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Patricia Sawyer Benner
Theory of Skill Acquisition in Nursing or
The from Novice to Expert model
Viel Q. Vizcarra
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Bibliography
Dr. Patricia Sawyer Benner is a very accomplished nursing theorist. She was born on
May 10, 1955 to parents Ethel and Donald Brushett in Hampton, Virginia. She went to Pasadena
College and received her BSN in 1964. She then received her Masters Degree in Medical
Surgical Nursing from the University of California, San Francisco in 1970 and went to get
her Ph.D. in Stress, Coping and Health from the University of California, Berkeley in 1982. Dr.
Benner is currently a professor of nursing in the Department of Social and Behavioral Nursing at
the University of California, San Francisco. She is an internationally known researcher and
lecturer on health, stress and coping, skill acquisition and ethics and has had great influence on
the world of nursing.
She is the author of nine books including,From Novice to Expert: Excellence and Power
in Clinical Nursing Practice in 1982. In this book, Dr. Benner outlined her own theory as to
how a nurse transitions from a beginner to an expert in the nursing profession.
From 1978 to 1981, Benner was the author and project director of a federally funded
grant, Achieving Method of Intraprofessional Consensus, Assessment and Evaluation, known as
the AMICAE project. This led to the publication of From Novice to Expert (1984a) and
numerous articles. Benner directed the AMICAE project to evaluation methods for participating
schools of nursing and hospitals in the San Francisco area. It was an interpretive, descriptive
study that led to the use of Dreyfus five levels of competency to describe skill acquisition in
clinical nursing practice.
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Introduction of the Theory
Dr. Benner introduced the theory that expert nurses develop skills and understanding of
patient care over time through a sound educational base and a multitude of experiences. The
premise of this theory is that the development of knowledge on applied disciplines such as
medicine and nursing is composed of the extension of practical knowledge through research and
understanding the know-how of clinical experience. It states that nursing requires procedural
or scientific knowledge, technique, and the advancement of knowledge through practice and
experience. Before the publication of her most widely known book From Novice to Expert:
Excellence and Power in Clinical Nursing Practice, there was no real characterization of the
learning process of nurses
Benner adapted the Dreyfus model to clinical nursing practice. The Dreyfus brothers
developed the skill acquisition model by studying the performance of chess masters and pilots in
emergency situations. The model is situational and describes five levels of skill acquisition and
development: 1: novice, 2: advanced beginner, 3: competent, 4: proficient, 5: expert. The model
posits that changes in four aspects of performance occur in movement through the levels of skill
acquisition as follows: 1: movement from a reliance of 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 learners perception of the situation from viewing it as a compilation of equally
relevant bits to viewing it as an 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.
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Theoretical Assertions of Theory
Benner stated that there is always more to any situation than theory predicts. The skilled
practice of 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
can lead to discovering and interpreting theory, precedes and extends theory, synthesizes and
adapts theory in caring nursing practice. Some of the relationship statements included in
Benners works follow:
Discovering assumptions, expectations, and sets can uncover an unexamined area ofpractical knowledge that can then be systematically studied and extended or refuted
(Benner, 1948a, p.8).
Clinical knowledge is embedded in perceptions rather than percepts. Perceptual awareness is central to good nursing judgment and. (for expert) begins
with vague hunches and global assessments that initially bypass critical analysis;
conceptual clarity follows more often than it precedes (Benner, 1948a, p. xviii).
Formal rules are limited and discretionary judgment is needed in actual clinicalsituations.
Clinical knowledge develops over time, and each clinician develops a personal repertoireof practice knowledge that can be shared in dialogue with other clinicians.
Expertise develops when the clinician tests and refines propositions, hypotheses, andprinciple-based expectations in actual practice situations (Benner, 1984a, p.3)
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The Nursing Metaparadigm
Nursing
Nursing is described as a caring relationship, an enabling condition of connection and
concern (Benner & Wrubel, 1989, p.4). Caring is primary because caring sets up the possibility
of giving help and receiving help (Benner & Wrubel, 1989, p.4). Nursing is viewed as a caring
practice whose science is guided by the moral art and ethics of care and responsibility (Benner
& Wrubel, 1989, p.xi). Benner and Wrubel (1989) understand nursing practice as the care and
study of the lived experience of health, illness, and disease and the relationships among these
three elements.
Person
Benner and Wrubel (1989) use Heideggers phenomenological description of person,
which they are describe as 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 no reflective understanding of the self in the world (p.41). The person is
viewed as a participant in common meanings(Benner & Wrubel, 1989, p.23).
Finally, the person is embodied Benner and Wrubel (1989) have conceptualized the
following four major aspects of understanding that the person must deal with:
1. The role of the situation2. The role of the body3. The role of personal concerns4. The role of temporality
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Together, these aspects of the person make up the person in the world. This view of the
person is based on the works of Heidegger (1962), Merleau-Ponty (1962), and Dreyfus (1971,
1991). Their goal is to overcome Cartesian dualism, the view that the mind and body are distinct,
separate entities (Visintainer, 1988).
Benner and Wrubel (1989) define embodiment as the capacity of the body to respond to
meaningful situations. On the basis of the work of Merleau-Ponty (1962), Dreyfus (1979, 1991),
and Dreyfus (1962), they outline the following five dimensions of the body Benner and Wrubel
(1989):
1. The unborn complex, unacculturated body of the fetus and newborn baby2. 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 (Benner &
Wrubel, 1989, p.71).
3. The projective body that is set (predisposed) to act in specific situations (for example,opening a door or walking)
4. The actual projective body indicating an individuals current bodily orientation orprojection in a situation that is flexible and varied to fit the situation, such as when an
individual is skillful in using a computer.
5. The phenomenal body, the body aware of itself with the ability to imagine and describekinesthetic sensations.
They point out that nurses attend to all these dimensions of the body and seek to
understand the role of embodiment in particular situations of health, illness, and recovery.
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Health
On the basis of the work of Heidegger (1962) and Merleau-Ponty (1962), Benner and
Wrubel focus on the lived experience of being healthy and being ill (1989, p.7). 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 is described as not just the absence of disease or illness. Also, on the basis of 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 (Benner &Wrubel, 1989).
Situation (Environment)
Benner and Wrubel (1989) use the term situation rather that environment, because
situation conveys a social environment with social definition and meaningfulness. They use the
phenomenological terms being situated and situated meaning, which are defined by the persons
engaged interaction, interpretation, and understanding of the situation. Personal interpretation of
the situation is bounded by the way the individual is in it (Benner &Wrubel, 1989, p.84). This
means that each persons past, present, and future, which include their own personal meanings,
habits, and perspectives, influence the current situation.
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Model of Theory or Conceptual Design
Patricia Benner described 5 levels of nursing experience as;
1. Novice2. Advanced beginner3. Competent4. Proficient5. Expert
Stage 1: NOVICE
In the novice stage of skill acquisition in the Dreyfus model, the person has no
background experience of the situation in which he or she is involved. Context-free rules and
objective attributes must be given to guide performance. There is difficulty discerning between
relevant and irrelevant aspects of situation. Generally, this level applies to students of nursing,
but Benner has suggested that nurses at higher levels of skill in one area of practice could be
classified at the novice level if placed in an area or situation unfamiliar to them (Benner, 1984a).
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Stage 2: ADVANCED BEGINNER
The advance beginner stage in the Dreyfus model develops when the person can
demonstrate marginally acceptable performance having coped with enough real situations to
note, or to have pointed out by a mentor, the recurring meaningful components of the situation.
The advanced beginner has enough experience to grasp aspects of the situation (Benner, 1984a).
Unlike attributes and features, aspects cannot be objectified completely because they require
experience based on recognition in the context of the situation.
Nurses functioning at this level are guided by rules and are oriented by task completion.
They have difficulty grasping the current patient situation in terms of the larger perspective.
However, Dreyfus and Dreyfus (1996) state the following: Through practical experience in
concrete situations with meaningful elements which neither the instructor nor student can define
in terms of objective features, the advanced beginner starts intuitively to recognize these
elements when they are present. We call these newly recognized elements situational to
distinguish them from the objective elements of the skill domain that the beginner can recognize
prior to seeing concrete examples. (p.38)
Clinical situations are viewed by nurses at the advanced beginner stage as a test of their
abilities and the demands of the situation placed on them rather than in terms of the patient needs
and responses (Benner et al., 1992). Advanced beginners feel highly responsible for managing
patient care, yet they still rely on the help of those more experienced (Benner et al., 1992).
Benner places most newly graduated nurses at this level.
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Stage 3: COMPETENT
Through learning from actual practice situations and by following the actions of others,
the advanced beginner moves to the competent level (Benner et al., 1992). The competent stage
of the Dreyfus model is typified by considerable conscious and deliberate planning that
determines which aspects of the current and future situations are important and which can be
ignored Benner, 1984a).
Consistency, predictability, and time management are important in competent
performance. A sense of mastery is acquired through planning and predictability Benner et al.,
1992). There is an increased level of efficiency, but the focus is on time management and the
nurses organization of the task world rather than on timing in relation to the patients needs
Benner et al., 1992, p.20). the competent nurse may display hyperresponsibility for the patient,
often more than is realistic, and may exhibit an ever-present and critical view of the self Benner
et al., 1992).
The competent stage is most pivotal in clinical learning, because the learner must begin
to recognize patterns and determine which elements of the situation warrant attention and which
can be ignored. The competent nurse devises new rules and reasoning procedures for a plan
while applying learned rules for action on the basis of relevant facts of the situation.to become
proficient, the competent performer must allow the situation to guide responses (Dreyfus and
Dreyfus, 1996). Studies point to the importance of active teaching and learning in the competent
stage to coach nurses making the transition from competency to proficiency (Benner et al., 1996;
Benner et al., 1999).
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Stage 4: PROFICIENT
At the proficient stage of the Dreyfus model, the performer perceives the situation as a
whole (the total picture) rather than in terms of aspects, and the performance is guided by
maxims. The proficient level is a qualitative leap beyond the competent. Now, the performer
recognizes the most salient aspects and has an intuitive grasp of the situation based on
background understanding (Benner, 1984a).
Nurses at this level demonstrate a new ability to see changing relevance in a situation,
including the recognition and the implementation of skilled responses to the situation as it
evolves. They no longer rely on preset goals for organization, and they demonstrate an increased
confidence in their knowledge and abilities (Benner et al., 1992). At the proficient stage, there is
much more involvement with the patient and family. The proficient stage is a transition into
expertise (Benner et al., 1996).
Stage 5: EXPERT
The fifth stage of the Dreyfus model is achieved when the expert performer no longer
the relies on analytical principle (rule, guideline, maxim) to connect her or his understanding of
the situation to an appropriate action" (Benner, 1984a, p. 31). Benner describe the expert nurse
as having an intuitive grasp of the situation and as being able to identify the region of the
problem without losing time considering a range of alternative diagnoses and solutions. There
qualitative change as the expert performer knows the patient, meaning knowing typical
patterns of responses and knowing the patient as a person. Key aspect of the expert nurses
practice are follows (Benner et al., 1996):
Demonstrating a clinical grasp and resource-based practice
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Possessing embodied know-how Seeing the big picture Seeing the unexpected
The expert nurse has this ability to recognize patterns on the basis of deep experiential
background. For the expert nurse, meeting the patients actual concerns and needs is of
outmost 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 (Banner et al., 1992).
Critique of the Theory
Personal
There have been many articles, editorials, and scholarly works written about Dr. Benners
work. Some of them address whether her work is a theory or a concept. Several articles have
called attention to her incorporation of intuition into the process of becoming an expert. I
suspect this is because intuition is not tangible and very hard to measure. Benner describes the
expert nurse as having An intuitive grasp of the situation (Benner 1982). The seasoned
nurses well-honored sixth sense enables her to make lifesaving decisions (Benner, & Tanner
1987). Tabers medical dictionary defines intuition as Assumed knowledge; guesswork; a
hunch (Venes 2005). While intuition may involve some guesswork, it is based on the
knowledge and experience of the clinician, which cannot be taught in a textbook. Expert
intuition demonstrates acute awareness on the part of the clinician and often times precedes clear
evidence of clinical changes in the patient. Ian English wrote an article in reference to Benners
Novice to Expert model that was published in theJournal of Advanced Nursing. He concluded
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that Benner needed to accurately define the term expert. English feels that nursing experts need
to be objectively quantified so that they can be measured. (English 1993). While scientist often
use objective, empirical data to compare statistics and make theory based findings, some things
in life just cannot be quantified. Intuition is one of these elements. The fact the intuition cannot
be objectively measured, does not, in my opinion, diminish its significance in the clinical setting.
I believe that Dr. Benner has accurately enunciated the learning curve that clinicians must
transcend to become an expert in their profession. Her steps to becoming an expert in the field
of nursing are logical and evidence based. One can compare her steps to a first year resident
medical doctor, who has been highly educated in medical theory, but who lacks the experience of
an expert. At this point in his or her career, the resident is simply a novice, highly educated, but
with little Real world clinical experience. The progression from novice to expert is highly
correlated to work experience, as it should be. Benners theory made me realized that book
knowledge is important, but it is only a beginning, and by no means, regardless of your
educational level, makes one an expert.
From Other People
Meleis (1991) describes a method for critiquing a theory suggesting the following areas
be assessed. Clarity, consistency, simplicity and visual representation. Although Benners model
most closely fits the definition of a philosophy, certain aspects can be critiqued as if it were a
theory.
Clarity
Clarity denotes precision of boundaries, a communication of a sense of orderliness,
vividness of meaning and consistency throughout the theory. Benner provides theoretical
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definitions for all major concepts, but not the operational definitions necessary for empirical
measurement. She follows the logical sequence developed by Dreyfus, does not deviate by
introducing other concepts and states her philosophy simply and briefly. Benners philosophy is
general, yet situation dependent; it encompasses many aspects of nursing from students through
expert practitioners and espouses a broad range of applications within nursing such as in
administration and research. Thus, the theory of Benner is not that much clear.
Consistency
Consistency is determined by evaluating the congruency between each component of a
theory. Benners model contains concepts which are consistent with each other and are
consistently utilized. Since first proposing the philosophy, Benner has continued to research the
phenomena and has not changed her concepts. This is difficult to quantify, however, since
specific operational definitions have not been articulated.
Simplicity vs. Complexity
It relates to the number of phenomena the theory considers and the relationships which
could develop. Depending on the purpose of the theory, either simplicity or complexity could be
preferred. The model is relatively simple in regard to the five stages of skill acquisition and it
provides a comparative guide for identifying levels of nursing practice from individual nurse
descriptions and observations of actual nursing practice. The essence of the model is easy to
grasp and explain.
Visual Representation
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Visual representations of the theory may further enhance its clarity. Benner does not
present a visual representation, but the stages can be referred to as being along a continuum.
Progress along this continuum is sequential from novice to expert, but may include regression
when the nurse is in an unfamiliar situation.
Contagiousness
Contagiousness is whether or not it is adopted by others and must look at the
geographical location and type of intuition which adopted the theory. This theory has been
adopted in many countries and by many different types of institutions. This is evident, in a
simple form, by reviewing the literature, noting articles from different countries and relating to
different uses of the philosophy.
Usefulness
Assessing the usefulness of a theory includes its usefulness in practice, research,
education, and administration. Benners model has been utilized in all areas to be assessed.
Benners model has become the foundation for preceptor programs for students and new
graduate nurses (Myrick & Barrett, 1992), as well as continuing education programs. Many
research studies have been conducted based on the concepts proposed by Benner. Many schools
of nursing adopted this model as a basis for providing education, as noted by English (1993).
Nursing administration has utilized this model to develop career ladders, staff development and
recognition and rewards programs (Nelson & McGillion2004).
Values
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Values include those of the theorist and the critic, other professions and society. Values
are not explicitly identified in this theory. This theory was borrowed from another profession
which demonstrates congruence.
Social Significance
Finally, the social significance must be assessed because in our attempt to enhance
nursing science and articulate the discipline of nursing we must not neglect the significance of its
practice to humanity and society (Meleis 1991, p.237). This model is proposed as a method for
determining the expert practitioners and developing more expertise in practitioners. This has
social ramifications as it is optimal to have the best, most knowledgeable, practitioners providing
care. Benners model has been criticized for not being quantitative; her research used a
qualitative approach. The philosophical basis of Benners work challenges the traditional notion
of objective science. The study conducted by Benner included small number of participant, so
the theory developed by such study might contain bias.
Implications of the Theory
Nursing Education
Benner (1982) has critiqued the concept of competency-based testing by contrasting it
with the complexity of the proficiency and expert stages described in the Dreyfus Model of Skill
Acquisition and the 31 competencies described in the Achieving Method of Intraprofessional
Consensus, Assessment and Evaluation (AMICAE) project (Benner, 1984a). In summary, she
stated, Competency-based testing seems limited to the less situational, less interactional areas of
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patient care where the behavior can be well defined and patient and nurse variations do not alter
the performance criteria (1982, p.309).
Fenton (1984, 1985) described the application of the domains of clinical nursing practice
as the basis for studying the skilled performance of clinical nurse specialists (CNSs). Her
analysis validated that the CNSs studied demonstrated competencies in common with those skills
of expert nurses reported in the AMICAE project. She also identified additional areas of skilled
performance for the CNSs including the consulting role, and she delineated five preliminary
categories relevant for curriculum evaluation in the graduate program. Ethical, clinical, and
political dilemmas, positions or stances that promote success or failure, and new knowledge that
blends the empirical and theoretical were among these categories.
According to Barnum (1990), it was not Benners development of the seven domain of
nursing practice that has had the greatest impact on nursing education , but the appreciation of
the utility of the Dreyfus model in describing learning and thinking in our discipline (p.170). As
a result of Benners application of the Dreyfus Model, nursing educators have realized that
learning needs at the early stages of clinical knowledge development are different from those
required at later stages. These differences need to be acknowledged and valued in developing,
nursing education programs appropriate for the background experience of the students. Some in
nursing have come to appreciate that knowledge does develop in practice and that practice is
more complex than any one theory can encompass, but the platonic quest for application of
abstract theories continues to be a strong thrust in academia.
In Expertise in Nursing Practice, Benner and colleagues (1996) emphasized the
importance of learning the skill of involvement and caring through practical experience, the
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articulation of knowledge with practice, and the use of narratives in undergraduate education.
This work provides further support for the thesis that it may be better to place a new graduate
with a competent nurse preceptor who can explain nursing practice in ways that the beginner
comprehends than with the expert, whose intuitive knowledge may elude beginners who do not
have the experienced know-how to grasp the situation.
In Clinical Wisdom in Critical Care, Benner and colleagues (1999) urged greater
attention to experiential learning and presented the work as a guide to teaching. They designed a
highly interactive CD-ROM to accompany the book (Benner et al; 2001).
Nursing Practice
Banner describes clinical nursing practice by using an interpretive phenomenological
approach. From Novice to Expert (1984a) includes several examples of the application of her
work in practice settings (Dolan, 1984; Huntsman, Lederer, & Peterman, 1984; Ullery, 1984). As
noted earlier, Benners approach has been used to aid in the development of clinical promotion
ladders, new graduate orientation programs, and clinical knowledge development seminars.
Symposia focusing on excellence in nursing practice have been held for staff development,
recognition, and reward and as a way to demonstrate clinical knowledge development in practice
(Dolan, 1984). Fenton (1984) reported the use of Benners approach in an ethnographic study of
the performance of clinical nurse-specialists. Her findings included identification and description
of competencies of nurses functioning at an advanced level of preparation. Balasco and Black
(1988) and Silver (1986a, 1986b) used Benners work as a basis for differentiating clinical
knowledge development and career progression in nursing.
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Neverveld (1990) used Benners rationale and format in her development of basic and
advanced preceptor workshops. Farrell and Bramadat (1990) used Benners paradigm case
analysis in a collaborative educational project between a university school of nursing and a
tertiary care teaching hospital to better understand the development of clinical reasoning skills in
actual practice situations. Crissman and Jelsman (1990) applied Benners findings in developing
a cross-training program to address staffing imbalances. They delineated specific cross-training
performance objectives for novice nurses, but also provided support for the experiential
judgment needed to function in unfamiliar settings by designating a preceptor in the clinical area.
The aim is for the novice to be able to perform more like an advanced beginner with an
experienced nurse available as a resource.
Benner has been cited extensively in nursing literature regarding nursing practice
concerns and the role of caring in such practice. She continues to advance understanding of the
knowledge embedded in clinical situations through publications (Benner 1985a, 1985b, 1987;
Benner & Tanner, 1987; Benner, et al., 1996; Benner et al., 1999). Benner edited a clinical
exemplar series in the American Journal of Nursing during the 1980s. In 2001, she began editing
a series called Current Controversies in Critical Care in the American Journal of Critical Care.
Nursing Research
The preceding example by Fenton (1984, 1985) presented an application of educational
research. Lock and Gordon (1989), medical anthropologists who had been research assistants on
the AMICAE project, extended the inquiry to study the formal models used in nursing practice
and medicine. They concluded that formal models may serve as maps that direct care, substitute
knowledge and result in conformity. Gordon (1984) cautions that a misuse of formal models
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occurs when nurses apply models without using judgment, when they use models to exert
control, when they use language from model that may cover up meanings, or when they do not
understand the meaning of the models. And finally, formal models should be used with
discretion as tools and should not eclipse the relational, holistic, intuitive aspects of nursing
(p.242)
Application of the Theory Using the 11 Core Competencies
1. Safe and Quality Nursing CareOne important factor that contributes to nursing quality is the nurse's years of experience
in nursing (Aiken, Havens, & Sloane, 2009; Dunton, 2007). Multiple experiences of observing
cues, and recognizing patterns related to patient status that need to be acted on in specific ways,
lead to higher levels of clinical performance (Burritt & Steckel, 2009). An experienced nurse
may assess the same patient as an inexperienced nurse but respond differently based subtle
changes (cues) that serve as a forewarning of significant, underlying issues.
Daley (1999) has reported that novice nurses tend to learn through formal training, such
as review of policies and procedures and attendance at educational offerings. In contrast expert
practitioners supplement formal learning with a mature knowledge base that they have developed
over a period of years.
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2. Management of Resources and EnvironmentThe work environment for the practice of nursing has long been cited as one of the most
demanding across all types of work settings. Nurses provide the vast majority of patient care in
hospitals, nursing homes, ambulatory care sites, and other health care settings (AONE, 2000).
The first objective of the professional practice environment for nurses is to put the patient first.
Nurses and health care organizations must focus on patient safety and care quality and always
ask the question, "What is best for our patients?"
One must identifies tasks or activities that need to be accomplished, plans the
performance of tasks or activities based on priorities and verifies the competency of the staff
prior to delegating tasks
In Benners theory, the expert nurse, with an enormous background of experience, now has
an intuitive grasp of each situation on the accurate region of the problem without any wasteful
consideration of a large range of unfruitful, alternative diagnoses and solutions, thus, can do all
the above task.
3. Health EducationEducation influences expertise by providing a theoretical and practical knowledge base that
can be tested and refined in actual situations (Dreyfus & Dreyfus, 1996). Didactic learning alone
cannot generate clinical expertise, and one distinguishing aspect of nursing education is a focus
on clinical learning. Benner (2004) suggested that hands-on learning is at the heart of good
clinical judgment. Mentored clinical learning situations in both classrooms and practice sites
offer critical opportunities for nurses to apply and integrate theoretical knowledge with actual
events (Field, 2004). A sound educational foundation expedites the acquisition of skills through
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experience (Benner, 1984). Without background knowledge, nurses risk using poor judgment
and lack the tools necessary to learn from experience.
Theory and principles enable nurses to ask the right questions to hone in on patient problems
to provide safe care and make good clinical decisions. Bonner's (2003) research on nephrology
nurses showed expert and non-expert nurses differed based on types of learning opportunities
(both formal and informal) rather than years of experience. In a literature review on the
relationship between nursing education and practice, Kovner and Schore (1998) reported mixed
findings regarding whether and in what ways bachelor of science in nursing (BSN) prepared
nurses' skills and abilities differ from those of associate degree and diploma-prepared nurses.
4. Legal ResponsibilityThe ANA Code of Ethics notes it is the responsibility of both individual staff nurses and
nursing management to facilitate an environment of respect. Provision 6 of the Code notes that
managers and administrators are responsible for setting standards and managing the environment
of care to assure that each employee is treated fairly and is able to practice in an environment
conducive to the provision of quality health care consistent with the values of the profession
(ANA, 2001). Whether you are a novice or an expert, one must practice the core competencies
included in this area of responsibility.
5. Ethico-moral ResponsibilityJames Rests (1983; Narvaez & Rest, 1995) Four Component Model describes the
psychological that comprise an ethical or moral action. The model has been used for educational
design and intervention for several decades (see Rest & Narvaez, 1994). The model has been
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used to identify skills that can be taught based on a novice-to-expert pedagogy (Narvaez et al.,
2004; Narvaez, 2006). This document offers a way to assess skills related to each component.
The Four Component Model allows us to view moral behavior as a set of responses to
particular situational features. Experts in the skills of Moral Sensitivity are better at quickly and
accurately reading a moral situation and determining what role they might play. Experts in the
skills of Moral Judgment have many tools for solving complex moral problems. Experts in the
skills of Moral Self/Identity cultivate an ethical identity that leads them to prioritize ethical
goals. Experts in the skills of Moral Striving know how to keep their eye on the prize, enabling
them to stay on task and take the necessary steps to get the ethical job done.
6. Personal and Professional DevelopmentNursing is a unique profession in which the experience of the practitioner is the most
significant attribute to professional growth and knowledge development. Patric ia Benners
theory, novice to expert, and the concept of reflective practice both validate this idea. Benner
utilized reflection within her study of the nursing profession in order to depict the unique
characteristics and knowledge embedded in the experience of the nurse. Both the theory and the
concept have been employed to enhance knowledge development, professional growth and
innovative changes within the nursing profession.
7. Quality ImprovementContinuous quality improvement is a concept which includes: Quality assurance--the
provision of services that meet an appropriate standard. Problem resolution--including all
departments involved in the issue at hand. Quality improvement--a continuous process involving
all levels of the organization working together across departmental lines to produce better
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services for health care clients. Deming (1982b) and others have espoused total system reform to
achieve quality improvement--not merely altering the current system, but radically changing it.
It must be assumed that those who provide services at the staff level are acting in good faith and
are not willfully failing to do what is correct (Berwick, 1991). Those who perform direct
services are in an excellent position to identify the need for change in service delivery processes.
8. ResearchResearch without practice is folly, but practice without research is blind. There have been
several rather counterintuitive phenomena observed in different fields of research that
compared the performance of experts and novices. For example, studies of medical expertise
demonstrated that less experienced medical students may in some situations outperform
seasoned medical practitioners on recall of specific cases. Studies of cognitive load aspects
of complex skill acquisition in technical and academic domains demonstrated that more
experienced technical trainees or students may learn less than expected from instructions
that are very effective for novices. Apparently, in each of those phenomena, there is a
mechanism that disrupted successful expert performance while, at the same time, enhanced
performance of less experienced individuals.
9. Record ManagementThe records management key area includes core competencies of maintaining appropriate
documentation using the appropriate system and staying within legal boundaries in the area of
patient privacy.
Wherever you are in Benners 5 levels ofskill acquisition, nurses are held responsible as
to the proper documentation of the total care or interventions that were done for the patient. We
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should ensure that the entries in the patient chart are accurate for we are aware of the legal issues
that will require the involvement of these records. We should also facilitate the maintenance of
the confidentiality of these records in respect to our pledge of confidentiality to our patient.
10.Communication
Our initial responsibility as to the establishment of a strong foundation for
communication and cooperation is the establishment of trust or rapport with our patient and the
significant others. In as much as possible, we should make ourselves available to them to
facilitate interaction and listen to their concerns related to the disease process or to the
interventions that are or will be suggested.
We should also be sensitive enough as to communicating within the knowledge or level
of understanding of our patient. Identifying barriers that may hinder effective communication,
like language, beliefs/ culture, misconceptions, is also vital. Communication skills must be
present in all the 5 levels of Benners skill acquisition.
11.Collaboration and TeamworkThe current healthcare climate requires health professionals to incorporate evidence-
based scientific knowledge and perform competent skills while participating as team members.
In particular, members of a rural healthcare team are expected to provide safe and quality patient
care through interprofessional collaboration, communication, and coordination.
Interprofessional teamwork is a core competency which is seen important for effective rural
practice. Interprofessional collaborative practice should be promoted as it provides good role
modeling for students and new graduates of any discipline.
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In novice, some team members demonstrate limited awareness of each others
professional, legal and ethical frameworks for scope of practice. Some language used is
profession-specific. There is some confusion and ambiguity relating to tasks. Advanced
beginners demonstrate only superficial awareness of each others professional, legal and ethical
frameworks for scope of practice. Task allocation was hierarchical and structured with little
negotiation. Competent are aware of and/or communicate to each other their role and scope of
practice which relate to the situation. Team appears comfortable with interacting with each
other. Task allocation was negotiated with clear recognition of mutuality. In proficient, the team
is aware of each others scope of practice to undertake specific complementary skills and these
are appropriate to the situation. The team interacts well and there is open communication and
mutual respect demonstrated regarding roles and role limitations. And experts are clearly aware
of each others scope of practice to undertake specific complementary skills and opportunities
learn are extended appropriate to the acuity of the clinical situation. There is a high level of
interaction, open communication and mutual respect within the team.
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Bibliography
Biography of Patricia Benner, Available on http://home.earthlink.net/-bennerassoc/patricia.html Cited on 26th of June 2013
Dreyfus model of skill acquisition Available onhttp://en.wikipedia.org.wiki/Dreyfus_model_of_skill_acquisition, Cited on 26
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2013
Understanding Clinical Expertise: Nurse Education, Experience, and the HospitalContext, Available on http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998339/, Cited
on 27th of June 2013
Educational implications of expertise reversal effects in learning and performance ofcomplex cognitive and sensorimotor skills Available on
http://ro.uow.edu.au/edupapers/1066/ Cited on 27th
of June 2013
Seminar on Nursing Practice Expertise Available onfile:///C:/Users/jungle/Desktop/Nursing%20theory,%20expertise%20model.htm Cited on
27th
of June 2013
Alligood & Marriner Tomey (2009). Nursing Theory: Utilization and Application (4thed.) St. Louis: Mosby
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