Patricia E. Benner R.N., Ph.D., FAAN By Courtney Madsen, Barb Lentz, Denise Lyon, Yvonne Robles, Dawn Kooiman, and Lynda Chase

Historical Evolution of Theory: Novice to Expert Born in Hampton, Virginia Grew up in California Degrees: Baccalaureate~ Pasadena College- 1964 Masters in Nursing~University of California- 1970 PhD~ University of California- 1982 Published From Novice to Expert- 1984 Became a Fellow in the American Academy of Nursing- 1985

Model as Framework for Patient Assessment Novice to Expert The Novice: First Year of Education No background experience Instructor provides clear directions Students are coached and need supervision Advanced Beginner: New Graduate Now have full legal and professional responsibilities Style of evaluation still lacks Continues to rely on textbook s/s and may have difficulties recognizing subtle variations

Model as Framework for Patient Assessment Cont. Competent Stage: 1 to 2 Years in Practice Time for planning of the immediate future related to learned information from past experiences A nurse can now forecast using planning and analysis More subtle s/s are now recognized

Model as Framework for Patient Assessment Cont. Proficiency: A nurse now has an enhanced ability to read a situation Now open to correction an discomfirmation of a situation Responsiveness to changes and critical thinking unfolds

Model as Framework for Patient Assessment Cont. Expertise: Now attends primarily to actions rather than assessment of signs and symptoms The integrated rapid response is the hallmark of expertise More proficient in an emergent situation

Model used in Clinical Practice Implement a staff development program A clinical ladder evaluation tool Novice: ICU nurse transferred to the OR, these require very different nursing skills Advanced Beginner: New graduate nurse on a med-surg floor would require a much more in-depth orientation than a nurse with previous experience Competent: An OB nurse has the ability to care for a patient on a labor and delivery unit, but if a more difficult and serious situation arises a proficient or expert OB nurse would need to step in

Model used in Clinical Practice Cont. Proficient: A cardiac rehab nurse recognizes changes in the patients ECG monitor while the patient exhibits exertion. The nurse immediately implements her skills from knowledge and expertise that appropriately prevent a worsening outcome Expert: ICU nurse caring for a post open-heart patient in which he or she is able to anticipate needs from various tests and readings. This nurse also has the ability to teach using a through explanation to the patient and family. An expert nurse exhibits leadership qualities and is a good preceptor to new nurses

Model used in Clinical Practice Cont. Clinical Ladder Evaluation Tool: It can be used as an advancement program for nurses. A clinical ladder helps with retention of experienced nurses “Clinical ladders recognize and reward nurses for their clinical development and expertise, while encouraging them to remain involved in direct patient care activities” As a nurse moves along the ladder, they need to show proof of advancement in their practice such as continuing education and leadership qualities

Model within Nursing Education The movement from novice to expert reflects learning and shows changes in three aspects of performance Working paradigm shifts from reliance on abstract principles to concrete past experiences Shifts from seeing situations as discreet unrelated parts, to seeing situations as part of a whole Position shifts from detached observer to involved performer Studies show novice professionals tend to govern their practice with rule-oriented behavior. Must rely on rules they have learned in preparatory education to function

Interested in the Dreyfus model of skill acquisition and applied it to nursing Area of concern~ not how to do nursing, but rather, “how do nurses learn to do nursing?” Worked several years in intensive care, then became a nurse researcher Studied the nature of nursing practice and how nurses gain expertise Studied with Richard Lazarus who developed a theory of stress and coping Influenced by Heidegger, who stressed phenomenological descriptions of people defined by their concerns, practices, and life experiences

Metaparadigms Person: A self interpreting being that becomes defined in the course of living a life. A person is embodied Four major aspects of understanding The situation Their body Their personal concerns The fact that they are only temporary When caring for the person, nurses tend to all four aspects Health Nursing

Metaparadigms cont. Situation (Environment): Situation conveys a social interaction, interpretation, and understanding Each situation is individual because their meanings, habits, and perspectives influence the situation People will react differently in each situation because of their own personal interpretation (Alligood @ Tomey, 2010, p. 149) Health: Two aspects include health and well-being Health~ can be assessed at the physical level Well-being~ human experience of health Health is not just the absence of disease

Metaparadigms cont. Nursing: Nursing is viewed as a caring practice whose science is guided by the moral and ethical standards of care and responsibility

Current Research Status Benner’s model serves as a map that directs care, and is used as a tool in current nursing practice Her work is useful in that it frames nursing practice in the context of what nursing actually is and does Many occupations have adapted this model to benefit their employees and their customers Benner’s call is to “increase public storytelling” to validate nursing as an ethical caring practice, and “to extend, alter, and preserve ethical distinctions and concerns” (Benner, 1991, pp. 19-20) Her approach continues to be dynamic and specific for each institution

Unique Concepts The model is situational, based on skill level and changes in performance Performance is a function of a nurse’s familiarity with certain situations Performance level can only be determined by expert judges and the outcomes of the situation Clinicians at different levels of practice live in different clinical worlds Author & project director of Achieving Methods of Intraprofessional Consensus, Assessment and Evaluation

Unique Concepts Cont. Benner’s explanation of nursing practice goes beyond rules and theories – based on “reasonable behavior that responds to the demands of a given situation” Incorporated Lazarus’s stress and coping theory – used this key concept to describe clinical nursing practice in terms of nurses making a positive difference by being a part of the situation in a caring way Novice to Expert concept, shows that clinical experience becomes knowledge and theory Benner differentiated between practical and theoretical knowledge

Strengths and Limitations Continue to learn through experience Experience becomes a prerequisite for becoming an expert Lays ground work for the development of preceptors and mentors Preceptors help new nurses deal with the uncertainty of the clinical setting Not everyone fits into this model You need to be able to classify in order for the theory to work No room for advancement or no opportunity for a certification in a specialty area

Analysis: Benner proposes that one could gain knowledge and skills (“knowing how”) whithout learning the theory (“knowing that”) (Dracup, 2004) Accomplished by defining 5 levels of development The novice sees the patient as a list of tasks An expert sees all of the pieces and makes a whole

Insights: This model can serve as a basis for developing a mentorship program at facilities to support new nurses as they enter the field This is particularly important with the magnitude of nurses that graduate each year Due to the changes in healthcare and advancements in technology more nurses will be needed Longevity is increasing everyday and now healthcare will be available to more people in the future Understanding this model and the five levels from Novice to Expert will assist nurses with excelling in their careers

References Acclaim Images, LLC. Nurse Clipart. Picurtes and photos. http://www.picturesof.net/search_term_pages/nurse.html Alligood, M .R. & Tomey, A. M. (2010). Nursing Theorists and their Work. Maryland Heights, MO: Mosby, Elsevier (978-0-323- 05641-0) Benner, P. (1982). From novice to expert. American Journal of Nursing, 82, 402-407. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, California: Addison-Wesley Publishing Company. Benner, P., & Tanner, C. (1987). Clinical judgment: How expert nurses use intuition. American Journal of Nursing, 87, 23-31. Benner, P., Tanner, C., & Chesla, C. (1992). From beginner to expert: Gaining a differentiated clinical world in critical care nursing. ANS Advances in Nursing Science, 14(3), 13-28. Benner, P. (2004). Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education. Bulletin of Science Technology Society. Vol. 24. No. 3 Pp. 188-199. Doi 10.1177/0270464604265061 Brykczynski, Karen A (2010). Caring, Clinical Wisdom, and Ethics in Nursing Practice, A.M. Tomey, M.R. Alligood, Nursing theorists and their work (7th ed., pp.137-164) Maryland Heights, MD: Mosby Elsevier Dracup, K. and Bryan-Brown, C. (2004) From Novice to Expert to Mentor: Shaping the Future. American Journal of Critical Care, 13 (6), 448-450. Retrieved from http://ajcc.aacnjournals.org/cgi/content/full/13/6/448 Haag-Heitman, B. (1999). Clinical practice development using novice to expert theory. Gaithersburg, MD: Aspen. Marshall, June (2006). Retain top nurses with a clinical ladder. HCPro’s Weekly Update on the ANCC Magnet Recognition Program. University of California, San Francisco. (2006) Patricia Benner: Faculty Profile. UCSF of Nursing. Retrieved from http://nurseweb.ucsf.edu/www/ffbennp.htm