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Benners' Novice to Expert Model

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Distinctive Positions in Nursing

Associate Professor at University of California

International Lecturer/Researcher on Health

Chief Faculty Development Officer

Honorary Fellow of The Royal College of Nursing

Director of Carnegie Foundation for advancement of teaching National Nursing Education

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Primary work:  Book, "From Novice to Expert: Excellence and Power in Clinical Practice"

How developed:  Expansion in Stages of Clinical Competence adaption from Dreyfus Model
(Benner, 1982)(Bulletin of Science, 2004)

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Confidence of Nurse Educator

Experience related to practice

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Perceived Levels of Nurse Educators Attainment of NLN Core Compe

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Practitioner growth in stages

Comparative to primary experience as Registered Nurse

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  American Journal of Nursing  

      Issue: Volume 97(6), June 1997, p 16BBB, 16DDD
      Copyright: (C) Lippincott-Raven Publishers.
      Publication Type: [Nurse Practitioner Extra]
      ISSN: 0002-936X
      Accession: 00000446-199706000-00024       

 [Nurse Practitioner Extra]

  Becoming an Expert Nurse  

  Benner, Patricia PhD, RN, FAAN; Tanner, Christine A. PhD, RN, FAAN; Chesla,
Catherine A. DNSc, RN  

    Author Information 

  Patricia Benner is a professor of nursing at the University of California-San
Francisco. Christine A. Tanner is a professor of nursing at the Oregon Health
Science University, Portland, OR, and editor of the Journal of Nursing
Education. Catherine A. Chesla is an assistant professor at the University of
California-San Francisco.  

  Adapted with permission from Expertise in Nursing Practice: Caring, Clinical
Judgment, and Ethics, by Patricia Benner, PhD, RN, FAAN, Christine A. Tanner,
PhD, RN, FAAN, and Catherine A. Chesla, DNSc, RN, with contributions by Hubert
L. Dreyfus, PhD, Stuart E. Dreyfus, PhD, Jane Rubin, PhD.  

----------------------------------------------

    Outline

    Abstract

    Response based on understanding

    Comfort with emotional involvement

    Feeling an ethical responsibility

    Making it all work

    SELECTED REFERENCES

Abstract

Learning to 'read' your patient is as important as any lesson taught in the
classroom. Based on their six-year study, these nurse researchers explain how
the expert nurse combines practical experience and textbook knowledge in
responding to the needs of patients.

----------------------------------------------

If you take a moment to evaluate your practice, you'll see that you can look at
your patients and notice the smallest changes in them. When something is wrong,
you can almost feel it, even if it doesn't register on a monitor. You observed
subtleties-a slight variation in breathing pattern or an alteration in color.
From past clinical experiences, you know when there's about to be a major change
in a patient's status, and combining experience with scientific knowledge, you
instinctively prepare for treating that challenge. You are an expert nurse.

Your development as a nurse was gradual. From beginner to competent practitioner
to proficient practitioner and, finally, to expert, each interrelated step was
marked by a progressive increase in clinical knowledge and critical thinking. At
each level, your ways of thinking and acting shifted and your performance
improved.

For example, at the proficient level you had the capacity for recognizing whole
patterns and a budding sense of salience. Relevant aspects of a given situation
simply stood out without recourse to calculative reasoning. You could read a
situation, recognize changing relevance, and shift your perspective on the
situation, though your ways of responding weren't yet linked to ways of seeing
the situation. You still had to think about what to do.

At the level of expert practice, you've developed intuitive links and are able
to see salient issues in a situation and know how to respond to them. The links
between a patient's condition and your actions are strong. This intuitive link
in the practice of expert nursing is illustrated in the following scenario,
involving a patient who was hemorrhaging and had stopped breathing, as recounted
by an expert nurse. The focus of the nurse's narrative is on the action taken
rather than the identified problem.

So we didn't even call the code. We just called the doc stat and got him up
there. [They had sufficient people available to resuscitate the patient, so no
formal page for additional help was needed.] I looked at his heart rate and I
said: "OK, he is bradying down. Someone want to give me some atropine?" I just
started calling out the drugs that I needed to get for this guy, so we started
to push these drugs in. In the meantime, I said, "Can we have some more blood?"
I was just barking out this stuff. I can't even tell you the sequence. I was
saying, "We need this." I needed to anticipate what was going to happen and I
could do this because I had been through this a week before with this guy and
knew what we had done [and what had worked]. The anesthesiologist came in and
did a good intubation. He asks: "What kind of lines do we have?" I said, "We
have a triple lumen and we have blood. All ports are taken. We need another kind
of line. He's got no veins left." He goes, "OK, fine, give me a cut-down
tray[horizontal ellipsis]"

Response based on understanding

In the preceding narrative, recognition and assessment language are minimal,
partially because the number of actions per problem are limited, but also
because recognition and assessment become so linked with actions and outcomes
that they're self-evident. In this situation, the response was exceptionally
fluid because the nurse had taken care of the patient during a previous
resuscitation. She had learned, first-hand, what worked and what didn't. Her
responses weren't rote, but based on understanding gained from the previous
experience.

As an expert nurse, your practice is characterized by engaged practical
reasoning, which relies on mature and practiced understanding, and a perceptual
grasp of similarities and differences in particular situations. Though you know
what to anticipate and how to prepare for possible issues and problems, you
remain open to what each circumstance presents. When deeply involved in a
problem, your view isn't detached, Rather, your actions reflect your attunement
to the situation. Your responses are shaped by a watchful reading of the patient
without recourse to conscious deliberation. Your performance is fluid, almost
seamless. When you recall an event, you focus on informed action, rather than
organization, priority setting, and task completion.

Comfort with emotional involvement

At the expert level, you're comfortable in your emotional involvement with
patients and their families. Rather than offering uniform or standardized
responses, emotional involvement varies considerably with the needs and openness
of the patient and family. In narratives of connection and attunement, expert
nurses focus on the needs, resourcefulness, and concerns of the other, not their
own virtuosity and virtousness in providing care.

You can readily describe those patients and families with whom you've had a
special connection that was either sustaining for the patient or gave you a new
understanding of the patient's world and what was important to him. You don't
harbor illusions that such relationships are possible with all patients; you
know they're not. For extremely vulnerable patients, you know emotional
connections are necessary for survival, as is illustrated in the following
narrative about a physician who was critically ill and mechanically ventilated.
For the nurse involved, the case became a paradigm for unusually close and
lifesaving connections with patients.

Nurse: He developed ARDS [acute respiratory distress syndrome] like I've never
seen anybody develop ARDS. Within hours, he was on a 100% O2 and 15 of pressure,
and then he had pneumos and bradycardia if they took him off the ventilator.
This was all very sudden and unexpected for an elderly man who was healthy[horizontal
ellipsis] He was a retired physician. So he really wanted to be interactive, and
you really couldn't let him be because his airway pressure was so high, that he
would try to write or try to communicate and I was afraid that he would blow
another pneumo. So with this type of balance going on[horizontal ellipsis]

Interviewer: What made you want to pick him as a patient-what attracted you?

Nurse: He just was really vital. He wanted to know what was going on and he was
writing and he had really bad spelling, and I remember thinking, he's so great,
and yet his spelling is atrocious. He's really trying to communicate with me and
I'm trying to sedate him and there was just a lot of me trying to allay his
anxiety and his family's and to try to keep him going, and it was a frightening
situation not to have that much more to offer in such a quick period of
time[horizontal ellipsis]it wasn't like he was bleeding and you could give him
blood. It was a pulmonary process, which was going on and on for whatever
unknown [reason]. No one ever knew what happened to him. On this day in ICU, it
was really stormy. He arrested a couple of times. Jean[another nurse] was taking
care of him one time and he was very unstable; if you didn't watch his color,
his eyes, if he tremored, you really had to pick up on it, much more than his
numbers, much more than his monitoring[horizontal ellipsis]Sometimes I just had
to gauge what I was doing with him, and how quickly he would become hypoxic[horizontal
ellipsis]There weren't any numbers because I would have to get a blood gas, take
it to the lab, and do whatever you had to do. You had to base a lot of what you
were doing on what was happening right then, rather than get a test to say:
"I've documented it." You had to more or less look at him and just know. And to
know his fatigue, know just how much he could do[horizontal ellipsis]You ask
somebody if you want to get out of bed, you want to eat? There are so many
things he didn't want to do after this withdrawal period, or he would only be
selective with people that he was involved with, that he cared about. Was he
tired? It was just a matter of why he resisted it. Does it mean coax him or that
you have pushed him too far?

Feeling an ethical responsibility

Knowing your patient and being able to act on your knowledge is essential. If
warning signs for cardiac arrest, such as "his color, his eyes, if he tremored,"
came before overt changes in vital signs, this lead time could be critical in
preventing cardiac arrest by adjusting intravenous medications and ventilator
settings. As the nurse in the previous scenario noted, it was necessary to be
able to distinguish when the patient was resisting movement from when he was too
tired or weak for planned activities and treatments. Expert care in this
situation required a high level of patient attunement and an ability to link the
patient's condition with instant therapeutic responses.

Central to expert practice is a concern for revealing and responding to patients
as persons, respecting their dignity, caring for them in ways that preserve
their personhood, protect them in their vulnerability, help them feel safe in a
somewhat alien environment, comfort their families, and preserve the integrity
of close relationships. Because you're enabled by clinical experience and
perceptual acuity, your ethical responsibility to the patient is embedded in
your everyday practice. Your skill of involvement with the patient, family, and
clinical situation allows you to manage technology, preventing unnecessary
technological intrusions, and work with and through others on your patient's
behalf.

Making it all work

The clinical aspects of expert nursing are intertwined with the moral and
emotional dimensions of your relationship with patients. Your decisions
regarding care are made possible by the relationships you develop with your
patients and their families. As an expert nurse, you also have a responsibility
to help show novices, by example, how to treat patients with empathy and
progress in their development to an expert nurse.

SELECTED REFERENCES

Benner, P., et al. From beginner to expert: Gaining a differentiated clinical
world in critical care nursing. ANS Adv.Nurs.Sci. 14(3):13-28, Mar. 1992.

Dreyfus, H. L., and Dreyfus, S.E. Mind over Machine: The Power of Human
Intuition and Expertise in the Era of the Computer. New York, Free Press, 1986.

Tanner, C. A., et al. The phenomenology of knowing the patient. Image J.
Nurs.Sch 26:273-280, Winter 1993.



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Role of Nursing Leadership in Novice Nurses

Documents transition represented in first stage of Theory

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New Graduate Nurse Transition Programs and Clinical Leadership Skills in Novice RNs

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Purpose: Self-evaluation of Skill  Set  and professional growth, understanding experience

Scope: High Middle-Range Theory

Origin: Dreyfus Model of Skill Acquisition

Major Concepts:

Impact of Nursing experience

Developing Nursing skill Sets

Applying Evidenced-based practice

Five stages of Proficiency

1. Novice

2. Advanced Beginner

3. Competent

4. Proficient

5. Expert

(Benner, 1982)

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Analysis of Patricia Benner's: From Novice to Expert Theory

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Analysis of Patricia Benner's: From Novice to Expert Theory

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Patricia Benner  Analyzation of Theory.edited 2