Patricia Benner

From novice to expert : excellence and power in clinical nursing practice

1. Uncovering the Knowledge Embedded in Clinical Nursing Practice. 2. The Dreyfus Model of Skill Acquisition Applied to Nursing. 3. An Interpretive Approach to Identifying and Describing Clinical Knowledge. 4. The Helping Role. 5. The Teaching-Coaching Function. 6. The Diagnostic and Monitoring Function. 7. Effective Management of Rapidly Changing Situations. 8. Administering and Monitoring Therapeutic Interventions and Regimens. 9. Monitoring and Ensuring the Quality of Health Care Practices. 10. Organizational and Work-Role Competencies. 11. Implications for Research and Clinical Practice. 12. Implications for Career Development and Education. 13. The Quest for a New Identity and New Entitlement in Nursing. 14. Excellence and Power in Clinical Nursing Practice. Epilogue: Practical Applications. References. Glossary. Appendix. Index.

Quality of life: a phenomenological perspective on explanation, prediction, and understanding in nursing science.

A Heideggerian phenomenological approach to explanation, prediction, and understanding in the study of health, illness, and disease is presented. The extremes of objectification and subjectivism as barriers to understanding illness and suffering are explored. It is argued that meaning terms are essential when studying practical activity and relational issues, and that a privileged position is not gained by developing structural analyses or power terms that get behind or beyond meaning. Hermeneutics, or interpretive methodology, is a holistic strategy because it seeks to study the person in the situation rather than isolating person variables and situation variables and then trying to put them back together. Paradigm cases, exemplars, and thematic analysis are described as interpretive and presentational strategies.

From beginner to expert: gaining a differentiated clinical world in critical care nursing.

The purpose of this study was to further explicate the Dreyfus Model of Skill Acquisition in the practice of critical care nursing. For this analysis data were used from a sample of 105 nurses practicing in the adult, pediatric, and newborn intensive care units of eight hospitals in three metropolitan areas. The data were composed of group interviews in which nurses gave narrative accounts of exemplars from their practice and close observations and intensive personal history interviews of a subsample of nurses. Two interrelated aspects were found to distinguish four levels of practice, from advanced beginner through expert. First, practitioners at different levels of skill literally live in different clinical worlds, noticing and responding to different directives for action. Second, a sense of agency is determined by ones clinical world and shows up as an expression of responsibility for what happens with the patient.

Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education

Three studies using the Dreyfus model of skill acquisition were conducted over a period of 21 years. Nurses with a range of experience and reported skill-fulness were interviewed. Each study used nurses’ narrative accounts of actual clinical situations. A subsample of participants were observed and interviewed at work. These studies extend the understanding of the Dreyfus model to complex, underdetermined, and fast-paced practices. The skill of involvement and the development of moral agency are linked with the development of expertise, and change as the practitioner becomes more skillful. Nurses who had some difficulty with understanding the ends of practice and difficulty with their skills of interpersonal and problem engagement did not progress to the level of expertise. Taken together, these studies demonstrate the usefulness of the Dreyfus model for understanding the learning needs and styles of learning at different levels of skill acquisition.

The role of experience, narrative, and community in skilled ethical comportment.

Two major types of narrative—constitutive or sustaining narratives and narratives of learning—are presented to illustrate the functions of narrative in everyday ethical expertise and socially embedded caring practices. Four narrative themes illustrate constitutive and sustaining narratives: healing and transcendence, the heroic saving of a life, fostering care and correction, and stories of being present. Five themes illustrate narratives of learning: the skill of involvement, being open to experience, disillusionment, facing death and suffering, and liberation. Quandary- and rights-based procedural ethics address ethical problems and breakdown and overlook everyday ethical comportment. Public storytelling is recommended as a way to explore notions of the good and ethical concerns.

Individual, practice, and system causes of errors in nursing: a taxonomy.

Practice errors by nurses can cause harm to patients, families, practitioners, systems, and the profession. Because the nursing errors reported to the State Boards of Nursing are typically serious, analyzing their data has great potential for developing new strategies to reduce dangerous errors. With the guiding rationale being identification of categories central to the nurse’s role and function in healthcare delivery errors, 21 case studies of nursing errors from 9 State Boards of Nursing files were analyzed to develop a taxonomy of nursing errors. Eight categories of nursing errors representing a broad range of possible errors and contributive or causative factors were identified: lack of attentiveness; lack of agency/fiduciary concern; inappropriate judgment; lack of intervention on the patient’s behalf; medication errors; lack of prevention; missed or mistaken MD/healthcare provider’s orders; and documentation errors. Causes for the error, at the system and practice responsibility levels, were identified in each case. The categories, an assessment of causes of errors, and an examination of the remediation actions taken were the first steps in devising a taxonomy of nursing error, designed with prevention in mind. The authors discuss their work and present the taxonomy.

Skilled Clinical Knowledge : The Value of Perceptual Awareness

In this article, the authors present strategies for clinical knowledge development, for documenting, conserving, and enhancing the unique knowledge of the experienced clinician. They examine differences between practical and theoretical knowledge and the implications for enhancing the practical knowledge gained through clinical experience. Clinical knowledge development strategies are a means for job enrichment and for retaining experienced nurses and improving patient care.

A Dialogue between Virtue Ethics and Care Ethics

A dialogue between virtue and care ethics is formed as a step towards meeting Pellegrinos challenge to create a more comprehensive moral philosophy. It is also a dialogue between nursing and medicine since each practice draws on the Greek Virtue Tradition and the Judeo-Christian Tradition of care differently. In the Greek Virtue Tradition, the point of scrutiny lies in the inner character of the actor, whereas in the Judeo-Christian Tradition the focus is relational, i.e. how virtues are lived out in specific relationships, particularly unequal relationships where vulnerability of one of the members is an issue. In a care ethic relational qualities such as attunement rather than inner qualities are the point of scrutiny. A dialogue between these two traditions makes it possible to consider the relational virtues and skills of openness and responsiveness that are required for a respectful meeting of the other.

Skilled clinical knowledge: the value of perceptual awareness, part 1.

In this two-part article, the authors present strategies for clinical knowledge development, for documenting, conserving and enhancing the unique knowledge of the experienced clinician. In Part 1, they examine differences between practical and theoretical knowledge and discuss the implications for enhancing the practical knowledge nurses gain through clinical experience. Part 2, which will appear in the next issue of JONA, will examine clinical knowledge development as a means for enriching jobs, retaining experienced nurses, and improving patient care.

Health as continuity and balance in life

Research on immigrant health emphasizes that the elderly are more vulnerable than other age groups in many immigrant populations. This study describes the meanings of health, illness, and disease for Iranian elderly immigrants in Sweden and their relationships with life disruptions. Analysis of interviews using an interpretive-phenomenological method illustrates that the participants experience health as continuity and balance in life. Any disruption of this balance creates a sense of illness that is only partially related to the emergence of disease. Participants did not view health and disease as polarized. Rather, disease is just one component among many that may disrupt the experience of health. Health is perceived as a sense of well-being, can be achieved in spite of disease, and can be disrupted even in the absence of disease. This description of the meaning of health, disease, and illness contrasts with the Western biomedical perspective and is similar in its holism to various non-Western medical systems and complementary approaches. This knowledge can foster more culturally sensitive care.