 469–471.

Benner, P., & Benner, R. V. (1999). The clinical practice development model: Making the clinical judgment, caring, and collaborative work of nurses visible. In B. Haag-Heitman (Ed.), Clinical practice development: Using novice to expert theory (pp. 17–42). Gaithersburg, MD: Aspen.

Benner, P., Hooper-Kyriakides, P., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Philadelphia: Saunders.

Benner, P., & Tanner, C. A. (1987). Clinical judgment: How expert nurses use intuition. American Journal of Nursing, 87(1), 23–31.

Benner, P., Tanner, C., & Chesla, C. A. (1996). Expertise in nursing practice: Caring, clinical judgment and ethics. New York: Springer.

Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Menlo Park, CA: Addison-Wesley.

Benner, P., & Wrubel, J. (2001). Response to: Edwards S. D. (2001) Benner and Wrubel on caring in nursing. Journal of Advanced Nursing, 33(2), 172–174.

Benner Associates. (2002). Short resume of Patricia Benner. Available online at http://home.earthlink.net/~bennerassoc/patricia.html.

Bradshaw, A. (1995). What are nurses doing to patients? A review of theories of nursing past and present. Journal of Clinical Nursing, 4, 81–92.

Brykczynski, K. A. (1998). Clinical exemplars describing expert staff nursing practices. Journal of Nursing Management, 6, 351–359.

Brykczynski, K. A. (2006). Patricia Benner. From novice to expert: Excellence and power in clinical nursing practice. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 140–166). Philadelphia: Mosby.

Carlson, L., Crawford, N., & Contrades, S. (1989). Nursing student novice to expert–Benner’s research applied to education. Journal of Nursing Education, 28(4), 188–190.

Cash, K. (1995). Benner and expertise in nursing: A critique. International Journal of Nursing Studies, 32(6), 527–534.

Darbyshire, P. (1994). Skilled expert practice: Is it “all in the mind”? A response to English’s critique of Benner’s novice to expert model. Journal of Advanced Nursing, 19, 755–561.

Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Air Force Office of Scientific Research (AFSC), USAF (Contract F49620-79-c-0063), University of California at Berkley.

Dreyfus, H. L., & Dreyfus, S. E. (1996). The relationship of theory and practice in the acquisition of skill. In P. Benner, C. Tanner, & C. Chesla (Eds.), Expertise in nursing practice: Caring, clinical judgment, and ethics (pp. 29–47). New York: Springer.

Edwards, S. D. (2001). Benner and Wrubel on caring in nursing. Journal of Advanced Nursing, 33(2), 167–171.

English, I. (1993). Intuition as a function of the expert nurse: A critique of Benner’s novice to expert model. Journal of Advanced Nursing, 18, 387–393.

Gatley, E. P. (1992). From novice to expert: The uses of intuitive knowledge as a basis for district nurse education. Nurse Education Today, 12, 81–87.

Haag-Heitman, B. (Ed.). (1999). Clinical practice development, using novice to expert theory. Gaithersburg, MD: Aspen.

Heidegger, M. (1962). Being in time (J. MacQuarrie & E. Robinson, Trans.). New York: Harper & Row.

Horrocks, S. (2000). Hunting for Heidegger: Questioning the sources in the Benner/Cash debate. International Journal of Nursing Studies, 37, 237–243.

Horrocks, S. (2002). Edwards, Benner and Wrubel on caring. Journal of Advanced Nursing, 40(1), 36–41.

Horrocks, S. (2004), Saving Heidegger from Benner and Wrubel. Nursing Philosophy, 5, 175–181.

Kuhn, T. S. (1970). The structure of scientific revolutions (2nd ed.). Chicago: University of Chicago Press.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

MacIntyre, A. (1981). After virtue. Notre Dame, IN: University of Notre Dame Press.

Meretoja, R., Erickson, E., & Leino-Kilpi, H. (2002). Indicators for competent nursing practice. Journal of Nursing Management, 10, 95–102.

Meretoja, R., Isoaho, H., & Leino-Kilpi, H. (2004). Nurse Competence Scale: Development and psychometric testing. Journal of Advanced Nursing, 47(2), 124–133.

Merleau-Ponty, M. (1962). Phenomenology of perception (C. Smith, Trans.). London: Routledge and Kegan Paul.

Noyes, J. (1995). An explanation of the differences between expert and novice performance in the administration of an intramuscular injection of an analgesic agent to a patient in pain. Journal of Advanced Nursing, 22, 800–807.

Padgett, S. M. (2000). Benner and the critics: Promoting scholarly dialogue. Scholarly Inquiry for Nursing Practice: An International Journal, 14(3), 249–266.

Paley, J. (1996). Intuition and expertise: Comments on the Benner debate. Journal of Advanced Nursing, 23(4), 665–671.

Polanyi, M. (1958). Personal knowledge. Chicago: University of Chicago Press.

Rubin, J. (1996). Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In P. Benner, C. Tanner, & C. Chesla (Eds.), Expertise in nursing practice: Caring, clinical judgment, and ethics (pp. 170–192). New York: Springer.

Taylor, C. (1985). Theories of meaning. In C. Taylor, Human agency and language: Philosophical papers (Vol. 1, pp. 248–292).

Cambridge: Cambridge University Press. Thompson, C. (1999). A conceptual treadmill: The need for “middle ground” in clinical decision making theory in nursing. Journal of Advanced Nursing, 30(5), 1222–1229.

University of California, San Francisco (2008). Faculty Profiles: Patricia Benner. Available online at http://www.nurseweb.ucsf.eud/www/ffbennp.htm.

Urs, L. R., Van Rhyn, L. L., Gwele, N. S., McInerney, P. & Tanga, T. (2004). Problem-solving competency of nursing graduates. Journal of Advanced Nursing, 48(5), 500–509.

Selected Bibliography (2002–2007)

Ali, N. S., Hodson-Carlton, K., Ryan, M., Flowers, J., Rose, M. A., & Wayda, V. (2005). Online education: Needs assessment for faculty development. Journal of Continuing Education in Nursing, 36 (1), 32–38.

Benner, P. (2003). Attending death as a human passage: Core nursing principles for end-of-life care. American Journal of Critical Care, 12, 558–561.

Benner, P. (2003). Avoiding ethical emergencies. American Journal of Critical Care, 12(1), 71–72

Benner, P. (2003). Beware of technological and commercial interests that prevent best practices. American Journal of Critical Care, 12, 469–471.

Benner, P. (2003). Enhancing patient advocacy and social ethics. American Journal of Critical Care, 12, 374–375.

Benner, P. (2003). Reflecting on what we care about. American Journal of Critical Care, 12, 165–166.

Benner, P. (2004). Designing formal classification systems to better articulate knowledge, skills, and meaning in nursing practice. American Journal of Critical Care, 13, 426–430.

Benner, P. (2004). Seeing the person beyond the disease. American Journal of Critical Care, 13, 75–78.

Benner, P. (2005). Extending the dialogue about classification systems and the work of professional nurses. American Journal of Critical Care, 14, 242–244.

Benner, P. (2005). Honoring the good behind rights and justice in healthcare when more than justice is needed. American Journal of Critical Care, 14, 152–156.

Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K., & Jamison, D. (2002). Individual, practice, and system causes of errors in nursing. A taxonomy. JONA, 32, 509–523.

Benner, P., & Sutphen, M. (2007). Learning across the professions: The clergy, a case in point. Journal of Nursing Education, 46(3), 103–108.

Cathcart, E. B. (2008). The role of the chief nursing officer in leading the practice: Lessons from the Benner tradition. Nursing Administration Quarterly, 32(2), 87–91.

Chang, S. U., & Corgan, N. L. (2006). A partnership model for the teaching nursing home project in Taiwan. Nursing Education in Practice, 6, 78–86.

Christensen, M., & Hewitt-Taylor, J. (2006). From expert to tasks, expert nursing practice redefined? Journal of Clinical Nursing, 15, 1531–1539.

Dunn, K. S., Otten, C., & Stephens, E. (2005). Nursing experience and the care of dying patients. Oncology Nursing Forum, 32 (1), 97–104.

Floyd, B. O., Kretschmann, S., & Young, H. (2005). Facilitating role transition for new graduate RNs in a semi-rural healthcare setting. Journal for Nurses in Staff Development, 21 (6), 284–290.

Larew, C., Lessans, C., Spunt, D., Foster, D., & Coving, B. G. (2005). Application of Benner’s theory in an interactive patient care simulation. Nursing Education Perspectives, 27(1), 16–21.

Lathan, C. L., & Fahey, L. J. (2006). Novice to expert advanced practice nurse role transition: Guided student self-reflection. Journal of Nursing Education, 45(1), 46–48.

Meretoja, R., Ericksson, El, & Leino-Kilpi, H. (2002). Indicators for competent nursing practice. Journal of Nursing Management, 10, 95–102.

Richards, J., & Hubbert, A. O. (2007). Experiences of expert nurses in caring for patients with postoperatiave pain. Pain Management Nursing, 8(1), 17–24.

Robinson, J. A., Flynn, V., Canavan, K., Cerreta, S., & Krivak, L. (2006). Evaluating your evaluation plan. Are you meeting the needs of nurses? Journal for Nurses in Staff Development, 22(2), 65–69.

Weiss, S. M., Malone, R. E., Merighi, J. R., & Benner, P. (2002). Economism, efficiency, and the moral ecology of good nursing practice. Canadian Journal of Nursing Research, 34(2), 59–119.

Annotated Bibliography

• Barrett, C., Borthwick, A., Bugeja, S., Parker, A., Vis, R., & Hurworth, R. (2005). Emotional labour: Listening to the patient’s story. Practice Development in Health Care, 4(4), 213–223.
• This article discusses the dissociation between “patient” and “person” found in expert nurses when doing program evaluation using an empowerment evaluation strategy. The authors report that expert nurses developed a level of cynicism that sometimes prevented them from hearing the patient’s story and seeing them as unique human beings. The authors state that while expert nurses desired to function as described by Benner, the realities of health care encouraged cynicism as a protective mechanism against burnout.
• Bonner, A., & Greenwood, J. (2006). The acquisition and exercise of nephrology nursing expertise: A grounded theory study. Journal of Clinical Nursing, 15, 480–489.
• This grounded theory study of 11 expert nurses and six non-expert nurses examined skill acquisition by nephrology nurses on an Australian renal unit. Three levels of skill were identified: non-expert, experienced non-expert, and expert. Comparisons with Benner’s five stages of skill acquisition are provided.
• Evans, R. J., & Donnelly, G. W. (2006). A model to describe the relationship between knowledge, skill, and judgment in nursing practice. Nursing Forum, 41(4), 150–157.
• This article introduces a model showing the relationships between knowledge, skill and judgment built upon the work by Benner. Allowance is made for varying levels of skill acquisition.
• Fennig, T., Bender, J., Colby, H., & Werner, R. R. (2005). Genesis of a professional development tool for ambulatory pediatric nursing practice. Health Care Manager, 24, 369–373.
• Benner’s work is used as the basis for development of a performance review tool used in a children’s hospital in Wisconsin. Job descriptions and rating tools were developed for use in the orientation program and evaluation of staff.
• Gobet, F., & Chassy, P. (2007). Towards an alternative to Benner’s theory of expert intuition in nursing: A discussion paper. International Journal of Nursing Studies. Retrieved June 14, 2007, from http://www.sciencedirect.com. Benner’s concept of expert intuition is reviewed in light of numerous published discussions of the concept. An alternative model is suggested along with a discussion of areas of agreement and disagreement with Benner’s work.
• Johns, C. (2005). Dwelling with Alison: A reflection on expertise. Complementary Therapies in Clinical Practice, 11, 37–44.
• This article discusses the concepts of reflection and clinical judgment in expert practice. Using the work of both Benner and Carper’s fundamental patterns of knowing in nursing, the author presents a case study and discusses the role of reflection for making conscious efforts to improve expertise as a complementary therapist.
• King, L., & Clark, J. M. (2002). Intuition and the development of expertise in surgical ward and intensive care nurses. Journal of Advanced Nursing, 37, 322–329.
• The authors use a qualitative study design to identify levels of expertise for 61 postoperative nurses, with particular attention to the concept of intuition. Findings are divided into advanced beginner, competent, proficient, and expert nursing levels of practice. Both intuition and analytical thinking were evident at all levels of practice. Ability to use intuition skillfully was more characteristic of expert nurses.
• Meretoja, R., Isoaho, H., & Leino-Kilpi, H. (2004). Nurse Competence Scale: Development and psychometric testing. Journal of Advanced Nursing, 47(2), 124–133.
• The authors present a discussion of the development of the Nurse Competence Scale that was derived from Benner’s work on skill acquisition in nursing. The resulting 73-item scale consisted of seven subcategories and showed good internal consistency. The tool is suggested to be useful in a variety of hospital work environments.
• Robinson, K., Eck, C., Kech, B., & Wells, N. (2003). The Vanderbilt professional nursing practice program. Part 1: Growing and supporting professional nursing practice. JONA, 33(9), 441–450.
• A career advancement model is presented based on Benner’s work on professional development in nursing. Four levels of practice are identified (advanced beginner to expert) along with related behaviors.
• Schoessler, M., & Waldo, M. (2006). The first 18 months of practice. A developmental transition model for the newly graduated nurse. Journal for Nurses in Staff Development, 22(2), 47–52.
• Benner’s work is used as the basis for a transition model for newly graduated nurses. Other aspects are included in the model drawn from transition management and learning theory. The model was developed using an interpretive phenomenological study of graduate nurses. Themes identified include relationships with patients, their families, and coworkers; organizational ability; and marker events. Three time phases are presented.
• Spichiger, E., Wallhagen, M., & Benner, P. (2005). Nursing as a caring practice from a phenomenological perspective. Scandinavian Journal of Caring Sciences, 19, 303–309.
• This article expands on Benner’s pivotal concept of caring in nursing practice. The concepts of caring, practice, and caring practices are examined from a phenomenological viewpoint.
• Simpson, E., Butler, M., Al-Somail, S., & Courtney, M. (2006). Guiding the transition of nursing practice from an inpatient to a community-care setting: A Saudi Arabian experience. Nursing and Health Sciences, 8, 120–124.
• Benner’s work on novice to expert nursing practice was used by the authors as the basis of the Transitional Practice Model in order to provide a smooth transition for nurses into the community setting. The model includes dimensions, domains of practice, and evaluation methods for each of the five stages of skill acquisition identified by Benner.
• Twycross, A., & Powls, L. (2006). How do children’s nurses make clinical decisions? Two preliminary studies. Journal of Clinical Nursing, 15, 1324–1335.
• Nurses’ decision making regarding postoperative pain management for children is examined across experience levels. All 27 nurses involved, regardless or experience level or setting (medical or surgical), tended to use the same type of decision-making skills in contrast to Benner’s assertion that decision-making skills change as nurses progress in professional skill development. In comparing the decision-making outcomes, more experienced nurses did not always make better decisions than less experienced nurses.
• Uys, L. R., Gwele, N. S., McInerney, P., van Rhyn, L., & Tanga, T. (2004). The competence of nursing graduates from problem-based programs in South Africa. Journal of Nursing Education, 43, 352–361.
• This qualitative study described the examination of the competency of 49 graduates from four nursing programs designed as problem-based learning programs compared to three conventional nursing programs in South Africa between six and nine months after graduation. Examples of behaviors indicative of each of the Benner’s novice, advanced beginner, competent, and proficient levels of skill acquisition were evident in the behaviors. No differences were found between the two groups related to level of practice.

Nursing Theories. The Base for Professional Nursing Practice, Sixth Edition

Chapter 22: Philosophy of Caring and Expert Nursing Practice: Patricia Benner

ISBN: 9780135135839 Author: Julia B. GeorgeRN, PhD

Copyright © Pearson Education (2011)

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