LeeAnn Disbrow, Keri Foster, Amy Haines, Marianne Lannen

What is a Nursing Theory? What is a Nursing Model? Introduction

Nursing theories are used to describe, explain, predict or prescribe nursing care. Nursing models involve integration of nursing theory and knowledge to provide care to patients using the nursing process. ( theories.html)

The Nurse Theorist that I most identify with introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experience. Who is this Nurse Theorist? ( er_From_Novice_to_Expert.html)

Assumptions & Point of View Her research and theory work provides the nursing profession with the Novice to Expert model. Within this model are Benner’s stages of clinical competence which were developed from the Dreyfus model of skill acquisition. (Benner, 2010)

Benner believed that experience is essential to nursing because it allows a nurse to expand their knowledge and to provide and competent care to patients; therefore she developed the Novice to Expert model. Benner believed that experience is essential to nursing because it allows a nurse to expand their knowledge and to provide holistic and competent care to patients; therefore she developed the Novice to Expert model. Benner’s 5 stages of nurse development Novice Advanced Beginner Competent Proficient Expert There are 5 stages that a nurse will go through to develop competence and expertise. ( ng-models-theories.html)

Patricia Benner’s philosophic values about nursing and knowledge development: Benner teaches  philosophy of nursing science  stress and coping  skill acquisition  ethics Her research focuses on  Skills  Clinical judgment in nursing practice She believed that development of knowledge is based on both the extension of practical knowledge through research and the characterization and understanding of the clinical experience. ( nursing-models-theories.html)

She proposed that one could gain AND Without ever learning the theory and believes that skill experience will lead to becoming an expert. ( _nursing-models-theories.html)

The Dreyfus model influenced Benner’s philosophy She based her stages of clinical competence on the Dreyfus model and developed the Novice to Expert Model. The Dreyfus Model Expert: Needs to expand knowledge and experience. Proficient: Needs unhindered practice and “the big picture”. Competent: Needs real world exposure. Advanced Beginner: Needs simple, controlled simulations. Novice: Needs recipes, monitoring and first successes. Benner’s 5 Stages Novice Advanced Beginner Competent Proficient Expert ( _nursing-models- theories.html)

Benner believes that it takes a strong educational base as well as many experiences to develop sound skills and an understanding of patient care. += ( t_ _nursing-models- theories.html)

Information and Concepts Concept of Nursing Human Being Environment Health Nursing

Human Being (Person) “a person is a self-interpreting being, that is, the person does not come into the world predefined but gets defined in the course of living a life. A person also has … an effortless and nonreflective understanding of the self in the world. The person is viewed as a participant in common meanings.” (Brykczynski, 2010, p.148) Brykczynski describes Benner’s description of person as

4 major aspects of understanding that the person must deal with: The role of the situation. The role of the body. The role of personal concerns. The role of temporality

Brykczynski (2010) writes that Benner and Wrubel describe the five dimensions of the body as based on the work of Merleau-Ponty (1962), Dreyfus (1979, 1991), and Dreyfus and Dreyfus (1986) as those listed above. The unborn complex The habitual skilled The projective The actual projected The phenomenal The 5 dimensions of the body:

THE UNBORN COMPLEX: The acculturated body of the fetus and newborn baby. THE HABITUAL SKILLED: Body complete with socially learned postures, gestures, customs, and skills evident in bodily skills such as sense perception and “body language” that are learned over time through identification imitation and trial and error. THE PROJECTIVE: Body that is set (predisposed) to act in specific situations (e.g., opening a door or walking).

THE ACTUAL PROJECTED: Body indicating an individual’s current bodily orientation or projection in a situation that is flexible and varied to fit the situation, such as when an individual is skillful in using a computer. THE PHENOMENAL: Body aware of itself with the ability to imagine and describe kinesthetic sensations.

Environment (Situation) Brykczynski (2010, p. 149) writes about the term of situation rather than environment as written by Benner and Wrubel in 1989 because they state situation conveys a social environment with social definition and meaningfulness. “Each person’s past, present, and future, which include their own personal meanings, habits, and perspective, influence the current situation.” (Brykczynski, 2010, p.149)

Health Brykczynski (2010) writes 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. ) Brykczynski (2010) also writes that based on the work of Kleinman, Eisenberg,and Good (1978), a person may have a 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 (p. 149).

Nursing Benner describe s Nursing 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” (Brykczynski, 2010, p. 148). Benner also states that “nursing practice is the care and study of the lived experience of health, illness, and disease and the relationships among these three elements” (Brykczynski, 2010, p. 148).

Human Being Environment Health Nursing are that it is collaborative and nursing exceeds the bounds of formal theory (Brykczynski, 2010, p. 149).

Interpretation & Inference and Implications & Consequences Clarification of Origins Benner clearly acknowledges that her thinking in nursing has been influenced greatly by Virginia Henderson (Brykczynski, 2010, p. 137) and that she adapted the Dreyfus model of Skill Acquisition to clinical nursing practice (Brykcyznski, 2010, p. 140). Virginia Henderson Benner’s use of the Dreyfus model of Skill Acquisition was the first time that it was used to further define nursing. Stuart and Hubert Dreyfus

While the Dreyfus model has been tested and by some considered possibly to be a” middle- range theory” (Altmann, 2007, p.120), Benner’s work seems to still be classified and listed by most as a Benner’s philosophy has been” adopted by many countries and by many institutions” and well as “adapted by many schools of nursing, hospitals, social agencies and developers of continuing education for nursing” (Altmann, 2007, p. 120).

. The Novice to Expert model’s “strength is that data-based research contributes to the science of nursing as a practice discipline” and the significance “lies in her conclusion that a nurses clinical knowledge is relevant to the extent to which its manifestation in nursing skills makes a difference in patient care and patient outcomes”(Brykcynski, 2010, p. 153).

Benner’s 5 Stages of nursing experience Novice Advanced Beginner Competent Proficient Expert

 Beginner with no experience  Taught general rules to help perform tasks  Rules are context free, independent of specific cases, and applied universally  Rule governed behavior is limited and inflexible

 Demonstrate acceptable performance  Has gained prior experience in actual situations to recognize recurring meaningful components  Principles, based on experiences, begin to be formulated to guide actions

 Typically a nurse with 2-3 years experience on the job in the same area or in similar day-to-day situations  More aware of long term goals  Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization

 Perceives and understands situations as whole parts  More holistic understand improves decision making  Learns from experiences what to expect in certain situations and how to modify plans

 No longer relies on principles, rules, or guidelines to connect situation and determine actions  Change in learner’s perception of situations as whole parts rather than in separate pieces  Passage from a detached observer to an involved performer, no longer outside the situation but now actively engaged in participation

While the model does not necessarily describe the four global concepts of theory, Benner’s foundation for the model and her various collaborations specifically address all of the concepts and has “explicated the themes of nursing, person, situation and health in their publications” (Brykcynski, 2010, p 148). Patricia Benner’s nursing model is one that can be used in many nursing practices as well as universally in many disciplines. In any area, one has the ability to advance practice through experience. VIEW AND CONCEPTS

PRACTICE SITUATIONS Of Benner’s approach Aid in development of clinical promotion ladders New graduate orientation programs Clinical knowledge development seminars Contributed to error recognition and enhancement of the safety of nursing practice Used for critical care nursing practice and advance d practice nursing

Patricia Benner’s Novice to Expert model 1) You are a nurse who feels highly responsible for managing patient care but still rely on more experienced nurses to guide and help you frequently during the shift. According to Benner, what level are you as a nurse and what characteristics do you have? 2) As a nurse you have been practicing for 10 years in the same ER department. A patient comes into emergency with a variety of priority needs. You take control of the situation and immediately prioritize and address each medical crisis. You have an understanding of your patient and the typical patterns of responses, see the big picture of what your patient needs first and anticipate the unexpected responses that could occur. Meeting the patient’s actual concerns and needs is of utmost importance to you, even if it means planning and negotiating for a change in the plan of care. According to Benner, what nursing level are you operating at?

3) You are in a yearly review with your manager and she describes you in the following way: “Your care shows consistency, predictability and really good time management skills however at times you display almost a hypersensitivity to the patient and may need to work on determining which elements of a situation warrant attention and which can be ignored”. What stage according to Patricia Benner’s Novice to Expert model would you say you are at? 4) You have 15 years of experience working as a nurse in the Surgical Recovery Unit and have been identified as an “expert” nurse. You decide it is time for a change and start a new job in the Cardiac ICU. Are you still operating at an “expert” level of nursing?

KEY 1) You are at the Advanced Beginner level 2) You are considered to be at an Expert level 3) You are considered to be working at the Competent level 4) There really isn’t a right answer. What do you think? Part of the controversy regarding Benner’s model is that the model does not get specific enough when trying to differentiate between the stages and what prompts progression.

REFERENCES Novice to expert. (2010, November 13). Retrieved from Brykczynski, K. A. (2010). Caring, Clinical Wisdom, and Ethics in Nursing Practice. In M. R. Alligood, & A. M. Tomey, Nursing Theorists and Their Work (7th edition) (pp ). Maryland Heights: Mosby-Elsevier. Altmann, T., (2007). Contemporary Nurse. An evaluation of the seminal work of Patricia Benner: theory or philosophy? 25(1-2),