Seminar on Seminar on Nursing Practice ExpertiseNursing Practice Expertise

A Theory by Patricia Benner

PresenterTilarupa Bhattarai

M.Sc. First Year, 2009 Batch

SupervisorMr. R.S. MehtaAssociated Professor, Department of Medical Surgical Nursing, College of Nursing

ContentContentIntroduction of Patricia BennerConcept of the TheoryPatricia Benner’s Theory of

Nursing Practice ExpertiseCritique of the TheoryNovice to Expert ScaleSummary

Introduction of Patricia BennerPatricia Benner is a Professor in the Department of Physiological Nursing in the School of Nursing at the University of California, San Francisco.

Dr. Benner received her bachelor's degree in nursing from Pasadena College, Master's degree in medical surgical nursing from the University of California, San Francisco, The Ph.D. from the University of California, Berkeley, in Stress and Coping and Health under the direction of Hubert Dreyfus and Richard Lazarus.

Dr. Benner is the author of nine books including

1. From Novice to Expert, named an American Journal of Nursing Book of the Year for nursing education and nursing research in 1984

2. The Primacy of Caring, co-authored with Judith Wrubel, named Book of the Year in 1990, also in two categories. Her books have been translated into eight languages.

3. Interpretive Phenomenology: Embodiment, Caring and Ethics in Health and Illness,

4. The Crisis of Care, 5. Expertise in Nursing Practice: Caring, Clinical Judgment,

and Ethics, 6. Caregiving, 7. Clinical Wisdom and Interventions in Critical Care: A

Thinking-In-Action Approach.

Is an internationally noted researcher and lecturer on health, stress and coping, skill acquisition and ethics.

Recently elected an honorary fellow of the Royal College of Nursing.

Staff nurse in the areas of medical-surgical, emergency room, coronary care, intensive care units and home care.

Currently, her research includes the study of nursing practice in intensive care units and nursing ethics.

Concept of the TheoryConcept of the Theory Expertise Expertise can be defined as the professional artistry and practice

wisdom inherent in professional practice.

Again professional artistry can be defined as the meaningful expression of a uniquely individual view within a shared tradition. It involves a blend of: practitioner qualities , practice skills, creative imagination processes (Titchen & Higgs, 2001).

Practice wisdom is the possession of practice experience and

knowledge together with the ability to use them critically, intuitively and practically. Including characteristics of clarity, discernment and caring deeply from an objective stance, practice wisdom is a component of professional artistry.

Development of Expertise

Expertise or tacit knowledge is a manifestation of an individual's experiential knowledge acquired over the life course.

Adaptation of implicit knowledge to new situations requires ◦ thinking and ◦ reflective skills.

Reflectivity is associated with the expansion of an expert's horizon.

Students need to learn to recognize and describe "the context, meanings, characteristics, and outcomes of their connoisseurship"

Philosophical Underpinnings

Benner's ideas are based on the difference between practical and theoretical knowledge.

Practical situations are more complex than they initially appear.

Both experience and mastery are necessary for a skill to be transformed to a higher level skill.

Other central tenets underpinning Benner's

philosophy are the connections between external and internal events .

Benner believes that nurses develop and accumulate global sets and paradigms about patients, those paradigms develop expert intuition and sets not readily apparent to the outside observer.

Expert nurses use empirics, ethics and personal knowledge.

Benner supports that individuals interpret their own concerns, practices and life experiences.

Ways of KnowingWays of KnowingEmpiricMoral or ethical knowledgePersonal KnowledgeAesthetic

Dreyfus Model of Skill Dreyfus Model of Skill AcquisitionAcquisition

Novice

Advanced Beginner

Expert

Proficient

Competent

One is a movement from reliance on abstract principles to the use of past concrete experience as paradigms.

The second is a change in the learner's perception of the demand situation, in which the situation is seen less and less as a compilation of equally relevant bits, and more and more as a complete whole in which only certain parts are relevant.

The third is a passage from detached observation to involved performer. The performer no longer stands outside the situation but is now engaged in the situation.

Dimension of change in different phases

Patricia Benner's Theory of Patricia Benner's Theory of Nursing Practice ExpertiseNursing Practice Expertise

Benner acknowledges that she utilizes the same five stages which Dreyfus posited.

The stages are utilized after Benner's initial observations of 120 nurses and identification of 31 skills.

Stage 1: NoviceStage 1: Novice

Beginners have had no experience of the situations in which they are expected to perform.

Novices are taught rules to help them perform.

The rules are context-free and independent of specific cases; hence the rules tend to be applied universally.

The rule-governed behavior of the novice is extremely limited and inflexible.

As such, novices have no "life experience" in the application of rules.

"Just tell me what I need to do and I'll do it."

Stage 2: Advanced Beginner

Can demonstrate marginally acceptable performance

Have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components can recognize in actual situation

Principles to guide actions begin to be formulated.

The principles are based on experience.

Stage 3: Competent

Competence, typified by the nurse who has been on the job in the same or similar situations two or three years.

Develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware.

For the competent nurse, a plan establishes a perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem.

The conscious, deliberate planning that is characteristic of this skill level helps achieve efficiency and organization.

Lacks the speed and flexibility of the proficient nurse but does have a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing.

The competent person does not yet have enough experience to recognize a situation in terms of an overall picture or in terms of which aspects are most salient, most important.

Stage 4: Proficient

The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims.

Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals.

The proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events.

The proficient nurse can now recognize when the expected normal picture does not materialize.

This holistic understanding improves the proficient nurse's decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones.

The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later.

Once one has a deep understanding of the situation overall, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation.

Stage 5: The Expert

The expert performer no longer relies on an analytic principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action.

The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions.

The expert operates from a deep understanding of the total situation.

The chess master, for instance, when asked why he or she made a particularly masterful move, will just say: "Because it felt right; it looked good."

The performer is no longer aware of features and rules;' his/her performance becomes fluid and flexible and highly proficient.

This is not to say that the expert never uses analytic tools. Highly skilled analytic ability is necessary for those situations with which the nurse has had no previous experience.

Analytic tools are also necessary for those times when the expert gets a wrong grasp of the situation and then finds that events and behaviors are not occurring as expected When alternative perspectives are not available to the clinician, the only way out of a wrong grasp of the problem is by using analytic problem solving.

Critique of the Model as a Critique of the Model as a TheoryTheory

Meleis (1991) describes a method for critiquing a theory suggesting the following areas be assessed:

Critique of the TheoryCritique of the Theory

Although Benner's model most closely fits the definition of a philosophy, certain aspects can be critiqued as if it were a theory.

ClarityClarity 'denotes precision of

boundaries, a communication of a sense of orderliness, vividness of meaning and consistency throughout the theory'.

Benner provides theoretical definitions for all major concepts, but not the operational definitions necessary for empirical measurement.

She follows the logical sequence developed by Dreyfus, does not deviate by introducing other concepts and states her philosophy simply and briefly.

Benner's philosophy is general, yet situation dependent; it encompasses many aspects of nursing from students through expert practitioners and espouses a broad range of applications within nursing such as in administration and research.

Thus the theory of Benner is not that much clear

ConsistencyConsistency is determined by evaluating

the congruency between each component of a theory.

Benner's model contains concepts which are consistent with each other and are consistently utilized.

Since first proposing the philosophy, Benner has continued to research the phenomena and has not changed her concepts.

This is difficult to quantify, however, since specific operational definitions have not been articulated.

Simplicity Vs. Complexity It relates to the number of phenomena the

theory considers and the relationships which could develop. Depending on the purpose of the theory, either simplicity or complexity could be preferred.

The model is relatively simple in regard to the five stages of skill acquisition and it provides a comparative guide for identifying levels of nursing practice from individual nurse descriptions and observations of actual nursing practice'.

The essence of the model is easy to grasp and explain.

A degree of complexity is, however, encountered when trying to differentiate between the stages and exactly what prompts progression.

Visual RepresentationVisual representations of the theory

may further enhance its clarity.

Benner does not present a visual representation, but the stages can be referred to as being along a continuum.

Progress along this continuum is sequential from novice to expert, but may include regression when the nurse is in an unfamiliar situation.

Contagiousness Contagiousness 'is whether or not it is adopted by

others' and must look at the geographical location and type of institution which adopted the theory.

This philosophy has been adopted in many countries and by many different types of institutions.

This is evident, in a simple form, by reviewing the literature, noting articles from different countries and relating to different uses of the philosophy.

Benner's model has been adapted by schools of nursing, hospitals, social agencies and by developers of nursing continuing education programs.

Usefulness Assessing the usefulness of a theory includes its usefulness

in practice, research, education and administration. Benner's model has been utilized in all areas to be

assessed (Darbyshire 1994; Effken 2001; McKee et al. nd; Shapiro 1998).

Benner's model has become the foundation for preceptor programs for students and new graduate nurses (Myrick & Barrett, 1992), as well as continuing education programs.

Many research studies have been conducted based on the concepts proposed by Benner.

Many schools of nursing adopted this model as a basis for providing education, as noted by English (1993).

Nursing administration has utilized this model to develop career ladders, staff development and recognition and rewards programs (Nelson & McGillion 2004).

ValuesValues include those of the theorist and

the critic, other professions and society.

Values are not explicitly identified in this philosophy.

This philosophy was borrowed from another profession which demonstrates congruence.

The knowledge level of the practicing nurse is especially important to the individual receiving the care, thus to society.

Social Significance

Finally, the social significance must be assessed because 'in our attempt to enhance nursing science and articulate the discipline of nursing we must not neglect the significance of its practice to humanity and society' (Meleis 1991: 237).

This model is proposed as a method for determining the expert practitioners and developing more expertise in practitioners.

This has social ramifications as it is optimal to have the best, most knowledgeable, practitioners providing care.

In 1978, Carper described four patterns of knowing in nursing: empirics, moral/ethical knowledge, personal knowing and aesthetics. Benner only specifically discusses ethical and personal knowing.

Benner's model has been criticized for not being quantitative; her research used a qualitative approach. The philosophical basis of Benner's work challenges the traditional notion of objective science.

The study conducted by Benner included small number of participant, so the theory developed by such study might contain bias.

SummarySummaryThe theory is based on Dreyfus model of

skill acquisition.

It explains the five stages of novice, advanced beginner, competent, proficient and expert to acquire expertise in nursing practice.

Highlights the differences between the theoretical and the practical knowledge.

Considered as model and philosophy rather than theory.

ReferencesReferences1. Tanya KA. "An evaluation of the seminal work of

Patricia Benner: theory or philosophy?". Contemporary Nurse. FindArticles.com. 24 Mar, 2010. http://findarticles.com/p/articles/mi_6813/is_1-2_25/ai_n28442030/

2. Dracup K, Bryan-Brown CW. Editorial, American Journal of Critical Care;13; 2004: 448-450, Available on http://ajcc.aacnjournals.org/cgi/content/full/13/6/448, Cited on 7th June 2010.

3. Biography of Patricia Benner, Available on http://home.earthlink.net/~bennerassoc/patricia.html ; Cited on 7th June 2010

4. Dreyfus model of skill acquisition Available on http://en.wikipedia.org/wiki/Dreyfus_model_of_skill_acquisition, Cited on 7th June 2010.