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Prepared by :

Supervised by :
mohammad al-naeem Prof. Dr. Wasileh petro
khaled al-shollol

The university of Jordan

Patricia
Benner
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. (Benner, 1984a)

OUTLINS
* Objectives of presentation
* Credentials and background of Patricia Benner
* Theoretical Resources and Dreyfus model
* Major concepts & Definitions of Benner theory
* Use of empirical evidence
* Major Assumptions of Benner work
* Metaparadigm of Benner theory.
* Logical form
* acceptance by the nursing community.
* Benner Work Critique
* scope of utilization of beener theory
* application of beener theory
* Conclusion & * Reference

OBJECTIVES
At the end of my lecture, all students will
be able to:
- Introduce Patricia Benner and discuss Dreyfus model
- Identify the Major concepts & Definitions of theory
- Identify the Major Assumptions (metaparadiam) of
Benner work
- describe the acceptance of theory by the nursing
community
- Discuss the scope of utilization of beener theory and how we
can applied it nowadays

Credentials and background of


Patricia Benner

Life:
Patricia Benner was born in 1942 in Hampton, Virginia. And
spent her childhood in California.
She was married to Richard benner on 1967,they have a son and
a daughter.

Professional:
* Bachelor degree in nursing from Pasadena College, in 1964 .
* Master in medical-surgical nursing from the University of California,
San Francisco (UCSF), in 1970 .
* PhD - from the University of California Berkeley , in 1982.

Benner Background

(cont.)

1985, Benner was inducted into the american academy of


nurses
Benner retired from full time teaching in 2008 as
professor from university of California san Francisco
(UCSF)
She is currently a Distinguished Visiting Professor at
Seattle University School of Nursing,

Benner Background (cont.)


Published 9 books and numerous articles
Published Novice to Expert Theory in 1982 named
an American Journal of Nursing Book of the Year for
nursing education and nursing research in 1984 .

Received Book of the Year from AJN in 1984,1989,1996,


1999.

Benner Background (cont.)


Benner was appointed by carnegie
foundation for preparation professions
program in march 2004

this project focus on the role of nursing


school In preparing nurses by addressing
issues of teaching and learning Instruction,
curriculum assessment and institutional
context

Award
Benner received an award for outstanding contributions to the
profession by national council of state boards of nursing in 2002 for
her work on developing an instrument to capture the sources and
nature of nursing errors .This instrument is entitled ( Taxonomy of
Error ,Root Cause and Practice (TERCAP).

She recived the american association of colleges of nursing


pioneering spirit award in may 2004 for her work in skill acquisition
and articulationj of nursing knowledge in critical care.

Benners Books
(1979): New Nurses Work Entry: A Trouble
Sponsorship
(1984): Stress and Satisfaction on the Job

(1989): The Primacy of Caring: Stress and Coping in


Health and Illness

(1999) : Clinical Wisdom and Interventions in Critical


Care: A Thinking-In-action Approach

Benners Books (cont.)


(2000): From Novice to Expert: Excellence and Power
in Clinical Nursing Practice, Commemorative
(2009) : Expertise in Nursing Practice, Caring, Clinical
Judgment, and Ethics (expansion of research by
Tanner and Chesla)
(2011): Clinical Wisdom and Interventions in Acute and
Critical Care.
She coneptualizes in her writing about nursing skills as
experience is a prerequisite for becoming an expert.

Benners Theoretical Sources


Benner studies clinical nursing practice in an attempt to
discover and describe the knowledge embedded in
nursing practice.( lack of charting???)
knowledge

From

From

Theory

Practice

Theoretical knowledge
=
Knowing that

Practical knowledge

VS

=
knowing how

Benners Theoretical Sources


Beener belived that :
( inductive )
nurses have been lack of documentation
deprive nursing theory of uniqueness and richness of knowledge
knowledge is embedded in clinical practice

Knowing that ----- lends itself to theoretical explanation


( establishe causal relationship between events

---------------------------------------------------Knowing how------ may elude precise abstract formulation


( skill acquisition that defy Knowing that)
Ex: COPD . O2 therapy + CO2 ??? )

Benners Theoretical Sources


Benner and description of knowing how in practice
Benner proposed that one could gain knowledge and skills
(knowing how) without ever learning the theory (knowing)
She stated that The extension of practical knowledge (knowhow) through theory-based scientific investigations (knowthat) is necessary for Knowledge development in a practical
discipline.

Benners Theoretical Sources


Benner and description of knowing how in practice
Practical knowledge may extend theory or be developed
before scientific formulas.

Clinical situation are always more varied and complicated


than theoretical accounts; therefore ,clinical practice is an
area of inquiry and source of knowledge development.
Theory is derived from practice and practice is altered or
extended by theory. (ex: hand washing, pain score..???)

Benners Theoretical Sources


Benner work influence philosophically and ethically by:

Stuert Dreyfus and Hubert Dreyfus (1980).. Dreyfus model


Richard (1985) mentored benner in the filed of caring &stress
Judith wrubel (1989) ( participant & co-author with beener)
Joseph dunne (1993 )
Kund logestrub (1995, 1997)
Onora (1996)

Benner in 1984 adapted the dreyfus model to


clinical nursing practice.

Dreyfus model
stuert Dreyfus and Hubert Dreyfus developed the skill
acquisition model by studying the performance of chess master
and pilots in emergency situations.
The model is situational , developmental , and describe five level
of skills acquisitions . Each level build up on the pervious level.

Dreyfus model
Movement through the 5 levels(ex: school students)
course

primary-tawjehi

Dreyfus model (cont.)


from

to

Reliance on abstract principals

Use of past concrete experience

Analytical rule-based thinking

Intuition

Receive situation as compilation of


equally relevant bits

Increasingly complex whole


inspite of more/less relevant
parts

observer, outside the situation

Fully engaged in the situation

Major concepts & Definitions

Dreyfus model (cont.)


Performance level can be determined by :
1- validation of Expert judges.
2- Outcomes of the situation.

In applying dreyfus model to nursing , Benner


noted : Experience-based skill acquisition
will be safer and quicker when it rests on a
sound educational base.
Ex: . CPR

Benner identified 2 aspects of practice distinguishing


levels from novice to expert:
1- Clinicians at different levels of practice recognize
and respond to different situated needs for action .
2- Clinicians develop a sense of responsibility toward
patient (agency) > > fully participating members
of health care team.

When a familiar situation is encountered,


there is embodied recognition of its
meaning (Embodied intelligence).

Benner stated : skilled activity , which is


made possible by our embodied
intelligence , has been long regarded as
lower than intellectual ,reflective activity

Person has no background experience of the situation.


Context-free rules & objective attributes must be given to
guide performance.
There is difficulty discerning relevant and irrelevant
aspect of a situation.
e.g.. students of nursing, or unfamiliar with a certain
situation

Major concepts & Definitions


Advance beginner

Person can demonstrate marginally acceptable


performance having coped with enough real situations to
note the recurrent , meaningful components of the
situation.

Have enough experience to grasp aspects of a situation.

Nurses guided by rules & are oriented by task completion,


with difficulty grasping the current patient situation in
terms of the larger perspective.

They view the clinical situation as a test of their


abilities and the demands of the situation placed on
them, rather than in term of patients needs &
responses.

highly responsible for managing patient care , yet


they still rely on the help of those more experienced .
E.g.. most newly graduated nurses .

Major concepts & Definitions


competent

Considerable conscious & deliberate planning


that determines which aspects of the current &
future situations are important & which can be
ignored.
Consistency, predictability, &time management
are important in competent performance . And
sense of mastery can be acquired, & is more
realistic.
Increased level of efficiency, but the focus on the
organizational satisfaction rather than on
patients needs. May display hyper-responsibility
for the patient.

Major concepts & Definitions


competent
Devises new rules & reasoning procedures for a
plan while applying learned rules for action on
the bases of relevant facts of that situation.

The competent stage is most pivotal


in clinical learning .

Major concepts & Definitions


proficient
Perceive the situation as a whole, the performance is
guided by maxims , have a sense of quality, more
confident in their abilities and knowledge.
Demonstrates new abilities to see changing relevance in
a situation, including the recognition & implementation of
skilled responses to the situation evolved.
Much more involvement with the patient & the family.

Major concepts & Definitions


expert
The expert performer achieved when No longer relies
on analytical principle (rules, guidelines & maxim) to
connect understanding of a situation to an appropriate
action.
Intuitive grasp of the situation identifies the problem
without losing time, considering a range of alternative
diagnoses & solutions.
The expert nurse has this ability to recognize patterns on
the basis of deep experiential background.

Key aspects of expert nurses


practice:
Demonstrating a clinical grasp & resourcebased practice.
Possessing embodied know-how.
Seeing the big picture.
Seeing the unexpected.

Video

Major Concepts & Definitions


Aspect of a
Attributes of

situation

a situation
Exemplar
Salience
Domain
Maxim

Paradigm
case

Experience
comportment

Hermeneutics
Competency

1st concept:

Major Concepts Definitions

Concept -1: Aspect of a situation

The aspects are the recurring meaningful


situational components & understood in
context because the nurse has recognized as
previous experience .

Major Concepts Definitions


Concept -2: Attributes of a situation

Attributes are measurable properties of a


situation that can be explained without
previous experience in the situation.

Major Concepts Definitions

Concept -3: Competency

An interpretively defined area of skilled


performance identified & described by
its intents, functions, & meanings .

Major Concepts Definitions


Concept -4: Domain
An area of practice having a number of competencies
with similar intents, functions,& meanings.

Concept -5: Exemplar


An example of clinical situation that conveys one
or more intents, functions, meanings, or outcomes
easily translated to other clinical situations.

Major Concepts Definitions


Concept -6: Experience
Is not a mere passage of time, but an active process of
refining & changing preconceived theories, notions,
& ideas when confronted with actual situations.

Concept -7: Maxim


Is a cryptic (hidden) description of skilled
performance that requires a certain level of
experience, to recognize the implications of the
Instructions (S.E) .

Major Concepts Definitions


Concept -8: Paradigm case
Is a clinical experience (event) that stands out & alters
the way the nurse will perceive & understand future
clinical situations.

Paradigm cases Creates new clinical understanding &


open new clinical perspectives & alternative.

Concept -9: Salience


Perceptual stance or embodied knowledge whereby
aspects of a situation stand out as more or less
important.

Major Concepts Definitions


Concept -10: comportment
A style & manner of acting and interacting,
which includes gestures, posture,& stance.
Concept -11: Hermeneutics . interpretive
Refers to describing & studying meaningful human
phenomena in a carful & detailed manner as free as
possible from prior theoretical assumptions, based
instead on practical understanding .

Use of empirical evidence

From Novice To Expert.(1984)


Expertise In Nursing Practice.(1996)
Clinical Wisdom and intervention In
Critical Care.(1999)

Use of empirical
evidence

From novice to expert

Benner was the project director of AMICAE, which


led to the publication of From Novice to Expert
(1984).
AMICE project was an interpretive, descriptive study.
Lead to used Dreyfus model to describe skill
acquisition in clinical nursing practice.
More than 1200 nurse completed questionnaires and
interviews as a part of the AMICAE project.
AMICAE: achivement methods of intraprofessional consensus
assessmen and evaluation

Use of empirical
evidence

From novice to expert

Thirty-one competencies emerged.


From these competencies, seven domains were inductively
derived on the bases of similarity of function and intent:
1- The helping role.

2- The teaching-coaching function.


3- The Diagnostic and patient caring function.
4- Effective management of rapidly changing situations.
5- Administering and monitoring therapeutic interventions.
6- Monitoring and ensuring quality of care practices.
7- Organizational work-role competencies.

Use of empirical
evidence

Expertise in Nursing Practice

Extended from research presented in 1984 From novice


to Expert.
The book was based on 6-year study of 130 hospital
nurses, primarily Critical Care Nurses.
As a result of this study, there was a clearer
understanding of the distinctions between engagement
with a problem or situation and the requisite nursing
skills of interpersonal involvement.
These nursing skills appeared to be learned overtime
experientially.
The skill of involvement seems central in gaining nursing
expertise.

Use of empirical
evidence

Clinical Wisdom In Critical care

Took place from 1996-1997 and published in 1999.


Considered phase two of the project.
Included 76 nurses (32 are APNs) from 6 hospitals
9 domains of critical care practice were identified as
broad themes.
1. Diagnosing and managing life-sustaining physiological
functions in unstable pt
2. Preventing hazards in a technological environment .
3. Using the skilled know-how of managing a crisis.
4. Providing comfort measures for the acute critically ill.
5. Caring for patients families.

Use of empirical
evidence

Clinical Wisdom In Critical care

9 domains of critical care practice were identified as


broad themes.
6. Facing death : end of life care
7. Communication and negotiating multiple perspectives
8. Monitoring quality and managing breakdown
9. Using the skilled know-how of clinical leadership

Major Assumptions of Benner work


1 - There are no interpretation- free data
the neutral science assumption : there is an independent
reality whose meaning can be represented by
abstract terms & concepts.
2- There are no nonreactive data .
3- People sharing a common cultural and language
history have a background of common meanings ,
that allow for understanding & interpretation .

Major Assumptions (cont.)


4- Meanings are embedded in skills, practices,
intentions, expectations, & outcomes.
They are taken for granted & often not recognized
as knowledge and cannot be made completely
explicit; but they can be interpreted by someone
who shares a similar language & cultural background
& can be consensually validated by the participants &
relevant practitioners .

5- Humans are integrated, holistic beings.

The Nurse Theorists - Patricia Benner


Video

Take a break

Metaparadigm of Benners theory


1. Nursing
Nursing is described as a caring relationship, an enabling

condition of connection and concern.


Caring is primary because caring sets up the possibility
of giving and receiving help.
Nursing is viewed as a caring practice whose science is

guided by the moral art and ethics of care.


Benner understand Nursing practice as the care and study
of the lived experience of health, illness, and disease

and the relationships among the three elements.

Metaparadigm of Benners theory


2. Person
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.

Together
, these
aspects
of the
person
make up
the
person
in the
world.

The role of
Situation

The role of
Temporality

Person
The role of
Personal
Concerns

The role of
Body

Metaparadigm of Benners theory

3. Health

Benner and Wrubel focused on the lived


experience of being healthy & being ill.

Health is defined as what can be assessed,


whereas well- being is a human experience of
health or wholeness.

Health is not just the absence of disease & illness


; a person may have a disease but not experience
him self as illness, because illness is a human
experience of loss or dysfunction, but disease is
what can be assessed at the physical level. (HF-RF)

Metaparadigm of Benners theory

4. Situation

Benner use the term Situation rather than environment,


because situation conveys a social environment with
social definition & meaningfulness.

They use the phenomenological terms being situate &


situated meaning, which are defined by the persons
engaged interaction, interpretation, & understanding of
the situation.

Person interpretation of the situation is bounded by the


way the individual is in it

Theoretical Assertions
Some relationship statements included
in Banner's work:
1- Clinical knowledge is embedded in perceptions rather than
precepts.
2- Perceptual awareness is central to good nursing judgment.
3- Formal rules are limited and discretionary judgment is needed
in actual clinical situations.
4- Expertise develops when the clinician tests and refines
propositions, hypotheses and principle-based expectations in
actual clinical practice.

Logical Framework
Is the Benner work is inductive or deductive ??
By following Dreyfus models logical sequence,
Benner was able to identify the performance
characteristics and teaching-learning needs in each
level of skill by a qualitative descriptive research.
Benner claims that new knowledge and
understanding are constituted by articulating
meanings, skills, and knowledge that taken from
clinical practice.

Acceptance by the nursing


community
Practice
Education
Research

Benners theory and nursing practice


1- Practice

From Novice To Expert includes several examples of the


application of her work in practice settings & she has been
cited extensively in the literature regarding nursing practice
concerns& roles of caring in such practice.

Benner approach has been used to aid in the development


of clinical promotion ladders, new graduate orientation, &
clinical seminars. Focusing on excellence in nursing
practice have been held for staff development, recognition &
reward.

Benners theory and nursing practice

(Sliver 1986) ,used benner works as a basis for


differentiating clinical knowledge development & career
progression in nursing.

(Neverveld 1990) ,used benners rational and format in the


development of basic & advanced preceptor workshops.

Benner continue to advance understanding of the


knowledge embedded in clinical situation through
publications (1985 1987 1996 1999 )

Benners theory and nursing practice

(Crissman 1990) ,applied Benners finding in developing a


cross-training program to address staffing imbalances.

Benners theory and nursing Education


2- Education

She stated that competency-based testing seems limited


to the less situational , less interaction areas of the patient
care .

She validated the CNS clinical nursing specilaist


competencies in AMICAE project.

By using Benner theory, nurse educator realized that the


learning needs at the early stages of clinical knowledge
development are different from those required at late stage.

Benners theory and nursing Education


2- Education

(cont.)

Benner theory guide nursing curricula world wide


Emphasized the importance of learning the skill of
involvement and caring through practical experience
(Articulation of knowledge with practice).

Place novice or advance beginner with competent nurse


preceptor is more suitable than expert nurse whose intuitive
knowledge may elude beginners.

Benners theory and nursing

Research

3. Research

1.
2.
3.
4.

In AMICAE project, they concluded that formal models may


serve as maps that direct care, substitute knowledge, & result in
conformity.
But the misuse of those models according to Gordon occurs
when:
nurses apply models without using judgment,
when they use them to exert control (apply control),
when they use language from models that may cover-up
meanings,
when they do not understand the meaning of the models

Benners theory and nursing

Research

3. Research (cont.)
SO, formal models should be used discretions
as tools & should not eclipse (cover) the
relational, holistic, intuitive aspects of nursing.

Further Development
Benner has taken a hermeneutical form to uncover the
knowledge embedded in clinical nursing practice.
As she does this, she is also uncovering the nursingcaring with which it is deeply intertwined
It doesnt provide us with any universal truths about
caring in general or about nursing-caring in particular
Dunlop (1986).

Scope of utilization of beener


theory

application of Beener theory


Nursing applies Benners Theory through:

Nursing school curriculum


Building clinical ladders for nurses (Frisch, 2009)
Developing mentorship programs
Preceptors for student nurses
Mentors for newly graduated nurses (Dracup and Bryan- Brown,
2004)

Development of the Clinical Simulation Protocol (Larew


et al., 2006)

Example of Benner application

Icu + ccu ---- ACLS \ BLS

application of Beener theory


Modification on Benner theory
situation --- controlled situation
good enverinment help to develop of nurses in dreyfus modle

External factor that effect situation may be motivate the nurse to


becom as expert OR frastrate to develop.

Inter-ward compatancy exam


(3 times\ year) reward for expert improve weakness from other
+ training
50-60%

60-70%

Novice adv. Begginer

70-80%

80-90%

competant

90-100%

proficient expert

Exam
50% clinical
50% knowldge

application of Beener theory

Modification on Benner theory


patient outcome & manager satisfaction
1- through satisfaction quastinnare about nursing) positive
feedback -- reward
2- if there is a harm on patient . Modified nursing skill through
(skill training + course training)

Reset counter (when you are a manger)


1- Do not judge on any one untill you interfere with him
2- Avoid first impression before you see \ observe them
3- Ehical moral aspect

application of Beener theory


Real examples from our nursing field that show
how the benner theory applicable untill
nowadays:

From Eductional field


From bedside clincal field

Conclusions
1. Strength of the theory:

2. Limitation of theory

Benner Work Critique


Benner Work Critique

Simplicity

How clear is theory


How simple is theory
?

Generality

How general is
this theory?

Empirical
Precision

Derivable
Consequences

How accessible
Is this theory ?

How important
Is this theory ?

Benner Work Critique

Simplicity
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.
Description of novice level of performance would be
possible but expert description would be difficult if not
impossible and limited to its usefulness.
A degree of complexity is encountered in subconcepts for
differentiation among the levels of competency and the need
to identify meanings and intentions.

Benner Work Critique


Generality

The model has universal characteristics; it is not restricted by


age, illness, health, or location of nursing practice.
has the potential for universal application as a framework, but
the descriptions are limited by dependence on the actual
clinical nursing situations from which they must be derived.

Benner Work Critique


Generality

Finally , clinical knowledge is relational and contextual and


involves local , specific , historical issues. It is generealizable
in terms of the translation of meaning to similar situation.

Benner Work Critique

Empirical Precision
Benner theory is researchable, and qualitative research has been
the primary paradigms to discover embedded knowledge of clinical
practice.
Quantitative attempt have been made to design and validate nurse
competence scale.
Her work can be considered as hypothesis generating rather than
hypothesis testing .
So it is an inductive theory .

Benner Work Critique

Derivable Consequences

The strength of the Beener model is that data base


research contribute to the science of nursing as
practice discipline

The significant of beener research finding lays in her


conclusion that a nurses clinical knowledge is relevant
to the extent to which it is manifestation in nursing
skills making a difference in patient care and patient
outcomes.

References
References
Tomey, A. M. and Alligood, M.R. (2006). Nursing theorists and their work.
http://www.jointcommissioninternational.org/improve/get-accredited-academicmedical-center-hospitals/
http://www.jnc.gov.jo/arabic/Nursing%20Polices.htm
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing
practice. Reading, MA: Addison-Wesley.
Dreyfus, H. L., & Dreyfus, S. E. (1986). Mind over machine: The power of human
intuition and expertise in the era of the computer.

Meleis, A. (2007). Theoretical nursing. New York: Lippincott.Patricia Benners


Nursing Theories,accessed at http://~kmckee/utilization.html on 5 April 2004.

Thank You !!

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