Patricia Benner’s Theory: From Novice to Expert

Nursing is a theory-based practice that is continuously evolving and developing. It is an exceptional profession in which the experience of the nurse is the most important aspect to professional growth and development. The development of Patricia Benner’s theory, novice to expert has been used to direct clinical practice and transform the view of the nursing profession. Benner applied various experiences within her study of the nursing profession to describe the unique features and knowledge embedded in the experience of the nurse (Benner, 2001). Her theory has enhanced individual knowledge development, professional growth and innovative changes within the nursing profession.

This paper will discuss in depth Benner’s theory, novice to expert and explore how it applies to advanced practice nursing. In addition, the disadvantages of applying this theory to advanced practice nursing will be explored. After reviewing this paper, the reader will understand Benner’s theory and will be able to identify how it applies to the role of the advanced practice nurse (APN). The novice to expert theory was chosen because of its profound impact on the structure of today’s nursing profession. Benner’s theory is unique in that it is able to provide a framework for advanced growth and development among many professions. It has been used to guide practice and advance today’s nursing profession (Alligood, 2014). Description of Theory: Novice to Expert

In 1984 Patricia Benner introduced her theory from novice to expert after an observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors (Benner, 2001). Benner (2001) proposed that nurses develop skills and patient care expertise over time through firm education and experience. She claims that nurses can gain concrete knowledge and expertise without ever learning the theory and concept behind the skills. Benner (2001) differentiates practical, “knowing how”, and theoretical knowledge, “knowing that” in nursing practice (p. 2). From novice to expert was one of the first theories to describe the learning process of nursing. Benner (2001) extended her theory to contain the identification and incorporation of caring into the practice of skill acquisition.

Benner’s (2001) novice to expert theory was created to highlight the skill acquisition of professional nurses. In this theory, Benner claims that developing nursing skills through situational experience is a prerequisite for expertise. Benner adapted to nursing practice the skill acquisition model developed by Dreyfus and Dreyfus (1986). She utilizes the Dreyfus model to describe performance characteristics and to identify general learning needs at each stage of nursing development. The Dreyfus model theorizes that when developing skills, an individual moves through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert (Benner, 2001).

The model explains that as an individual advances through these levels, changes are mirrored in three aspects of skill performance. One, the individual shifts from depending on abstract principles to the use of past concrete experiences. Secondly, there is a change in the learner’s outlook of the situation, where it is seen less as distinct equal pieces and more as a whole where only certain parts are significant. Lastly, the individual changes from an outside observer of the situation to an engaged performer (Benner, 2001). Novice

Benner (2001) describes a novice as a beginner with no experience of the situation in which they are expected to accomplish. The novice nurse needs to experience new clinical situations in order to develop skills. Benner (2001) explains that novice nurses are educated about their patient conditions in terms of objective qualities such as weight, vital signs and other measurable parameters of a patient’s situation. This learning approach allows the beginner nurse to recognize features of the patient’s condition without any situational experience (Benner, 2001). Novice practice in the clinical setting is very restricted and inflexible. The beginner nurse utilizes strict guidelines to oversee practice because of having limited to no clinical experience. The rules are context-free and independent of specific cases which tend to be applied universally.

Novice performers are unable to isolate relevant pieces of the situation because of the limitations and rule-governed practice. Instead, the novice nurse visualizes all pieces of the situation as equal parts (Benner, 2001). Nursing students are not the only novices; any nurse entering a clinical environment where he or she has limited practice with the patient population may be restricted to the beginner level of performance if the objectives and tools of patient care are unfamiliar. This highlights the situational, experience-based concepts of the Dreyfus model, which differentiates between the level of skilled performance taught in school and the clinical judgments and skills that can only be developed in actual clinical settings (Benner, 2001). Advanced Beginner

Benner defines the advanced beginner as a nurse “who can demonstrate marginally acceptable performance, ones who have coped with enough real situations to note the recurring meaningful situational components that are termed aspects of the situation in the Dreyfus Model” (Benner, 2001, p. 22). Aspects, in contrast to the measurable objective qualities or the routine lists of tasks to do that are used by the beginner, require previous clinical experience in order to identify significant components. For example, assessing the patient’s willingness to learn depends on prior experience with patients that have comparable learning needs (Benner, 2001).

Advanced beginners need support in the clinical setting and require assistance in prioritizing, since they still follow general guidelines and are just starting to recognize significant patterns in their clinical practice. They begin to develop principles based on prior experiences to help guide their actions when providing individualized care. However, nursing care should be monitored by preceptors to ensure that the patient’s central needs are being met because the advanced beginner is still learning how to sort out what is most important (Benner, 2001). Competent

A competent nurse is a nurse who has gained two to three years of experience in the same clinical setting or working conditions (Benner, 2001). Benner states that competence develops when the nurse begins to visualize or organize his or her actions in terms of long-range goals. Unlike the novice and advanced beginner, the competent nurse plans actions based on the relevant aspects of the situation instead of including all aspects. However, the competent nurse still does not have enough clinical experience to recognize a situation in terms of an overall picture (Benner, 2001).

For the competent nurse “a plan establishes perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem” (Benner, 2001, pg. 26). The competent nurse lacks the promptness and flexibility of the proficient nurse, however has developed a feeling of familiarity and the ability to manage the countless possibilities of clinical nursing. They perform routine skills concentrating on outcomes rather than specific tasks. The ability to effectively plan helps the competent nurse to be more organized and resourceful (Benner, 2001).

Proficient
Proficient nursing can typically be found in individuals who have worked in the same patient population for about three to five years. They can identify situations as a whole instead of in terms of aspects and can recognize when the expected typical picture does not emerge. According to Benner, “perspective is not thought out but presents itself based upon experience and recent events” (Benner, 2001, p. 27). Perception is essential to the proficient nurse. Proficient nurses learn from numerous past experiences and begin to develop a feeling of intuition. In this stage of nursing, the individual understands more holistically, thus enhancing decision making and critical thinking skills. The proficient nurse learns from practice what scenarios to anticipate in a given clinical situation and how procedures need to be adjusted in response to these situations (Benner, 2001). Expert

The last level in the skill acquisition model is the expert nurse. According to Benner (2001), the expert nurse functions from a deep understanding of the total situation. The nurse no longer relies on principles, rules, or guidelines to link his or her understanding of the situation to determine an action. “Expert nurses are infinitely adaptable in their responses to the situations at hand because they are able to engage in situated, context-driven reasoning” (Day, 2009, p. 481). In this level, the nurse has a vast background of experience and an intuitive grasp of each situation. The expert nurse incorporates knowledge of pathophysiology and physiology to assess symptoms and guide patient care (Day, 2009).

The performance of the expert nurse is fluid, flexible, and extremely proficient. Though the expert nurse can make assumptions based on intuition, Benner acknowledges that the expert nurse still needs to be exceedingly skilled in the use of analytic tools. These tools are critical for times when the expert nurse gets a wrong grasp of the situation (Benner, 2001). Benner’s Theory Applied to the Role of the Advanced Practice Nurse The APN transitions from novice to expert in the same manner as the novice nurse transitions to expert (Benner, 2001). Transitioning from novice to expert as an APN is a process that evolves over time. APNs will often arrive to their practice as expert nurses at the bedside, however the APN must understand that an expert nurse does not automatically confer expert status among corresponding disciplines.

Recognizing that one is back at the novice stage of development even in a new role can be frustrating and challenging. It is essential for the APN to show perseverance and patience in order to successfully transition from novice to expert (Hamric, Hanson, Fran Tracy, & O’Grady, 2013). Novice APNs often feel overwhelmed by most clinical situations, especially while adjusting to a new provider role. As a novice, a new APN’s practice is governed by rules and typically provides task focused care. The novice APN relies on guidelines and principles, rather than experience-based knowledge (Latham & Fahey, 2006). As advanced beginners, APNs have developed safe practice guidelines but lack a strong body of knowledge of the discipline. The APN begins to increase skill performance, however still relies on external principles, rules, and input to guide practice.

They tend to focus on the moment, rather than the bigger picture. In this level, the APN begins to prioritize and organize in order to complete tasks. The advanced beginner APN may feel overwhelmed by the required knowledge and complexity of skills, and become dependent on the judgment of others. As the APN’s confidence improves so does the understanding of their new role (Latham & Fahey, 2006). Competent APNs will find they can prioritize their time better and will begin to use past experiences to guide patient care (Hamric et al., 2013). In this level, the APN begins to increase clinical understanding, organizational skills, and ability to anticipate patient trajectories. The competent APN becomes a more active team member with an increased comfort level in communicating with physicians. They may feel stressed about coping as the competent APN feels a greater responsibility for their actions (Latham & Fahey, 2006).

Proficient APNs are no longer concerned with merely performing tasks and begin to show signs of intuitive decision making. APNs have a strong grasp of their patient’s situation, can prioritize needs and regularly predict patient outcomes. Over time knowledge levels expand with respect to patients and the complexity of their needs. The proficient APN becomes more flexible, responsible, and appropriately involved with all team members. Stress decreases as the necessary actions to achieve outcomes become more apparent (Latham & Fahey, 2006). Expert APNs are confident, have an extensive knowledge base and can quickly grasp complex patient situations (Hamric et al., 2013). The expert recognizes a situation, its changing relevance, and can shift perspective accordingly. In this level, the APN may feel possibly frustrated due to lack of acknowledgement and accommodation.

Expertise is holistic, including embodied perceptual skills, shared background knowledge, and cognitive ability (Latham & Fahey, 2006). Disadvantages of Benner’s Theory to Advanced Practice Nursing Benner’s theory of skill acquisition is a nonlinear process. The skill acquisition theory is a situation-based model, not a specific trait model. Thus, the level of proficiency is not an individual characteristic of a certain nurse but is a sense of the nurses’ familiarity with a certain situation in combination with his or her educational background (Hamric et al., 2013). A major implication of the novice to expert theory for advanced practice nursing is the assertion that even experts can be expected to perform at lower skill levels when they come across new situations. Even after making the transition to an APN role, the progression in role application is not a direct process.

There are several gaps, with movement back and forth as the trajectory begins again. The APN’s level of expertise can change with each situation or setting. For example, the expert APN can revert to the novice role when confronted with a new drug, new technique, or unfamiliar situation and disease. In order to not become complacent it is essential for the APN to continue their education, to foster continued growth, and understanding of changes in the field (Hamric et al., 2013). Benner claims that intuitive expertise and understanding without a rationale is the final stage of nursing practice.

Rolfe (2011) proposed a further stage of nursing that he referred to as advanced practice. The APN knowingly reflects on their intuitive expert practice to produce explicit and understandable knowledge from practice. They form a body of knowledge and principle from their own practice that they are able to articulate and share with less proficient APNs (Rolfe, 2011). Rolfe points out that “it is not enough for advanced practitioners to practice what they preach; they must also be able to preach what they practice” (Rolfe, 2011, p. 2372). The level of skill, knowledge, leadership, and autonomy progresses with advanced practice nursing (Hamric et al., 2013). Conclusion

The novice to expert theory has provided a significantly valued framework for advanced growth and development of the nursing profession. Benner’s theory has been a basis in practice, education, and leadership development. Benner directed an observational study of clinical nursing practice in an effort to learn and portray the knowledge that is rooted in nursing practice. New nurses and their preceptors were interviewed to learn how nurses acquire skills and knowledge over time (Benner, 2001). In applying the skill acquisition work of Dreyfus and Dreyfus (1986) to nursing, Benner described five levels of proficiency: novice, advanced beginner, competent, proficient, and expert. Benner emphasizes that nurses are not experts in every situation and that expertise is situational.

As a nurse transitions into a higher level of skill performance a more holistic approach is utilized in practice. The expert nurse identifies the situation as a whole, uses past concrete situations, and concentrates on the problem without wasteful consideration of irrelevant actions; whereas the less experienced nurse relies on rules and guidelines for determining clinical actions. Benner emphasizes the need for experts to use analytic thinking in certain situations. For example, when there was no previous experience with the situation, or when intuitions were incorrect (Benner, 2001). Benner’s theory is also utilized in advanced practice nursing. Role development in advanced practice nursing as well as transitioning from novice to expert is a process that evolves over time. However, even after making the transition to an APN role, the progression in role implementation is not a linear process.

The expert APN can revert to the novice role when confronted with an unfamiliar situation. Therefore, it is essential for the APN to remain current and up to date with medical knowledge in order to achieve successful patient outcomes (Hamric et al., 2013). Benner’s development of the novice to expert theory has been used to guide practice and produce innovative changes to the nursing profession (Alligood, 2014). The emphasis on the complexity of nursing practice, particularly how knowledge of practice is acquired overtime has been utilized in developing practice models, advances in nursing research, as well as preceptor and orientation programs in healthcare settings (Alligood, 2014). Benner’s theory highlights the significance of knowledge development through actual clinical conditions. The professional goals for each APN should be to become an expert in all aspects of their practice and to help others achieve the same (Ulrich, 2011).