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Copy of Patricia Benner's Theory of Novice to Expert

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Transcript of Copy of Patricia Benner's Theory of Novice to Expert

Get briefly description of the theorist Accomplishments.

Describe the five level of skill acquisition according to dreyfus’ Model .

Define Metaparadigm and major concept of the theory.

Identify Major assumption of the theory.

Differentiate the practice of a colleague with consideration of "novice to expert" levels of capability.
Level of Nursing Experience
Patricia Benner
Patricia Sawyer Benner
SKILLS ACQUISITION
Majd T. Alsayyed RN
From Novice to Expert
At the end of this interactive discussion,
you should be able to:
Patricia Benner was born on August of 1942 in Hampton Virginia ,and spent her childhood in California, where she received her early and professional education

Patricia was married to Richard Benner on 1967. They have a son and a daughter.
BSN 1964
MSN 1970
PhD 1982
FROM NOVICE TO EXPERT
Richard Benner
Virginia Henderson
Hubert and Stuart
Dreyfus
Richard Hiedegger
Soren Kierkegaard
Maurice Merleau-Ponty
Practical Knowledge without
Theoretical understanding is
problematic
Theoretical Influences
Hubert and Stuart Dreyfus
From UCSF
Five
levels of Skills Acquisition
Dreyfuses' model is
situational

It was developed by studying the
processes the experts used
to play chess, as well as the armored tank drivers and airplane pilots' performance in emergency situations.
Reliance on abstract
principles
Use of past concrete
experience as paradigms
Change in the learner's perception of the situation:
Situation is seen less as a mass of equally relevant bits
Change in the learner's perception
of the situation:
More as a complete whole where
only certain parts are relevant
Detached observation
Involved performer
1
3
4
The model posits that changes in 4 aspects of performance occur in movement through the levels of skills acquisition as follows:
Advanced Beginner
Competent
Proficient
Novice
Expert
7 Domains of Nursing Practice
1. Helping role
2. Teaching-coaching function
3. Diagnostic-patient monitoring-function
4. Effective management of rapidly changing
situations
5. Administration and monitoring of therapeutic interventions and regimen
6. Monitoring and ensuring the quality of healthcare practices
7. Organizational and work role competencies
Her interest in becoming a nurse sparked
when she was working as clerk at a local hospital


Rainbow of Accomplishment


Richard Benner completed studies on situational leadership; Benner stated that his work had a deep impact on her practice (Sitzman & Eichelberger, 2011).


Benner has rich background in research and began this part of her career in 1970 as a postgraduate nurse researcher in the School of Nursing at the University of California, San Francisco.

Has a wide range of clinical experience including acute medical-surgical, critical care, emergency room, and home healthcare.

Teaching as associate professor in the department of physiological nursing as well as the department of psycological nursing at UCSF.1989

In 2002, she moved to the department of social and behavioral sciences at UCSF.

She is the first occupant of Thelma Shobe Endowed Chair and Lectureship in Ethics and Spirituality

Director of National Nursing Educ.
Authored and published 9 books and many articles.
Benner continues to be involved in presentations and consults, as well as writing and research projects.

she puplished many articles and many books
Benner, P. (Why does nursing need a theory?)
The Japanese Journal of Nursing Research, 18(1), 3-30.

Benner, P. & Tanner, C. (Clinical judgment: How expert nurses use intuition?), American Journal of Nursing, 78(1), 23-31.

Tanner, C., Benner, P., Chesla, D. The phenomenology of knowing a patient. The Journal of Nursing Scholarship
From novice to Expert (1984)
The primacy of caring (1989)
The Crisis of Care(1994)
Expertise in nursing practice (1996)
Clinical wisdom and interventions in critical care (1999)

Honors and Awards
Book of the year award from American Journal Of Nursing ,1984, 1989,1996, and 1999
Selected for the CHOICE list of Outstanding Academic Books
her books translated to 10 languages
National League for nursing linda Richard
Award for leadership in education
The Excellence in nursing research and nursing education Award
The Alumnus of the year Award in 1993
Become an Honorary fellow in the Royal College
Award for outstanding contribution to the profession by National Council 2002
American Association Of Colleges of nursing spirit award
- Virginia Henderson
wrote that “the
unique
function of the nurse is to
assist
the individual, sick or well, in the performance of those activities contributing to health, that he would perform
unaided
if he had the strength in such a way as to help him gain
independence
as rapidly as possible”.
- Henderson
influenced
her thinking in nursing
- Benner’s definition of the role of nursing: is to care for the individual within the
context
of the
person’s self interpreting world
Jane Rubin:
- Benner influenced by Jane Rubin’s scholarship, teaching, and colleague ship and take it as a sources of
inspiration
.

Judith Wrubel

- He has been a
participant
and
coauthor
with Benner for years,
collaborating
on the ontology of caring and caring practices.

The model is
situational
rather than being a trait or talent model.
The model is
developmental
in that changes in the performance in particular situations can be compared across time.
Nursing practice is
complex
,
varied
, and
underdetermined
Good
practice requires that the nurse develop skillful ethical comportment as good clinical judgment informed by scientific evidence and technological development
Perceptual

acuity
in recognizing salient signs, symptoms,
and responses to therapies are required
Recognizing and keeping track of clinical changes in the patient over time
requires
the logic of reasoning in transition
Benner combine between knowing how and knowing that !!
2
Shift from reliance on analytic
rule based thinking
Intuition
Major Concepts
Derived concepts
primitive concepts
Abstract Vs concrete concepts
compartment :refers to style and manner of acting and interacting which include gesture , posture and stance .

Maxim: A cryptic(hidden) description of skilled performance that requires a certain level of experience

Salience: a perceptual stance of embodied knowledge

Paradigm case: A clinical experience alters the way of understanding and perceiving future clinical situations.

variable Vs non variable
Aspect of a Situation: The characteristics of the situation recognized and understood in context because of prior experience

Attribute of a Situation: Measurable properties of a situation that can be explained without previous experience in the situation.

Experience: not a mere passage of time but an active process of refining and changing preconceived theories, notion, and ideas when confronted with actual situations; implies there is a dialogue between what is found in practice and what is expected
Novice
Novice as a beginner has
no experience
of the situation
Novice nurses
must be taught
about a patient’s condition in
objective
and
measurable
parameters.
Novices are
taught rules
to help them perform.
Novice practice is very
limited
and
inflexible
they
utilize strict rules
to govern practice because they have -
limited to no- clinical experience.

Because of this inflexibility and rule based practice, the novice nurse
cannot separate out the relevant pieces
of the situation; instead this all pieces are seen as
equal
.
In order for the novice nurse to develop skills, the nurse must be put into
new
clinical situations.
-They act in a manner of
“tell me what I need to do and I will do it”
Advance beginner
Advance beginner as a nurse “who can demonstrate
marginally
acceptable performance, one who have
coped
with
enough
real situations
The advanced beginner develops principles based on
experience
and begins the use of these experiences
to guide
their actions, knows the rules and follows the rules
exactly and without deviation.
-Treats all attributes as
equally
important.
-feel
highly responsible
for managing patient care yet still largely rely on the help of those more experienced
-Most
newly graduated nurses
would be considered Advance Beginner.

competent nurse
A competent nurse is a nurse who has gained
2-3 years
of experience in the same work area or in similar
day-to-day
situations (Benner, 1984).
see or plan his or her actions in terms of
long-range goals.
plans actions
based
on the pertinent(
related
or
relevant
) aspects of the situation instead of including all aspects.
-It’s the most
pivotal
stage in which the learner started to recognize patterns and determine which elements of the situation
warrant attention
and which can be
ignored
.
-They
don’t see the total scope
of their patient’s situation beyond the setting.
-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

proficient
The proficient nurse perceives situations as a
whole
instead of in terms of aspects.
Perception is
fundamental
to the proficient nurse.
In this level, the nurse understands more
holistically
, thus improving decision making .
-The proficient nurse has learned from
experience
typical events to expect in a clinical situation and how plans need to be
modified
to response to these events (Benner, 1984).
-There is much more
involvement
with patient and family and an increased personal
confidence
in skills and abilities.

expert
expert nurse has a
deep connection
and
understanding
of the situation.
-The expert no longer relies on analytic principle(rule, guideline); instead, the expert has an
intuitive
grasp of situations that is utilized to determine actions
- The performance of the expert nurse is
fluid
,
flexible
, and
highly
proficient (Nursing Theories, 2011).
-Clinical
grasp
: a clinical inquiry in action that includes problem identification and clinical judgment across time about the particular transition of particular patients and families.
-Seeing the
unexpected
.
expert nurse can make assumptions based on “
hunches
”,
expert nurse skills
exceedingly
the use of analytic tools,
-benner described the expert nurse as being able to
identify the region of the problem without losing time
considering a range of alternative diagnoses and solutions.

competency:
an interpretively defined area of skilled performance identified and described by it is intent, function, and meaning .
Domain
this is an area of practice having a number of competencies with similar intents, function, and meanings
exemplar
is an example from clinical situation that conveys one or more intent , meaning , function,or outcomes easily translated to other clinical situation


Assumption
Humans are integrated, holistic beings
There are no interpretation free data
There are no non reactive data
Meaning are embedded in skills , practice , intention, expectation , and outcomes
they are taken for granted and often are not recognized as knowledge
People share a common cultural and language history have a background of common meanings that allows for understanding and interpretation
Explicit
Implicit
The meanings embedded in skills , practices ,intentions, expectations, and outcomes cannot be made completely explicit
Functional component
Nursing
Described as a
caring
relationship, an "enabling condition of
connection
and
concern
".
-caring is a
primary
because caring sets up the possibility of
giving
help and
receiving
help.
Nursing: a caring practice whose science is
guided
by the moral art and ethics of care and responsibility.
-Nursing practice: is the care and study of the lived experience of health, illness, and disease and the relationships among these three elements.


Person
Health
What can be
assessed
, whereas well being is the human experience of health or wholeness.

Not just the
absence
of disease and illness; person may have a disease and
not
experience himself as ill because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at the physical level.

Situation
Benner uses the term
situation
rather than environment because situation conveys a people environment with social definition and
meaningfulness
defined by The person’s
engaged
interaction, interpretation, and understanding of the situation
she uses the phenomenological terms of being
situated
, "to be
situated
implies that one has a past, present, and future and that all of these aspects influence the current situation.
Persons enter into
situations
with their own sets of meaning, habits, and perspectives.
personal interpretation of the situation is bounded by the way the individual is in it
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. the person is
Viewed
as a participant in common meanings.
Benner and Wrubel have conceptualized
4 aspect
to understand a person
1. the role of the situation
2. the role of the body
3. the role of the person concern
4 . the role of temporality
together these 4 aspects make up the person in the world

cultural organization and meanings precede and influence individual understanding
Humans are self interpreting beings
Usefulness
Congruence with social and cultural values
Clinical experiences and nurse’s stories provide the necessary background understanding for everyday ethical comportment
This theory changed the profession's understanding of what it means to be an expert, placing this designation not on the nurse with the most highly paid or most prestigious position, but on the nurse who provided "the most exquisite nursing care.”
Persons share background meanings, skills ,and habits derived from their cultural practices.

social significance
The novice to expert theory has provided a highly valued framework for advanced development of the nursing profession. This philosophy has been a foundation in practice, education, and leadership development in the nursing profession.
-Practical knowledge is essential to knowledge development and professional growth of nursing.
Benner model provides a general framework for identifying, defining, and describing clinical nursing practice.
-The significance of Benner's research findings lies in her conclusion that "a nurse's clinical knowledge is relevant to the extent to which its manifestation in nursing skills makes a difference in patient care and patient outcome".

Testability
The model was empirically tested using qualitative methodologies. 31 competencies , 7 domains of nursing practice , and 9 domains of critical care practice were derived inductively
Her work seems to be hypothesis generating rather than hypothesis testing
Subsequent research suggests that the framework is applicable and useful in providing knowledge of the description of nursing practice
it is precisely the use of an alternative qualitative process of discovering nursing knowledge that make it difficult to address the body of Benners work within a rational - empirical framework for critique
Benner provide no universal " how to " for nursing practice but instead provides a methodology for uncovering and entering in to the situated meaning of expert nursing care


Relationship between structure and function
1. simplicity
:
She uses the
five
concepts to describe nursing practice ,
competencies
were identified and these were grouped
inductively
in to seven domains of nursing practice followed by nine domain of critical care nursing
A degree of complexity is encountered in the
sub
concepts for differentiation among the levels of competency and the need to identify meanings and intention
.....
description
of the novice level of performance would be
possible
but expert
description
would be difficult if not
impossible
and limited to its usefulness
2
.
clarity
:
she explored the differentiation of practice in depth and suggested that nurses at different levels live in different worlds
The model is relatively clear in regard to the five stages of skill acquisition and it provides a comparative guide for identifying levels of nursing practice from individual nurse description and observations of actual nursing practice.

Diagram of the theory
Framework for theory description
practice
Education
Administration
Expert nurse development must include risk taking, deliberate practice, social models and mentors, and external rewards; these factors are influential in nursing leadership for skill development and expert performance and learning (Haag-Heitman, 2008).
Expert nurses are leaders in the profession who are self-directed involved performers who continually strive to improve and make breakthroughs in their performance and the nursing profession (Haag-Heitman, 2008).

Acceptance by the nursing community
Benner approach has been used to aid in the development of clinical promotion ladders ,new graduate orientation program and clinical seminar
Sliver 1986 , use Benners work as a basis for differentiating clinical knowledge development and a career progression in nursing
Neverveld 1990, used Benners rational and format in her development of basic and advance preceptor workshop
Farrell 1990, used Benners paradigm case analysis in a collaborative educational project between a university school of nursing
Crissman 1990, applied Benners finding in developing a cross -training program to address staffing imbalances
Benner continues to advance understanding of the knowledge embedded in clinical situation through publication , 1999
Benner began editing a series called current controversy in critical care in the american journal of critical care
What about
Research

3
.
Generality

The model has
universal

characteristics
; that is not restrictive by age, illness, health, or location of nursing practice
has the potential for
universal

application
as a framework but the description are limited by dependance on the actual clinical nursing situation from which they must be derived .
it is use depend on the
understanding
of the five levels of competency and the ability to identify the
characteristic
intentions and meaning inherenit at each level of practice
4
.
Consistency
Consistency is determined by evaluating the
congruency
between each component of a theory. Benners model contains concepts which are
consistent
with each other and are consistently utilized.
Summary

* Benner seeks to affirm and restore nurses caring practice
* she maintains the caring practices are embued with knowledge and skill
*Benners philosophy of nursing practice is a dynamic , emerging ,holistic perspective .
*her hope voiced in the preface to from novice to expert
*the holistic approach is maintained through out the research process from beginning to

The end
Strengths and Weakness
Benner’s theory is strong enough, and, it captures some aspects of experts’ development fairly well, It provides important insights on the complex interaction between nursing theory and practice.
Benner’s theory does not account for the development of expertise and intuition well, when compared to empirical data. A key aspect of
the theory is the presence of stages in expertise development. However, these stages are poorly documented in the literature,,,,
Benner studied the
difference
between nurses worked in a
special
care unit and those work in
regular
unit

then
,Benner was a research
consultant
for nursing
activity
and
productivity

after that,,,
Benner
conducted
a systematic evaluation of competencies, job finding, and work problems
from 1978 and 1981 she was the author and director of
AMICAE PROJECT
,,, it is
aimed
to evaluate methods of nursing school and hospitals in UCSF

Her research was
descriptive
,
interpretive
, and she used the Dreyfus model , this model give her an
explanation
and
rich description
of nurses practice ( hermeneutics)
31 competencies
were emerged from analysis of the transcripts about detailed descriptions of patient care included their
intentions
and
interpretation of events
From these competencies identified , 7 domains were inductively emerged on bases of similarity and intent ....
Then she extend her research to include nine domains of critical care nursing practice that were identified as broad themes :
Nursing Problems :
Nurse patient interaction
If you ask
why this theory ?
we are both an administrative student and Benner is our mentor , we are influenced with her theory
Prepositions
Substantial
• "discovering assumptions, expectations, and sets can uncover an unexamined area of practical knowledge that can be systematically studied and extended or refuted "(benner, 1984a,p.8).
• Clinical knowledge is embedded in perceptions rather than precepts.
• " expertise develops when the clinician tests and refines propositions , hypotheses, and principle-based expectations in actual practice situations"
Sequential or Coexist
The knowledge embedded in practice can lead to discovering and interpreting theory , precedes and extends theory, and synthesizes and adapts theory in caring nursing practice.
Concrete experience provides learning about the exceptions and shades of meaning in a situation
"perceptual awareness is central to good nursing judgment and … { for the expert} begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than it precedes"
Deterministic
Benner (1984a) stated that there is always more to any situation than theory predicts.
The skilled practice of nursing exceeds the bounds of formal theory.
Formal rules are limited and discretionary judgement is needed in actual clinical situation.
Clinical knowledge develops over time ,and each clinician develops a personal repertoire of practice knowledge that can be shared in dialogue with other clinicians.
SIGNIFICANCE OF THE THEORY

These levels reflect movement from reliance on abstract principles to the use of past
concrete experience as paradigms and change in perception of situation as a complete whole in which certain parts are relevant

Each step builds on the previous one as abstract principles are refined and expanded by experience and the learner gains clinical expertise.

It recognized that nursing was poorly served by the paradigm that called for all of nursing theory to be developed by researchers and scholars, but rather introduced the revolutionary notion that the practice itself could and should inform theory.

The significance of the theory increase the theory scope and then broaden its generality ,, so what do you think ?
is it middle range or grand theory ?
1. Diagnosing and managing life –sustaining physiological functions in unstable patients
2. Using the skilled know-how of managing a crisis
3. Providing comfort measures for the critically ill
4. Caring for patient's families
5. Preventing hazards in a technological environment
6. Facing death: end-of-life care and decision making
7. Communicating and negotiating multiple perspectives
8. Monitoring quality and managing breakdown
9. Using the skilled know-how of clinical leadership and the coaching and mentoring of others.

It is a theory with a wide scope , high level of generality
Have a great significance and influence to nursing discipline
There are a variety in concepts ,focus on rich aspects of relationships
Have more than substantive focus
Not susceptible to empirical testing
Is
It
An Inductive?
according to

Tomey and Alligood 2006

" her work can be

considered as hypothesis

generating rather than


hypothesis testing "


so it is an inductive theory

pg 155
here you can grasp the theory goal
she stated that " competency -based testing seems limited to the less situational , less interaction areas of patient care "
she validated the clinical nurse specialist (CNSs)competencies in AMICAE project
she identified additional areas of skills performance for CNSs
nursing educators have realized that learning needs at early stages of clinical knowledge are different those required at later stages and these differences need to be valued in programs
in
Expertise in nursing practice 1996 , she emphasized the importance of learning and skill of involvement
in Clinical Wisdom in critical care , she urged greater attention to expertial learning and presented the work as guide in a highly interactive CD
the nurse patient interaction based to overcome the old view as " you are dealing with a distinct,separate entities
the interaction determined by your embodiments
" your capacity to respond to meaningful situation"
through this interaction , the role of embodiment is to understand a particular situation of health ,illness and recovery
Benner differentiate between knowing how and knowing that, and she stated that knowing how,or the knowledge development in practice lead to knowledge development
she believes that the problem is when the nurses has been delinquent in documenting their clinical learning ,,,, this lack in charting deprives nursing theories from uniqueness and richness of knowledge embodied in practice
Visual representations of the theory may further enhance its clarity. Benner does not present a visual representation, but the stages can be referred to as being along a continuum
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