I. SKILL ACQUISITION
It is the process of attaining and
learning tasks as well as body of knowledge in different levels of competence
and translating them into useful, practical and sensible ability.
NOVICE
This is the starting point of
Skills Acquisition, the person has no background and no experience on the
platform that he/she is expected to perform. In nursing, these are mostly
undergraduates or nurses who were highly skilled in an area of nursing practice
but are in an unaccustomed area facing unfamiliar task. Rules and objectives
guide the performances, close supervision by an expert is essential and
difficulty in discerning between relevant and irrelevant aspects of situation
arises. Moreover, the quality of work is unlikely to be satisfactory, decisions
take more thought, time and effort, as well as a nurse is dependent on an
expert for task delivery.
ADVANCED BEGINNER
Second stage of Skills Acquisition,
in this stage a person is able to demonstrate marginally acceptable performance
based on real-life experience. In the clinical world of advanced beginners,
clinical situations are perceived as learning opportunities to weave
theoretical knowledge into practice. Patient’s changing status, family concerns
and distress forms the background of focus. Furthermore, experiencing the
clinical world among nurses in advanced beginner stage is a test of their
personal capabilities and skills. Advanced beginners have a deep sense of
responsibility managing patients but would still need a degree of assistance
from more experienced personnel. Benner includes most newly graduate students
in this level. Additionally, advanced beginners are concerned with their level
of competence which can interfere with their ability to cope with the clinical
situations encountered. Their energies are directed towards accomplishing a
task to be done at the moment and cannot readily expand vision of past and
present expectations. Strategies are developed to organize the job and a sense
of fulfillment arises when advanced beginners completes a task in the minimum
amount of time.
COMPETENT
A time of analysis, planning, and
confrontation where consistency, predictability and time-management are vital in
a competent performance (Benner, 1992). In nursing, it takes at least 2 years
into the clinical world to be categorized under this level. Different from
advanced beginners, competent nurses have an increased clinical understanding,
technical skill, organizational ability and ability to anticipate the likely
course of events. (Expertise in Nursing Practice by Benner, et.al). A shift of focus from getting the task done
to clinical issues encountered such as clinical conditions and management. A
degree of mastery along with competence has been acquired through experience in
dealing with familiar situations. At this stage, a nurse gained the ability to
recognize and anticipate a patient’s response to treatment modalities in
relation to experiential learning. In addition, the learners distinguish
patterns and define which of the aspects of a given situation requires
attention and which can be disregarded.
The competent nurse may be overly responsible
for the patient, often more than realistic and becomes more aware of the roles
of the healthcare team. Apparently, organizational skill development has been
observed during this stage as well the increase capacity to handle a complex
situation. To become proficient, the
competent performer must allow the situation to guide responses (Dreyfus &
Dreyfus, 1996).
PROFICIENT
This is a transition phase leading
to expertise and a qualitative leap from competence. The performer begins to recognize clinical situations
with a higher level of discernment based on background understanding. In addition, the performer identifies the
most salient aspects and has an instinctive understanding of a situation. Nurses
at this level are able to show the new ability to articulate a given situation
and applies or implements skilled responses as it unfolds. This is also the
stage where patterns learned and applied are open to correction or
disconfirmation.
A proficient nurse’s involvement is
more active in this stage; they demonstrate an increase in confidence with
their skills and knowledge. They have a clearer grasp of the clinical ground
and remember significant responses that will be utilized in future situations
similar to what was encountered.
Furthermore, Nurses also gain a holistic view in interrelating between
physiological states rather than in terms of aspects and the way of practice is
guided by individual principle.
EXPERT
In the last stage of Skills
Acquisition the performer waves off from analytic knowledge and operates on the
intuitive grasp on the situation. Decisions are made quickly and instinctively
based on previous experience and able to zero in all aspects of a problem on
hand without any wasteful or unfruitful possibilities. The expert performer
“knows the patient”, this means knowing the patient as a person, how she/he
reacts or responds to a treatment or management and what are the patient’s
distinctive patterns of behavior or warning signs of his/her disease as well as
interventions that worked or did not worked during the course of care.
Key aspects of expert nurse’s practice are as
follows: (Benner et al,. 1996)
- Demonstrating a clinical grasp and resource
based practice
- Possessing the embodied know-how
-
Seeing the big picture
-
Seeing the unexpected
The expert nurse has a deep
experiential background that provides her the ability to pick up patterns fast.
Mature practical knowledge of a
particular patient population shapes the expectations and sets of nurses
(Benner et al). Expert nurses call for expert caring practices, thus nurses
utmost priority and concern at this stage are the patient’s actual concerns and
needs, even if it means planning and negotiating for a change in the plan of
care. (Benner et al., 1992)
II. DOMAINS
This is an area of practice having
a number of competencies with similar intents, functions, and meanings (Benner,
1984a). The seven domains were derived inductively from the competencies
identified from actual practical situations and these are:
·
The helping role
·
The teaching – coaching function
·
The diagnostic and patient- monitoring function
·
Effective management of rapidly changing
situations
·
Administering and monitoring therapeutic
interventions and regimens
·
Monitoring and ensuring the quality of health
care practices
·
Organizational work-role
III. COMPETENCIES:
- The seven domains were identified
inductively form Benner’s 31 competencies.
HELPING ROLE: 8 competencies
- Creating
a climate for and establishing a commitment to healing
- Providing
comfort measures and preserving personhood in the face of pain and extreme
breakdown
- Presence
(being with the patient)
- Maximizing
the patient’s participation and control in his or her own recovery
- Interpreting
kinds of pain and selecting appropriate strategies for pain management and
control
- Providing
comfort and communication through touch
- Providing
emotional and informational support to patient’s families
- Guiding
a patient through emotional and developmental change (Benner, 1984/2011, p. 50)
TEACHING – COACHING FUNCTION: 5
competencies
- Capturing
the patient’s readiness to learn (timing)
- Assisting
patients to integrate the implications of illness and recovery into their
lifestyles
-
Eliciting
and understanding the patient’s interpretation of his or her illness
-
Providing
an interpretation of the patient’s condition and giving a rationale for
procedures
-
Making
culturally avoided aspects of an illness approachable and understandable
(Benner, 1984/2001, p. 79)
DIAGNOSTIC AND MONITORING FUNCTION:
5 competencies:
- Detecting
and documenting significant changes in patient’s condition
- Anticipating
breakdown and deterioration prior to explicit confirming diagnostic signs
-
Anticipating
problems
-
Understanding
particular demands and experiences of an illness
-
Assessing
the patient’s potential for wellness and for responding for various treatment
strategies (Benner, 1984/2001, p. 97)
EFFECTIVE MANAGEMENT OF RAPIDLY
CHANGING SITUATIONS: 3 competencies:
1. Skilled
performing in extreme life–threatening emergencies
2. Rapid matching of demands and resources in
emergency situations
3. Identifying
and managing a patient crisis until a physician assistance is available
(Benner, 1984/2001, p. 111)
ADMINISTERING AND MONITORING
THERAPEUTIC INTERVENTIONS AND REGIMENS: 4 competencies:
1. Starting
and maintaining intravenous therapy with minimal risks and complications
2. Administering
medications accurately and safely, including monitoring untoward effects,
reactions, therapeutic responses, toxicity, and incompatibilities
3. Combating
the hazards of immobility, including preventing and intervening with skin
breakdown, ambulating, exercising patients to maximize mobility and
rehabilitation, and preventing respiratory complications
4. Creating
a wound management strategy that fosters healing, comfort, and appropriate
drainage (Benner, 1984/2001, p. 123)
MONITORING AND ENSURING THE QUALITY
OF HEALTHCARE PRACTICES:
3 competencies:
1. Providing
a back-up system to ensure safe medical and nursing care
2. Assessing
what can safely be omitted from or added to medical orders
3. Getting
appropriate and timely responses from physicians (Benner, 1984/2001, p. 137)
ORGANIZATIONAL AND WORK-ROLE: 3
competencies
1. Coordinating,
ordering, and meeting multiple patient needs and request – in other words,
setting priorities
2. Building
and maintaining a therapeutic team to provide optimal therapy
3. Coping
with staff shortage and high turnover (Benner, 1984/2001, p. 147)
IV. There are also nine (9) domains of
critical care nursing practice that were also identified inductively using
similar techniques:
1. Diagnosing
and managing life–sustaining physiological functions in unstable patients
2. Using
skilled know–how to manage a crisis
3. Providing
comfort measures for a critically ill
4. Caring
for patient’s families
5. Preventing
hazards in a technological environment
6. Facing
death: end–of–life care and decision making
7. Communicating
and negotiating multiple perspectives
8. Monitoring
quality and managing breakdown
9. Using
the skilled know–how of clinical leadership and the coaching and mentoring of
others (Benner et al., 1999)
In their 1999 publication, Benner,
Hooper-Kyriakidis, and Stannard provide readers with an entire chapter of
narrative that explains and provides exemplars for each identified domains of
critical care nursing practice. In addition, the nine domains of critical care
nursing practice are used as broad themes in data interpretation for the
identification and description of six aspects of clinical judgment and skilled
comportment, which are:
1. Reasoning–in–transition:
practical reasoning in an ongoing situation
2. Skilled
know–how: also known as embodied intelligent performance; knowing what to do,
when to do it, and how to do it
3. Response–based
practice: adapting interventions to meet the changing needs and expectations of
patients
4. Agency:
one’s sense of and ability to act upon or influence a situatio
5. Perceptual
acuity and skill of involvement: the ability to tune into a situation and hone
In on the salient issues by engaging with the problem and the person
6. Links
between clinical and ethical reasoning: the understanding that good clinical
practice cannot be separated from ethical notions of good outcomes for patient
and families (Benner et al., 1999)
EXPERIENCE
Experience is not a merely passage
of time, but an active process of refining and changing
preconceived theories,
notions, and ideas when confronted with actual situations; it implies there is
a dialogue between what is found in practice and what is expected (Benner &
Wrubel, 1982).
