From Novice to Expert: Excellence and Power in Clinical Nursing Practice [Paperback]

Patricia Benner (Author)

Book Description

Publication Date: 1984 | ISBN-10: 020100299X | ISBN-13: 978-0201002997

Winner of the 1984 American Journal of Nursing Book of the Year Award in the Nursing Education and Nursing Research categories, this landmark work is a testimonial to the importance of nursing This book provides ideas and images that nurses can draw upon in their interactions with others and in their interpretation of what nurses do. It documents nurses' concern for their clients' welfare and comfort, as well as the care that follows that concern. Based on Dr. Benner's seminal research, From Novice to Expert uses the Dreyfus Model of Skill Acquisition to explore how nurses progress in the development of expertise. It also explains the seven domains of nursing practice: helping, teaching-coaching, diagnostic and patient monitoring, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of health care practices, and organizational and work-role competencies. It includes many clear, colorful examples from actual nursing practice, as well as a special epilogue describing how the findings of this study have been applied in five major hospitals. This book is of direct and special interest to staff development educators, nursing administrators, and nurse educators in senior-level trends and issues courses.

Editorial Reviews

From the Back Cover

This coherent presentation of clinical judgement, caring practices and collaborative practice provides ideas and images that readers can draw upon in their interactions with others and in their interpretation of what nurses do. It includes many clear, colorful examples and describes the five stages of skill acquisition, the nature of clinical judgement and experiential learning and the seven major domains of nursing practice. The narrative method captures content and contextual issues that are often missed by formal models of nursing knowledge. The book uncovers the knowledge embedded in clinical nursing practice and provides the Dreyfus model of skill acquisition applied to nursing, an interpretive approach to identifying and describing clinical knowledge, nursing functions, effective management, research and clinical practice, career development and education, plus practical applications. For nurses and healthcare professionals. --This text refers to an alternate Paperback edition.

Excerpt. © Reprinted by permission. All rights reserved.

Preface

This book is based on a dialogue with nurses and nursing, descriptive research that identified five levels of competency in clinical nursing practice. These levels — novice, advanced beginner, competent, proficient, and expert — are described in the words of nurses who were interviewed and observed either individually or in small groups. Only patient care situations where the nurse made a positive difference in the patient's outcome are included. These situations offer vivid examples of excellence in actual nursing practice. They are not abstract ideals, however; they emerge from the imperfections and contingencies with which nurses work daily.

A Note to the Skeptics

Some who read the exemplars will be skeptical that such nursing is possible. Their skepticism is warranted, because these examples are drawn from outstanding clinical situations where the nurse learned something about her practice or made a significant contribution to a patient's welfare. But if the reader's skepticism stems from a generalized disillusionment with nursing in hospitals and from the belief that nurses are rendered impotent to give compassionate, lifesaving care in hospitals — then this book offers a resounding rebuttal to the skeptic and a ray of hope to the disillusioned.

The Perceptual Origins of Excellence

This book questions some of nursing's most dearly held beliefs and assumptions. The book asserts that perceptual awareness is central to good nursing judgment and that this begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than it precedes. Experienced nurses often describe their perceptual abilities using phrases such as "gut feeling," a "sense of uneasiness," or a "feeling that things are not quite right." This kind of talk makes educators and clinicians uncomfortable, because the assessment must move from these perceptual beginnings to conclusive evidence. Expert nurses know that in all cases definitive evaluation of a patient's condition requires more than vague hunches, but through experience they have learned to allow their perceptions to lead to confirming evidence.

In the quest for a scientific rationale, the importance of perceptual skills can be overlooked by any clinician — nurse, physician, or counselor. If nurses were disembodied computers or mechanical monitoring devices, they would have to wait for clear, explicit signals before identifying one singular feature of a problem. Fortunately, however, expert human decision makers can get a gestalt of the situation and proceed to follow up on vague, subtle changes in the patient's condition with a confirmatory search aided by the whole health care team. Experts dare not stop with vague hunches, but neither do they dare to ignore those hunches that could lead to early identification of problems and the search for confirming evidence.

The Importance of Discretionary Judgment

Considering the early history of nursing education in this country, I am concerned that the model of skill acquisition described here could be misinterpreted as advocating informal trial-and-error learning. Therefore, it is important to point out that the Dreyfus Model of Skill Acquisition was originally developed in research designed to study pilots' performance in emergency situations. In that context, no one worried that people might misinterpret the model and suggest that the pilot should just go out and "get the feel of the plane" through trial and error; under those circumstances the beginning pilot would not even survive basic training. The same holds true for nursing. Providing nursing care involves risks for both nurse and patient, and skilled nursing requires well-planned educational programs. Experience-based skill acquisition is safer and quicker when it rests upon a sound educational base.

This book's purpose is to present the limits of formal ales and call attention to the discretionary judgment used actual clinical situations. This does not place the expert a special, privileged position outside the principles of physiology, nursing, and medicine. The book does not advocate a chaotic or anarchical position that would claim there are no rules — that would confer a license, for instance, to ignore the rules of asepsis simply because sterile technique must be sometimes ignored in life-and-death emergencies. Attending to the particular contingencies of a situation does not warrant the inclusion that the general principles governing that station can be generally ignored. My position is not a careless recommendation for the abandonment of rules. Instead, I am claiming that a more skilled, advanced understanding of the situation allows orderly behavior without rigid rule following.

Once the situation is described, the actions taken can understood as orderly, reasonable behavior that demands of a given situation rather than rigid principles and rules. More descriptive rules could be generated to allow for multiple exceptions, but the expert would still function flexibly in other new situations requiring new exceptions. The book addresses the risky, situation-specific decisions that are usually covered up but that nurses face daily in their practice. Menzies (1960) referred to hiding behind rules and policies as a defense against anxiety, a coping strategy. But as a coping strategy it is unrealistic and creates the additional burden of lack of recognition and legitimization of actual nursing performance.

Reflecting the Realities of Practice

Readers would probably prefer that I had chosen only exemplars reflecting ideal collaborative behaviors and ideal relationships with physicians. In fact, nursing administrators and physicians have warned me that they do not like the exemplars showing the doctor-nurse relationship in a bad light. I, too, wish that in conducting this study I had found only enlightened, collaborative relationships between nurses and physicians, but that would have been fiction and not descriptive research — an ideal model instead of an empirically tested one. If there is a bias, it is probably in the other direction: that troubled nurse-physician exchanges are under-represented, given the amount of interview time nurses spent describing troubled interactions.

In the real world, nurses and physicians alike have good and bad days; some are frankly incompetent. When immediate physician attention to a crisis is not available, the nurse fills the gap far more often than is formally acknowledged. We can claim that this is not nursing, but we do so only by ignoring what nurses actually do. Therefore, skilled performance was considered excellent because, even lacking the best of circumstances (e.g., collaborative relationships or formally acknowledged nursing functions), the nurse procured or did what was needed for the patient. By attending to the ideal and presenting only what we hope to become, we would miss much of what is significant about our actual practice. Not knowing who and what we are about now will seriously impede what we want to become.

A Kaleidoscope of Intimacy and Distance

The reader would be correct to question the representativeness of this work. The goal was not to describe a typical day or hour but rather the highlights, the ,growing edges of clinical knowledge. The participants were asked to present clinical situations that stood out in their minds. Nurses make many contacts with patients daily; most of the time they are unaware of the impact their interventions have on the patient's recovery. Many of these contacts and interventions are routine and not even remembered by the nurses. In other words, the nurse-patient relationship is not a uniform professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life. The mundane moments were not captured because this research strategy asked specifically for outstanding clinical situations. So this bias remains, even though we asked for descriptions of both typical and unusual days. Since we sought to describe skilled performance, deficits were not the point of inquiry, there are no negative examples of deficits identified (see Fenton, pp. 262-74 for an example of identification of deficits).

Not an End but a Beginning

I am concerned about hasty system builders who will want deify the 31 competencies described or who might want p complete the list, as though there were a finite list of competencies that can be captured for all time. Ending with 31 is indeed a bit whimsical, but the intent of this work is to encourage nurses to collect their own exemplars and to pursue the lines of inquiry and research questions raised by their own clinical knowledge. This work presents new ways to view nursing practice so that we do not continue to limit the description of such practice to a simplified, linear, problem-solving process. Such uniformity and constriction limit our understanding of the complexity and significance of our practice. As one nurse said with a note of realization, in a group discussion: "You know, I acted very quickly and saved a baby's life today. That's not insignificant!" It seemed that she had failed to take account of the import of her actions in her earlier analytical reporting.

I am grateful to colleagues who have enriched this work by providing descriptions — an early map, so to speak — of the practical applications of this work (see Epilogue).

Patricia Benner

--This text refers to an alternate Paperback edition.

Product Details

• Paperback: 307 pages
• Publisher: Prentice Hall (1984)
• Language: English
• ISBN-10: 020100299X
• ISBN-13: 978-0201002997
• Product Dimensions: 8.2 x 5.3 x 0.6 inches
• Shipping Weight: 11.4 ounces
• Average Customer Review: 4.6 out of 5 stars  See all reviews (21 customer reviews)
• Amazon Best Sellers Rank: #239,822 in Books (See Top 100 in Books)

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Most Helpful Customer Reviews

55 of 55 people found the following review helpful:

5.0 out of 5 stars A classic work worth revisiting often., May 1, 1999

By 

Ramona Charles, MSN, RNC, CNAA, charlesram@lr... (Durham, NC) - See all my reviews

This review is from: From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Paperback)

Published in 1984 and still in print! Many of us knew from first reading that this book was destined to be a classic. The work provides two valuable contributions. Actual patient care experiences reported by 1200 respected nurses were described and analyzed. What nurses actually do is presented in clear discussion using commonly understood language. The Dreyfus Model of Skill Acquisistion is then applied to this analysis of expert nursing practice. This view into the "mystery"of nursing contributes to understanding and appreciation of the unique role of this essential healthcare discipline. It is likely to be valuable to physicians, administrators and others whose work is interdependent with that of nurses as well as speaking directly to nurses. Understanding a skill acquisition process as it applies to the profession of nursing has direct relevancy both for basic educational preparation and for practice models and work assignments. Many applications, articles and books have and continue to grow from this original work. However, I still find repeated reasons to return to this primary source and the book continues to hold a special place on my desk top.

29 of 30 people found the following review helpful:

5.0 out of 5 stars Classic model in use world-wide, October 5, 2003

By 

D. Campbell "music lover" (Murrysville, PA USA) - See all my reviews
(REAL NAME)   

This review is from: From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative Edition (Paperback)

I'm surprised that there are not more reviews of this classic. From Novice to Expert is now THE model used to describe development in nursing and is the basis for probably 99% of all the clinical ladders in existence. Benner deserves our undying gratitude for finding a way to describe what it is that nurses really DO. Her following books based on this one are also excellent. In the late '80s and '90s she used her model to describe critical care nursing, and is now using her model to describe expert nursing practice in long term care. In graduate school, so many of the models I was required to learn had nothing to do with actual nursing practice--because they were created by PhD nurse educators who had not practiced for years or decades. For her work, Benner went to bedside nurses actually doing nursing, and built her model upon what she discovered there and from them. As a clinical nurse specialist, I use this model everyday when working with other nurses and with patients.

4 of 4 people found the following review helpful:

5.0 out of 5 stars Should be required reading for all RN's, August 21, 2007

By 

SuezqRN (Western NY) - See all my reviews

This review is from: From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Paperback)

This book should be required reading for all nurses in all nursing programs. It is an unspoken nursing student idea that when you graduate from your nursing program that you should, "know it all." This is unrealistic for the new/novice nurse. This book explains the process and gives comfort the the new nurse that expecting you to "know it all" is unreasonable and is not an expectation of the profession.