10.

1177/0270467604265061
Benner / DREYFUS MODEL IN NURSING PRACTICE
BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

Using the Dreyfus Model of Skill Acquisition to

Describe and Interpret Skill Acquisition and
Clinical Judgment in Nursing Practice and
Education

Patricia Benner
University of California, San Francisco

Three studies using the Dreyfus model of skill ac- studies of skill acquisition in nursing have been guided
quisition were conducted over a period of 21 years. by the Dreyfus model of skill acquisition (Benner,
Nurses with a range of experience and reported skill- 1982, 1984; Benner, Hooper-Kyriakidis, Stannard,
fulness were interviewed. Each study used nurses’nar- 1999; Benner, Tanner, & Chesla et al. 1992, 1996).
rative accounts of actual clinical situations. A Hubert and Stuart Dreyfus served as consultants in
subsample of participants were observed and inter- each of these three studies.
viewed at work. These studies extend the understand- The first study, conducted between 1978 and 1981
ing of the Dreyfus model to complex, under- (Benner, 1982, 1984), was based on 21 paired inter-
determined, and fast-paced practices. The skill of views with newly graduated nurses and their precep-
involvement and the development of moral agency are tors, and interviews and/or participant observations
linked with the development of expertise, and change were conducted with 51 additional experienced nurse
as the practitioner becomes more skillful. Nurses who clinicians, 11 newly graduated nurses, and 5 senior
had some difficulty with understanding the ends of nursing students to further delineate and describe
practice and difficulty with their skills of interpersonal characteristics of nurse performance at different levels
and problem engagement did not progress to the level of education and experience. The interviews (small
of expertise. Taken together, these studies demonstrate group and individual) were conducted in six hospitals:
the usefulness of the Dreyfus model for understanding two private community hospitals, two community
the learning needs and styles of learning at different teaching hospitals, one university medical center, and
levels of skill acquisition. one inner-city general hospital. A second study of skill
acquisition and clinical knowledge of critical-care
Keywords: nursing practice; phronesis nurses was conducted between 1988 and 1994

Stuart E. Dreyfus, an applied mathematician, and (Benner et al., 1992; Benner et al., 1996). One-
hundred and thirty nurses practicing in intensive care
Hubert L. Dreyfus, a philosopher, developed a model units and general floor units from eight hospitals,
of skill acquisition based on the study of chess players, seven of which are located in the far western and one in
air force pilots, and army tank drivers and command- the eastern region of the country, comprised the study
ers (S. E. Dreyfus, 1982; H. L. Dreyfus & Dreyfus, population. Small group narrative interviews, individ-
1977, 1986; S. E. Dreyfus & Dreyfus, 1979, 1980). ual interviews, and participant observation were used
The Dreyfus model of skill acquisition has illuminated as data collection strategies. The two aims of the study,
ongoing research on skill acquisition and articulation relevant to this article, were (a) to describe the nature
of knowledge embedded in expert practice in nursing. of skill acquisition in critical-care nursing practice and
The Dreyfus model is developmental, based on situ- (b) to delineate the practical knowledge embedded in
ated performance and experiential learning. Three expert practice. The third study was an extension of

Bulletin of Science, Technology & Society, Vol. 24, No. 3, June 2004, 188-199
DOI: 10.1177/0270467604265061
Copyright  2004 Sage Publications
 Benner / DREYFUS MODEL IN NURSING PRACTICE 189

this study, conducted between 1996 and 1997 to reduced to techne. But note that skillfulness and craft
include other critical-care areas (including emergency based on experience may still be essential to success-
departments, flight nursing, home health, the operat- ful performance of techne. In situations where the
ing room, and postanesthesia care units [N = 75 patient’s particular response must be considered and
nurses]) and to enlarge our sample of advanced prac- perceptual acuity is required to recognize salient
tice nurses.1 This article presents key findings of these changes in the patient, as well as situations where
three studies using data from each of the studies. attuned relationships and judgment require skillful
Nursing, like other practice disciplines, is not comportment, both techné and phronesis (situated
merely an applied field in the sense that the practice is actions based on skill, judgment, character, and
complex, varied, and underdetermined. Good practice wisdom) are essential.
requires that the nurse develop skillful ethical com- At the heart of good clinical judgment and clinical
portment as a practitioner and that the nurse use good wisdom lies experiential learning from particular
clinical judgment informed by scientific evidence and cases. Bad judgments must be refined and corrected in
technological development. The sciences of medicine particular cases; anomalies and distinctions must be
and nursing are broad and multidisciplinary and noticed. The Dreyfus model of skill acquisition
require translation into the particular practice situa- addresses this kind of experiential learning in a com-
tion. Basic sciences of biochemical, physical, and bio- plex, underdetermined field over time. The model is
logical processes; physiological processes; research situational rather than being a trait or talent model
and development of specific therapies and technolo- because the focus is on actual performance and out-
gies; and finally clinical trials and more make up a comes in particular situations. The model is develop-
broad range of relevant science used in the practice of mental in that changes in the performance in particular
medicine and nursing. situations can be compared across time. However, the
A recent development in nursing and medical prac- model does not focus or identify particular traits or tal-
tice has been to aggregate clinical trial research out- ents of the person that generates the skillful
comes to summarize and recommend the best evi- performance.
dence for treatment of specific clinical conditions. Nursing, as a practice, requires both techné and
However, the logic of scientific decision making and phronesis as described by Aristotle. Techné can be
the logic of the practitioner working with single cases captured by procedural and scientific knowledge,
or unique populations are necessarily different. The knowledge that can be made formal, explicit, and cer-
practitioner must reason across time about the particu- tain, except for the necessary timing and adjustments
lar through changes in the patient’s condition and made for particular patients. Phronesis, in contrast to
changes in the clinician’s understanding of the techne, is the kind of practical reasoning engaged in by
patient’s condition. Because practice in the individual an excellent practitioner lodged in a community of
case is underdetermined (i.e., open to variations not practitioners, a practitioner who, through experiential
accounted for by science), the practitioner must use learning and for the sake of good practice, continually
good clinical reasoning to intelligently select and use lives out and improves practice (Benner et al., 1999;
the relevant science. Perceptual acuity in recognizing Dunne, 1997; Gadamer, 1960/1975; MacIntyre, 1981;
salient signs, symptoms, and responses to therapies Shulman, 1993). Techne, or the activity of producing
are required for the clinician to use good clinical outcomes, is governed by a means-ends rationality
judgments in particular clinical cases. where the maker or producer governs the thing pro-
Recognizing and keeping track of clinical changes duced or made by gaining mastery over the means of
in the patient over time requires the logic of reasoning producing the outcomes. By contrast, phronesis is
in transition (Benner, 1994; Taylor, 1993). This is a lodged in a practice and so cannot rely solely on a
form of argument about the outcomes of successive means-ends rationality because one’s acts are gov-
changes. Patient changes must be evaluated as erned by concern for doing good in particular circum-
improved, stable, or deteriorating over time. Clini- stances, where being in relationship and discerning
cians call this recognizing trends in the patient. Some particular human concerns are at stake must guide
aspects of practice can be subjected to more standard- action. For example, nurses describe the excessive use
ization and to what Aristotle described as techné. Stan- of power over a patient that subjects said patient to
dard measurements of vital signs and laboratory met- unwanted, futile therapies to prolong his or her life at
rics are examples of clinical assessments that can be any cost as flogging the patient, violating both good
190 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

nursing and good doctoring (Benner et al., 1999, pp. nurse must be able to articulate clearly the reason for
363-403). In such bad practice, means and ends are using a standing order or protocol or going beyond the
violently separated so that both are distorted. usual boundaries of usual nursing practice. This is
Doctoring and nursing particular patients requires expected and defensible when it is critical for the
relational and communication skills and art. The rela- patient’s survival. Recognizing the unexpected (i.e.,
tionship between the patient and nurse, for example, when tacit global expectations of patients’ recovery
determines what will be disclosed, what can be are not met) is also a hallmark of expert practice.
thought about and talked about together, and what
level of acceptance and endorsement of the therapies Major Shifts in the Style of Practice
will be acceptable to patients and clinicians alike. With the Development of Expertise
Patients often rehearse their most fearful concerns
with nurses who they expect to be more approachable As noted above, the nurse’s capacity for effective
and effective in helping them communicate with phy- moral agency changes with developing practice skills
sicians. Technique alone cannot address interpersonal and insights from experience. Also, the skills of prob-
and relational responsibilities, discernment, and situ- lem and person engagement grow more attuned. The
ated possibilities required by caring for persons made development of agency and skills of involvement can
vulnerable by illness and injury. Phronesis is required. be seen at each stage of skill acquisition. The nurse
Means and ends are inextricably related in caring for increasingly is able to recognize when he or she does
the ill. Clinician and patient bend and respond to the not have a good grasp of the clinical situation, and this
other so that horizons and world are opened and lack of sense of understanding guides the nurse’s ques-
reconstituted so that new possibilities can emerge. tioning and problem solving.
As the Dreyfus model suggests, experiential learn- As the skill model predicts, with more experience
ing requires the stance of an engaged learner rather comes increased grasp of the nature of particular clini-
than a stance of one expert in techné who skillfully cal situations, including opportunities and constraints,
applies well-established knowledge in prespecified, which then guides the nurse’s actions and interactions.
clear circumstances. Experiential learning requires Consequently, responses to patients become more
openness and responsiveness by the learner to improve contextualized and attuned. Recognition of clinical
practice over time. The learner who develops an situations moves from abstract textbook accounts of
attuned, response-based practice learns to recognize general features to an experience-based response to
whole situations in terms of past concrete experiences, the situation. Grasp of the situation, with its possibili-
as pointed out by the Dreyfus model. ties and constraints, enables the competent nurse to
We found that responding to the situation as an move from rule-governed thinking to an intuitive
instance of particular concern is central to the logic of grasp of the situation (Dreyfus & Dreyfus, 1986).
excellent practice. For example, this is a situation of This intuitive grasp is based on experience and not
heart-pump failure or fluid depletion. Interventions based on extrasensory powers or wild hunches. It is sit-
depend on clarifying and confirming the nature of the uated in the clinician’s grasp of the situation.
clinical situation at hand. The skillful practitioner Improved skills of involvement create disclosive
learns to hold his or her background understandings in spaces in which pressing concerns or the most plausi-
a fluid or semipermeable way so that he or she can rec- ble actions can be discovered. Relational skills are
ognize when these tacit expectations are not met. For schooled by learning to be at home in a highly differ-
example, a nurse with expertise in detecting heart entiated clinical world where some actions are plausi-
arrhythmias on a unit where all patients’ cardiac func- ble and effective and others are experienced as ill
tioning is monitored will only notice aberrations in timed or implausible. A sense of salience develops
sound patterns rather than attending to the familiar over time so that some things stand out as more plausi-
sounds in the foreground of attention. Whereas in ble and appropriate than others. The proficient practi-
some skill situations, such as playing chess or driving tioner develops a richer sense of the ends and possibili-
a car, experts would not need to articulate their per- ties of practice based on shared notions of good
spectives before taking action, must make a case, that practice within the profession (Rubin, 1996).
includes articulating their perspective and evidence to Because the Dreyfus model of skill acquisition is a
get the appropriate physician intervention. In emer- situated and descriptive phenomenological account of
gencies, when there is no physician available, the the development of skill over time, it does not point to
 Benner / DREYFUS MODEL IN NURSING PRACTICE 191

isolated competencies nor enabling traits or talent. carefully select patient care situations that are rela-
Consequently, it allows that a practitioner may be at tively stable and that provide coaching about possible
different levels of skill in different areas of practice changes in the patient’s condition. The instructor fore-
based on the particular practitioner’s background casts for the student what he or she should expect, and
experience and knowledge. For example, a practitio- students typically rely on standard nursing care plans
ner skilled in caring for adults at an expert level will to guide their planned care activities. Exceptions and
not be at that level of skill when caring for young chil- contraindications must be identified for the student by
dren or premature infants. The continuities in patient the nursing instructor or staff nurse caring for the
populations one cares for determine the opportunities patient. The meanings of vital signs in the particular
for experiential learning. situation must be reviewed with the instructor or prac-
ticing nurse and the range of relevant signs and symp-
Novice: First Year of Education toms are reviewed in terms of relevance and are
assessed in the particular patient. A large number of
The novice stage of skill acquisition occurs in areas signs and symptoms (e.g., lethargy, skin turgor, mental
on which the student has no experiential background status, etc.) can only be recognized and assessed after
to base approach or understanding of the clinical situa- they have been seen in a range of patients.
tion. For example, the art and skill of a range of medi- The best clinical educators are good ethnographers
cal and nursing interventions on particular patients who can give the students access to the culture and
will be new. The educator must offer good descriptions expectations of the clinical units where they are gain-
of features and attributes of the situation that the nov- ing clinical experience. The clinical educator offers
ice can recognize. For example, to determine fluid bal- broad guidelines and timelines to guide the student’s
ance, students are given clear parameters and understanding of the task world and of the subculture
guidelines: of expectations of a particular unit. Good informants
are identified as resources for the new students in the
To determine fluid balance, check the patient’s unit, and the clinical supervision is on call to deal with
morning weights and daily intake and output for questions or emergencies encountered by the student.
the past three days. Weight gain and an intake Novices have only a very limited ability to forecast
that is consistently greater than 500 cc. could futures because of the student’s lack of experience
indicate water retention, in which case fluid with other patients. Usually, the student must rely on
restriction should be started until the cause of the textbook forecasts.
imbalance can be found. (Benner, 1984, p. 21)
Advanced Beginner, New Graduate
An experienced clinician will immediately think of
all the situations where this evaluation would be inap- The newly graduated nurse has usually functioned
propriate or too stringent. But the novice is given clear very close to the level of a beginning staff nurse in his
directions of safe ways to proceed until the signifi- or her final year of nursing education. Typically, newly
cance of fluid balance for different clinical conditions graduated nurses will not have functioned in any ad-
can be learned. The rules and guidelines must not re- ministrative or managerial functions, though they will
quire prior experience for their recognition. They must have studied principles and practices related to these
provide a safe beginning point for specific, situated roles. The striking change for the newly graduated
learning in the clinical situation. Fluid balance is sa- nurse is that he or she now has full legal and profes-
lient, but what the novice must learn is the particular sional responsibility for patients. This new level of re-
salience of fluid balance for particular patients. sponsibility and entitlement brings with it changes in
The rule-governed behavior of the novice is the way nurses experience themselves and the practice
extremely limited and inflexible. The student is environment. They no longer feel that they can always
coached in comparing and matching textbook exam- look to other nurses to tell them what to do or to bear
ples with actual clinical cases. Skills that are per- their responsibility. This level of individual and team
formed easily on a mannequin in a skills lab require professional responsibility heightens the new nurse’s
adaptation and communication and reassurance skills sense of engagement with the patient and with clinical
when performed on a range of patients who may be problems. This new level of felt responsibility in-
calm or highly anxious. The nursing instructor must creases the beginning nurse’s attentiveness to his or
192 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

her recognition of features and relevant aspects of the myriad of competing tasks, all of which may feel of
situation; however, the style of evaluation remains de- equal priority to the new nurse. Anxiety and excessive
tached and typically lacks integration with other ob- fatigue are frequent experiences for new nurses. Worry
jectively evaluated signs and symptoms. Beginning and anxiety tend to be more global because the ad-
nurses look to patients and family members to fill in vanced beginner does not yet have a sense of salience
expectations of them in their newly forming role. This with a range of situations, and the anxiety of learning
heightened and qualitatively different kind of engage- to perform new tasks is ever present:
ment heightens experiential learning and spurs the de-
velopment of a sense of moral agency in the And I just talked to myself and I had a great night
professional role (Benner et al., p. 93): because this was the first time I did it. . . . I was
(saying to myself) “Okay. Just take it one step at a
The quality of learning is quite different for new time. You’re only human, do one thing then go
as opposed to more experienced nurses. Begin- onto the next thing. It will all get done, it will get
ners have a level of trust in the environment and done easier if you’re calm and because you think
in the legitimacy of co-workers’ knowledge, better that way”. . . . And the shift went great.
which allows them to absorb information as fact. (Benner et al., p. 50)
This trust sets up qualities of freedom and exhila-
ration in learning that are probably only avail- In coaching an advanced beginner, strategies for
able to those who do not yet comprehend the keeping anxiety at bay and staying calm enhance per-
contingent nature of both the situation and what formance capacity because the anxiety is so general.
is known about it. This freedom in learning is The sense of foreboding and anxiousness over particu-
furthered because advanced beginners do not yet lar clinical situations is not yet very attuned to the de-
feel responsible for managing clinical situations mands, possibilities, and constraints of the situation
with which they are unfamiliar. simply because of a lack of experienced past similar
In what follows, an advanced beginner evi- situations.
dences this “lightness of being” about learning as
Anxiety is ameliorated by this very lack of
he describes a post-operative patient who had
attunement and sense of salience. Therefore, much of
undergone complex GI surgery. His entire state-
the experiential learning required of an advanced be-
ment was delivered in an excited, enthusiastic
ginner has to do with recognizing more subtle aspects
tone.
of the situation. Advanced beginners rely on textbook
I had learned so much. There are two clinical accounts of patient signs and symptoms related to dis-
nurse specialists involved right now. There are eases, injuries, and therapies, but they may have diffi-
people on the unit who are CNII’s and CNIII’s culty recognizing subtle variations and cannot gauge
who are just really knowledgeable on major GI the level of severity in comparison with other cases
surgery on infants. I talked to all these people and simply because of their lack of experienced past and
pediatric surgery were really helpful, and our future trajectories with similar patients. For example,
Attendings and fellows were . . . I mean, I just advanced beginners collect their assessment data care-
learned so much in the last three days, I couldn’t fully and then consult about the meanings of the num-
even tell you. (Benner et al., 1996, p. 52) bers and signs and symptoms in a particular case. They
will need to ask questions such as the following: Is this
The advanced beginner has a heightened awareness of the usual amount of bleeding? Is this a frank hemor-
any feedback on performance and pays close attention rhage in a postoperative or obstetrical patient? Drain-
to the practice of colleagues. He or she actively age from wounds and tubes must be evaluated in rela-
searches for credible sources of good and useful infor- tion to usual quantities and qualities. But these
mation. The nurses now attend their ability to recog- quantities may vary with specific procedures, patient
nize these aspects of the situation as they are pointed conditions, and characteristics. The range and variega-
out by colleagues and as they come to notice them on tions cannot be captured fully in textbook, a problem
their own. In the situation above, clinical nurse spe- known in philosophy as the limits of formalism. Also,
cialists assisted with the care of the infant but also en- the perceptual skills associated with recognizing fuzzy
gaged in intensive teaching of the new nurse. The ad- or family resemblances, qualitative distinctions, and
vanced beginner can experience each situation as a real-life presentations complete with their range of
 Benner / DREYFUS MODEL IN NURSING PRACTICE 193

manifestations cannot be captured in two-dimensional quently, how fast someone can gain competence
textbooks or single case presentations. This depends on how varied and complex his or her patient
relationship to clinical mentors is vividly illustrated in population is. Obviously, nurses working in a high-
the following nursing student’s account of a clinical volume heart surgery center will gain more experience
emergency: sooner. But even in the high-volume center, it is usu-
ally a while before the newer nurse is assigned com-
This man is a very pleasant fellow, very bright, plete responsibility for complicated postoperative
very alert and awake, and was unfortunately patients. Competence with particular patient popula-
requiring tracheal suctioning approximately tions will develop unevenly depending on experience
every hour to two hours for moderate amounts of with that population and with the quality of clinical
tracheal secretions which were relatively tena- teaching available in the institution.
cious in character, relatively white tannish in The competent stage of skill acquisition is typically
color. He unfortunately did not tolerate the a time of heightened planning for what are now more
suctioning extremely well. It was relatively predictable immediate futures. The competent nurse
uncomfortable for him, caused a moderate now decides what is more or less important based on
amount of cough and gag reflex, which in turn informal yardsticks learned from past experiences
caused a transient increase in blood pressure. with other patients. The competent nurse tries to limit
Following suctioning on one occasion, as I was the unexpected through planning and analysis and by
replacing his tracheal mist mask, he began forecasting the needs and contingencies of the imme-
coughing up very copious amounts of bright red diate future, but he or she realizes that there are no
blood per mouth. I mildly panicked, called for rules to help him or her do it. Anxiety is now more at-
help from the nurse next door, placed him a mod- tuned to the situation, as illustrated in the following
erate Trendelenberg position, opened his I.V. to a example where the nurse describes her discovery (ex-
rapid rate, and continued to experience mild periential learning) that a postheart transplant surgery
panic. Perhaps more like moderate panic. patient could not maintain good oxygenation when
(Benner, 1984, p. 19) placed on the nonoperative side, a physiological prin-
ciple that the new graduate would probably recognize
This advanced beginner nurse performed well consid- in a formal, written test but that is more ambiguous to
ering the enormity of the situation. The student won- her in the actual situation:
ders tacitly whether his suctioning technique was too
traumatic and therefore whether it caused the bleed. Nurse: It kind of humbles you. [She realizes that
But notice that the advanced graduate cannot know the physiological explanation for this occurrence
this because he has had little experience with patients was straight forward, but that she had not been
with similar compromised situations and with the skill able to recognize the problem as manifested in
of suctioning itself. There are extraneous details of the the particular patient.] At one point, I’m feeling
story, and the language is couched in textbook terms. like I have things straight now, and I can handle
His account responds to the immediate situation, with the situations, and when something like this hap-
little or no forecasting of the future. He gives a full ac- pens, I think, well, I still have a lot of learning to
count of his own anxiety in the situation that results, in do. I can handle the situations that are status quo;
part, from his lack of experiential knowledge about it’s the unexpected that I have to learn to deal
what can be done in the situation. Like the novice, the with now. But then I think back to situations
advanced beginner is dependent on others for filling in when I was brand new. Things that are status quo
his or her experience-based comparisons, interpreta- now weren’t back then. Things I can trouble-
tions, and qualitative distinctions. Later, we will shoot and solve now were much different back
contrast this episode with the account from the then. I usually needed help. (Benner et al., 1996,
expert’s perspective. p. 95)

Competent Stage: 1 to 2 Years in Practice Anxiety is now more tailored to the situation than it
was at the novice or advanced beginner stage when a
general anxiety exists over learning and performing
Developing skill and clinical grasp in particular
well without making mistakes. Coaching at this point
cases is dependent on experiential learning. Conse-
194 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

should encourage competent-level nurses to follow Experiential learning with past patient care enables
through on a sense that things are not as usual, or even the nurse to develop a greater sense of salience. As il-
on vague feelings of foreboding or anxiety, because lustrated in the nurse’s statement above, there is an in-
they have to learn to decide what is relevant with no creasing sense of when the nurse has or does not have a
rules to guide them. There is now enough of an experi- good clinical grasp of the situation. He or she can use
ential base to have these emotional responses to act his or her sense of confusion or questioning to propel
like fuzzy recognition of similar and/or past clinical his or her understanding of the clinical situation. Be-
dissimilar situations. Nurses at this stage feel exhila- cause nurses have now lived through more clinical fu-
rated when they perform well and feel remorse when tures, they can now better predict immediate likely
they recognize that their performance could have been events and needs of patients and can plan for them.
more effective or more prescient because they had paid Toward the upper limits of competent performance,
attention to the wrong things or had missed relevant the nurse may begin to apprehend the limits of formal
subtle signs and symptoms. These emotional re- and practical knowledge. Nurses can now recognize
sponses are the formative stages of aesthetic apprecia- that not everyone is a proficient or expert clinician, just
tion of good practice. These feelings of satisfaction at the point that they realize that they must develop a
and uneasiness with performance act as a moral com- perspective on the situation to perform well in the situ-
pass that guides experiential ethical and clinical learn- ation. They typically buy more comprehensive refer-
ing. There is a built-in tension between the deliberate ence works and medical and nursing textbooks at this
rule- and maxim-based strategies of organizing, plan- point because loss in confidence in the advice of spe-
ning, and prediction and developing a more response- cific others may be overgeneralized, and conse-
based practice, as pointed out in our study of critical- quently, the nurse may feel hyper-responsible. This
care nurses: inability to trust colleagues can be aggravated by
encountering incompetence and a lack of social inte-
Not needing help, ordering the task world, and gration and informal coaching in the particular clinical
planning based on goals and predictions struc- unit.
ture what the nurse notices, and what are consid-
ered issues. It is not accidental that this vision of Proficiency: A Transitional Stage
performance and agency is institutionally on the way to Expertise
rewarded and encouraged as “standard.”
Structuring the day by goals and plans, how-
It is the felt crisis in the limits of formalism and the
ever, interferes with perceiving the demands of
limits of planning and prediction along with an en-
the situation and with timing interventions in re-
hanced ability to read the situation that may propel the
sponse to the patient’s responses and readiness.
nurse into the proficient stage of performance.
The competent nurse seldom sees that signs and
Whereas skill development up until this point has been
symptoms have taken on a new relevance in a incremental, now, to progress, the learner must make a
clinical situation due to changes in the patient’s qualitative leap in the way he or she engages and per-
condition. Their skill of seeing is hampered by forms in the situation. The nurse must literally learn to
the need to organize data collection and to situate himself or herself differently in relation to his
achieve goals. Inevitably the clinical situation in- or her work. At this stage, first-person, experience-
trudes by not matching the goals and plans and near narratives (Geertz, 1987) often take the form of
the nurse must adapt . . . conceptual descriptions describing changes in the perspective of a situation.
do not automatically lead to recognition of actual The narrative structure is often as follows: “I went into
signs, and varied responses require time to as- the situation thinking that I knew what was going on,
similate and interpret. Slavishly following one’s or that this particular thing was going on, only to have
plans and holding on to preset expectations can it disconfirmed by the patient’s responses to my as-
limit perceptual grasp. . . . Holding on to this de- sessment.” This is evidence for developing the ability
liberative form of agency (sense of personal in- to let the situation guide nurses’ responses:
fluence in the situation) prevents the nurse from
having expert clinical and ethical comportment
The nurse is now synthesizing the meaning of
because response-based organization is not yet
patient’s responses through time. She imagines that a
achieved. (Benner et al., pp. 95-96)
computer could capture all her readings, but she fails
 Benner / DREYFUS MODEL IN NURSING PRACTICE 195

to recognize that her understanding of the patient is necessary and if all goes well, experiential clinical
now situated, and based upon a practical understand- learning occurs. They describe the frustrating situa-
ing of the patient’s responses [and qualitative changes] tion of “chasing a problem” and never being quite “in
made over time rather than a collection of data points. synch” with the situation when they do not have a good
The clinician struggles with articulating this practical perceptual grasp of the situation at hand (Benner et al.,
grasp: 1999, pp. 23-87; Benner et al., 1996, pp. 146-147). En-
Nurse: I had drawn a [blood] gas on a person and gaged reasoning through transitions requires being
the gas was pretty poor and I took another gas to open to correction and dis-confirmation. The ethos of
the house officer and he looked at it and said: “I openness, rather than prediction and control, and fidel-
don’t believe this gas, the patient hasn’t changed. ity to what one sees and hears, rather than excessive
And at that point—it takes a while to get to this suggestibility and confusion, are embodied and linked
point, but I felt comfortable in saying to him: to emotional responses to the situation. Thus, one’s
“What do you mean, this patient hasn’t skilled emotional responsiveness guides perceptual
changed?” This patient’s blood pressure has acuity and responsiveness to changes in the situations
gone up to 200, and I presented him with a pic- that are similar or dis-similar to past situations, but
ture of this patient that he had obviously over- when novelty or surprise occurs, the nurse tries to fig-
looked. It takes a while to get to the point where ure out why and how this situation is different. (Benner
you can feel comfortable saying this to the doctor et al., 1996, pp. 116-117)
and feeling comfortable, feeling that you can go The nurse gains a much more differentiated world
with your instincts. of practice at the proficient level. The nurse feels in-
Int: What happened in that situation? creasingly at home in the situation and can now recog-
Nurse: I was right . . . nize when she or he has a good sense of the situation.
Int: How did you learn that the objective signs In the following excerpt the nurse demonstrates this
that you were seeing were correlated with blood new comfort level by describing open-heart surgery
gas? patients’ trajectories:
Nurse: Just experience and seeing different
patients and different breathing patterns and
Nurse: I feel pretty comfortable, and you learn
knowing by looking at the patient that this
when they’re warming to start giving the volume
breathing pattern is effective and this one isn’t,
and when to stop because now maybe they need a
knowing whether there is air exchange there or
little bit of Levophed to keep their blood pressure
not. These breaths aren’t effective and he’s wear-
up, when to shut off the Levophed because
ing himself out and that could be the cause of his
they’re waking up and you know their catechol-
deterioration in his gas, and just experience and
amines have kicked in and that kind of thing. It’s
seeing different cases and how people adjust to
almost routine, whereas before it took a lot of
physical things that are going on.
trial and asking questions.
This change is based on procedural knowl-
Though difficult to articulate, this practical grasp is edge and protocols, but the transition being de-
not mystical. It reflects the skill of seeing practical scribed is the flexible recognition of patient
manifestations of changed physiological states, pa- changes in particular situations. This recognition
tient responses and noticing these transitions. The occurs in the context of the predictable changes
nurse actively interprets the direction of the change over time in a recovering heart surgery patient.
and keeps track of what can be ruled in and ruled out. These decisions cannot be based on quantitative
Practical grasp is perceptually grounded and response physiological measures alone, but must be based
based and requires being open to correction and on understanding the relationship between the
disconfirmation as the situation unfolds. The clinician numbers and the way the patient looks and re-
is always in the situation with some practical under- sponds. This form of response-based action is
standing, and it is that practical understanding that is crucial for performing well in a rapidly changing
revised or confirmed. When the practitioner’s grasp of emergency…(Benner et al., P.123).
the patient’s clinical situation is jarred by changes or Because the proficient level nurse is learning
unexpected patient responses, the practitioner to adjust his or her responses to the situation, the
searches for a new grasp and deliberation becomes skill of both problem and person engagement be-
196 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

comes more differentiated and attuned. Observ- practice; rather, they extend good practice in challeng-
ing nurses across situations reveals that they vary ing underdetermined situations. As noted in our
their relationships with patients and families research, ways of seeing the situation increasingly just
based upon their understanding of what the situ- call for appropriate actions.
ation requires. Timing becomes much more re- Intuitive links develop between seeing and re-
fined, and recognizing opportunities in the situa- sponding to the situation. This is revealed by observ-
tion for patient learning or for supporting a ing the nurse in the situation and is partially captured
patient is now more attuned to the needs and in the following account of an emergency situation
concerns of the patient. where a patient who was hemorrhaging stopped
Nurse: Transplant patients become so de- breathing. The links between the patient’s condition
pendent on you for everything—Can I brush my and action are sufficiently strong that the nurse attends
teeth now? Do you think I should do this? And primarily to actions rather than assessment of signs
you have to really encourage them to take control and symptoms. This is reasonable because, in extreme
back. It’s a hard concept for a lot of them because circumstances, the possible responses are fewer, but
they need to be dependent because it’s safe for experience is required to make this shift in
them to be dependent. . . . I’ve learned how to performance:
give them control back slowly and how to en-
courage them to take that control back over their Nurse: So we didn’t even call the code. We just
own life. (Benner et al., pp. 125-126) called the doctor stat [emergency] and got him up
there. [They had sufficient people available to
Once begun, the proficient nurse usually continues resuscitate the patient, so no formal page for
to refine his or her reading of particular situations. Re- additional help was needed.] I looked at his heart
fining discriminations through deliberate compari- rate and I said: “O.K. he is bradying down.
sons with past experiences and other patients improves Someone want to give me some atropine?” I just
the nurse’s grasp of the situation. started calling out the drugs that I needed to get
for this guy, so we started to push these drugs in.
Expertise: Phronesis (Practical Wisdom) In the meantime, I said, can we have some more
blood?” I was just barking out this stuff [the
Once a nurse has progressed to proficiency, the things that were needed and had to be done]. I
style of being a situated, response-based performer can’t even tell you the sequence. I was saying,
propels experiential learning and the ability to switch “We need this.” I needed to anticipate what was
from taken-for-granted tacit expectations to switching going to happen and I could do this because I had
to focusing on aspects of the situation that are chang- been through this a week before with this guy
ing and creating an altered sense of the situation. The and knew what we had done [and what had
expert nurse is response based in using techné and worked].
phronesis. The expert can now integrate his or her The recognition and assessment language are
grasp of the situation with his or her responses. minimal, in part, because the number of actions
The expert is able to take up theories and ends of per problem are limited, but also because recog-
practice in multiple ways, often creating new possibil- nition and assessment language become so
ities in the situation (Taylor, 1991). These situated linked with actions and outcomes that they be-
practical innovations or sensible variations in practice come self-evident or “obvious” for the expert
seem intuitively obvious to the practitioner and might practitioner. This is the kind of “maximum
not be captured easily in a narrative description of the grasp” of the expert that is not available to the
situation. This is why observation and informal inter- proficient performer. Immediate futures obvious
viewing in actual situations are required to discover to the expert order the situation. In this case the
and describe all levels of practice, but particularly pro- nurse becomes the situational leader because of
ficient and expert levels of practice. The innovations or this maximum grasp of this particular patient,
sensible variations in practice typically make sense to and the sequence of events. The integrated rapid
others as the most effective response in the situation. response is the hallmark of expertise. (Benner
They are not breaks with the understanding of good et al., 1996, pp. 142-143)
 Benner / DREYFUS MODEL IN NURSING PRACTICE 197

Based on enriched experiential learning spawned secondary to radiation erosion. That wound had
by increasing ability to read the current situation in become septic and he had developed respiratory
terms of their deep familiarity with similar and dissim- failure and he was in ICU for that. So I looked at
ilar situations, nurses develop a sense of whether they the dressing and it was dry, the blood was coming
have a good (better or poorer) grasp of the situation. out of his mouth. The man had a tracheostomy
Skilled know-how now allows for more fluid and rapid because of the type of surgery that had been
performance of procedures. Narratives often focus on done. He also had an N.G. tube in for feedings,
new clinical learning or troubling moral dilemmas or and I got to thinking that it might be the
conflicts in the situation. Qualitative distinctions asso- innominate or the carotid artery that had eroded.
ciated with nuanced responses make the nurse able to So we took him off the ventilator to see if any-
know and do more than he or she can tell or think to de- thing was going to pump out of his trach. There
scribe (Polanyi, 1958/1962). [Good. This is expertise was a little blood, but it looked mostly like it had
alright. Notice there is no talk her of innovation.] come down from the pharynx into the lungs. So
Attunement allows for flexible fusion of thought, we began ventilating him, trying to figure what
feeling, and action. Seeing the unexpected based on was inside his mouth that was pumping out his
having a rich set of expectations as well as a rich sense tremendous amount of blood. (Benner, 1984, p.
of the particular situation requires engagement with 17)
the patient and openness to notice when things do not
go as implicitly expected, and evidence that This nurse went on to describe her quick actions to
disconfirm one’s assumptions can be encountered draw blood for a cross-match and typing and preparing
(Benner et al., 1999, pp. 85-86). The relational skills of the man for an immediate transfer to the operating
attunement to the patient’s concerns and to the clinical room after marshalling all the resources for the surgi-
situation create the possibility for patients and family cal team. She gives us an immediate, direct grasp of the
members to disclose or reveal their concerns and fears nature of the situation. Action, thought, and feeling are
to the nurse and for the nurse to notice changes in the fused. She evaluates the resistance in the lungs by hand
patient or family across time (transitions). The quality ventilating the patient. Fortunately, because of her
of attentiveness and of the relationship literally creates rapid responses, the patient survived the hemorrhage.
different disclosive spaces and moods for the patient Expert practice, by its very nature, is of local, spe-
and family so that different clinical issues are noticed cific knowledge; know-how; and technical and scien-
based on qualitatively different disclosive possibili- tific knowledge that is more transferable to other prac-
ties. [This is as innovative as expertise gets.] tice contexts. Because practice is a way of knowing
Now it is possible to compare the expert’s narrative through experiential learning and embodied know-
below of the situation of the patient who developed a how, it is highly valuable to study and articulate the
carotid hemorrhage with the advanced beginner’s ac- knowledge embedded in highly complex practices
count given earlier: such as nursing and medicine. Articulation of the
knowledge embedded in proficient and expert prac-
I had worked late and was just about ready to go tice, plus articulation the range of practical knowledge
home, when a nurse preceptor said to me, learned by beginning practitioners in local settings,
“Jolene, come here.” Her voice had urgency in it, creates the possibility of self-improving practice
but not Code Blue. I walked in and I looked at the based on making experiential learning public and
patient and his heart rate was about 120, and he therefore open to development so that experiential
was on the respirator and breathing. And I asked learning and practical wisdom becomes cumulative
her: “What’s wrong?” There was a new graduate and shared.
taking care of him. And he just pointed down to
the patient who was lying in a pool of blood. Summary
There was a big stream of blood drooling out of
his mouth. This man’s diagnosis was mandibular Each of the studies was based on extensive first-
cancer, which had been resected, and about a person, experience-near narrative accounts of clinical
week previous to that he had had a carotid bleed situations that stood out in the participants’ minds. In
from external carotid, which had been, ligated addition, a subsample of participants was observed
198 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / June 2004

and informally interviewed in its practice. We deliber- dence in each situation. This computational and
ately sampled nurses with a range of experience and calculative approach to practice, coupled with a disci-
reported skillfulness and interviewed nurses with like plined stance of detachment, blocked experiential
backgrounds in small group narrative interviews. We learning. The model was also useful in helping us
created an open dialogue with the tenets of the Dreyfus articulate knowledge and skill embedded in the prac-
model of skill acquisition and the philosophical basis tice of nursing. The rational-technical vision of perfor-
for this model. We found that the model was predictive mance is that of a practitioner or technical expert
and descriptive of distinct stages of skill acquisition in developing mastery of a body of knowledge and
nursing practice. The most qualitatively distinct dif- applying that knowledge in prespecified ways for
ference lies between the competent and proficient prespecified outcomes. The rational-technical model
level, where the practitioner begins to read the situa- does not account for development of relational, per-
tion. The proficient performer begins to increasingly ceptual, or skillful comportment over time. It also does
change his or her perception of the nature of the situa- not account for the role of experiential learning in
tion and then deliberates about changing plans or strat- learning to practice in a dynamic, underdetermined,
egies in response to the new understanding of the situ- and complex practice such as nursing and medicine. A
ation. The expert develops yet another qualitatively strict technical application of knowledge does not take
distinct way of being in the situation by developing the into account the skills required for discerning the
capacity to fluidly respond to the situation, even as the nature of the situation and its possibilities and con-
situation changes and the relevance of the actions straints. Even the expert in the Dreyfus model of skill
taken change. The study of nursing practice, because it acquisition must stay attuned to the situation and must
is an underdetermined, complex practice that requires remain open to the unexpected. Practitioners on the
skillful comportment, articulation, and highly devel- account of expert comportment provided by the
oped relational skills, allowed us to identify qualita- Dreyfus model must remain open to experiential learn-
tively distinct forms of moral agency and skills of ing and reading changes in transitions in fast-paced,
involvement at different levels of skill acquisition. The open-ended environments. In the Dreyfus model, the
development of moral agency and the influence of practitioner is assumed to dwell with increasing skill
emotional engagement with the person and the prob- and finesse in a meaningful, intelligible, but changing,
lem, as well as emotional climate, on skill acquisition world.
vary distinctly at each stage of skill acquisition. For
example, the advanced beginner focuses on getting Note
everything done adequately. The competent nurse
increases his or her ability to advocate for the patient, 1. The first study was sponsored by a grant from the Depart-
getting what the patient needs or requests. At the ment of Health and Human Services, Public Health Service, Divi-
sion of Nursing, Bureau of Health Professions (Grant No. 7 D10
expert level, the moral agency and skills of involve-
NU 29104-03). The Helene Fuld Health Trust funded the second
ment create disclosive spaces that would not have even and third studies.
been imagined at the earlier stages. New possibilities
and notions of good practice are instantiated in more
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Dunne, J. (1997). Back to the rough ground, practical judgment
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P. Rabinow & W. Sullivan (Eds.), Interpretive social science: A Action Approach (1999). All three of these books have won
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MacIntyre, A. (1981). After virtue: A study in moral theory. Notre and have been translated into other languages.
Dame, IN: University of Notre Dame Press.