The proficient nurses perceive situations as wholes rather than in terms of distinct aspects, and performance is determined by maxims. Perceive or perception is the main word: The perspective is not thought out but presents itself based on experience and earlier events. Proficient nurses understand a situation because they perceive its meaning in regard to long-term goals. Because of their experience, proficient nurses can recognize when the expected normal picture does not materialize, which can considerably improve decision making (Benner, 1984, p. 27-29.)
Lastly, the expert performers do not have to count on an analytic principle, such as a rule, guideline or maxim, to connect their understanding of a situation to an appropriate action. Because of their strong background with an intuitive grasp of situations, they can zero in on the accurate region of the problem without trying unfruitful alternative solutions.
Benner's model of skill acquisition is based on one earlier developed by Stuart and Hubert Dreyfus in 1980. Their model argues that in the acquisition and development of a skill a student passes through these five stages that reflect changes in three general aspects of skilled performance: The first is a movement from reliance on abstract principles to the use of past concrete experience as paradigms; the second is a change in the learner's perception of the demand situation, where this situation appears less and less as a compilation of equally relevant bits and more and more as a complete whole in which only certain parts are relevant; the third is a passage from detached observer to involved performer (Benner, 1980, p. 13).
In her model Benner also notes that accounts of practical situations stated in narrative form with the context intact are laden with assumptions, expectations and sets that may not be a part of formally recognized knowledge. When a narrative account is studied for these assumptions, new questions can arise for additional clarity, development and testing. For instance, after observing the clinical course of many similar and dissimilar patients, nurses may learn to expect a certain course of events without ever formally stating those expectations. These expectations may show up only in clinical practice and not in known abstractions or generalizations (Benner, 1980, p. 13).
Benner's work has raised questions and debate among others in the field. In order to understand the debate, it is necessary to understand how Benner, herself, is debating the other nursing model. In her book (1996, p. 7-9), she explains that the cognitive model by Ian English and others has its shortcomings. "This (cognitivist) view overlooks the possibility that humans inhabit their worlds in an involved way, rather than through mental representations or schema...The cognitivist view also fails to recognize the ways in which clinicians become socialized into their professional culture, developing habitual ways of seeing and responding to patients."
Thompson's article "A conceptual treadmill: the need for 'middle ground' in clinical decision making theory in nursing" (1999) explores the strengths and weaknesses of the two major theoretical approaches to furthering of decision making in the nursing research literature: systematic-positivist approaches as seen through information processing theory and Benner's intuitive-humanistic approach.
The strengths and weaknesses for both of these approaches can be divided into the areas of communicability, simplification, context specificity and applicability.
Communicability: It is almost impossible for intuitive models to communicate something that is intangible and which the practitioner is unable to express. Given that Benner's model relies on experimental knowledge as the basis of "knowing" as opposed to the science of communicable research, it is difficult to think of a situation where nursing's knowledge base becomes a shared resource open equally to all practitioners.
Similarly, systematic-rational models may promote communicability, but the process itself may not be that relevant if it does not fit with reality of clinical practice (Thompson, 1999, p.1225).
Simplification: If the information processing model does not capture all variables in decision making and clinical diagnosis, and also communicating this incomplete picture to other practitioners in the form of scientific evidence, then nursing's knowledge base will continue to develop in an ad hoc manner with major holes in the complete picture. The intuitive model at least permits the complexity of decisions akin to healthcare provision and sees that health is more than the sum of its parts. Also,