Benner's Work Research Articles

Advancing nursing practice: redefining the theoretical and practical integration of knowledge

The aim of this paper is to offer an alternative knowing-how knowing-that framework of nursing knowledge, which in the past has been accepted as the provenance of advanced practice. The concept of advancing practice is central to the development of nursing practice and has been seen to take on many different forms depending on its use in context. To many it has become synonymous with the work of the advanced or expert practitioner; others have viewed it as a process of continuing professional development and skills acquisition. Moreover, it is becoming closely linked with practice development. However, there is much discussion as to what constitutes the knowledge necessary for advancing and advanced practice, and it has been suggested that theoretical and practical knowledge form the cornerstone of advanced knowledge. The design of this article takes a discursive approach as to the meaning and integration of knowledge within the context of advancing nursing practice. A thematic analysis of the current discourse relating to knowledge integration models in an advancing and advanced practice arena was used to identify concurrent themes relating to the knowing-how knowing-that framework which commonly used to classify the knowledge necessary for advanced nursing practice. There is a dichotomy as to what constitutes knowledge for advanced and advancing practice. Several authors have offered a variety of differing models, yet it is the application and integration of theoretical and practical knowledge that defines and develops the advancement of nursing practice. An alternative framework offered here may allow differences in the way that nursing knowledge important for advancing practice is perceived, developed and coordinated. What has inevitably been neglected is that there are various other variables which when transposed into the existing knowing-how knowing-that framework allows for advanced knowledge to be better defined. One of the more notable variables is pattern recognition, which became the focus of Benner's work on expert practice. Therefore, if this is included into the knowing-how knowing-that framework, the knowing-how becomes the knowledge that contributes to advancing and advanced practice and the knowing-that becomes the governing action based on a deeper understanding of the problem or issue.

Evaluation of the Lasater Clinical Judgment Rubric

Clinical judgment is an elusive concept that educators struggle to present and assess. Benner's seminal work in 1984 and continuing work in 1996 of novice to expert along with Tanner's continuing work on clinical judgment provides a model of “thinking in action” that focuses on four phases: noticing, interpreting, responding, and reflecting. This model served as the basis for the Lasater Clinical Judgment Rubric (LCJR) that was developed to evaluate a single patient encounter requiring clinical judgment using simulation.

A Model to Describe the Relationship Between Knowledge, Skill, and Judgment in Nursing Practice

This paper explores the relationship between knowledge, skill, and judgment and proposes a model to describe that relationship. Through illustration of the components and interrelationships within this model one can more clearly understand the nature of nursing work. Drawing on Benner's work on novice to expert, the model shows the interrelationship and the evolution of knowledge, skill, and judgment in a nurse's practice.

A 'toolkit' for clinical educators to foster learners' clinical reasoning and skills acquisition.

IntroductionTeaching clinical skills, whether at a patient's bedside or in simulated settings, continues to be a mainstay of assisting novice practitioners towards competence and expertise. Quality preceptorship is vital for the retention of new graduates and preceptors' satisfaction (Broadbent, Moxham, Sander, Walker, & Dwyer, 2014; Haggerty, Holloway, & Wilson, 2013; Smedley, Morey, & Race, 2010). The shift of nursing education from hospitals to tertiary settings emphasises theory informing practice (praxis). However, there has not been a matched rigour to ensure that clinical educators engage in sound educational practices when teaching 'hands on' clinical skills. Instead, those undertaking clinical roles such as nurse educators, preceptors or clinical teaching associates, draw primarily from their own tacit knowledge of how to transmit their practice wisdom about skills mastery (Kinchin, Cabot, & Hay, 2009). The 'intuitive' teaching of clinical skills reflects the persistence of a traditional apprenticeship model, whereby learners develop technical competence but might not be able to articulate a critical analysis of whether and why a technique is best practice. Clinical reasoning may lag far behind technical know-how.The focus of this article is the micro-skills of clinical teaching, to make tacit knowledge accessible. There is scant literature that brings together these micro-skills in a way that is readily accessible to nurse educators. What follows is a synthesis of three models and three specific skills, underpinned by theory. Together, these provide a 'toolkit' of teaching approaches, enabling those providing clinical education to plan learners' skills acquisition, maximising efficiency and satisfaction on the part of the educator and the learner. Effective clinical teaching is, of course, also shaped by 'bigger picture' contexts, such as collaboration between clinical institutions and tertiary providers to ensure undergraduate nursing students have optimal learning experiences (see for example Bourgeois, Drayton, & Brown, 2011; Edgecombe & Bowden, 2009). Other important institutional components shape educators' role development. These include an organisational commitment to professional development, mentoring and adequate staffing. Gaberson, Oermann and Shellenbarger (2015) and Rose and Best (2005) usefully provide indepth analyses of the foundations of clinical teaching.BackgroundThe classic work of Patricia Benner, From novice to expert (1984), drew from the work of Dreyfus and Dreyfus (1986) in explaining the progression of novice nurses to becoming expert practitioners. Benner emphasised the importance of novices learning alongside experts. Despite the considerable influence of her research, which shapes the Nursing Council of New Zealand Competencies for Registered Nurses (2012), her early work pays limited attention to the details of how experts transmit knowledge of clinical skills and enable learners to blend holistically psychomotor skills, human interactions and adaptation to the instability of patients' needs and wishes. Significantly, Benner proposed that expert nurses' work is fluid and becomes ordinary to these practitioners to the extent that they are not consciously aware of what makes up their craft. Field (2004) provides a valuable critique of Benner's work. She contends that greater efficiency in the shift from novice to expert is facilitated by educational support of mentors, rather than accepting that practical know-how is for the most part acquired tacitly.In a recent study, Benner, Sutphen, Leonard, and Day's (2010) overview of clinical teaching addresses contextual factors related to learning skills, rather than explicitly concentrating on stages or frameworks for the acquisition process per se. Benner et al. identify that professional practice excellence develops out of a synthesis of three 'apprenticeships'; intellectual, practical and ethical. …

Managing change in process and people: Combining a maturity model with a competency-based approach

This study is concerned with an integrated approach to the management of change. The approach described combines a process improvement approach derived from the Capability Maturity Model with a model of competency derived from Benner's work in health care. The paper describes the original models and how they have been adapted for use. It then describes how they have been integrated and encapsulated within a software tool. A case study application is described together with some of the initial findings from its deployment. The paper concludes with some comments about future developments.

The Vanderbilt Professional Nursing Practice Program

Professional practice programs are designed to attract, retain, and reward nurses. This three-part series will describe Vanderbilt's performance-based career advancement system, the Vanderbilt Professional Nursing Practice Program (VPNPP). Part 1 outlines the overall program's foundation, philosophical background, and basic structure. The VPNPP is built upon Benner's work, distinguishing among four levels of practice: novice, competent, proficient, and expert. Work by many in the organization identified the expected behaviors for nurses at each level, which were then used to develop clear process evaluation criteria. Part 2 will examine the performance measurement and evaluation system created to support the program. The process of advancing within the program will be described in part 3.

Grief as a transformative experience: weaving through different lifeworlds after a loved one has completed suicide.

Using Heidegger's hermeneutic phenomenology informed by van Manen's and Benner's work, this research is an exploration and interpretation of the lived experiences of family members since they lost a close family member to suicidal death. Data from in-depth interviews with six participants, the researcher's journal entries and published literature were analysed. Findings gave rise to a grief model where suicide survivors moved through four modes of being-in-the-world characterized by 13 lifeworlds or themes. Surviving suicide was a transformative process that in time enabled survivors to discover new ways of understanding and relating to the world. The findings have implications for nurses and counsellors working in the area of suicide bereavement.

A clinical ladder program based on Carper's Fundamental Patterns of Knowing in Nursing.

Clinical and career ladder programs were popular adjuncts to recruitment and retention during the nursing shortage of the 1980s. Programs commonly used Benner's work as an organizing framework and typically used activities such as continuing education credit, committee participation, work experience, certifications, academic degrees, community service, and performance appraisal scores as criteria for advancement. The authors present a unique clinical ladder program based on Carper's Fundamental Patterns of Knowing in Nursing. This philosophical work has been debated in the literature for many years, yet to the authors' knowledge, this work has never been used as the conceptual basis for program development. The four patterns of knowing in nursing were found to be consistent with the definition of professional nursing, and provided a meaningful organizing framework that was well received by staff registered nurses. An overall history of clinical ladders is presented, followed by the organization's prior experience with these programs, and finally the details of development and implementation of the program with plans for evaluation.

Benner's remnants: culture, tradition and everyday understanding.

Benner's account of meaning and embodiment in nursing depends on a theory which she has never fully articulated, although she makes numerous allusions to it. Behind the background of shared meanings hovers something called 'culture', which provides each individual with meaning, determines what counts as real for her, and actively hands down interpretation-laden practices. This view is based, Benner claims, on the Heideggerian assumption that the meaning and organization of a culture precedes individual meaning-giving activity. I explore Benner's implicit view of culture, drawing on her published work over 15 years, and offer an appraisal of it. In doing so, I attempt to make sense of some rather strange remarks Benner has recently made about 'remnants' of Cartesian and Kantian thinking being found in the everyday understandings of people with asthma. The concept of culture is developed with reference to both Benner's own work and that of the anthropologist, Clifford Geertz, whose work she frequently cites. Having identified the principal tenets of what we might conveniently call the Benner-Geertz theory, I proceed to interrogate the theory, using the recent anthropological literature -- and, in particular, materialist attacks on the idea of culture as a system of meanings -- in order to cast doubt on it. I also review, very briefly, an alternative way of understanding 'culture', which is not vulnerable to the same criticisms. Benner's implicit theory of culture is revealed, somewhat ironically, as an inverted form of Cartesian dualism. Its intellectual provenance is not Heidegger, who appears to reject it, but the sort of American sociology associated with Talcott Parsons. As a corollary, it is suggested that Benner's 'remnants' analogy cannot be justified, and that the idea of Cartesian and Kantian concepts permeating Western culture, infecting both the providers and receivers of health care, is a myth.

Development of educator competencies and the professional review process.

As staff development educators prepare themselves and their organizations for forthcoming healthcare challenges, educators influence the practice of staff development through the use of competencies. Because competencies and peer review are expectations for staff, educator competencies and educator professional review should be essential for those who train staff. Based upon the American Nurses Association Standards of Practice, National Nursing Staff Development Organization research, and Patricia Benner's work, competencies for educators reflect practice levels from novice to expert and challenge educators to attain levels of excellence in practice. Use of educator competencies includes the professional review process components of peer input, self-evaluation, and portfolio development. Portfolio development provides documentation of educator accomplishments for the organization. This approach to educator competencies serves as a strategy to position educators to meet healthcare demands and demonstrates leadership in the profession. The staff development educators at a large Midwestern health system have refined this process during the past 2 years, and their unique approach to educator competencies and professional review can benefit both individual educators and healthcare organizations now and in the future.

Intuition and the development of expertise in surgical ward and intensive care nurses.

The aim of this study was to explore and identify nurses' clinical expertise in surgical ward and intensive care settings in England. One of the objectives of the study and the focus of this paper was the exploration of these nurses' understanding and use of intuition in the context of their practice. Since 1980 many studies have investigated qualified nurses' use of intuition within aspects of their practice. However, it was Benner's (1982, 1984) seminal work that firmly established the relationship between intuition and expert clinical practice. Since that time a possible relationship between intuitive components of decision-making and nonexpert nurses' practice has remained relatively unexplored until recently. This constructivist qualitative study incorporated observation and interview to explore 61 qualified nurses' expertise through their assessment of patients following major surgery. Specific findings highlighted refinement in nurses' use of intuitive and analytical elements of decision-making across the four identified levels of expertise. The most fluent and effective use of intuitive and analytical components of decision-making was found in the expert group. These results are discussed in relation to current understanding of the components of expert decision-making in nursing practice. Both intuitive and analytical elements should be recognized in any model that seeks to depict the true nature of nurses' decision-making as they develop clinical expertise.

Delya's story: from expert to novice, a critique of Benner's concept of context in the development of expert nursing practice

The concepts identified within Benner's Nineteen Eighty Four research ‘From Novice to Expert’ have been widely adopted within UK nursing education and development. This paper combines a narrative from a post-registration student with analysis of the literature as a case study for gaining greater understanding of Benner's work in practice. Delya's story both validates aspects of the concept of skill acquisition and challenges some of the interpretations of the model within professional education. The focus of the critique of Benner's work within the literature to date has been on a deconstruction of the concepts and semantics of her work. In presenting verbatim extracts from a case study this paper seeks to move the focus to nursing practice.

Science, abduction and the fuzzy nurse: an exploration of expertise

Benner's work on expertise in nursing drew heavily on the writing of Dreyfus and Dreyfus in the field of computing. Dreyfus and Dreyfus argued that the continued failure of computer programmers to create an 'expert system', a program which could replicate the way that a human expert thinks, implied that experts do not think in a rational, analytic way. Dreyfus and Dreyfus therefore concluded that expertise is an intuitive process, and that 'the expert is simply not following any rules! He is ... recognising thousands of special cases'. Applied to nursing, this model of expertise has a number of profound implications for practice and education, and has been criticised for being elitist and deliberately obscure. This paper examines some recent innovations in computer logic, and argues that nursing can learn from a new breed of 'fuzzy' computer programmes which appear to be able not only to perform better than experts, but to verbalize their decision-making processes. By beginning to understand how experts think, it might be possible to develop expertise in a more controlled and logical way, thereby improving the practice of nursing.

Intuition and expertise: comments on the Benner debate

The rift between "science' and "phenomenology' in current nursing theory is explored through an examination of two recent evaluations of the work of Patricia Benner, who has proposed a model of skill acquisition, latterly within a Heideggerian framework. English offers a critique of Benner's ideas from the perspective of cognitive psychology; while Darbyshire defends them against what he describes as a "positivist' attack. No attempt is made, in this paper, to evaluate Benner's work directly, but Darbyshire's response to the "critique' is analysed; and it is noted that, in making his defence, he invokes a network of concepts which he ascribes to a "traditional notion of objective science', and accuses English of subscribing to it. It is suggested that this "Cartesian' worldview is an outmoded myth, superseded by the philosophy of science during the last 30 years, and based on the rhetoric rather than the reality of scientific practice. Nursing is not, therefore, obliged to choose between "positivism' and a philosophy whose chief virtue is that it represents a "challenge' to positivism. It could instead build a scientific basis for research and theory by drawing, not on mid-century thinking, but on a more contemporary understanding of the nature of science.

What are nurses doing to patients? A review of theories of nursing past and present

This paper looks critically at the nature of nursing theory from three perspectives. Firstly, it examines the current state of nursing theory with a particular focus on Patricia Benner's work. This examination concludes that nursing theory is currently beset by the problems of scientific and moral relativism and philosophical incoherence because it has abandoned a traditional realist approach to the care of patients. Secondly, the roots of this contemporary nursing position are analysed and the conclusion is reached that nursing theorists are implicitly presuming this traditional 'common sense' view of nursing, although their own philosophical assumptions do not support it and indeed are removing the ground from beneath it. The traditional theory underpinning the quality of the nurse's care, and hence the ethos of nursing, is rearticulated. In conclusion it is suggested that nursing needs to debate the modernist views that are now holding sway in nursing and rediscover a theory for the care of patients that holds together the personal, the pastoral, the scientific and the technological aspects of patient care.

Expert: a discussion of the implications of the concept as used in nursing.

The concept 'expert' has become common in the nursing literature since Benner's (1984) work more than a decade ago. Whilst the term has a common meaning, it is apparent that when used in nursing it refers to a multitude of attributes and lacks clear definition. This paper uses the strategy for concept analysis developed by Walker & Avant (1988) to seek an operational definition for the concept of 'expert', and suggests the defining attributes of: possession of a specialized body of knowledge and skill; extensive experience in a field of practice; highly developed levels of pattern recognition, and acknowledgement by others. These are discussed in relation to nursing practice and the circumstances under which the concept is used. Development of cases is carried out to exemplify the concept, and the antecedents and consequences of the attributes are discussed, suggesting that the concept lacks clarity, both in conceptualization, and in use. A first definition of the concept is posed to open debate concerning the relevance of the term for the future. The conclusions reached suggest that whilst an operational definition is unlikely to be found, because of the problems of definition and measurement, it is possible, through various strategies, to recognize expert practice and use it to further develop nursing. Furthermore, it is likely to become increasingly important to recognize and reward expert practitioners, given the political and economic constraints in health care today.

Skilled expert practice: is it 'all in the mind'? A response to English's critique of Benner's novice to expert model.

In a recent critique of the work of Patricia Benner in relation to expertise, skilled intuitive grasp and the Dreyfus model of skill acquisition, English (Journal of Advanced Nursing 1993, vol. 18, pp. 387-393) uses the tenets of positivism and cognitive psychology to criticize Benner's work for lacking objectivity, validity, generalizability and predictive power. In this response to English's critique I show how he has misread, failed to read, and consequently misunderstood her work, and, equally importantly, its philosophical basis. Benner's work is developed from a philosophical foundation grounded in interpretive and Heideggerian phenomenology. This wholly different 'take' on the world and on human behaviour embodies a strong critique of those very same traditional-science worldviews which English uses to damn her work. English's critique is valuable in highlighting the ways in which Benner's work can be misrepresented and this response tries to remedy this misunderstanding by attempting to clarify the fundamental differences between phenomenological and cognitive understandings. These differences are crucial to understanding Dreyfus's and Benner's work. Here, I also attempt to correct some of English's wilder assertions regarding Benner's work. Finally, I try to show how Benner's work has empowered, enthused and challenged, rather than being 'denigrating to the majority of nurses'.

Nurse education in a specialist environment

The curricula discussed here have been designed to promote and support the practice of registered nurses in cardiorespiratory nursing. Drawing on Benner's (1984) work, levels of practice from novice to expert have been identified and descriptors for each determined. These reflect Benner's (1984) ideas combined with Bloom's (1956) taxonomy as well as our own work in current nursing issues such as accountability and research in practice. Practice is underpinned by an academically validated theoretical programme ensuring that theory and practice are intrinsic to each course. There is a reciprocal relationship between progression in practice from novice through advanced beginner to expert and increasing intellectual enquiry and the evaluation of research. In this way a continuum of theory and practice has been recognised and an education programme from Certificate to Masters Degree level developed to promote this.

From competent novice to competent expert: a discussion of competence in the light of the post registration and practice project (PREPP)

The nursing profession in the UK, is today faced with major changes in the light of the Post Registration and Practice Project (PREPP) (UKCC 1990). This paper raises questions about how the maintenance of professional competence as detailed in PREPP can be assured. Through a discussion of professional portfolios and continuing education, the subjectivity of guaranteeing a practitioner's competence at tri-annual re-registration is raised. With reference to Benner's (1984) work, the paper suggests that there may be some similarities on the ‘novice to expert’ continuum that relate directly to the UKCC's proposals. However, the inherent deficiencies with such a mandatory approach to professional development are discussed and questions posed about the extent of nurses' continuing education needs being met. In view of the controversy that still surrounds who will finance the changes, and what format the portfolios will adopt, practitioners are at risk of conforming to the changes but being denied the opportunity of ensuring that they possess the necessary skills and frameworks, that are essential in ensuring the maintenance of clinical competence. The paper suggests that a concerted effort will be required by both educators and service personnel to ensure that the PREPP proposals are successful.

Reflections on Benner: a critical perspective.

This paper examines the theoretical perspective of Patricia Benner (1984; 1989) as outlined in two of her recent works. The evaluative criteria used are the critical perspective developed by Carr and Kemmis (1986). The interpretive strengths of her work are identified and extended by comparison with the work of Lawler (1991). Problems in Benner's analyses are found to centre around the weaknesses of the interpretive perspective. An analysis of the structural constraints that act to distort the interpretation of nurses' work is offered as an alternative. An evaluation is given of the relevance to practice of Benner's work.