NURSING THEORISTFROM NOVICE TO EXPERT

Patricia Benner R.N., Ph.D., F.A.A.N., F.R.C.N.

Kelly LockhartSara YoungNURS 324Spring 2013

Patricia Benner (photo by Robert Foothorap)

Patricia BennerR.N., Ph.D., F.A.A.N, F.R.C.N.

• Current Professor Emerita at the University of California, San Francisco

• Has taught and been involved in research since 1979.

• Well published in journals and books.

• Named one of the American Academy of Nursing’s “Living Legends” in August, 2011.

• Introduced her “Novice to Expert” theory in 1982.

• Many publications refer to her nursing practice model.

Patricia Benner http://www.bing.com/images/search?

q=Nursing+Symbols&FORM=RESTAB#

Purpose

• Basic overview of nursing theory

• Explanation of Patricia Benner’s work “From Novice to Expert” model

• Relation of Benner’s work to current practices

Photo courtesy http://www.123rf.com/search.php?word=abstract_nursing&start=0&searchopts=&itemsperpage=60

What is nursing theory?

• “A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and/or prescribing.”

• Many nursing theories incorporate the four paradigms: nursing, person, health and environment

(Nursing Theories, 2012)

Why is theory important?

• When nursing practice is built on sound theories, the profession is strengthened

• Using theory in nursing helps us to:• Think critically • Analyze information and make clinical judgments• Assist in decision making• Support excellence in practice• Assist novices in becoming experts therefore improving

patient care (Black, 2011)Photo courtesy http://blogs.hpedsb.on.ca/hjc/1213nevan/

From Novice to Expert Nursing Model

“Patricia Benner developed a concept known as “From Novice to Expert”. This concept explains that

nurses develop skills and an understanding of patient care over time from a combination of a strong

educational foundation and personal experiences.” Benner’s theory identifies five levels of nursing

experience: novice, advanced beginner, competent, proficient, and expert.

(Nursing Theory, 2011)

Benner’s Motivation for Novice to Expert

• Nursing practice has been studied primarily from a sociological perspective as opposed to the study of nursing practice itself

• Nursing knowledge is accrued over time; it is embedded in expertise. Thoughts are based on the Dreyfus model.

• Knowledge has gone uncharted and unstudied because differences between practical and theoretical knowledge have been misunderstood

• Well charted nursing practice and observation are essential for theory development (Benner, 2001, p.

1)

Benner’s Philosophy

• Benner “proposed that a nurse could gain knowledge and skills without actually learning a theory” Described as “knowing how” without “knowing that”

• Development of knowledge in nursing is “a combination of knowledge through research and understanding through clinical experience”

(Nursing Theory, 2011)

Photo: http://www.canstockphoto.com/nurse-word-cloud-concept-11506014.html

Benner’s influences

• Virginia Henderson • Benner has acknowledged that her “thinking has been

influenced greatly by Virginia Henderson.”

• Dreyfus model of Skill acquisition• Developed in 1980 • Describes five levels of skill acquisition and

development• Model showed advancement through the stages by

changes in performance• Developed by studying chess players and pilots • Benner adapted the Dreyfus model for clinical nursing

practice, basis for her work: Novice to Expert.(Tomey & Alligood, 2006)

Dreyfus Model of Skill Acquisition

Skill Level

Mental function

Novice Competent Proficient Expert Master

Recollection

Non-situational

situational Situational Situational Situational

Recognition decomposed decomposed Holistic Holistic Holistic

Decision analytical analytical Intuitive Intuitive Intuitive

awareness monitoring monitoring monitoring Monitoring absorbed

Table 1: The model in 1980 shows how skill acquisition changes for the given mental functions throughout advancement in the given skill levels. (Dreyfus & Dreyfus, 1980)

Dreyfus vs. Benner

Dreyfus model including the 5 levels as of 1986 (moleseyhill.com)

Benner’s Stages of Nursing Proficiency (nursinginformatics.ca)

Novice to Expert

• Novice• Advanced Beginner• Competent • Proficient• Expert

Benner’s stages of Nursing Proficiency

Photo courtesy http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/

The Novice

• Begins with no prior experience

• Taught rules to perform tasks

• Rule governed behavior is limited and inflexible

• Being a novice is not exclusive to students- any nurse entering a setting without prior experience with that particular patient population may be limited to the novice level

(Benner, 2001, pp. 20-21) Photo: http://shop.atozteacherstuff.com/downloads/daily-5-self-evaluation-novice-apprentice-practitioner-expert.html

The Advanced Beginner

• Can demonstrate marginally acceptable performance

• Has gained prior experience in actual nursing situations

• Formulation of guidelines or principles from prior experiences provide guidance in future experiences

(Benner, 2001, pp. 22-23)

Photo courtesy http://youthvoices.net/discussion/nursing

The Competent Nurse

• Has been on the job in similar situations for 2-3 years

• Aware of long term goals-- gain perspective from planning their own actions

• Become more efficient and organized

(Nursing Theory, 2011)

Photo courtesy http://libguides.gvltec.edu/nursing

The Proficient Nurse

• Perceives and understands situations as whole parts

• Views patients holistically

• Has learned what to expect in certain situations and how to modify plans as needed

(Nursing Theory, 2011)

The Expert Nurse

• No longer relies on principles, rules or guidelines to connect situations and determine actions

• Performances are fluid, flexible, and highly proficient

• Expertise comes naturally

(Black 2011, p. 137) (Nursing Theory, 2011)

http://www.abstractbrokers.com/Buyers/IndustryLinks/tabid/62/Default.aspx

Benner’s Explanation of the Four Paradigms

• Nursing• Person• Health• Environment

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Nursing

Benner viewed nursing as the care and study of the lived experience and the relationship of these three elements:

• Health• Illness• Disease

(Nursing Theories, 2013)

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Person

“…the person does not come into the world predefined but gets defined in the course of living

a life”Benner believed that there are significant aspects that make the being. She conceptualized these as the roles of:• the situation• the body• personal concerns• temporality

(Nursing Theories, 2013)

Photo courtesy http://www.bing.com/images/search?q=nurse+images&qs=HS&form=QBIR&pq=&sc=8-0&sp=2&sk=HS1#view=detail&id=8B0FC4FBC4E9A78296B556430D55638F7399DF6D&selectedIndex=832

Health

Benner focused “on the lived experience of being healthy and being ill”

• Health can be assessed• Well-being is the human experience of health or

wholeness• Illness is the human experience of loss or

dysfunction

(Tomey & Alligood, 2006, p. 151)Photo courtesy http://learningfundamentals.com.au/resources/

Environment

Benner uses the term situation rather than environment. “Personal interpretation of the

situation is bounded by the way the individual is in it.”

A person’s past, present, and future influences their current situation

(Tomey & Alligood, 2006, p. 151)

Photo courtesy http://www.howtolearn.com/2012/01/what-did-we-learn-about-health-and-happiness-in-2011

http://bizchicks.org/2011/02/the-emotion-health-connection/

Relationship of Paradigms to Benner’s Model

The culmination of the four paradigms of nursing create experiences that nurses utilize

to advance through the stages of Benner’s model From Novice to Expert

Photo courtesy http://www.pearsoned.co.uk/Bookshop/detail.asp?item=229360

Photo courtesy http://www.clker.com/clipart-nurse-icon.html

Using Benner’s Model in Practice

Examples of use in practice:

• Preceptorship• Orientation processes• Nursing educational programs• Professional advancement ladders• Interdepartmental job changes (e.g. medical-

surgical nurse transitioning to an intensive care unit)

http://www.galaxyhealth.net/

Benner in Action

American Association of Critical-Care Nurses (AACN)

Synergy Model

• Developed as a basis for nursing practice

• Development utilized use of Benner’s Novice to Expert stages of development

• Combines nursing competencies with characteristics of patients to “enhance optimal patient outcomes” (Kaplow, 2002)

• Patient outcomes will be different at the different levels of the nurse’s expertise.

(photo courtesy AACN.org)

Benner in Action

Clinical Ladder Programs

• Most are based on stages of clinical competence of Benner’s (Murphy, 2012)

• Intention of the ladder is to retain experienced nurses

• Greater rewards at the expert levels than the novice level

Conclusion

This model can be applied to all areas of nursing. It looks at the education and development of a nurse

and how they become an expert.

Patricia Benner examined how nurses learn to nurse (Nursingtimes.net, 2010)

Photo courtesy http://depositphotos.com/9744222/stock-illustration-Nursing-home-logo.htmlPhoto courtesy http://nursesaidetraining.blog.com/

References

American Association of Critical-Care Nurses (2013). Retrieved from www.aacn.org

Benner, P., (2001). From novice to expert: Excellence and power in clinical nursing

practice (Commemorative edition). New Jersey: Prentice Hall Health.

Black, B.P. (2011). Becoming a nurse: Defining nursing and socialization into professional

practice. In K.K. Chitty & B.P. Black (Eds.), Professional nursing: Concepts and

challenges (6th ed. pp. 126-145). Maryland Heights, MO: Saunders Elsevier.

Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities involved

in directed skill acquisition (Operations Research Center Rep. No. ORC-80-2).

Kaplow, R. (2002). The synergy model in practice applying the synergy model to nursing

education. Critical Care Nurse, 22(3), 77-81.

References

Murphy, D. (2012, September/October). Novice to expert: clinical ladder programs as a recruitment

and retention tool. Ohio Nurses Review., 16-17. Retrieved from www.ohnurses.org

Nursingtimes.net [website]. (2010, March). Nursing Times. Retrieved from

http://www.nursingtimes.net/whats-new-in-nursing/hall-of-fame/patricia-benner-us-nurse-

theorist-and-author-of-from-novice-to-expert/5012095.article

Nursing Theory. (2011). Patricia Benner: Biography of Patricia Benner. Retrieved from

http://nursing- theory.org/nursing-theorists/Patricia-Benner.php

Nursing Theories. (2013). Patricia Benner: Metaparadigm in nursing. Retrieved from

http://nursingtheories.info/patricia-benner-metaparadigm-in-nursing/

Nursing Theories: a companion to nursing theories and models website. (2012). Retrieved from

www.currentnursing.com/nursing_theory

Tomey, A., & Alligood, M. (2006). Nursing theorists and their work (6th ed.). St. Louis, MO: Mosby

Elsevier.

Case Study #1

Sally had the opportunity to be a nurse extern at a hospital on a busy medical-surgical unit while she

finished her undergraduate studies. With this opportunity, Sally stated that she had the chance to become comfortable in a nursing role, and was able to relate nursing practice to the theory that she was learning in class. After graduation, Sally became an RN in the Neonatal ICU. Given her recent nursing

experience, which of Benner’s stages is Sally practicing at as a Neonatal RN?

Case Study #2

You and Ginger have been nurses together for the last five years. You have both worked on the Orthopedic unit since graduating nursing school. You both easily

perform the required nursing duties, seem to have “that nursing sense” about when something is going

downhill, and act as charge nurses on the unit. Ginger is reluctant to act as a preceptor to newer nurses

stating that “I still need to work on my organization before trying to help others learn the way.” You have

acted and excelled as a preceptor with excellent feedback. What stages of Benner’s model would you

place yourself and Ginger?