Nursing Theory Practice and their experts

Nursing Theory Practice and their experts
Select a theorist from those presented in Nursing Theories
Compose a 1400-word APA format paper
Include the following

Information about the theorist’s life, nursing role, and time period
An introduction to the theory, what level it falls under, and what influenced its development
The constructs of this theory in relation to the nursing metaparadigm
The influence the theorist has or had on the practice
How the theory continues to influence the role of the nurse

Cite a minimum of five scholarly sources.

Resource:

Philosophy of Caring and Expert Nursing Practice: Patricia Benner

Bobbe Ann Gray

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).

Nursing Theory Practice and their experts

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).

Nursing Theory Practice and their experts

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

Nursing Theory Practice and their experts

“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) Nursing Theory Practice and their experts

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).

Nursing Theory Practice and their experts 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.
Nursing Theory Practice and their experts

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.

Nursing Theory Practice and their experts 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.
Nursing Theory Practice and their experts

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 Theory Practice and their experts 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)
Nursing Theory Practice and their experts

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).

Nursing Theory Practice and their experts

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.
Nursing Theory Practice and their experts

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.

Nursing Theory Practice and their experts

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.
Nursing Theory Practice and their experts

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).

Nursing Theory Practice and their experts

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).
Nursing Theory Practice and their experts

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 experienc