Wednesday, September 30, 2015


" Excellence is an art won by training and habituation. We are what we repeatedly do. Excellence ,then, is not an act but a habit." These were the words from the Greek philosopher Aristotle once coined.

We are all neophytes when we started our nursing career. If not all, majority of us had sweaty foreheads and palms on the first day of work as a newbie nurse. Although we are armed with an arsenal of knowledge from the academe, theory alone is not enough to deliver the holy grail of nursing which is quality patient care.

Every nurse aspires to deliver quality nursing care and Benner's theory on nursing attests that this is immensely attainable. None of us begun as experts in the nursing profession but we gain knowledge and experience through time.


The following are the stages of Clinical Competence according to Benner. Stage 1 Novice: Novices have a very limited ability to predict what might happen in a particular patient. Stage 2 Advanced Beginner: they have the knowledge and the know-how but not enough in-depth experience. Stage 3 Competent: competent nurses recognize patterns and nature of clinical situations more quickly and accurately than advance beginner. Stage 4 Proficient: Nurses are capable to see situations as whole rather than parts. Stage 5 Expert: Nurses recognize demands and resources in situation to attain goals. Focus is on the relevant problems and not irrelevant ones.


Overall, Benner’s theory revolutionized the essence of being the expert nurse who is not the one with the top-paying job, but the individual who is equipped with ample knowledge and experience necessary to attain quality patient care. Furthermore, the theory also demonstrates that past experiences hone us to become an excellent care provider, the expert nurse.


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Tuesday, September 29, 2015

Patricia Sawyer Benner , RN, Ph.D, F.A.A.N., F.R.C.N.

EARLY LIFE
  • Benner was born Patricia Sawyer in August 1942 in Hampton, Virginia. Benner, her parents and her two sisters moved to California when she was a child.
  • Her parents were divorced when she was in high school, which she described as a difficult event for her entire family.
  • Benner decided to become a nurse while working in a hospital admitting department during college.
  • She earned an associate's degree in nursing from Pasadena City College simultaneously with a bachelor's degree from Pasadena College in 1964, her master's degree in medical surgical nursing from the University of California, San Francisco, and the Ph.D. from the University of California, Berkeley, in Stress and Coping and Health under the direction of Hubert Dreyfus and Richard Lazarus. 
  • She married Richard Benner in 1967 and they had two children.
 ACADEMIC CAREER
  • Benner joined the nursing faculty at UCSF in 1982.
  • Early in her academic career, Benner led the Achieving Methods of Intraprofessional Consensus, Assessment and Evaluation Project (AMICAE Project).
  • She held an endowed chair at UCSF in ethics and spirituality for several years.
  • Benner is a professor emerita at the UCSF School of Nursing and is a program leader with the school's PhD program in nursing health policy.
  • Dr. Benner is the author of nine books including From Novice to Expert, named an American Journal of Nursing Book of the Year for nursing education and nursing research in 1984, and 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. Her most recent books are: Interpretive Phenomenology: Embodiment, Caring and Ethics in Health and Illness, and The Crisis of Care, with Susan Phillips, both published in 1994, Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics, with Christine Tanner and Catherine Chesla, also named a Book of the Year in 1996, and Caregiving, with Suzanne Gordon and Nel Noddings, also published in 1996. To be published in December, 1998, is Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach, with Pat Hooper-Kyriakidis and Daphne Stannard (W.B. Saunders).

  •  Working with Judith Wrubel in 1989, Benner expanded her model to incorporate the concept of caring with the stages of skill acquisition. In addition to the influence of the Dreyfus model, the new model was inspired by the work of philosophers Maurice Merleau-Ponty and Martin Heidegger. It described four aspects of a person's understanding (the role of the situation, the role of the body, the role of temporal concerns, and the role of temporality), as well as five dimensions of the body to which nurses attend.
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Nursing

Nursing is described by Benner as "caring relationship" (Alligood & Marriner-Tomey, 2010) She emphasises on creating connections of concern and caring. “Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of care and responsibility” (Benner & Wrubel, 1989).

Nurses are given the responsibility of improving their skills on patient care as they progress through their profession by means of formal educational base coupled with experience. She believes the most important way a nurse can enhance their practice is through experience (Swingshift Nurses, 2009)

Person

Heidegger’s phenomenological definition of person was extensively used by Benner in her studies. A person is defined as being a self-interpreting entity. A person gets defined in the course of living a life, gains understanding through reflection of himself and his world  (Alligood & Marriner-Tomey, 2010).

Benner and Wrubel (1989) conceptualized four major aspects of understanding that the person must deal with:

1. The role of the situation

2. The role of the body

3. The role of personal concerns

4. The role of temporality.

These four, when summed up, make the totality of the person. This particular view veers away from the classical belief of Cartesian dualism, where the mind and the body are distinct and separate entities

Furthermore, Benner and Wrubel (1989) outline the following five dimensions of the body

1. The unborn complex - this includes the body of the fetus and the newborn baby

2. The habitual skilled body - this includes the body that has gained socially learned postures, gestures, customs, and skills (for example, body language). These are learned through social interaction as time passes and these skills are transferred from person to person.

3. The projective body - this include the body that is predisposed to act in specific situations (i.e. handling the doorknob upon opening a door)

4. The actual projected body indicating an individual’s current bodily orientation or projection in a situation that is flexible and varied to fit the situation. This would include the learned formal skills such as operating a computer or driving a car.

5. The phenomenal body, the body aware of itself with the ability to imagine and describe kinesthetic sensations

Health

The concept of health is defined by Benner as the state that can be assessed. On the other hand, the concept of well-being is the human experience of health or wholeness. Well-being and being ill are understood as distinct ways of being in the world. Benner uses the idea of health being not just the absence of disease and illness. In this particular case, health pertains more on the physical, physiological and observable, in contrast with well-being that is more on the experiential and psychological (Alligood & Marriner-Tomey, 2010)  .

She further adds that a person may acquire a disease and yet not experience illness, because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at the physical level (Benner & Wrubel, 1989).

Environment

Rather than using the word "environment," Benner and Wrubel (1989) use the term "situation" in their work. For them, a situation conveys a social environment with social definition and meaningfulness. Whereas other theories focus on the physical environment, Benner's work gives emphasis to the experiential interaction of the person with those around him.

They use the phenomenological terms "being situated" and "situated meaning," which are defined by the person’s engaged interaction, interpretation, and understanding of the situation. This means that various elements from the person's past, present, and future, own personal meanings, habits, and perspectives all influence the current situation.
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“Theory is derived from practice”


Citing Kuhn (1970) and Polanyi (1958), philisophers of science, Benner (1984a)emphasizes between “knowing-how”, a practical knowledge that may elude precise abstract formulations, and “knowing that”, which lends itself to theoretical explanations. Knowing that is the way an individual comes to know by establishing casual relationships between events. Clinical situations are always more varied and complicated that theoretical accounts; therefore, clinical practice is an area of inquiry and a source of knowledge development. By studying practice, nurses can uncover new knowledge. Nurses must develop the knowledge base of practice (know how), and, through investigation and observation, begin to record and develop the know-how of clinical expertise. Ideally, practice and theory dialog creates new possiblities. Theory is derived from practice, and practice is extende by theory. (Alligood 2014)



 2"Human wisdom is more than rational calculation”

Human beings can work out precise formal rules and ethical theory, but our intellect capacity to do this does not guarantee that we can trasfer this knowledge into actual ethical comportment. We cannot get beyond experience, and we must not rely on our theories to distance us from skillfull ethical comportment in concrete, specific relationships and local situations. The Platonic quest to get beyond the vagaries of experience was a misguided turn – a heroic quest to put us beyond habits, skills, practice, and experince. We can redeem the turn if we subject our theories to our unedited, concrete moral experince and acknowledge that skillful moral comportment calls us not to be beyond practice but to be tempered and taught by it. The relationship then, between ethical theory and skillful ethical comportment must be a dialogue between partners, each shaping and informing the other. Disengaged reason and rational calculation cannot replace engaged care as a moral source of wisdom. (Benner,Tanner, Chesla 2009)



3  “Theory frames issues and guides the practitioner in where to look and what to ask”

Nursing practice as a human service practice has a specific goal of improving human health, and has to be guided by a system of nursing knowledge that includes various sorts of theory. The role of theory in clinical practice viewed from the perspective of knowledge-use then needs to be considered from what the nature of nursing practice is and how nursing knowledge is structured. (klinisk sygepleje 2012)



4  “Practice is a systematic whole with a notion of excellence”

Intuition is not science but sometimes intuition can stimulate research and lead to greater knowledge and questions to explore. Intuition is related to experience. A student would not likely experience intuition about a patient care situation, but over time, as a nursing expertise is gained, the student may be better able to use intuition, Benner’s (2001) work, From Novice to Expert, suggests that intuition is really the putting together of the whole picture based on scientific knowledge and clinical expertise, not just a hunch, and intuition continues to be an important part of the nursing process (Benner et al., 2008)



5  “Caring is basis of altruism”

Benner argues for nurses to care for patients “as they see fit”. Benner seeks to move away from rules, bounding care towards the individual, autonomous judgement of practitioners inparticular circumstances. The nurse’s good decisions depend upon her ethical stance, which also equips her to perform caring functions. For Benner, caring is not altruism but rather an evolutionary stage in human development (Benner and Wrubel 1989). (Traynor 1999)



6"“Caring is essential requisite for all coping”

Recently much thought and writing has been given to the idea of caring as the essence of nursing. Benner and Wrubel describe nursing as follows:
Caring is the essential requisite for all coping… [It helps a person] to recover, to appropriate meaning, and to maintain or reestablish connection… from the place of care, the person can neither claim complete autonomy nor be the absolute source of meaning, involvement and caring may lead one to experience loss and pain but may also make joy and fulfillment possible. Caring is primary because it sets up the possibility of giving help and receiving help.(Small 1996)


7 “Caring and interdependence are the ultimate goals of adult development”

Caring is ultimately necessary for human survival. Benner and Wrubel (1989) argued that instead of valuing autonomy, caring and interdependence are the ultimate goals of human development. They explained “To care and feel cared promotes personal and societal health” (Benner & Wrubel, 1989, p.368). According to Benner and Wrubel (1989), “a culture that emphasizes independence and individualism cannot survive without a safety net of care and caring practices” (p.399). (Baker-Ohler & Holba 2009)



8“Concern is essential for the nurse to be situated”

9 “No practitioner can practice beyond experience”

The Dreyfus Model Skill of Acquisition (Dreyfus, 1979; Benner, 1984) is based upon determining the level of practice evident in particular situations. Situated practice capacities are described rather than traits or talents of the practitioners. At each stage of experiential learning (novice, advanced beginner, competent, proficient, expert), clinicians can perform at their best. For example, one can be the best advanced beginner possible, typically the first year of practice. However, no practitioner can be beyond experience regardless of the level of skill acquisition in most clinical situations and despite the necessary attempts to make practice as clear and explicit as possible. If the nurse has never encountered a particular clinical situation, experiential learning is required. (Basford & Slevin 2003)
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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).
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