From Novice to Expert: A Reflective Nursing Practice Narrative

Introduction: Benner's Novice-to-Expert Framework

In her landmark book From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Dr. Patricia Benner argues that nurses need both theoretical knowledge and practical knowledge in order to become experts in their field. Most disciplines place the focus on know-that knowledge — namely theoretical and academic knowledge — but Benner insists that the know-how knowledge born of experience is even more important for a nurse, or for anyone involved in a healthcare setting, since practitioners learn from an accumulation of experiences and from trial and error. Benner (2001) also posits five different levels of development that the healthcare practitioner moves through: novice, advanced beginner, competent, proficient, and expert. Each level builds on the one before as the nurse uses reflection gained from experience to improve her practice. Each of these five levels constitutes proficiency and skill not only in practical labor, but also in other components such as skilled communication and mentoring that are integral to the field of nursing.

The novice nurse, for instance, tends to see the patient as an object made up of discrete pieces of information and data, along with specific tasks she must master. The expert nurse, at the top of the continuum, moves beyond that approach, engaging her work in a more automatic fashion and seeing the patient as an individual who is worthy of — and requires — her full respect. At the same time, the expert nurse can effortlessly and diligently move through her tasks without becoming caught up in technical details. The expert is able to transcend individual tasks and read the whole picture while ignoring nothing in the process. Other responsibilities — such as communication with the patient, mentoring and interaction with other nurses, following physician instructions, and all the other minutiae involved in nursing — are performed in an expert, skilled manner. This is the domain of intuition.

Benner's thesis reminds me of a challenging situation that occurred not too long ago between a patient and me.

It was in a nursing home. I had endured a long and tiring day. There was one patient with whom I had a particularly tough time. She believed herself to carry blue blood, having been born and bred from a long line of British nobles — or so she told me and proclaimed to others — and she believed she deserved to be treated accordingly. I have always had a bias against such attitudes. I am a true, dyed-in-the-wool democratic American who believes that all people are equal and that none should receive preferential treatment. I had therefore often resented her haughty manner toward others and found it difficult to ignore her slights and rebuffs toward me.

A Challenging Patient Encounter

That day had been considerably stressful: I had been reprimanded by the supervisor for a fault I felt was not mine; I had assumed a great deal of extra work due to the absence of several nurses; I was tired from pressure at home; and I had also had a run-in with a colleague. None of this was improved when I was called to the patient's room to adjust her position in bed. I did so, focusing on the tasks as required. Being in Benner's novitiate stage and eager to please this particularly demanding patient, I concentrated on every detail — moving her carefully to one side, pulling the sheet just so beneath her without loosening my grasp, doing it gently — and so on. The patient, however, was not docile. She kept complaining and finally insulted me, calling me a whore and denigrating my race. I bit my lip, reminding myself that this patient was an elderly woman with little family to care for her who therefore needed particular attention, and I continued with my work.

A few minutes later the call bell rang again. The patient summoned me to her room, complaining that I had messed up her bed, that it was less comfortable than before, that she had never experienced such slovenliness in her life, and that if I did not complete the job to her utter satisfaction she would report me to the supervisor and ensure that I was fired.

Close to tears, I was about to turn on my heels and walk out when I remembered a recent scandal involving eleven nurses in a nursing home in Britain who were found to have slapped, kicked, sat on, and drenched their patients with water at a Winterbourne View care home in Bristol (Robinson, 2012). Investigation demonstrated that the care workers were generally poorly paid, undereducated, demotivated, and unable to gain entrance into other professions they would have preferred. The incident ruined their reputations forever. When I had read that article, I had wondered how nurses could be brought to such lows of behavior, but I realized now that challenging patients like the one I was encountering could push any nurse in that direction. The challenge was to overcome it.

From Novice Response to Expert Intuition

Without fully realizing it, I entered Benner's expert stage. I deliberately perceived the patient as a person. I told her that I wanted to please her but did not know how, and that I was genuinely upset that I had consistently failed in doing so. I told her that she knew her own situation best, and that if she could specify her requirements to me calmly, I would do my utmost to meet them. I said this in a calm and gently humorous way — and, remarkably, it worked. Shortly thereafter we fell into a conversation about her past and about my stressful day in nursing (the patient even offered to share some relaxation techniques with me), and we parted as friends.

I draw on Benner's concept of novice to expert here because both stages played a part in this incident. It instantiates the importance of intuition in nursing (Tanner, 2006). As Benner (2001) states, "The expert nurse … has an intuitive grasp of each situation and zeroes in on the accurate region of the problem" (p. 32). This is what I did, and what I try to do every day. This is also consistent with Thompson (1999), who stressed the need for nurses to use the "middle ground" in the decision-making process by incorporating both the systematic (theoretical) and intuitive (practical) approaches into practice. Tanner's (2006) research-based model of clinical judgment reinforces this view, emphasizing that expert nurses integrate experience, knowledge, and context-sensitive reasoning in real time.

My experience above, illustrating the transition from the domain of novice to that of expert, also reminds me of another important concept: unit environment and culture, and specifically the harmony I attempt to achieve in that environment.

Conclusion: Reflections on Growth and Leadership

This reflection has helped me toward that end. It has not only provided me with a measure of self-knowledge, but has also reinforced my confidence in my communication style and shown me that I am well on the way to progressing from novice to expert. I am, in fact, moving steadily toward my goal of becoming a transformational leader in my field.