1. Seminar on
Nursing Practice Expertise
A Theory by Patricia Benner
Supervisor
Mr. R.S. Mehta
Associated Professor, Department of Medical
Surgical Nursing, College of Nursing
Presenter
Tilarupa Bhattarai
M.Sc. First Year, 2009 Batch

3. Content
 Introduction of Patricia Benner
 Concept of the Theory
 Patricia Benner’s Theory of Nursing
Practice Expertise
 Critique of the Theory
 Novice to Expert Scale
 Summary

4. Introduction of Patricia Benner
Patricia Benner is a Professor in
the Department of Physiological
Nursing in the School of Nursing
at the University of California,
San Francisco.
Dr. Benner received her
bachelor's degree in nursing from
Pasadena College,
Master's degree in medical
surgical nursing from the
University of California, San
Francisco,
The Ph.D. from the University
of California, Berkeley, in Stress
and Coping and Health under the
direction of Hubert Dreyfus and
Richard Lazarus.

5. Dr. Benner is the author of nine books including
1. From Novice to Expert, named an American Journal of
Nursing Book of the Year for nursing education
and nursing research in 1984
2. The Primacy of Caring, co-authored with Judith Wrubel,
named Book of the Year in 1990, also in two
categories. Her books have been translated into
eight languages.
3. Interpretive Phenomenology: Embodiment, Caring and
Ethics in Health and Illness,
4. The Crisis of Care,
5. Expertise in Nursing Practice: Caring, Clinical Judgment,
and Ethics,
6. Caregiving,
7. Clinical Wisdom and Interventions in Critical Care: A
Thinking-In-Action Approach.

6.  Is an internationally noted researcher and
lecturer on health, stress and coping, skill
acquisition and ethics.
 Recently elected an honorary fellow of the
Royal College of Nursing.
 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.

7. Concept of the Theory
Expertise
 Expertise can be defined as the professional artistry and
practice wisdom inherent in professional practice.
 Again professional artistry can be defined as the meaningful
expression of a uniquely individual view within a shared
tradition. It involves a blend of: practitioner qualities , practice
skills, creative imagination processes (Titchen & Higgs, 2001).

 Practice wisdom is the possession of practice experience and
knowledge together with the ability to use them critically,
intuitively and practically. Including characteristics of clarity,
discernment and caring deeply from an objective stance,
practice wisdom is a component of professional artistry.

8. Development of Expertise
 Expertise or tacit knowledge is a manifestation of an
individual's experiential knowledge acquired over the life
course.
 Adaptation of implicit knowledge to new situations requires
◦ thinking and
◦ reflective skills.
 Reflectivity is associated with the expansion of an expert's
horizon.
 Students need to learn to recognize and describe "the context,
meanings, characteristics, and outcomes of their
connoisseurship"

9. Philosophical Underpinnings
 Benner's ideas are based on the difference
between practical and theoretical knowledge.
 Practical situations are more complex than they
initially appear.
 Both experience and mastery are necessary for a
skill to be transformed to a higher level skill.
 Other central tenets underpinning Benner's
philosophy are the connections between external
and internal events .

10.  Benner believes that nurses develop
and accumulate global sets and
paradigms about patients, those
paradigms develop expert intuition and
sets not readily apparent to the outside
observer.
 Expert nurses use empirics, ethics and
personal knowledge.
 Benner supports that individuals
interpret their own concerns, practices
and life experiences.

11. Ways of Knowing
 Empiric
 Moral or ethical knowledge
 Personal Knowledge
 Aesthetic

12. Dreyfus Model of Skill Acquisition
Expert
Proficient
Competent
Advanced
Beginner
Novice

13. Dimension of change in different phases
 One is a movement from reliance on abstract
principles to the use of past concrete experience as
paradigms.
 The second is a change in the learner's perception of
the demand situation, in which the situation is seen
less and less as a compilation of equally relevant bits,
and more and more as a complete whole in which only
certain parts are relevant.
 The third is a passage from detached observation to
involved performer. The performer no longer stands
outside the situation but is now engaged in the
situation.

14. Patricia Benner's Theory of Nursing
Practice Expertise
Benner
acknowledges that she
utilizes the same five
stages which Dreyfus
posited.
The stages are
utilized after Benner's
initial observations of
120 nurses and
identification of 31
skills.

15. Stage 1: Novice
 Beginners have had no experience of the situations in
which they are expected to perform.
 Novices are taught rules to help them perform.
 The rules are context-free and independent of specific
cases; hence the rules tend to be applied universally.
 The rule-governed behavior of the novice is extremely
limited and inflexible.
 As such, novices have no "life experience" in the
application of rules.
"Just tell me what I need to do and I'll do it."

16. Stage 2: Advanced Beginner
 Can demonstrate marginally acceptable
performance
 Have coped with enough real situations to
note, or to have pointed out to them by a
mentor, the recurring meaningful situational
components can recognize in actual situation
 Principles to guide actions begin to be
formulated.
 The principles are based on experience.

17. Stage 3: Competent
 Competence, typified by the nurse who has
been on the job in the same or similar
situations two or three years.
 Develops when the nurse begins to see his or
her actions in terms of long-range goals or
plans of which he or she is consciously
aware.
 For the competent nurse, a plan establishes
a perspective, and the plan is based on
considerable conscious, abstract, analytic
contemplation of the problem.

18.  The conscious, deliberate planning that
is characteristic of this skill level helps
achieve efficiency and organization.
 Lacks the speed and flexibility of the
proficient nurse but does have a feeling
of mastery and the ability to cope with
and manage the many contingencies of
clinical nursing.
 The competent person does not yet have
enough experience to recognize a
situation in terms of an overall picture or
in terms of which aspects are most
salient, most important.

19. Stage 4: Proficient
 The proficient performer perceives situations as
wholes rather than in terms of chopped up parts
or aspects, and performance is guided by
maxims.
 Proficient nurses understand a situation as a
whole because they perceive its meaning in
terms of long-term goals.
 The proficient nurse learns from experience
what typical events to expect in a given situation
and how plans need to be modified in response
to these events.
 The proficient nurse can now recognize when
the expected normal picture does not
materialize.

20.  This holistic understanding improves the
proficient nurse's decision making; it becomes
less labored because the nurse now has a
perspective on which of the many existing
attributes and aspects in the present situation
are the important ones.
 The proficient nurse uses maxims as guides
which reflect what would appear to the
competent or novice performer as unintelligible
nuances of the situation; they can mean one
thing at one time and quite another thing later.
 Once one has a deep understanding of the
situation overall, however, the maxim provides
direction as to what must be taken into
account. Maxims reflect nuances of the
situation.

21. Stage 5: The Expert
 The expert performer no longer relies on an analytic
principle (rule, guideline, maxim) to connect her or
his understanding of the situation to an appropriate
action.
 The expert nurse, with an enormous background of
experience, now has an intuitive grasp of each
situation and zeroes in on the accurate region of the
problem without wasteful consideration of a large
range of unfruitful, alternative diagnoses and
solutions.
 The expert operates from a deep understanding of
the total situation.
 The chess master, for instance, when asked why he
or she made a particularly masterful move, will just

22.  The performer is no longer aware of features
and rules;' his/her performance becomes fluid
and flexible and highly proficient.
 This is not to say that the expert never uses
analytic tools. Highly skilled analytic ability is
necessary for those situations with which the
nurse has had no previous experience.
 Analytic tools are also necessary for those times
when the expert gets a wrong grasp of the
situation and then finds that events and
behaviors are not occurring as expected When
alternative perspectives are not available to the
clinician, the only way out of a wrong grasp of
the problem is by using analytic problem solving.

23. Critique of the Model as a
Theory
 Meleis (1991) describes a method for
critiquing a theory suggesting the
following areas be assessed:

24. Critique of the Theory
Visual
Clarity Consist Simplicity Represe
ency ntation

25.  Although Benner's model most closely
fits the definition of a philosophy,
certain aspects can be critiqued as if it
were a theory.
Clarity
Clarity 'denotes precision of boundaries,
a communication of a sense of
orderliness, vividness of meaning and
consistency throughout the theory'.

26.  Benner provides theoretical definitions for all
major concepts, but not the operational
definitions necessary for empirical
measurement.
 She follows the logical sequence developed by
Dreyfus, does not deviate by introducing other
concepts and states her philosophy simply and
briefly.
 Benner's philosophy is general, yet situation
dependent; it encompasses many aspects of
nursing from students through expert
practitioners and espouses a broad range of
applications within nursing such as in
administration and research.
 Thus the theory of Benner is not that much clear

27. Consistency
 Consistency is determined by evaluating the
congruency between each component of a
theory.
 Benner's model contains concepts which are
consistent with each other and are
consistently utilized.
 Since first proposing the philosophy, Benner
has continued to research the phenomena
and has not changed her concepts.
 This is difficult to quantify, however, since
specific operational definitions have not been

28. Simplicity Vs. Complexity
 It relates to the number of phenomena the
theory considers and the relationships which
could develop. Depending on the purpose of the
theory, either simplicity or complexity could be
preferred.
 The model is relatively simple in regard to the
five stages of skill acquisition and it provides a
comparative guide for identifying levels of
nursing practice from individual nurse
descriptions and observations of actual nursing
practice'.
 The essence of the model is easy to grasp and
explain.
 A degree of complexity is, however,
encountered when trying to differentiate

29. Visual Representation
 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.
 Progress along this continuum is
sequential from novice to expert, but
may include regression when the nurse
is in an unfamiliar situation.

30. Contagiousness
 Contagiousness 'is whether or not it is adopted
by others' and must look at the geographical
location and type of institution which adopted
the theory.
 This philosophy has been adopted in many
countries and by many different types of
institutions.
 This is evident, in a simple form, by reviewing
the literature, noting articles from different
countries and relating to different uses of the
philosophy.
 Benner's model has been adapted by schools

31. Usefulness
 Assessing the usefulness of a theory includes its usefulness in
practice, research, education and administration.
 Benner's model has been utilized in all areas to be assessed
(Darbyshire 1994; Effken 2001; McKee et al. nd; Shapiro 1998).
 Benner's model has become the foundation for preceptor
programs for students and new graduate nurses (Myrick &
Barrett, 1992), as well as continuing education programs.
 Many research studies have been conducted based on the
concepts proposed by Benner.
 Many schools of nursing adopted this model as a basis for
providing education, as noted by English (1993).
 Nursing administration has utilized this model to develop career
ladders, staff development and recognition and rewards
programs (Nelson & McGillion 2004).

32. Values
 Values include those of the theorist and the
critic, other professions and society.
 Values are not explicitly identified in this
philosophy.
 This philosophy was borrowed from another
profession which demonstrates congruence.
 The knowledge level of the practicing nurse is
especially important to the individual
receiving the care, thus to society.

33. Social Significance
 Finally, the social significance must be
assessed because 'in our attempt to enhance
nursing science and articulate the discipline of
nursing we must not neglect the significance of
its practice to humanity and society' (Meleis
1991: 237).
 This model is proposed as a method for
determining the expert practitioners and
developing more expertise in practitioners.
 This has social ramifications as it is optimal to
have the best, most knowledgeable,
practitioners providing care.

34.  In 1978, Carper described four patterns of
knowing in nursing: empirics, moral/ethical
knowledge, personal knowing and aesthetics.
Benner only specifically discusses ethical and
personal knowing.
 Benner's model has been criticized for not
being quantitative; her research used a
qualitative approach. The philosophical basis
of Benner's work challenges the traditional
notion of objective science.
 The study conducted by Benner included
small number of participant, so the theory
developed by such study might contain bias.

37. Summary
 The theory is based on Dreyfus model of skill
acquisition.
 It explains the five stages of novice, advanced
beginner, competent, proficient and expert to
acquire expertise in nursing practice.
 Highlights the differences between the
theoretical and the practical knowledge.
 Considered as model and philosophy rather
than theory.

38. References
1. Tanya KA. "An evaluation of the seminal work of
Patricia Benner: theory or philosophy?".
Contemporary Nurse. FindArticles.com. 24 Mar, 2010.
http://findarticles.com/p/articles/mi_6813/is_1-
2_25/ai_n28442030/
2. Dracup K, Bryan-Brown CW. Editorial, American
Journal of Critical Care;13; 2004: 448-450, Available
on
http://ajcc.aacnjournals.org/cgi/content/full/13/6/448,
Cited on 7th June 2010.
3. Biography of Patricia Benner, Available on
http://home.earthlink.net/~bennerassoc/patricia.html ;
Cited on 7th June 2010
4. Dreyfus model of skill acquisition Available on
http://en.wikipedia.org/wiki/Dreyfus_model_of_skill_ac
quisition, Cited on 7th June 2010.