Patricia Benner's novice to expert theory in nursing

Clinical Nursing Practice

For a number of years, the nursing profession suffered a drought in the pool of candidates. This situation has improved recently, but in many cases nurses have had to be trained more quickly than before. The question is whether they are learning the information and skills to provide the care required by the growing number of people needing healthcare. In From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Patricia Benner, chair of the Department of Social and Behavioral Sciences at the University of California, San Francisco, introduced the concept that expert nurses develop skills and understanding of patient care over time through a firm educational base in addition to a wide variety of experiences. She suggested that a person could gain education and skills, or "knowing how," without ever learning the theory, or "knowing that." Her theory is that the development of knowledge in applied disciplines such as medicine and nursing consists of the extension of practical knowledge through research and the characterization and understanding of the "know how" of clinical experience. In other words, experience is a prerequisite for becoming an expert. Many believe that until Benner's work placed an emphasis on critical care nurses, this characterization of the learning process has been mostly undefined. Others in the field question parts of her model and approach.

Benner is the current Director of a National Nursing Education Research Project of the Carnegie Foundation for the Advancement in Teaching. This three-year research project is part of a larger project studying the preparation for the professions for the advancement of training. This is the first national study of nursing education for the past 30 years. She is also Co-Principal Director of the project entitled "Clinical Knowledge Development of Nurses in an Operational environment," which seeks to address three research aims: 1. To articulate, describe, and interpret experiential learning regarding medical and nursing care during combat operations in order to evaluate and extend this knowledge. 2. To provide narratives of combat practice that could assist in the design and teaching of combat healthcare and 3. To create a collection of narratives around practice topics or issues that are identified that can be published as a learning resource for nurses.

Benner is also completing a six-year research project to develop a taxonomy of nursing error and a data collection instrument for the National Council of State Boards of Nursing Entitled "The Taxonomy of Root Cause Analysis for Practice Responsibility" This data collection tool is now being implemented nationally by State Boards of Nursing.

Based on a dialogue with nurses, Benner identified five levels of competency in the clinical nursing practice: novice, advanced beginner, competent, proficient and expert (Benner, 1984, p. xvii). Novices are beginners who have had no experience in the situations that will confront them. In order to help them perform in such situations, they are taught such objectifiable and measurable attributes such as weight, intake and output, temperature, blood pressure and pulse. They also learn context-free rules that guide action in respect to these attributes. For example, weight gain and intake that is consistently higher than output by greater than 500cc could indicate water retention. Such rule-governed behavior normal for the novice is very limited and inflexible, since they have no prior experience upon which to base decisions (Benner, 1984, p. 20-21). It must be stressed that not only students are novices. They can also be any nurse entering a clinical setting where he/she has had no experience with the patient population.

Advanced beginners can demonstrate slightly acceptable behavior, cope with enough real situations to note the meaningful situational components or aspects. In this case, aspects are different than the measurable, context-free attributes learned and used by the beginner, because they require prior experience in actual situations for recognition. For example, assessing the patient's readiness to learn about his illness depends on experience with previous patients about this need (Benner, 1984, p. 22).

Competent nurses, usually those who have been in their positions two to three years, begin to see their actions in terms of long-range goals or plans that dictate which aspects of a situation should be addressed and which should be ignored. However, the competent nurse lacks the speed and flexibility of the proficient nurse (stage four), but does have the feeling of mastery and the ability to cope with and manage the numerous contingencies of clinical nursing (Benner, 1984, p. 27).

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."