Dreyfus Model Research Articles

Role of the advanced nurse practitioner in prescribing and general practice

Acquisition of the skills of prescribing and clinically assessing patients is probably the most inspiring and interesting new area for nurses. These skills complement each other; nevertheless, their attainment is challenging and needs knowledge and experience. Skills aquisition according to the Dreyfus Model that was generalised by Benner (1984) to nursing is reviewed in this article.

Teaching and Assessing Surgical Competency in Ophthalmology Training Programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence. An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence. "Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation. An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.

Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education

Three studies using the Dreyfus model of skill acquisition were conducted over a period of 21 years. Nurses with a range of experience and reported skill-fulness were interviewed. Each study used nurses’ narrative accounts of actual clinical situations. A subsample of participants were observed and interviewed at work. These studies extend the understanding of the Dreyfus model to complex, underdetermined, and fast-paced practices. The skill of involvement and the development of moral agency are linked with the development of expertise, and change as the practitioner becomes more skillful. Nurses who had some difficulty with understanding the ends of practice and difficulty with their skills of interpersonal and problem engagement did not progress to the level of expertise. Taken together, these studies demonstrate the usefulness of the Dreyfus model for understanding the learning needs and styles of learning at different levels of skill acquisition.

A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review.

To create a framework for teaching the knowledge and skills of practice-based learning and improvement to medical students and residents based on proven, effective strategies. The authors conducted a Medline search of English-language articles published between 1996 and May 2001, using the term "quality improvement" (QI), and cross-matched it with "medical education" and "health professions education." A thematic-synthesis method of review was used to compile the information from the articles. Based on the literature review, an expert panel recommended educational objectives for practice-based learning and improvement. Twenty-seven articles met the inclusion criteria. The majority of studies were conducted in academic medical centers and medical schools and 40% addressed experiential learning of QI. More than 75% were qualitative case reports capturing educational outcomes, and 7% included an experimental study design. The expert panel integrated data from the literature review with the Dreyfus model of professional skill acquisition, the Institute for Healthcare Improvement's (IHI) knowledge domains for improving health care, and the ACGME competencies and generated a framework of core educational objectives about teaching practice-based learning and improvement to medical students and residents. Teaching the knowledge and skills of practice-based learning and improvement to medical students and residents is a necessary and important foundation for improving patient care. The authors present a framework of learning objectives-informed by the literature and synthesized by the expert panel-to assist educational leaders when integrating these objectives into a curriculum. This framework serves as a blueprint to bridge the gap between current knowledge and future practice needs.

Dreyfus on expertise: The limits of phenomenological analysis

Dreyfus's model of expert skill acquisition is philosophically important because it shifts the focus on expertise away from its social and technical externalization in STS, and its relegation to the historical and psychological context of discovery in the classical philosophy of science, to universal structures of embodied cognition and affect. In doing so he explains why experts are not best described as ideologues and why their authority is not exclusively based on social networking. Moreover, by phenomenologically analyzing expertise from a first person perspective, he reveals the limitations of, and sometimes superficial treatment that comes from, investigating expertise from a third person perspective. Thus, he shows that expertise is a prime example of a subject that is essential to science but can only be fully elaborated with the aid of phenomenological tools. However, both Dreyfus's descriptive model and his normative claims are flawed due to the lack of hermeneutical sensitivity. He assumes an expert's knowledge has crystallized out of contextual sensitivity plus experience, and that an expert has shed, during the training process, whatever prejudices, ideologies, hidden agendas, or other forms of cultural embeddedness, that person might have begun with. One would never imagine, from Dreyfus's account, that society could possibly be endangered by experts, only how society's expectations and actions could endanger experts. The stories of actual controversies not only shows things do not work the way Dreyfus claims, but also that it would be less salutary if they did. Such stories amount to counterexamples to Dreyfus's normative claims, and point to serious shortcomings in his arguments.

Making social science matter: why social inquiry fails and how it can succeed again

ABSTRACT This book is a thoughtful antidote to the simple views that see social science as a science like any other-positivistic science. It begins with a well-grounded empirical case of the development and application of expert knowledge, then moves through consideration of context and values, the centrality of power, and a reconsideration of the Greek roots of modern knowledge. It concludes with some salient observations based on the author's own feedback and research practice. Making Science Matter: Why Inquiry Fails and How Can Succeed Again. Bent Flyvbjerg: Cambridge: Cambridge University Press, 205 Pages. INTRODUCTION is one of those phrases that, as an apprentice social scientist, I wished I had heard about 30 years ago. I was studying for a doctorate degree then, a process in which much musing was centered on some central issues in the philosophy of social science. In the texts that I read and the debates that I encountered there was a lot of about physics envy, that is. What was in short supply was much to make one feel confident as a social science researcher. Instead, rather like a character in a Beckett play, one was waiting for a character-the great deliverer of a truly social science-that never shows up. So I had to write a thesis regardless. Of course, there were various sightings that raised anticipations in different audiences, at different times: some barracked for Parsons, others for Marx, as a great unifier while others just got on with and didn't think too much about what it might mean. They just did it. How they did seemed to be based on an assumption that, while social science isn't physics, does have some formal similarities. It has hypotheses; contains propositions; and, maybe, some covering law-like explanations. (One colleague claims that the universal relationship between the size of organizations and their increasing need for centralization is such a relation.) If only Bent Flyvbjerg's book had been available then! BEYOND THE SCIENCE WARS The author begins with the hoax played by the physicist, Alan Sokal, one of the editors of the journal Text. Most people probably know about it. Sokal (1996) submitted an article that appeared to deconstruct physics and the editors accepted and published it. Thus was the latest salvo in the debate about the two cultures fired across the bows of the global social science community. The implications were clear: for bona fide-not to say macho-real scientists, social science is unreal and unnatural: simplistic in its assumptions, short on quality controls, and peopled by beings of lesser judgment, if not intelligence, than those to be found in the Natural Science Faculties. Flyvbjerg (page 3) is quite explicit about the implications of such warfare: Social science is locked in a fight that cannot hope to win, because has accepted terms that are self-defeating. What is to be done to change these terms and avoid defeat? Go back to Aristotle and start over again, says Flyvbjerg. Eschew Aristotle's path to knowledge that routes through the virtues of either techne or episteme and instead use Aristotle's account of a prudent and wise science-one founded on phonesis-and integrate with a Foucauldian conception of power. The route to Aristotle turns out to be quite contemporary-it works through the phenomenology of human learning in the light of the Dreyfus and Dreyfus (1986) model. This is the model that demonstrates that expert learning goes far beyond knowing and using the rules to accomplish an activity. Indeed, such explicit knowledge and referral is, in fact, counter to expertise that seems to rely on tacit knowledge and intuition embedded in context much more than does on explicit and disembedded knowledge. Physics envy is closely related to Cartesian anxiety-the fear of nihilism and relativism that lies outside the borders of a strict analytical and rational scientific tradition. …

The Skill Acquisition of Two Newly Qualified Occupational Therapists

This research was an investigation, using a case study approach, to gain an understanding of the professional development of two newly qualified occupational therapists. Six interviews were undertaken with each therapist between November 1997 and June 1998. A reflective assignment written in May 1997 by the subjects when they were students also added to the data collection. The progressive nature of their learning resembled the Dreyfus and Dreyfus (1986) model of skill acquisition, where advancement to proficiency level of many skills was evident. Their progression in such a short time was an important finding of this research. This suggested that the amount of exposure to clinical experience was not an indicator of skill acquisition. Instead, the individual merits of the learner, as evidenced by the skills that he or she demonstrated, was a better indicator of professional development. The progression through the stages was explained by reflection on experience. The rapid advancement to proficiency level by the two therapists was thought to be due to their good reflective skills, which facilitated their learning.

From Managing the Car to Managing the Road: The Development of Driving Skills

Skilled driving requires complex cognitive and recognitional abilities. We used a Cognitive Task Analysis (CTA) and a low tech simulation to study experience linked differences in these abilities. Inexperienced (n=18) and experienced (n=17) drivers participated. The inexperienced drivers struggled with control. They worked to keep their car between the lines and execute turns. In time, automatized performance replaced conscience control. Some situations, like icy roadways, were automatized later than others. As driving reached automaticity, drivers began attending to a wider range of cues. They predicted and avoided problems. A broader view of the roadway emerged in parallel with the development of anticipation. We also observed that experienced drivers were more likely to know their limits and adopted effective compensatory strategies. The Dreyfus & Dreyfus (1986) model of expertise is used to describe these systematic changes. Protocol analysis suggested guidelines for training novice drivers and for upgrading skills of long term drivers.

Learning in the restructured workplace: a case study

Workplace restructuring implies people changing roles, leading to the deskilling of people who must learn their way back to competence. Reports the case of a person learning in a new role. The conceptual framework for the analysis is the Dreyfus model of skill development. Shows the model to be effective both for research and for individuals to understand their own development. The results enrich the understanding of workplace learning, in particular the manner in which people can be helped to learn a new role.

Education in emergency nursing: a new beginning. Part I

The movement of nurse education to the tertiary sector is all but complete in Australia. Trends are changing as new partnerships are being forged and the focus of education is now responsive to economic and political factors. These factors have resulted in the regionalisation of health care facilities and the de-institutionalisation of health services in Queensland, Australia. Moreover, de-institutionalisation of services coupled with economic rationalism has pre-empted the offering of post-graduate clinical courses by university nursing facilities. This paper addresses the process of developing the content of new courses under the umbrella of the Graduate Diploma/Masters in Emergency Care Nursing offered at Griffith University Gold Coast, Australia. This initiative is the first in Queensland and has revisioned the education of emergency care nursing. This course includes a tapestry of knowledge enhancing, clinical and factual subjects presented by experienced clinicians teaching with academics, recognising the collaborative nature of nursing practice with academics and clinicians working jointly in course development, teaching and clinical placement. Strategies developed collaboratively addressed course content including logistics, time management, the critical selective selection of appropriate content, assessment criteria, registerability within Queensland and other states and clinical competence. Moreover, this process of developing the course utilised the Australian National Registering Authorities' Competencies and Benner's use of the Dreyfus model to guide the knowledge level of the clinician at course completion. In particular this paper will not only address the blending of theory and practice to consolidate the relationship inherent between the clinician and education, but will establish the fact that no gap exists.

Education in critical care nursing: a new beginning.

The movement of nurse education to the tertiary sector is all but complete in Australia. Trends are changing as new partnerships are being forged and the focus of education is now reponsive to economic and political factors. These factors have resulted in the regionalisation of health care facilities and the de-institutionalisation of health services in Queensland. Moreover, de-institutionalisation of services coupled with economic rationalism has pre-empted the offering of post-graduate clinical courses by university nursing faculties. This paper addresses the process of developing the content of new courses under the umbrella of the Graduate Diploma/Masters in Critical Care Nursing offered at Griffith University Gold Coast. This initiative is the first in Queensland and has provided new vision in education for critical care nursing. This course includes a tapestry of theoretical knowledge enhancing clinical and factual subjects presented by experienced clinicians teaching with academics. The collaborative nature of nursing practice is reflected in academics and clinicians working jointly in course development, teaching and clinical placement. Strategies which were developed collaboratively addressed course content including logistics, time management, the critical selective selection of appropriate content, assessment critera, 'registerbility' within Queensland and other states, and clinical competence will be addressed. Moreover, this process of developing the course content utilised Australian National Registering Authority (ANRAC 1990) Competencies and Benners' (1984) use of the Dreyfus model to guide the expected knowledge level of the clinician at course completion. In particular this paper will not only address the blending of theory and practice to consolidate the relationship inherent between the clinician and education, but will establish the fact that no gap exists.

Decision‐making models of Finnish nurses and public health nurses

This study described nursing decision-making models and variables related to these models. For this purpose a 56-item Likert-type questionnaire was constructed according to the Dreyfus model of skill acquisition as applied to nursing by Benner and information processing theory. The target group consisted of 100 registered nurses working in inpatient clinics and 100 public health nurses working in preventive health care. The decision-making variables explored were nurses' experience, education and knowledge as well as the nature of the nursing task and context. The results revealed four different types of decision-making: (a) unquestioning/questioning decision-making, (b) creative-diversive decision-making, (c) patient/nurse-oriented decision-making, and (d) rule- and situation-based decision-making. The most important factors related to decision-making were experience and the nature of the nursing task and context.

From Beginner to Graduate Social Worker: Preliminary Findings of an Australian Longitudinal Study

A central issue for social work educators is to delineate the process of how social work students become competent practitioners. Previous literature has tended to concentrate on value and attitudinal change as a result of education. The authors are currently engaged in a five-year longitudinal study of a cohort of 39 Victorian social workers which explores this issue, as well as the changes in knowledge, skills and theory use. The study also explored whether the Dreyfus model of skill acquisition was applicable in social work. This paper describes the study and its preliminary findings at mid-point in the study with respondents having completed two years of social work education and now practising as social workers. Participants have been interviewed twice yearly and data consists of participants' descriptions of critical incidents from their course experience and responses to case vignettes. After content analysis, preliminary findings indicate that some stages similar to the Dreyfus model, can be identified. Particular themes emerged including a predominantly individualizing approach to problems, a reluctance to deal with men and situations involving conflict and a disillusionment about the nature of social work. Some implications of these findings, including competency-based education, are discussed.

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'.

Novice CNS and Role Aquisition

A master's-prepared nurse in an introductory role as a CNS will find the experience both challenging and rewarding. The CNS's first year is a time of self-exploration, stimulation, ambivalence, and growth, both professionally and personally. These nurses are often experienced clinicians who strive to be in positions in which they can affect a large group of patients and colleagues with both their knowledge and expertise. Stress occurs because the experienced nurse who has felt competent, confident, and comfortable in his or her previous role as a direct caregiver is now in the role of novice CNS who must learn the expectations and responsibilities of a new role, and develop a broad set of new skills. Utilizing the Dreyfus model, as applied to the nursing profession by Benner, this article will explore the transition of the nurse from experienced staff nurse to novice CNS. Enhancing and restraining factors that influence role realization, as well as effectiveness in supporting staff, to achieve optimal outcomes for patients will be identified.

From beginner to expert: gaining a differentiated clinical world in critical care nursing.

The purpose of this study was to further explicate the Dreyfus Model of Skill Acquisition in the practice of critical care nursing. For this analysis data were used from a sample of 105 nurses practicing in the adult, pediatric, and newborn intensive care units of eight hospitals in three metropolitan areas. The data were composed of group interviews in which nurses gave narrative accounts of exemplars from their practice and close observations and intensive personal history interviews of a subsample of nurses. Two interrelated aspects were found to distinguish four levels of practice, from advanced beginner through expert. First, practitioners at different levels of skill literally live in different clinical worlds, noticing and responding to different directives for action. Second, a sense of agency is determined by one's clinical world and shows up as an expression of responsibility for what happens with the patient.

Does the nursing process reflect quality care?

The nursing process is a very linear method that does not require that the nurse use knowledge gathered over the years; instead it requires an objective assessment of data accessible to the senses. Although this method should assure uniform practice, it will not assure quality practice. Some authors liken it to the scientific method. It is not. The scientific method begins with a perceived problem which is defined as facts, events, or situations that lack explanation or that are incongruent with accepted beliefs, expectations, or preconceptions. Without expectations, and beliefs, life holds no surprises and no problems. Only with years of accumulated experiences can expert nurses quickly determine the problems and "the solutions to problems using experience-based holistic recognition of similarity which produces deep situational understanding." This understanding and the solutions to problems may be and should be different for each nurse. This is not so when nurses use the nursing process. All phenomena are abstracted from the personal; they are context free. The Dreyfus Model of Skill Acquisition, related to nursing by Benner, explains this kind of practice as Novice. The Expert, on the other hand, "knows what to do based on mature and practiced understanding. Experts solve problems using know-how, the sort of ability we all use all the time as we go about our everyday tasks." They know problems without analyzing them; they sense them. Benner states, "If experts are made to attend to the particulars or to a formal model or rule, then performance actually deteriorates."(ABSTRACT TRUNCATED AT 250 WORDS)

Teaching interviewing skills by interactive video: Intertalk

Intertalk, an interactive video program for teaching interviewing skills, is described. It was developed on an AT&T 6300+ microcomputer with a Microkey video controller card, Pioneer 6000 videodisc player, and a Sony color monitor that accepted both analog and digital signals. All programming was done in TenCore, a commercially available authoring language. The Dreyfus and Dreyfus model of complex skills acquisition provided the theoretical foundation for the development of the program. Future directions for the application of interactive video to the instruction of interviewing skills conclude the paper.

Application en danse de la répétition mentale à partir du modèle d’apprentissage de Dreyfus & Dreyfus

In the field of dance, a model of mental imagery to favour during mental rehearsal is set forth in this article. Based on the Dreyfus and Dreyfus (1987) model of learning, mental imagery processes for each of the five levels are proposed. A sixth level of learning has been added by the authors in order to promote the full artistic development of the dancer.

Models of clinical expertise in American nursing practice

This paper analyzes nursing job descriptions that compose a career ladder. These job descriptions, an ethnomodel of expertise, are compared to the Dreyfus model that describes five stages of skill acquisition. While the Dreyfus model posits the replacement of analytic reasoning with intuitive response as the characteristic of expert practice, the ideal posited in the nursing model places theoretical knowledge at the apex. Nursing job descriptions can best be understood in the context of this profession's search for greater power and legitimacy.