This assignment asked us to answer the question, “how can I think differently?” when it comes to nursing theory and its application to practice. After much consideration, I discovered nursing theory is as relevant today as it was in the early days of the Crimean War.
Dr. Patricia Benner’s From novice to expert theory, originally developed in 1984 and refined further in the years following greatly influenced modern nursing. Benner’s work describes the stages nurses move through as they progress towards “expert” status. I will consider the theory’s utility in my practice as a clinical nurse educator and specifically identify the ways in which it guides my approach to education development. While Dr. Benner’s theory has much utility in my daily work, I will also discuss gaps identified in Benner’s theoretical approach to the development of nursing expertise.
My Epistemological Stance
My epistemological stance has been influenced by the views of Hesook Suzie Kim (2015) and Dr. Patricia Benner’s From novice to expert theory (1984). Nursing knowledge is complex and is best considered as a combination of multiple types of knowledge. As Kim’s critical normative epistemology tells us, there are five different types of knowledge, generalized, ethical, critical hermeneutic, situated hermeneutic, and aesthetic (Kim, 2015). After considering Kim’s epistemology in the context of my nursing practice, I concur with her conclusion that knowledge can be both “knowable objectively… as well as through interpretations as contextually embedded phenomena” (Kim, 2015, p. 57).
Interestingly, Benner’s From novice to expert theory describes a blending of the five types of knowledge described by Kim (2015) as nurses move through the stages of development. From novice to expert proposes that knowledge builds over time through clinical nursing practice and “consists of extending practical knowledge (‘know-how’) through theory-based scientific investigations and through the charting of the existent ‘know-how’ developed through clinical experience in the practice of that discipline (Benner, 1984, p. 3). Benner’s ‘know-how’ is the type of knowledge Kim (2015) classifies as generalized knowledge. To ‘know-that,’ according to Benner (1984) is to employ Kim’s (2015) situated hermeneutic knowledge, critical hermeneutic knowledge, ethical knowledge and aesthetic knowledge, either alone or in combination. Interweaving these five types of knowing meaningfully within the context of nursing is what I consider to be nursing knowledge.
Key Elements of Benner’s From Novice to Expert Theory
The From novice to expert theory developed by Dr. Patricia Benner, published in 1984, applies the Dreyfus model of skill acquisition to nursing practice (Brykczynski, 2017; Ozdemir, 2019). While the Dreyfus model was based on airplane pilots and chess players, Benner noted that nurses moved through the same levels of skill acquisition and development. According to Benner, expertise is developed on a foundation of theoretical knowledge combined with knowledge gained from clinical experience over time (Benner, 1984).
Benner recognized that theoretical learning was limited to context-free conditions, while clinical situations contained much more nuance and were influenced by a wide variety of complicating factors. Thus, she proposed that nursing knowledge must be developed in the context of nursing practice (Brykczynski, 2017). According to Benner, it is through this practice that clinical expertise is built (Benner, 1984). All nurses begin at the novice stage and progressively move through the stages of advanced beginner, competent, and proficient until they reach expert status in their practice area as they gain experience over time. Benner defines experience as “an active process of refining and changing preconceived theories, notions, and ideas when confronted with actual situations” (Benner & Wrubel, 1982). Each skill level is defined by unique performance characteristics and teaching-learning needs (Benner, 1984).
In Benner’s model, the novice nurse possesses only theoretical knowledge and has no prior practical experience. In the clinical setting, the novice will require cues to apply their theoretical knowledge to any given situation. The skill of distinguishing between pertinent and non-pertinent details in each situation has not yet been developed at this stage. Nursing students are typically thought to be in the novice stage of Benner’s model, however, a nurse at a higher skill level could return to the novice level under the right circumstances (Benner, 1984).
Advanced beginner nurses are considered safe to practice independently but continue to require support as they transition their theoretical knowledge more fully into practice. Advanced beginners very closely adhere to the rules but have not yet developed the critical thinking skills to consider the rules in the wider context of the situation. They are task-oriented and view clinical situations personally as opposed to situated around the patient (Benner, 1984). Most newly graduated nurses would fall at the advanced beginner level of Benner’s model (Brykczynski, 2017).
A nurse who has reached the competent stage practices with confidence, consistency, predictability, and in a timely manner. However, at this stage, the competent practitioner remains self-focused as opposed to patient focused. For example, the competent practitioner’s time management would be organized around the tasks they must accomplish as opposed to the patient’s needs. In Benner’s model, nurses are expected to reach this stage after 2-3 years of clinical experience (Benner, 1984). Benner considered “the competent stage [to be the] most pivotal in clinical learning because the learner begins to recognize patterns” and develop the skill of discernment in clinical situations (Brykczynski, 2017, p.102). Active teaching and learning are crucial at this stage to facilitate the transition from competency to proficiency (Benner, 1984).
In the proficiency stage, nurses can see situations fully and have acquired the skill of discernment. The proficient nurse can understand situations intuitively and uses analytical thinking to choose an action as guided by the situation (Benner, 1984). Their ability to view situations holistically allows proficient practitioners to identify meaning as defined by the patient’s long-term goals. The proficient nurse can recognize atypical patient presentations and navigate situations with advanced decision-making skills (Terry, 2017). Nurses at the proficient stage are transitioning to the stage of expertise (Benner, et al., 1996).
The final stage of Benner’s model, expert, is reached when the “performer no longer relies on analytical principles (i.e., rule, guideline, maxim) to connect an understanding of the situation to an appropriate action” (Benner, 1984, p. 31). The expert nurse is “a fluid, flexible, and highly proficient performer with intuitive understanding of situations” (Terry et al., 2017, p. 86). Benner ascertains that “intuition and holistic perception are necessary for performing at the expert level” (Gobet, 2008, p. 132). Benner’s expert nurse can act naturally without explicitly making decisions or using analytical thinking to problem solve due to their deep and extensive clinical experience and understanding (Gobet, 2008).
According to From novice to expert, supervisor’s judgements and years of experience are used to determine at which stage a nurse is practising. However, it is important to note that while one may be at the expert stage in a particular area of practice, should this person move to a new and/or unfamiliar area of nursing practice, they may find themselves at a completely different stage of development (Benner, 1984).
Applying Benner’s From novice to expert Theory to the Role of a Clinical Nurse Educator
At the most basic level, Benner’s theory highlights how different the “learning needs at the early stages of clinical knowledge development are different from those required at later stages” (Brykczynski, 2017). Her model is most useful to me as it provides a framework to appreciate, assess, and meet the learning needs of nurses at different stages of professional development. Consideration of these principles when planning education and orientation allows me to create effective programs where staff feel as if they have the necessary tools to do their jobs well and are supported to address their learning needs.
Consideration of the characteristics of nurses at each stage of development, as described in Benner’s From novice to expert theory, also allows me to identify which nurses need mentorship and which nurses are best suited to become mentors; I can then pair these individuals accordingly. Mentorship has been shown to be essential to nurse development through the stages of expertise described by Benner (1984). Benner’s From novice to expert also provides guidance regarding the ideal way to provide mentorship to nurses based on their current stage of development. For example, using Benner’s From novice to expert framework, I know the competent nurse would benefit from encouragement to trust their instincts and further investigate based on their intuition. Receiving support from more experienced and trusted colleagues is how the competent nurse builds the skill of discernment, especially in situations where there may not be rules to guide their decision making (Brykczynski, 2017). In this case, as an educator, I now have a path to providing mentorship to the competent nurse as well as guidance to develop mentorship skills for the proficient and expert nurses acting as mentors to the competent nurse.
Strengths of Benner’s “From Novice to Expert” Theory
Benner integrates theoretical and practical knowledge and thereby infuses the context where nursing occurs into nursing knowledge application and development (Brykczynski, 2017). In the From novice to expert theory, “persons are always situated – that is, they are engaged meaningfully in the context of where they are” (Brykczynski, 2017, p. 100). Benner highlights the scope and complexity of nursing practice and makes way for nursing education to become more relevant to the learner by embedding experiential learning into practice (Benner, 1984).
Reflection becomes an important method for advancement of skill as nurses at lower skill levels learn to recognize similar intents and meanings from shared experiences of others through mentorship and subsequently apply this learning to situations they have experienced themselves (Benner, 1984). However, skill development in Benner’s model is not limited to ‘know-how’ or what Kim (2015) termed “generalizable knowledge.” In describing the actions which demonstrate knowledge at each stage, Benner considers the development of situated hermeneutic, critical hermeneutic, ethical, and aesthetic knowledge as indicators of an individual’s level of expertise.
Finally, by focusing on the ways in which nurses demonstrate and apply knowledge based on their level of expertise instead of focusing on the performance of tasks or generalizable knowledge, Benner achieves generalizability of the theory. By doing so, Benner’s stages of development can be applied across all areas of nursing practice, regardless of specialty (Brykczynski, 2017).
Weaknesses of Benner’s “From Novice to Expert” Theory
Despite the many strengths of Benner’s From novice to expert theory, as Terry and colleagues (2017) point out, the necessary steps to increasing knowledge, and subsequently advancing to higher levels of proficiency or nursing wisdom remain uncertain. The criteria used in Benner’s model for assigning nurses to stages, years of experience and supervisor judgements, are not reliable and do not always correlate with expertise (Gobet, 2008). Likewise, simply gaining experience over time has proven to be insufficient in advancing expertise and does not necessarily translate into observable gains in nursing expertise (Terry et al., 2017). Skill acquisition has been shown to be a more important predictor of competency than time in each role (Shirey, 2007). A more direct path to designing and providing support to nurses at lower levels of expertise to advance their practice would be a helpful addition to Benner’s theory.
According to Benner, “becoming an expert requires that a person’s knowledge moves along two dimensions: from explicit to implicit and from abstract to concrete” – however, nurses use a great deal of explicit knowledge across all levels of expertise, including at the expert stage. Research by the Dreyfus brothers in 1986 showed that while most expert performance is nonreflective, “when time permits and outcomes are crucial, an expert will deliberate before acting” (Gobet, 2008, p. 131). This deliberation “involves critically reflecting on one’s intuitions” (Gobet, 2008, p. 132). Benner posits that experts only use analytical thinking in situations that are unfamiliar but does not suggest there may be a way to combine intuition with analytical thinking (Benner, 1984; Gobet, 2008). In this way, Benner fails to consider the nuances inherent in the higher stages of expertise.
Conclusion
Nursing knowledge is ever changing, growing and evolving over time, with inquiry, and situated critical thinking and reflection. Thus, nursing epistemology is best thought of as a synthesis of the five types of knowledge as described by Kim (2015) developed within and integrated into nursing practice as described by Benner (1984) in her influential From novice to expert theory.
Benner’s From novice to expert theory has explicitly and implicitly informed and guided my work as a nurse educator, specifically in the domains of training and onboarding new staff and developing and coordinating mentorship for staff at all stages of nursing expertise. The scope and complexity of nursing is made clear in Benner’s work and while the From novice to expert theory has many strengths, it also contains inherent gaps. It is important to note that many of Benner’s later works, including but not limited to, Expertise in Nursing Practice (Benner et al., 1996), Clinical Wisdom in Critical Care (Benner et al., 1999) and Educating Nurses: A call for radical transformation (Benner, et al., 2010), address the gaps discussed here but were beyond the scope of this paper.
References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. The American Journal of Nursing, 84(1480) https://doi.org/10.1097/00000446-198412000-00025
Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Saunders.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Jossey-Bass.
Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in nursing practice: Caring, clinical judgment, and ethics, second edition. Springer.
Benner, P. & Wrubel, J. (1982). Skilled clinical knowledge: The value of perceptual awareness. Nurse Educator, 7(3), 11–17
Brykczynski, K. (2017). Caring, clinical wisdom and ethics in nursing practice. In M. Alligood (Ed), Nursing theorists and their work, ninth edition (pp. 98-119). Elsevier.
Kim, H. (2015). Nursing knowledge for practice [e-book] (Chapter 4). In The essence of nursing practice: Philosophy and perspective. (pp.55-66).
Shirey, M. (2007). Competencies and tips for effective leadership: From novice to expert. Journal of Nursing Administration, 37(4), 167-170. https://doi.org/10.1097/01.NNA.0000266842.54308.38
Terry, L., Carr, G., & Curzio, J. (2017). Expert nurses’ perceptions of the relevance of Carper’s patterns of knowing to junior nurses. Advances in Nursing Science, 40, 85-102. https://doi.org/10.1097/ANS.0000000000000142
Ozedmir, N. (2019). The development of nurses’ individualized care perceptions and practices: Benner’s novice to expert model perspective. International Journal of Caring Sciences, 12(2), 1279-1285. Retrieved from https://www.proquest.com/docview/2303666905/fulltextPDF/3E347AEC181E474CPQ/1?accountid=8408&sourcetype=Scholarly%20Journals
The Nimble Nurse 
Leave a comment