Theory in Practice: 1

Running head: THEORY IN PRACTICE: PATRICIA BENNER

Theory in Practice: Patricia Benner

Carol A. Lewallen

Briar Cliff University

Theory in Practice: Patricia Benner

Historical/Contexual Development

Patricia Benner has a rich history in research. Part of her career began as a postgraduate

nurse researcher in 1970 in California. 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.

She acknowledges that she has been influenced by Virginia Henderson (Tomey, 1994).

Benner became in involved in a research project called Achieving Methods of Intra-

professional Consensus, Assessment, and Evaluation (AMICAE) which became the foundation

for her famous book From Novice to Expert: Excellence and Power in Clinical Nursing Practice.

During this research it was discovered that knowledge could be gained in clinical practice and

that practice could be a way of knowing in and of itself. There were two outcomes of the

research project: “(1) validation and interpretation of the Dreyfus model of skill acquisition for

nurses; and (2) description for the domains and competencies of nursing practice” (Alligood &

Tomey, 2006 p. 131).

The Dreyfus skill acquisition and skill development model was developed by professors

Stuart and Hubert Dreyfus. The model was adapted by Benner to clinical nursing practice. She

further used the model to identify and distinguish levels of nursing practice from advanced

beginner to expert (Tomey, 1994).

Through her research project, observation of actual practice, and clinical situation

interviews, seven domains of nursing practice emerged. These domains included: the helping

role, the teaching-coaching function, the diagnostic and patient-monitoring function, effective

management of rapidly changing situations, administering and monitoring therapeutic

interventions and regimens, monitoring and ensuring the quality of health care practices, and

organizational work-role competencies. Thirty-one competencies emerged and were described as

well (Alligood & Tomey, 2006).

Synthetic Analysis of the theory

Benner‟s (1984) model describes five stages of nursing development: novice, advanced

beginner, competent, proficient, and expert. There are distinct differences in the practice abilities

and experience levels within the five stages.

Novices must be given rules to guide them because they have no experience in the

situations they have in front of them. Advanced beginners have had enough experience to be

guided by a mentor and have an understanding of the situation or the „aspects‟ of the situation.

The competent practitioner has 2-3 years of experience in the same or similar setting, engages in

conscious and deliberate planning, and consistently uses an analytical framework. The proficient

practitioner views situations as a whole rather than an „aspect‟ and are able to perceive the

meaning in the situation and anticipate expectations. The expert practitioner has practiced for six

or more years in the same or similar setting and does not rely on maxims, rules, or analytic

frameworks (Benner, 1984). Other major concepts of Benner include: aspects of a situation,

attributes of a situation, competency, domains, exemplars, experience, maxims, paradigm cases,

and salience (Tomey, 1994).

The major assumptions are nursing, person, situation and health. “This model assumes

that all practical situations are far more complex than can be described by formal models,

theories and textbook descriptions” (Tomey, 1994, p. 169).

Nursing is described as a caring relationship that sets up the possibility of giving and

receiving help, a science guided by morals, ethics, and responsibilities. “Benner understands
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nursing practice as the care and study of the lived experience of health, illness, and disease and

the relationships between these three” (Tomey, 1994, p. 169).

“A 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” (Tomey, 1994, p. 169). Understanding

the person, one must consider the role of the situation, the body, the personal concerns, and the

temporality. These aspects make up the person in the world. Benner defined embodiment as the

capacity of the body to respond to meaningful situations (Tomey, 1994).

Benner prefers to use the term situation instead of environment. Persons enter into

situations with their own opinions and understandings; how they may be involved in the situation

is their personal interpretation. She believes that being situated means that one has a past,

present, and future and that these effect the current situation. According to Benner and Wrubel

(1989), “situation implies a social definition and meaningfulness” (p. 80).

According to Benner, her published work The Primacy of Caring “focuses on the lived

experience of being healthy and being ill” (Benner & Wrubel, 1989, p. 7). Health and disease are

defined as what can be assessed at a physical level. Well-being and illness are the human

experience. A person may have a disease yet not consider themselves ill (Benner & Wrubel).

Focused theory evaluation

Christian worldview

Patricia Benner has helped to create an atmosphere within the nursing profession which

values the wholeness of human beings including their psychosocial and spiritual needs. Many of

her beliefs can be accepted and affirmed by Christian nurses. She calls to all nurses to be

“compassionate strangers”.
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The care ethic given to us in the Christian tradition has been marginalized in the current

market model of health care systems. . . The story of the Good Samaritan suggests that

the starting point in health care ethics should be in recognition and in relationship to the

universal human reality of vulnerability and suffering. . . Therefore, we are to be

compassionate strangers to those who fall outside our own communities and kinships

(Benner, 1998, p. 1).

How was the theory developed?

Patricia Benner has the educational and experiential background to develop a nursing

theory. The theory is inductive, based on evidence drawn from observations, personal

experiences, interviews, and exemplars provided by nurses. Benner applied her work to the

Dreyfus Model of Skill Acquisition developed by Herbert and Stuart Dreyfus both professors at

the University of California (Tomey, 1994).

How the theory is internally structured?

The theory is relatively simple with regard to the five stages of skill development and

understanding of the different levels of nursing practice. The complexity comes with the

differentiation between the levels of competencies. The key terms are well defined without the

overuse of unnecessary words.

How the theory is used

The theory has the potential to be used universally as a framework and is not restricted by

age, illness, health, or location of nursing practice. The model was empirically tested using

qualitative methodologies. The testing derived 31 competencies and seven domains of nursing

practice. “The strength of the Benner model is that it is data-based research that contributes to

the science of nursing” (Tomey, 1994, p. 173). The model is also used in educational curricula.
Theory in Practice: 6

The theory has social significance and is socially accepted. Benner has considered

ethically the greater good of society and that society expects nurses to be competent. Society has

put it‟s faith in nurses to be experts in their areas and provide competent care.

How the theory influences knowledge development

I do not believe the theory has great potential to generate other theory but the theory can

be further studied. It is forward-looking and is a valuable resource that is currently used and will

continue to be used to improve the nursing practice as other nursing skills and situations are

evaluated. It will also be a valuable resource to use as nursing practice continues to evolve;

nurses are expected to grow with technology and as new procedures are developed. “Subsequent

research suggests that the framework is applicable and useful in providing knowledge of the

description of nursing practice” (Tomey, 1994, p. 173).

How the theory stands up to testing

The theory testing has minimal use and can be used only as a framework. According to

Tomey (1994), the model has potential universal application as a framework but it is dependent

on actual clinical nursing situations. The properties do not allow for predictions as it is based on

phenomenological perspectives.

Review of related research and literature

Theory’s contribution to a moral commitment to the public

According to Benner (1998), “Moral worth and respect is to be accorded to all fellow

human beings” (p. 1). Benner‟s theory leads practitioners to understand that an everyday ethical

comportment is meeting and recognizing the healthcare concerns of patients and their families.

Nurses are expected to be advocates and act in the best interests of patients and families.

Becoming a „good‟ practitioner is more than a moral obligation and more than just following the
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patients‟ rights. It is being involved in the patient‟s vulnerability and responding to the patient as

a fellow human being. The „good‟ practitioner also requires learning from experience and that

experiential learning needs to be shared with other practitioners (Benner & Shobe, 2003).

Advocacy for good everyday ethical comportments, social ethics and public policy that

address social inequities are also essential to ensuring that healthcare is a right and fulfills

notions of good essential to a healthy society . . .As moral agents, clinicians are required

to learn from their experience in order to develop better judgment and character over time

. . . Our fiduciary relationship to patients extends to social justice and preventive public

health measures to reduce human suffering and vulnerability (Benner & Shobe, 2003, p.

374).

Theory’s contribution to education

Benner has described a variety of approaches to education and clinical expertise

development including: clinical knowledge development seminars, dialogue around clinical

narratives, exchanges, research participation and the writing of paradigm cases (Benner, 1984).

The National Organization of Nurse Practitioner Faculties (NONPF) is the organization that

provides leadership in promoting nurse practitioner (NP) education. In 2004, NONPF released

four curriculum models. The models they suggest follow the theoretical basis of Benner‟s novice

to expert concepts. Each model has the same level of competencies starting with a pre-

professional level moving into basic nursing, clinical leader, nurse specialist and finally to the

doctoral competencies (National Organization of Nurse Practitioner Faculties [NONPF], 2004).

Balancing teaching and maintaining clinical practice competence are among the greatest

challenges of nurse educators. It is an expectation that nurse educators are experts in clinical
Theory in Practice: 8

practice and education concurrently. Benner‟s (1984) description of the development of nursing

practice can give nurse educators guidance in their dual roles.

Little and Milliken (2007) state, it would be difficult for nurses to gain experience,

knowledge and skills in the educational and clinical areas at the same time to achieve the dual

expert levels that are expected. Therefore, they have proposed “that the term „competence‟ is

more accurate and achievable than „expert‟ when describing the clinical practice requirements

for a full-time faculty member” (p.2).

Theory’s contribution to practice

Benner‟s work, for the most part through the use of narratives, has been able to show

other ways of uncovering and seeing much of the value, depth, and complexity of skilled nursing

practice (Darbyshire, 1994).

Benner‟s entire project, her research, writing, speaking, promotion of narratives and

clinical-ladders development in hospitals . . . has been to understand better and re-vision

skilled nursing practice as shared and common understandings. It has been to learn more

about how nurses develop expertise and practice expertly and it has been to encourage

and enable nurses to describe, uncover and share their expertise (Darbyshire, 1994, p.

758).

In 1990, NONPF published a set of domains and core competencies for primary care

NP‟s. There are seven domains and within each domain are 75 specific competencies. The

competencies were based on Benner‟s (1984) domains of expert care nursing. She “described

domains and competencies for advanced nursing practice” (National Organization of Nurse

Practitioner Faculties [NONPF], 2002, p. 2).

Theory’s contribution to knowledge development

Benner studied clinical nursing practice as she was trying to find and describe the

knowledge that nurses hold and gain over time in practice. She describes the difference between

practical and theoretical knowledge that “knowing how” is practical knowledge and “knowing

that” is theoretical knowledge. She has given nursing a unique way to understand that theory is

derived from practice and practice is then altered or extended by theory. “Knowledge

development in a practice discipline 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” (Tomey, 1994, p.

164). Benner believes that nurses have failed to document their clinical experiences and

observations and in turn this has deprived nursing theory from the unique knowledge embedded

in expert practice (Tomey, 1994).

Recommendations for theory integration in Advanced Practice

In your practice

I will be able to integrate Benner‟s model in my practice. I have developed a better

understanding of the different stages of expertise and I believe I will be able to determine, for

myself, what skill level I am at depending on the situation in front of me. With that

understanding of the five different levels of skill development, I will be able to identify how to

better approach situations.

I am frequently asked to orient and precept new employees in the department I am

currently working. I feel in the current position I am working I would be considered an expert in

my field. I have been working in surgical services for the last 12 years and do not rely on rules

and frameworks. I have a deep knowledge and high skill level in the specialty I work in. I trust

and act on my intuitions as they relate to surgical patients. I struggle with preceptor situations
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and find that it is difficult to explain and difficult to show intuition or „knowing how‟. I believe

another nurse who is at a competent skill level may be a better fit for being a preceptor than

someone at the expert level. Suggesting this and using Benner‟s model as my research base may

be a way to incorporate better preceptor situations in the future.

Practicing and documenting observations and situations, as Benner recommends, is the

best way to allow practice to alter and extend theory. In turn, theory is incorporated into practice.

Understanding how to become empathetic and caring to patients and families, advocating for

vulnerable people and nurturing those in need are also ways to integrate theory into practice.

For the profession

Integration of Benner‟s model into the nursing profession is already underway with the

NONPF competencies being used for advance practice and advanced practice curriculum. The

NONPF domains and competencies are the recommended basic competencies for advance

practice nurses and will continue to be the recommendation as nine new domains and

competencies for the practice doctorate have been further developed, building on the existing

core competencies for all nurse practitioners. (National Organization of Nurse Practitioner

Faculties [NONPF], 2006).

References

Alligood, M. R., & Tomey, A. M. (2006). Nursing theory: Utilization and application (3rd ed.).

(Y. Alexopoulos & K. Hebberd, Eds.). Philadelphia: Elsevier.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. (N.

Evans, E. P. Lewis, & J. DeProsse, Eds.). Menlo Park, CA: Addison-Wesley.

Benner, P. (1998). The need for compassionate strangers. Retrieved October 20, 2008, from

http://www.cbhd.org/resources/healthcare/benner_1998-04-10.htm

Benner, P., & Shobe, T. (2003). Enhancing patient advocacy and social ethics. American Journal

of Critical Care, 12(4), 374-375.

Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness.

(N. Evans, Ed.). Menlo Park, CA: Addison-Wesley.

Darbyshire, P. (1994). Skilled expert practice: is it ‟all in the mind‟? A response to English‟s

critique of Benner‟s novice to expert model. Journal of Advanced Nursing, 19, 755-761.

Little, M. A., & Milliken, P. J. (2007). Practicing what we preach: Balancing teaching and

clinical practice competence. International Journal of Nursing Education Scholarship,

4(1), 1-14.

National Organization of Nurse Practitioner Faculties (2004). Curriculum models for practice

doctorates in nursing. Retrieved September 17, 2008, from

http://www.nonpf.org/Models1104.pdf

National Organization of Nurse Practitioner Faculties. (2002). Nurse practitioner primary care

competencies in specialty area: Adult, family, gerontological, pediatric, and women’s

health [Brochure]. Rockville, MD: US Department of Health and Human Services.

National Organization of Nurse Practitioner Faculties. (2006). Practice doctorate nurse

practitioner entry-level competencies. Retrieved September 17, 2008, from

http://www.nonpf.org/NONPF2005/PracticeDoctorateResourceCenter/CompetencyDraft

FInalApril2006.pdf

Tomey, A. M. (1994). Nursing theorist and their works (3rd ed.). (N. D. Como & B. M. Cowell,

Eds.). St. Louis, MO: Mosby.