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Dr. Patricia Benner is a nursing theorist who first developed a model for the stages of clinical competence in her classic book “From Novice to Expert: Excellence and Power in Clinical Nursing Practice”. Her model is one of the most useful frameworks for assessing nurses’ needs at different stages of professional growth. She is the Chief Faculty Development Officer for Educating Nurses, the Director of the Carnegie Foundation for the Advancement of Teaching National Nursing Education and honorary fellow of the Royal College of Nursing.
Dr. Benner was born in Hampton, Virginia, and received her bachelor’s degree in Nursing from Pasadena College in 1964, and later a master’s degree in Medical-Surgical Nursing from the University of California, Berkeley. After completing her doctorate in 1982, she became an Associate Professor in the Department of Physiological Nursing at the University of California, San Francisco. Dr. Benner is an internationally known lecturer and researcher on health, and her work has influenced areas of clinical practice as well as clinical ethics.
This nursing theory proposes that expert nurses develop skills and understanding of patient care over time through a proper educational background as well as a multitude of experiences. Dr. Benner’s theory is not focused on how to be a nurse, rather on how nurses acquire nursing knowledge – one could gain knowledge and skills (“knowing how”), without ever learning the theory (“knowing that”). She used the Dreyfus Model of Skill Acquisition as a foundation for her work. The Dreyfus model, described by brothers Stuart and Hubert Dreyfus, is a model based on observations of chess players, Air Force pilots, army commanders and tank drivers. The Dreyfus brothers believed learning was experiential (learning through experience) as well as situation-based, and that a student had to pass through five very distinct stages in learning, from novice to expert.
Dr. Benner found similar parallels in nursing, where improved practice depended on experience and science, and developing those skills was a long and progressive process. She found when nurses engaged in various situations, and learned from them, they developed “skills of involvement” with patients and family. Her model has also been relevant for ethical development of nurses since perception of ethical issues is also dependent on the nurses’ level of expertise. This model has been applied to several disciplines beyond clinical nursing, and understanding the five stages of clinical competence helps nurses support one another and appreciate that expertise in any field is a process learned over time.
Dr. Benner’s Stages of Clinical Competence
Stage 1 Novice: This would be a nursing student in his or her first year of clinical education; behavior in the clinical setting is very limited and inflexible. Novices have a very limited ability to predict what might happen in a particular patient situation. Signs and symptoms, such as change in mental status, can only be recognized after a novice nurse has had experience with patients with similar symptoms.
Stage 2 Advanced Beginner: Those are the new grads in their first jobs; nurses have had more experiences that enable them to recognize recurrent, meaningful components of a situation. They have the knowledge and the know-how but not enough in-depth experience.
Stage 3 Competent: These nurses lack the speed and flexibility of proficient nurses, but they have some mastery and can rely on advance planning and organizational skills. Competent nurses recognize patterns and nature of clinical situations more quickly and accurately than advanced beginners.
Stage 4 Proficient: At this level, nurses are capable to see situations as “wholes” rather than parts. Proficient nurses learn from experience what events typically occur and are able to modify plans in response to different events.
Stage 5 Expert: Nurses who are able to recognize demands and resources in situations and attain their goals. These nurses know what needs to be done. They no longer rely solely on rules to guide their actions under certain situations. They have an intuitive grasp of the situation based on their deep knowledge and experience. Focus is on the most relevant problems and not irrelevant ones. Analytical tools are used only when they have no experience with an event, or when events don’t occur as expected.
Beginner nurses focus on tasks and follow a “to do” list. Expert nurses focus on the whole picture even when performing tasks. They are able to notice subtle signs of a situation such as a patient that is a little harder to arouse than in previous encounters.
The significance of this theory is that these levels reflect a movement from past, abstract concepts to past, concrete experiences. Each step builds from the previous one as these abstract principles are expanded by experience, and the nurse gains clinical experience. This theory has changed the perception of what it means to be an expert nurse. The expert is no longer the nurse with the highest paying job, but the nurse who provides the most exquisite nursing care.