ADVANCED FOUNDATION ON

NURSING

FEBRUARY 3, 2013

SUBMITTED TO:

MS. JANINA ABAD

SUBMITTED BY:

LEI-ANN JESSICA R. CABULAY

MICHAEL T. BUCAYU

BIOGRAPHY OF DR. PATRICIA BENNER

Patricia Benner was born in Hampton, Virginia on May 10, 1942 in Hampton, Virginia. She spent her childhood in California, where she had her early and professional education. She received her Bachelor’s degree in Nursing from Pasadena College in 1964, her Master’s Degree in Medical Surgical Nursing from University of California, Berkely.

Upon completion of her doctorate in 1982, Benner achieved the position of Associate Professor in 1989 in the Department of Physiological Nursing in the School of Nursing at the University of California, San Francisco and become tenured professor in 2989. IN 2002, she moved to the Department of Social and Behavioral Sciences at UCSF, where she is a professor and the first occupant of the Thelma Shobe Cook Endowed Chair in Ethics and Spirituality.

Dr. Patricia Benner is an internationally noted researcher and lecturer on health, stress and coping, skill acquisition and ethics. Her work had wide influence on nursing both in the United States and internationally. She was recently elected an honorary fellow of the Royal College of Nursing. Her work has influence beyond nursing in the areas of clinical practice and clinical ethics. She has been a 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.

Dr. Patricia Benner acknowledged that her thinking in Nursing had been influenced greatly by Virginia Henderson, who commented that because of the nature and scope of her work, “From Novice to Expert”, it had potential to materially affect practice and at the same time, the nurses’ preparation.

Benner used systematic descriptions of five stages: novice, advanced beginner, competent, proficient, and expert. Thirty-one competencies emerged from an analysis of actual patient care episodes. From this work seven areas of nursing practice having a number of competencies with similar intents, functions, and meanings developed. They are identified as (1) the helping role, (2) the teaching-coaching function, (3) the diagnostic and patient-monitoring function, (4) effective management of rapidly changing situations, (5) administering and monitoring therapeutic interventions and regimens, (6) monitoring and ensuring the quality of health care practices, and (7) organizational work-role competencies. Benner's work describes nursing practice in the context of what nursing actually is and does rather than from context-free theoretic descriptions.

Due to her outstanding contribution to the nursing arena, she has received the following awards, namely:

1969-70 Title II Federal Traineeship-Public Health Service1977-78 Predoctoral Fellowship-National Research Service Award, Division of Nursing,

Health Resources Administration1982 Selected as "Author of the Month" for "The Nursing Journal of the 80's"1984 Book of the Year Award, Nursing Education; Book of the Year Award, Nursing

Research, American Journal of Nursing, December 1984 for Benner, P., (1985) From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Reading, Massachusetts; Addison-Wesley.

1989 National League for Nursing, the Linda Richards Award for Leadership in Education.

1990 Excellence in Nursing Research/Education Award, Organization of Nurse

Executives-California.1993 "Alumnus of The Year" Award, Point Loma College (formerly Pasadena

College).1994 Honorary Fellow, Royal College of Nursing, United Kingdom. (F.R.C.N..)1996 American Journal of Nursing Book of the Year Award for Advanced Nursing

Practice for Benner, P., Tanner, C.A., Chesla, C.A. Expertise in Nursing Practice, Caring Clinical Judgment and Ethics. New York: Springer.

1995-96 Library Choice Award for Phillips, S. and Benner, P. (Eds.) (1994) The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions. Wasington, D.C., Georgetown University Press.

CONCEPT OF THE THEORY (Nursing Expertise Model)

Dr. Patricia Benner introduced the concept that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences. She proposed that one could gain knowledge and skills ("knowing how") without ever learning the theory ("knowing that"). She further explains that the development of knowledge in applied disciplines such as medicine and nursing is composed of the extension of practical knowledge (know how) through research and the characterization and understanding of the "know how" of clinical experience.She conceptualizes in her writing about nursing skills as experience is a prerequisite for becoming an expert. The time required for transition varies for each individual nurse. We all learn skills at a different pace. There is no one size fits all when it comes to transitioning from novice to expert (Benner 1984).

EXPERTISE

Expertise can be defined as the professional artistry and practice wisdom inherent in the professional practice.

Again, professional artistry can be defined as the meaningful expression of a uniquely individual view within a shared tradition. It involves the blend of: practitioner qualities, practice skills and creative imagination processes.

Practice wisdom is the possession of practice experience and knowledge together with the ability to use them critically, intuitively and practically. Including characteristics of clarity, discernment and caring deeply from an objective stance, practice wisdom is a component of professional artistry.

DEVELOPMENT OF EXPERTISE

Expertise or tacit knowledge is a manifestation of an individual’s experiential knowledge acquired over the life course.

Adaptation of implicit knowledge to new situation requires thinking and reflective skills.

Reflectivity is associated with the expansion of an expert’s horizon.

PHILOSOPHICAL UNDERPINNINGS

Benner’s ideas are based on the difference between practical and theoretical knowledge.

Practical situations are more complex than they initially appear.

Both experience and mastery are necessary for a skill to be transformed to a higher level skill.

Other central tenets underpinning Benner’s philosophy are the connections between external and internal events.

Benner believes that nurses develop and accumulate global sets and paradigms about patients, those paradigms develop expert intuition and sets not readily apparent to the outside observer.

Expert nurses use empirics, ethics and personal knowledge.

Benner supports that individuals interpret their own concerns, practices and life experiences.

DIMENSION OF CHANGE IN DIFFERENT PHASES

One is a movement from reliance on abstract principles to the use of past concrete experience as paradigms.

The second is change in the learner’s perception of the demand situation, in which the situation is seen 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 observation to involved performer. The performer no longer stands outside the situation but is now engaged in the situation.

PATRICIA BENNER’S THEORY OF NURSING PRACTICE EXPERTIS

Benner acknowledges that she utilized the same five stages which Dreyfus posited.The stages are utilized after Benner’s initial observations of 120 nurses and identification of 31 skills.

STAGE 1: NOVICE

Beginners have had no experience of situations in which they are expected to perform.Novices are taught rules to help them perform.The rules are context-free and independent of specific cases; hence the rules tend to be applied universally.The rule governed behavior of the novice is extremely limited and inflexible.As such, novices have no life experience in the application of rules. (“Just tell me what I need to do and I’ll do it.”)

STAGE 2: ADVANCED BEGINNER

Can demonstrate marginally acceptable performance.Have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components can recognize in actual situation.Principles to guide actions begin to be formulated.The principle is based on experience.

STAGE 3: COMPETENT

Competence, typified by the nurse who has been on the job in the same or similar situations two or three years.Develops when the nurse begins to see his or her actions in terms of long range goals or plans of which he or she is consciously aware.

novice

advanced beginner

competent

proficient

expert

For the competent nurse, a plan establishes a perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem. The conscious,deliberate planning that is the characteristic of this skill level helps achieve efficiency and organization.

The competent nurse lacks the speed and flexibility of the proficient nurse but does have a feeling of mastery and ability to cope with and manage the many contingencies of clinical nursing.The competent person does not yet have enough experience to recognize a situation in terms of an overall picture or in terms of which aspects are most salient, most important.

STAGE 4: PROFICIENT

The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects and performance is guided by maxims.Proficient nurses understand a situation as a whole because they perceive its meaning in long term goals.The proficient nurse can now recognize when the expected normal picture does not materialize.This holistic understanding improves the proficient nurse’s decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones.

The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later.Once one has a deep understanding of the situation, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation.

STAGE 5: THE EXPERT

The expert performer no longer relies on 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 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.The performer is no longer aware of features and rules. His or her performance becomes flexible and highly proficient.

THE THEORY AND THE NURSING METAPARADIGM

CLIENT

• “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

• Benner believed that there are significant aspects that make up a person. She had conceptualized the major aspects of understanding that the person must deal as:

• The role of the situation

• The role of the body.

• The role of personal concerns.

• The role of temporarility.

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.

• Also, a person may have a disease and not experience illness because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at the physical level.

ENVIRONMENT

• Benner uses situation rather than environment because situation conveys a social environment with social definition and mindfulness.

• “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.

Seven Domains of Nursing Practice

• Helping role

• Teaching or coaching function

• Diagnostic client-monitoring function

• Effective management of rapidly changing situations

• Administering and monitoring therapeutic interventions and regiments

• Monitoring and ensuring quality of health care practices

• Organizational and work-role competencies

CONTRIBUTION TO NURSING EDUCATION

The education of a professional involves a complete socialization process. Socialization involves learning to behave, feel and see the world in a manner similar to other persons occupying the same role as one self. Benner’s theory involves socialization process, wherein a nurse learns how to do nursing, from being a novice to an expert in providing nursing care services. The five stages have implications for teaching and learning. Those who are one step ahead of the ladder have the responsibility to mentor their colleagues. Benner’s theory helped in strengthening and establishing the nursing profession in academia. She emphasized the difference between being knowledgeable and being skillful. In today’s curriculum, there is emphasis in the balance of these two. Nursing students are not only taught about nursing concepts; they are also trained how to perform nursing functions through exposures in the clinical and community settings. Requirements to meet certain grades stresses the importance of knowledge, while a documentation of procedures done in the operating room and delivery room help the students learn skills.

CONTRIBUTION TO NURSING PRACTICE

This theory changed the profession's understanding of what it means to be an expert, placing this designation on the nurse who provided "the most exquisite nursing care”.

In the present situation, the Nursing Expertise Model serves as a guide in evaluating skills in the nursing arena. As a nurse progress form one level to another, tasks and responsibilities also increase. Take for example, a complicated case is given to nurse who has a wide range of experience and who can surely provide the nursing care that the patient needs. Also this theory provides the basis for mentoring among nurses. Novices are mentored by the advanced beginners, competent and proficient nurses, until such nurse gains the skills and become independent.

CONTRIBUTION TO NURSING RESEARCH

Research, the collection of information, is the foundation of nursing theory development. This nursing theory serve as a guide for evaluation and intervention in patient care, thereby rendering nursing practice more efficient and effective. Several researches have used this theory as a framework in identifying gaps between nursing education and practice, since it supports the principle that knowledge must be put into practice and skills must be honed through real life experiences.

APPLICATION OF THE THEORY IN REAL SITUATIONS

The theory’s application is very much evident in real life situations.

A newly registered nurse, for example cannot be expected to be as skillful as a nurse who has been practicing the profession for quite some time, because the former has yet to hone his skills. That is why there is orientation and mentoring, in order to guide the novice in putting into practice the concepts he has learned.

Another example, a nurse who has worked on a surgical unit for seven years may have mastered her clinical skills, but if she is subsequently transferred to ICU, she may revert back an earlier stage simply because the skill needed to perform that specific job in the ICU have not been mastered.

Designations were also based on this theory. By just looking in the organizational chart, one can observe that persons who had a wide range of experience and are considered skillful hold the higher positions, but with the responsibility to manage, lead and mentor the subordinates. In fact, knowledge and skills have now become the requirement to be entitled for a higher position.