PATRICIA BENNER Novice-Expert Model

University of Bohol Graduate School & Professional Studies Department

Tagbilaran City, Bohol, Philippines

Mary Ann Tejano Adiong, RN, USRN – MasterandMary Ann Tejano Adiong, RN, USRN – Masterand

Patricia Benner, RN, PhD, FAAN, FRCN

Benner : As Author Dr. Benner is the author of books including: 1.From Novice to Expert 2.The Primacy of Caring 3.Interpretive Phenomenology: Embodiment, Caring and Ethics in Health and Illness 4. The Crisis of Care 5. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics 6. Caregiving 7. Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach.

 Is an internationally noted researcher and lecturer on health, stress and coping, skill acquisition and ethics.

 Recently elected an honorary fellow of the Royal College of Nursing.

 Staff nurse in the areas of medical-surgical, emergency room, coronary care, intensive care units and home care.

 Currently, her research includes the study of nursing practice in intensive care units and nursing ethics.

An Influential Nurse in the Development of the Profession of Nursing

Patricia Benner’s research and theory work provides the profession of nursing with what we now know as the Novice to Expert model, also known as Benner’s Stages of Clinical Competence. Benner’s work as applied to the nursing profession is adapted from the Dreyfus Model of Skill Acquisition.

Skil l Acquisit ionSkil l Acquisit ion

“The utility of the concept of skill acquisition lies in helping the teacher understand how to assist the learner in advancing to the next level” (McClure, 2005)

The Dreyfus Model of Skil l The Dreyfus Model of Skil l Acquisit ionAcquisit ion

 Dr. Benner categorized nursing into 5 levels of capabilities: novice, advanced beginner, competent, proficient, and expert.

 She believed experience in the clinical setting is key to nursing because it allows a nurse to continuously expand their knowledge base and to provide holistic, competent care to the patient.

 Her research was aimed at discovering if there were distinguishable, characteristic differences in the novice’s and expert’s descriptions of the same clinical incident.

Novice  The person has no background

experience of the situation in which he or she is involved.

 There is difficulty discerning between relevant and irrelevant aspects of the situation.

 Beginner to profession or nurse changing area of practice (Frisch, 2009)

 Generally this level applies to nursing students.

These inexperienced nurses function at the level of instruction from nursing school. They are unable to make the leap from the classroom lecture to individual patients. Often, they apply rules learned in nursing school to all patients and are unable to discern individual patient needs. These nurses are usually new graduates, or those nurses who return to the workplace after a long absence and are re- educated in refresher programs.

Novice

Advanced Beginner  The advance beginner stage in the Dreyfus

model develops when the person can demonstrate marginally acceptable performance having coped with enough real situations to note, or to have pointed out by mentor, the recurring meaningful components of the situation.

 Nurses functioning at this level are guided by rules and oriented by task completion.

 Still requires mentor or experienced nurse to assist with defining situations, to set priorities, and to integrate practical knowledge (English, 1993)

Competent  After two to three years in the same area of nursing

the nurse moves into the Competent Stage of skill acquisition.

 The competent stage is the most pivotal in clinical learning because the learner must begin to recognize patterns and determine which elements of the situation warrant attention and which can be ignored.

 The competent nurse devises new rules and reasoning procedures for a plan while applying learned rules for action on the basis of the relevant facts of that situation.

Proficient  After three to five years in the same area of nursing the nurse

moves into the Proficient Stage “The nurse possesses a deep understanding of situations as they occur, less conscious planning is necessary, critical thinking and decision-making skills have developed” (Frisch, 2009)

 The performer perceives the information as a whole (total picture) rather than in terms of aspects and performance.

 Proficient level is a qualitative leap beyond the competent.

 Nurses at this level demonstrate a new ability to see changing relevance in a

situation including the recognition and the implementation of skilled responses to the situation as is it evolves.

Expert  This stage occurs after five years or greater in the same area

of nursing (experienced nurses changing areas of nursing practice may progress more quickly through the five stages)

 The expert performer no longer relies on an analytic principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action.

 The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions.  The expert operates from a deep understanding of the total situation.

Benner’s Original Research

Goal: Goal: – Compare Novice & Expert Nurse’s descriptions and

responses to the same clinical situations Participants:Participants:

– 21 nurse preceptors & 21 new graduate nurses – 51 experienced nurses – 11 newly graduated nurses – 5 senior nursing students

Collection of Research:Collection of Research: – Interviews with narrative accounts of situations – Observation of behaviors in clinical settings (Benner,

1984)

Nursing Education Incorporates Benner’s

Theory Goal: Goal:

– Identify if simulating unstable patient scenarios by providing interactive teaching will transition nursing students to higher levels of expertise

Participants: Participants: – 190 Adult Health Nursing Students

Collection of Research: Collection of Research: – Observation of students in simulated patient rooms with

manikins providing clues to clinical scenarios Conclusion: Conclusion:

– Development of nursing competency requires practice and clinical simulation provides a safe, structured learning experience (Larew, Lessans, Spunt, Foster, and Covington, 2006)

Nursing Application of Benner’s Theory Nursing applies Benner’s Theory through: •Nursing school curriculum •Building clinical ladders for nurses (Frisch, 2009) •Developing mentorship programs

– Preceptors for student nurses – Mentors for newly graduated nurses (Dracup and

Bryan- Brown, 2004) •Development of the Clinical Simulation Protocol (Larew et al., 2006)

Four Domains of Nursing Paradigm

1. Client/Person 2. Health 3. Environment/Situation 4. Nursing

Client/ Person

“The person is a self- interpreting being, that is the person does not come into the world predefined but gets defined in the course of living a life.” – Dr. Benner

Health Dr. Benner focuses on the lived experience

of being healthy and being ill. Health is defined as what can be assessed,

whereas well being is the human experience of health or wholeness. Well being and being ill are understood as distinct ways of being in the world.

Environment/Situation

 Benner uses situation rather than environment because situation conveys a social environment with social definition .

 “To be situated implies that one has a past, present, and future and that all of these aspects… influence the current situation.” – Dr. Benner

Nursing

 Nursing is described as a caring relationship, an “enabling condition of connection and concern.” -Dr. Benner

 “Caring is primary because caring sets up the possibility of giving and receiving help.”

 Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of care and responsibility.

 Dr. Benner understands that nursing practice as the care and study of the lived experience

of health, illness, and disease and the relationships among the three elements.

Modern TheoristsModern Theorists

Benner is a relatively modern theorist, with her work having been done in the early 1980’s. Since that time health care has seen the advent of DRG’s, managed care, an increase in the acuity of patients in the hospital related to early discharge and bounce back admissions.

Hospital SurvivalHospital Survival

Her theory of expert nurses is critical today as the profession begins to realize the aging of the members of its workforce and the increasing age of the population who will require more nursing services. Her theory is applicable today, as it was at its publication, and provides us with a foundation to use for assigning clinical competence, a tool to use to assess competence in the staff nurse.

What can Nurse Leaders do?

Nurse leaders can help address the issues of nursing shortage and staff retention by supporting new graduate nurses by: • Advocating for transition or residency programs to competency, confidence & satisfaction of new RNs • Maintaining a healthy working environment

 Not using novice RNs to cover for staffing shortage before the end of orientation period

 Zero tolerance for lateral violence or bullying • Supporting experienced RNs who are serving as preceptors and mentors for novice RNs

Shaping our Future Nurse Leaders

• New graduate nurses are the future employee pool

• Job satisfaction & retention are greatly influenced by the quality of orientation and support received by the new graduate nurse.

• A positive experience will encourage the now proficient nurse to mentor novice nurses & give them the same positive experience he/she had during the transition period. The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.

– William Arthur Ward