Purpose & Introduction

The purpose of this presentation is to discuss and

examine the Nursing Theorist, Patricia Brenner, and
her nursing theory: From Novice to Expert.  Patricia
Brenner's theory explains how a nurse develops a
sense of intuition in their practice and develops
their critical thinking skills as a nurse (Blum, 2010).

http://www.truthaboutnursing.org/news/2010/jan/16_education.html#axzz1nRDAlWVi
Patricia Benner, RN, PhD,
FAAN, FRCN
Benner : As Author
Dr. Benner is the author of books including:
1.From Novice to Expert
2.The Primacy of Caring
3.Interpretive Phenomenology: Embodiment,
Caring and Ethics in Health and Illness
4. The Crisis of Care
5. Expertise in Nursing Practice: Caring,
Clinical Judgment, and Ethics
6. Caregiving
7. Clinical Wisdom and Interventions in
Critical Care: A Thinking-In-Action Approach.
An Influential Nurse in the Development of the
Profession of Nursing

Patricia Benner’s research

and theory work provides
the profession of nursing
with what we now know as
the Novice to Expert
model, also known as
Benner’s Stages of
Clinical Competence.
Benner’s work as applied to
the nursing profession is
adapted from the Dreyfus
Model of Skill Acquisition.
Skill Acquisition

“The utility of the concept of skill

acquisition lies in helping the
teacher understand how to assist
the learner in advancing to the
next level” (McClure, 2005)
 Origins of the Nursing Model
What Motivated Benner’s Novice to Expert Theory?

1. Patient needs increasing

2. Lengths of stays decreasing
3. Advancement in medical technology
4. Increased learning for nurses
5. Need for more specialized nursing 
6. Need for more experienced nurses

With all that is required in the nursing field, Benner

(1982) wanted to provide an understanding for
nurses, as they develop their skills, of what makes a
novice nurse become an expert nurse (Benner).
 Historical Background

Theory based on Dreyfus’s

(1980)  “A five stage model of
the mental activities involved in 
direct skills acquisition” model
(Dreyfus). Hubert & Stuart Dreyfus
http://socrates.berkeley.edu/~hdreyfus/

   
 http://www.ieor.berkeley.edu/People/Faculty/dreyfus.htm

Similarities
•Five developmental stages
•Increase in skills and experience gets advancement in stages

Benner’s nursing theory of novice to expert is also based on five

levels of skills; novice, advanced beginner, competent,
proficient, and expert (Benner).  Associate Professor Cheryl
Martin finds that nurses move through the five levels as they
“develop clinical expertise through experience and [gain]
knowledge” (Martin).
 Benner's Philosophy

    Benner worked in a variety of nursing areas

including Intensive Care Unit (ICU), medical-
surgical, emergency, and coronary.  She became
interested in not how to do nursing but how do
nurses learn to do nursing. 

    Using the Dreyfus model, Patricia applied the

philosophy of learning to nursing.  Aspects of
Benner's philosophy include:
 Benner's Philosophy

 practical situations are more complex than

they seem and formal methods such as
textbook descriptions, theories and models
are inadequate to explain the complexities. 
Experience and mastery are required to
bring a skill to a higher level.
Benner's Philosophy, cont.

 the connections between external and internal

events.  Even though it may not be apparent on
the outside, nurses develop and use their own
philosophies about patients and their care
using experience, ethics, and personal
knowledge.  Benner believes nurses should
"interpret their own concerns, practices, and
life experiences" (Altmann, 2007, Philosophical
Underpinnings section, para 1).
 
Benner's Philosophy, cont.

 Benner describes her work as

interpretive phenomenology which means
observing and interpreting actual
nursing practice to find the meaning of
the experiences (Altmann, 2007).
 Is an internationally noted researcher and lecturer
on health, stress and coping, skill acquisition and
ethics.

 Recently elected an honorary fellow of the Royal

College of Nursing.

 Staff nurse in the areas of medical-surgical,

emergency room, coronary care, intensive care
units and home care.

 Currently, her research includes the study of

nursing practice in intensive care units and
nursing ethics.
Benner’s Description of Nursing

•A caring relationship, “an enabling condition of

connection and concern”

“Caring is primary because caring sets up the

possibility of giving help and receiving help.”
“Nursing is viewed as a caring practice whose science
is guided by the moral art and ethics of care and
responsibility.”
Is the care and study of the lived experience of
health, illness,and disease and the relationships
among these three elements

(Alligood & Tomey, 2011, p.148)

http://www.himolde.no/db/57/3973.jpg
Benner’s Description of 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. A person
also has . . . an effortless and nonreflective
understanding of the self in the world.”
 "The person is viewed as a participant in common
meaning."
 The four major aspects of understanding that the
person must deal with: 
o The role of the situation 
o The role of the body 
o The role of personal concerns
o The role of temporality 
(Alligood & Tomey, 2011, p. 148)
http://www.himolde.no/db/57/3973.jpg
Benner’s Description of Health

 Health is defined as what can be assessed

 Well-being is the human experience of

health or wholeness

 A person may have a disease and not

experience illness
• Illness is the human experience of loss or
dysfunction
• Disease is what can be assessed at the physical
level

(Alligood & Tomey, 2011, p. 149)

http://www.himolde.no/db/57/3973.jpg
Benner’s Description of Situation
(Environment)

 She uses the term situation instead of

environment because situation conveys a social
environment with social definition and
meaningfulness

 “Personal interpretation of the situation is

bounded by the way the individual is in it.”
• Each person’s past, present, and future, which include
their own personal meanings, habits, and perspectives,
influence the current situation

(Alligood & Tomey, 2011, p. 149)

http://www.himolde.no/db/57/3973.jpg
 Interpretation

By applying the Dreyfus model to nursing, Benner

was able to explain how nurses can have different
stages of experience and knowledge and how these
different stages affect how the nurse sees and
interprets the nursing process, the patient, the
patient’s health, and the environment (situation)
the patient is in. This model demonstrates that
the majority of nursing knowledge and expertise
comes from actual on-the-job clinical experience.
 

http://www.ucsf.edu/news/2005/07/6290/ucsf-faculty-member-leads-first-major-study-nursing-education-more-th          
Interpretation

Patricia Benner visits a patient along with

Jenna Buffington, a first-year student in
the master's entry program in nursing at
UCSF.

http://www.ucsf.edu/news/2005/07/6290/ucsf-faculty-member-leads-first-major-study-nursing-education-more-th          
 Implications and Consequences

 Schools of nursing have adopted Benner's

model to use as a base for the education of
nurses.
 Hospitals and other nurse work places use the
model as a foundation for perceptor based
guidance of nursing students and new graduate
nurses.
 Social agencies and nursing continuing
education program developers also use
Benner's model.

http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/
 Implications and Consequences

 Nursing administrators utilize the model to

help "develop career ladders, staff
development, and recognition and rewards
programs" (Altmann, 2007, "Critique Of The
Model," para 7).

http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/
Implications and Consequences, cont.

 Benner's model is used to determine expert

nurses and as a method in developing more
expertise in nurses.  This can help optimize
nursing by having the most knowledgeable
expert nurses providing care and teaching the
less experienced.

 Benner's model was tested and confirmed to

be valid.  The stages that Benner developed
can be applied to any adult learning scenerio
and not just nursing (Chitty & Black, 2011).

http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/
 Evaluation of the Nursing Model

Origin

This philosophy can be used in any

professional setting. The novice to expert is
all about how knowledge, intuition, and
experience are achieved. The philosophy was
based on a skill acquisition model developed by
Dreyfus and Dreyfus that was based on a
study of chess players and airline pilots
(Benner, 1980).

http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/
 Evaluation of the Nursing Model

Content

This model adds to the global concept of human being,

environment, health and nursing. This model leads the
nurse from novice to expert by using education and
mentoring to allow nurses to grow to be experts.
During the nurses growth the global concepts are in
everything you learn and do. According to Hardt, “The
expert nurse profile includes extraordinary clinical
knowledge, supreme connection with the patient, and
the ability to differentiate between changes that
matter and those that are inconsequential.” 

http://nursetopia.net/2011/06/29/star-wars-flavor-to-dr-patricia-benners-novice-to-expert/
Evaluation of the Nursing Model

View
In the aspects of nursing this model can be used
in any type of nursing. Benner herself practiced
in Med/Surg, ER, Coronary Care, ICU’s and
Home Health Care. According to Chitty and
Black (2011), this model can be applied to any
adult learning situation giving it a broad view.
The concepts of Benner’s theory are pretty
specific. You have to master the skills in one
level before you can move to the next one. You
cannot jump from novice to expert without going
through the other three phases first .
Evaluation of the Nursing Model

Practice Situations

Novice/advanced  beginner:
I took care of this neuro patient the other night. I
am not as familiar with this type of patient as some of
the others that I have cared for in the year that I
have been a nurse. The patient was alert and oriented
and then within the span of a few hours was getting
more and more obtunded. The MD ordered a stat CT
scan and I had to transport the patient for the scan.
I was very nervous about this process because I had
only taken a few trips to CT scan before as an ICU
nurse and was unsure as to what may occur while I
was off the unit.
Evaluation of the Nursing Model

Practice Situations

Fortunately, I was able to complete the transport and

the patient's status did not change much while I was
gone. I considered this very successful because I was
able to complete this process without any ill effects
to the patient.
The Dreyfus Model of Skill
Acquisition
 Dr. Benner categorized nursing into 5 levels
of capabilities: novice, advanced beginner,
competent, proficient, and expert.
 She believed experience in the clinical setting
is key to nursing because it allows a nurse to
continuously expand their knowledge base
and to provide holistic, competent care to the
patient.
 Her research was aimed at discovering if
there were distinguishable, characteristic
differences in the novice’s and expert’s
descriptions of the same clinical incident.
 Novice
 The person has no background
experience of the situation in which
he or she is involved.
 There is difficulty discerning between
relevant and irrelevant aspects of the
situation.
 Beginner to profession or nurse
changing area of practice (Frisch,
2009)
 Generally this level applies to nursing
students.
 Novice

These inexperienced nurses function at the

level of instruction from nursing school. They
are unable to make the leap from the classroom
lecture to individual patients. Often, they apply
rules learned in nursing school to all patients
and are unable to discern individual patient
needs. These nurses are usually new
graduates, or those nurses who return to the
workplace after a long absence and are re-
educated in refresher programs.
Advanced Beginner
 The advance beginner stage in the Dreyfus
model develops when the person can
demonstrate marginally acceptable performance
having coped with enough real situations to
note, or to have pointed out by mentor, the
recurring meaningful components of the
situation.
 Nurses functioning at this level are guided by
rules and oriented by task completion.
 Still requires mentor or experienced nurse to
assist with defining situations, to set priorities,
and to integrate practical knowledge (English,
1993)
 Competent
 After two to three years in the same area of nursing
the nurse moves into the Competent Stage of skill
acquisition.
 The competent stage is the most pivotal in clinical
learning because the learner must begin to
recognize patterns and determine which elements of
the situation warrant attention and which can be
ignored.
 The competent nurse devises new
rules and reasoning procedures
for a plan while applying learned
rules for action on the basis of the
relevant facts of that situation.
 Proficient
 After three to five years in the same area of nursing the nurse
moves into the Proficient Stage
“The nurse possesses a deep understanding of situations as they
occur, less conscious planning is necessary, critical thinking and
decision-making skills have developed” (Frisch, 2009)

 The performer perceives the information as a whole (total

picture) rather than in terms of aspects and performance.

 Proficient level is a qualitative leap beyond the competent.

 Nurses at this level demonstrate a new ability to see changing

relevance in a
situation including the
recognition and the
implementation of
skilled responses to the
situation as is it evolves.
 Expert
 This stage occurs after five years or greater in the same area of
nursing (experienced nurses changing areas of nursing practice
may progress more quickly through the five stages)
 The expert performer no longer relies on an analytic principle (rule,
guideline, maxim) to connect her or his understanding of the
situation to an appropriate action.
 The expert nurse, with an enormous
background of experience, now has an
intuitive grasp of each situation and
zeroes in on the accurate region of the
problem without wasteful consideration
of a large range of unfruitful, alternative
diagnoses and solutions.
 The expert operates from a deep understanding
of the total situation.
Benner’s Original Research
Goal:
– Compare Novice & Expert Nurse’s descriptions and
responses to the same clinical situations
Participants:
– 21 nurse preceptors & 21 new graduate nurses
– 51 experienced nurses
– 11 newly graduated nurses
– 5 senior nursing students
Collection of Research:
– Interviews with narrative accounts of situations
– Observation of behaviors in clinical settings (Benner,
1984)
Nursing Education Incorporates
Benner’s Theory
Goal:
– Identify if simulating unstable patient scenarios by
providing interactive teaching will transition nursing
students to higher levels of expertise
Participants:
– 190 Adult Health Nursing Students
Collection of Research:
– Observation of students in simulated patient rooms with
manikins providing clues to clinical scenarios
Conclusion:
– Development of nursing competency requires practice
and clinical simulation provides a safe, structured
learning experience (Larew, Lessans, Spunt, Foster, and
Covington, 2006)
 Nursing Application
of Benner’s Theory
Nursing applies Benner’s 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)
Four Domains of Nursing
Paradigm

1. Client/Person
2. Health
3. Environment/Situation
4. Nursing
 Client/ Person
“The 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.”
- Dr. Benner
 Health
 Dr. Benner focuses on the lived experience
of being healthy and being ill.
 Health is defined as what can be assessed,
whereas 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.
Environment/Situation
 Benner uses situation rather than environment
because situation conveys a social environment
with social definition .

 “To be situated implies that

one has a past, present, and
future and that all of these
aspects… influence the
current situation.”
- Dr. Benner
 Nursing
 Nursing is described as a caring relationship, an
“enabling condition of connection and concern.” -
Dr. Benner
 “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
and responsibility.
 Dr. Benner understands that nursing practice as the
care and study of the lived experience
of health, illness, and disease and
the relationships among the three
elements.
 Modern Theorists
Benner is a relatively
modern theorist, with her
work having been done
in the early 1980’s.
Since that time health
care has seen the
advent of DRG’s,
managed care, an
increase in the acuity of
patients in the hospital
related to early
discharge and bounce
back admissions.
 Hospital Survival
Her theory of expert nurses is
critical today as the profession
begins to realize the aging of
the members of its workforce
and the increasing age of the
population who will require
more nursing services. Her
theory is applicable today, as it
was at its publication, and
provides us with a foundation
to use for assigning clinical
competence, a tool to use to
assess competence in the staff
nurse.
What can Nurse Leaders do?
Nurse leaders can help address
the issues of nursing shortage and
staff retention by supporting new graduate nurses by:
• Advocating for transition or residency programs to
competency, confidence & satisfaction of new RNs
• Maintaining a healthy working environment
 Not using novice RNs to cover for staffing shortage
before the end of orientation period
 Zero tolerance for lateral violence or bullying
• Supporting experienced RNs who are serving as
preceptors and mentors for novice RNs
Shaping our Future Nurse
Leaders
• New graduate nurses are the future employee pool
• Job satisfaction & retention are greatly influenced
by the quality of orientation and support received
by the new graduate nurse.
• A positive experience will encourage the now
proficient nurse to mentor novice nurses & give
them the same positive experience he/she had
during the transition period.
The mediocre teacher tells. The good teacher explains.
The superior teacher demonstrates. The great teacher
inspires. - William Arthur Ward
 Case Study
A nurse, with over 15 years’ experience on the obstetrics floor, is attempting to
teach a new mother how to breast feed her infant.  First thing she does is makes
sure the new mother has privacy, that the room is warm and the lighting is
dimmed.  The mother is now relaxed and comforted by her surroundings.  The
nurse proceeds to explain to the mother about how to hold her infant and get
him to latch on to her breast.  She shows the mother a pamphlet with pictures
explaining how this is done.  The mother is still a bit nervous, so the nurse
reassures her that she can do this, with explanations of how it benefits the
baby.  With this done, the mother is ready to try breast feeding for the first
time.  The nurse is careful to continue reassuring the new mother and to assist
her only when it’s necessary.  The nurse notices that the baby still will not latch
on to the breast and immediately intervenes before the mother gets
discouraged.  An explanation is given that different techniques can be used to
hold the infant, so they are more comfortable and can latch on better.  When
the mother places the infant, with instruction from the nurse, into the football
position the latch on is successful.  Of course, the new mother is over joyed but
asked the nurse what she will do if she is at home at cannot get the baby to eat. 
The nurse is fully prepared and is able to get the new mother phone numbers for
local support groups in her area.
  Question to Case Study

Given the previous scenario, in what stage is

the nurse in Patricia Benner’s Novice to Expert
theory? 
 Answer

The answer is the nurse is in the expert practitioner. She

performs her education with ease even when the situation
changes. She performs instinctively and knows her patients
needs automatically. She was able to diffuse a potential
negative situation with her patient before the patient got
discouraged.  The nurse was fully prepared to answer all
questions and provide outside resources (Nursing Theories).