Review of Patricia Benner's Theory of Novice to Expert in research

Patricia Benner's Theory of Novice to Expert: Does It Remain Valid?

What makes a nurse a good nurse? Patricia Benner's Theory of Novice to Expert examines the growth of a nurse's expertise and emotional development from her first years of practice to what Benner calls expertise, or higher-level competency. In Benner's view, expertise depends upon the development of the nurse's intuitive capacity. As noted by Lyneham, Parkinson, & Denholm (2008), this competency that Benner defined as "intuitive" is a little-understood term, given the basis of modern nursing in evidence-based practice (p.380). By intuition, Benner meant the internalization of experience as well as technical capabilities. To better understand Benner's ideas, the authors adopted a qualitative, phenomenological approach, interviewing 14 emergency room nurses who met Benner's standards of expert practice, to determine if Benner's framework was relevant. Specifically, the study attempted to respond to criticisms of Benner's model of expert practice.

Critics of the Benner model view intuition as inappropriate to use in nursing practice, which they view as a scientific, evidence-based exercise of knowledge (Lyneham, Parkinson, & Denholm, 2008, p.381). Not only does Benner allow for intuition to be used; she regards it as the highest manifestation of nursing practice. It should be underlined that Benner does not disregard or discount the need for the nurse to have technical, research-based knowledge but views the acquisition of these skills as part of the earlier stages of gaining expertise. Defenders of the Benner model thus counter that Benner is hardly anti-science, but rather that Benner strives to underline nursing's basis in an individual, patient-focused approach and a craft that is honed by years of experience. Nursing, in short, requires book knowledge but expertise cannot be honed from reading alone. Nursing is an art as well as a science.

One of the challenges of studying the Benner model is the difficulty of defining what is meant by intuition at all as an object of study. In contrast to years of schooling or the number of degrees possessed by a nurse, intuition is not something which can be quantified. This is one of the reasons the researchers selected a qualitative approach. Intuition, according to the researchers' criteria, is defined as knowledge which is "non-inferential" in nature, is not strictly rational, and takes place "below the threshold of consciousness" (Lyneham, Parkinson, & Denholm, 2008, p.382). The study involved a voluntary sample of one male nurse and 13 female nurses with 5 or more years of experience in Australian emergency rooms. The authors used a series of semi-structured interviews to gather data. What emerged is that the expert nurses all had different practices and used their intuition in different ways, but all seemed to operate on some level of intuitive consciousness. "Data analysis revealed that intuition is a developmental aspect of clinical practice. It comes as knowledge and experience in nursing work become entwined in our professional being" (Lyneham, Parkinson, & Denholm, 2008, p.383). Such assertions from experienced nurses seem to support the Benner model.

There were obvious limitations to the study. As with all qualitative studies, the number of participants had to be relatively small, to ensure the ability of the researchers to conduct thorough, searching interviews which touched upon all necessary aspects of the nurses' daily practices. The nurses were also all drawn from one subfield, a specialty which often demands quick, split-second decision making and in which nurses may have minimal time to get to know their patients. This may have biased the nurses in favor of using intuition versus other types and ways of knowledge. The sampling was also predominantly female and from a single healthcare system. The data was self-reported, based upon the participants' perceptions of their behaviors within the emergency room, versus observations of an outsider. Thus the actual interactions with patients may have been very different for these particular nurses, even though all of them said that they functioned on an intuitive level.

As well as confirming Benner's general approach, the authors also sought to refine her theory. Based upon the responses to interviews, the authors noted that the development of intuition exists in three distinct phases, beginning with cognitive intuition, which is "associated with the ability to process information on both conscious and unconscious levels;" followed by transitional intuition which allows for a transition or bridge to be connected between theory and practice, and cumulating with embodied intuition, which occurs when the nurse is finally able to act without "apparent reflexive thought " (Lyneham, Parkinson, & Denholm, 2008, pp.383-384). During the final phase of expert practice, the nurse can completely trust his or her intuition as valid and literally embodies intuition in all of his or her interactions.