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Clinical Nursing Theory

Patricia Benner was born in Hampton, Virginia and spent her childhood in California, where she received her early and professional education.

Majoring in nursing, she obtained a Bachelor of Arts degree from Pasadena College in 1964. In 1970, she earned a master’s degree in nursing, with her major emphasis in medical-surgical nursing from the University of California, San Francisco School of Nursing.

She worked as a research assistant to Richard Lazarus at the University of California, Berkeley, while working on her Ph.D. in the stress, coping, and health, which was conferred in 1982. Benner has a wide range of clinical experience including acute medical-surgical, critical care, and home healthcare.

She has held staff and head nurse positions. Benner has rich background in research and began this part of her career in 1970 as a postgraduate nurse researcher in the School of Nursing at the University of California, San Francisco.

In 1982, Benner achieved the position of associate professor in the Department of Physiological Nursing at the University of California, San Francisco and, in 1989, was tenured to professor, a position she currently holds. She teaches at the doctoral and master’s levels and serves on 8 to 10 dissertation committees per year (Tomey & Alligood, 2002.)

Benner studied clinical nursing practice in an attempt to discover and describe the knowledge embedded in nursing practice; that is, knowledge that accrues over time in a practice discipline and the difference between practical and theoretical knowledge. One of the first theoretical distinctions that Benner made was related to theory itself. Benner stated that knowledge development in a practice discipline “consist of extending practical knowledge (know-how) through theory-based scientific investigations and through the charting of the existence ‘know-how’ developed through clinical experience in the practice of that discipline.” She believes that nurses have been delinquent in documenting their clinical learning and “this lack of charting of our practices and clinical observations deprives nursing theory of the uniqueness and richness of the knowledge embedded in expert clinical practice;” Benner maintains that practical knowledge may extend theory or be developed before scientific formulas.

Clinical situations are always more varied and complicated than theoretical accounts; therefore clinical practice is an area of inquiry and a source of knowledge development. Clinical practice embodies the notion of excellence; by studying practice, nurses can uncover new knowledge. Nursing must develop the knowledge base of its practice (know-how) and, through scientific investigation and observation; it must begin to record and develop the know-how of clinical expertise. Ideally, practice and theory set up a dialogue that creates new possibilities.

Theory is derived from practice and practice is altered or extended by theory. Benner adapted Dreyfus and Dreyfus’ Model of Skill Acquisition and Skill Development to clinical nursing practice. Stuart and Hubert Dreyfus, both professors at the University of California at Berkeley, developed the Dreyfus model. The model is situational and describes five levels of skill acquisition and development: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert. The model assumes that changes in four aspects of performance occur in movement through the level of acquisition; (1) movement from reliance on abstract principles and rules to use of past, concrete experience; (2) shift from reliance on analytical, rule-based thinking to intuition; (3) change in the learner’s perception of the situation from viewing it as a compilation of equally relevant bits to viewing it as increasingly complex whole in which certain parts stand out as more or less relevant; and (4) passage from a detached observer, standing outside the situation, to one of a position of involvement, fully engaged in the situation.

The performance level can be determined only by consensual validation of expert judges and the assessment of outcomes of the situation. In subsequent research further explicating the Dreyfus model, Benner identified two interrelated aspects of practice that also distinguish the levels of practice from advanced beginner to expert. First, clinicians at different levels of practice live in different clinical worlds, recognizing and responding to different situated needs for action.

Second, clinicians develop what Benner terms agency, or the sense of responsibility toward the patient, and evolve into becoming a member of the healthcare team. Benner attempted to highlight the growing edges of clinical knowledge rather than to describe a typical nurse’s day. Benner’s explanation of nursing practice goes beyond the rigid application of rules and theories and is based on “reasonable behavior that responds to the demands of a given situation.”

The skills are acquired through nursing experience and the perceptual awareness that expert nurses develop as decision makers from the “gestalt of the situation” lead them to follow their hunches as they search for evidence to confirm the subtle changes they observe in patients (Tomey & Alligood, 2002.)

Benner stated that theory is crucial to form the right questions to ask in a clinical situation; theory directs the practitioner in looking for problems and anticipating care needs. There is always more to any situation than theory predicts. The skilled practice of the nursing exceeds the bounds of formal theory. Concrete experience provides learning about the exceptions and shades of meaning in a situation.

The knowledge embedded in practice discovers and interprets theory, precedes and extends theory, and synthesizes and adapts theory in caring nursing practice. Benner incorporated assumptions from the Dreyfus model, “that with experience and mastery the skill is transformed.” She stated, “This model assumes that all practical situations are far more complex than can be described by formal models, theories and textbook descriptions.” Benner and her collaborators explain the themes of nursing, person, situation, and health as follows: Nursing is describes as a caring relationship, an “enabling condition of connection and concern.” “Caring is primary because caring sets up the possibility of giving help and receiving help.” Nursing is viewed as a caring practice whose science is guided by moral art and ethics of care and responsibility.”

Benner and Wrubel have conceptualized the major aspects of understanding that the person must deal with as: the role of the situation, the role of the body, the role of personal concerns, and the role of temporality. Together, these aspects of the person make up the person in the world.

Health is defined as what can be assessed, whereas well being is the human experience of health or wholeness. Well being and being ill are understood as distinct ways of being in the world. Health is described as not just the absence of disease and not experience illness because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at the physical level.

Benner and Wrubel use the term situation rather than environment because situation conveys a social environment with social definition and meaningfulness. They use the phenomenological terms of being situated and situated meaning, which are defined by the person’s engaged interaction, interpretation, and understanding of the situation (Tomey & Alligood, 2002.)

Benner’s definitions of major concepts are as followed: Novice- That stage in the Dreyfus model of skill acquisition where no background understanding of the situation exists, so that context-free rules and attributes are required for safe entry and performance in the situation. It is unusual for a graduate nurse to be a novice, but it is possible. For example, an expert nurse in gerontology would be a novice in a neonatal intensive care unit. Many first-year nursing students will begin at the novice stage; however, students will begin at the novice stage; however, students who have had experience as nurse’s assistants will not be novice in basic nursing skills (Benner, 2001.)

Advance beginner- A stage in the Dreyfus model. One who can demonstrate marginally acceptable performance; one who has coped with enough real situations to note, or to have pointed out by a mentor, recurring meaningful situational components. The advanced beginner has enough background experience to recognize aspects of a situation (Benner, 2001)

Competent- A stage Dreyfus model of skill acquisition typified by considerable conscious, deliberate planning. The plan dictates which attributes and aspects of the current and contemplated future situation are to be considered most important and which can be ignored. The competent stage is evidenced by an increased level of efficiency (Benner, 2001)

Proficient- A stage in the Dreyfus model. The proficient performer perceives situations as whole rather than in terms of aspects, and performance is guided by maxims. There is a qualitative leap or discontinuity in problem approach between the proficient and the competent level of performance. The proficient performer recognizes a situation in terms of the overall picture. This person recognizes which aspects of the situation are most salient. The proficient performer has an intuitive grasp of the situation based upon a deep background understanding (Benner, 2001.)

Expert- The fifth stage of the Dreyfus model is achieved when “the expert performer no longer relies on analytical principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action.” Key aspects of the expert nurse’s practice are: (1) a clinical grasp and resource-based practice, (2) embodied know-how, (3) seeing the big picture, and (4) seeing the unexpected.

The expert nurse has the ability of pattern recognition on the basis of deep experiential background. For the expert nurse, meeting the patient’s actual concerns and needs is of utmost importance, even if it means planning and negotiating for a change in the plan of care. There is almost a transparent view of the self (Tomey & Alligood, 2002.)

Aspects of a situation- Cannot be described in a context-free way, can be understood only by a person with prior experience or understanding of the situation. For example, recognizing a patient’s readiness to learn or recognizing signs of withdrawal in children (due to depression over being separated from their parents) require prior experience with these concrete situations before they can be reliably recognized. Aspects of a situation can never attain the degree of certainty or clarity that is possible with attributes or measurable properties (Benner, 2001.)

Attributes of a situation- Quantifiable features or properties that can be explained without prior exposure to a real situation. For example, the nurse can learn to take temperature or blood pressure readings without prior knowledge of situations where blood pressure or temperatures are measured (Benner, 2001.)

Competency- An interpretively defined area of skilled performance identified and described by its intent, function, and meanings (as in competency statement). This use of competency is unrelated to the competent stage in the Dreyfus Model of Skill Acquisition (Benner, 2001.)

Domain- A domain of practice is a cluster of competencies that have similar intents, functions, and meanings (Benner, 2001.)

Exemplar- Refers to an example that conveys more than one intent, meaning function or outcome and can easily be compared or translated to other clinical situations whose objective characteristics might be quite different (Benner, 2001.)

Experience- Transactions count as experience only when the person actively refines preconceived notions and expectations. This “negative” view of experience has positive outcomes. Experience is gained when theoretical knowledge is refined, challenged, or disconfirmed by actual clinical evidence that enhances or runs counter to the theoretical understanding (Benner, 2001.)

Maxim- A cryptic description of skilled performance that can benefit one who has enough skill to recognize the implications of the instructions (Benner, 2001.)

Paradigm case- A clinical episode that alters one’s way of understanding and perceiving future clinical situations. These cases stand out in the clinician’s mind; they are reference points in their current clinical practice (Benner, 2001.)

Salience- The condition where certain aspects stand out as more or less important in a situation. Salience is a perceptual stance or embodied knowledge whereby a person does not deliberately have to calculate which aspects of the situation are more or less important; they just appear as more or less important. ( Benner, 2001.)

Patricia Benner’s From Novice to Expert theory is extremely clear and consistent with the framework from which it derived, which is the Dreyfus Model. The assumptions and assertions are consistent with the theory’s goal. Benner was not concerned about how nursing was to be done; instead her theory is based on how do nurses learn to do nursing (NurseScribe, 2000-2007).

Benner’s theory incorporated assumptions from the Dreyfus model “that with experience and mastery the skill is transform (Tomey & Alligood, 2002)

This theory is presented in an extremely simplified way, which an individual with little or no knowledge about the theory can comprehend.

Concepts and goals were specific to the level of expertise. The scope of theory is broad enough to establish significance.

Benner directed the AMICAE Project to develop evaluation methods for participating schools of nursing and hospitals in the San Francisco area. It was interpretive, descriptive study that led to the use of Dreyfus’ five levels of competency to describe skill acquisition in clinical nursing practice. IN describing the interpretive approach, Benner’s approach seeks a rich description of nursing practice from observation and narrative accounts of actual nursing practice to provide the text for interpretation.

The nurse’s descriptions of patient care situations in which they made a positive difference “present the uniqueness of nursing as a discipline and an art. Over 1200 nurse participants completed questionnaires and interviews; of these, trained researchers observed 51 participants.

Paired interviews with preceptors and preceptees were “aimed at discovering if there were distinguishable, characteristic differences in the novice’s amd expert’s descriptions of the same clinical incivations were conducted with 51 nurse-clinicians and other newly graduated nurses and senior nursing students to “describe characteristics of nurse performance at different stages of skill acquisition (Tomey & Alligood, 2002.)

Benner’s Theory: From Novice to Expert is highly important and was essential presented to guide research and nursing practice. Thanks to this model one can see how a nurse moves through each stage with experience.

This theory agrees with my own personal philosophy. I can see and understand how nursing students would be in the novice stage of skill acquisition. I also believe that with experience one eventually becomes an expert in the field.

The theory has been accepted by the nursing community. Even though there is an article that was recently written in 2007 stating that this theory is more of a nursing philosophy than a nursing theory. The article states that Benner’s work as a philosophy is more constructive ( Altmann, 2007.)

Another journal article on a simulation protocol structure, state that Benner’s concepts regarding the performance characteristics and learning needs of nurses with varying levels of clinical competency were incorporated into the development of the simulation. The simulation provided a positive learning experience in which students refined their patient management skills and collaborate with multidisciplinary team members to resolve common postoperative problems (Larew, et al, 2006.)

References

Altmann, T. K. (2007). An evaluation of the seminal work of Patricia Bennr. Theory or Philosophy? Contemporary Nurse: a Joural for the Australian Nursing Profession, 25(1/2), 114-23. Retrieved March 4, 2008, from ProQuest Health & Medical Complete database. (Document ID: 1320727201).

Benner, P (2001). From Novice to Expert. Excellence and Power in Clinical Nursing Practice. Commemorative Edition. Upper Saddle River, New Jersey. Prentice Hall Health.

Larew, C., Lessans, S., Spunt, D., Foster, D., Covington, B.G. (2006). INNOVATIONS IN CLINICAL SIMULATION: Application of Benner’s Theory in an Interactive Patient Care Simulation. Nursing Education Perspectives, 27(1), 16-21. Retrieved March 9, 2008, from ProQuest Health & Medical Complete database. (Document ID: 988894881).

NurseScribe. (2001-2007). Nursing Theorists. Retrieved March 5, 2008 from: www.enursescribe.com/nurse_theorists.htm.

Tomey, A. M., Alligood, M.R. (2002). Nursing Theorists and Their Work (5th Ed). St. Louis, MO: Mosby.