The Key Concepts and Definitions

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

1. Creating a climate for and establishing a commitment to healing    
2. Providing comfort measures and preserving personhood in the face of pain and extreme breakdown
3. Presence (being with the patient)
4. Maximizing the patient’s participation and control in his or her own recovery
5. Interpreting kinds of pain and selecting appropriate strategies for pain management and control
6. Providing comfort and communication through touch
7. Providing emotional and informational support to patient’s families
8. Guiding a patient through emotional and developmental change (Benner, 1984/2011, p. 50)

 TEACHING – COACHING FUNCTION: 5 competencies

1. Capturing the patient’s readiness to learn (timing)
2. Assisting patients to integrate the implications of illness and recovery into their lifestyles
3. Eliciting and understanding the patient’s interpretation of his or her illness
4. Providing an interpretation of the patient’s condition and giving a rationale for procedures
5. Making culturally avoided aspects of an illness approachable and understandable (Benner, 1984/2001, p. 79)

DIAGNOSTIC AND MONITORING FUNCTION: 5 competencies: 

1.  Detecting and documenting significant changes in patient’s condition
2.  Anticipating breakdown and deterioration prior to explicit confirming diagnostic signs
3. Anticipating problems
4. Understanding particular demands and experiences of an illness
5. 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).