Nursing is a caring practice guided by the moral art and ethics of care and re-sponsibility that unfolds in relationships between nurses and patients (Benner
& Wrubel, 1989). The original domains and competencies of nursing practice (B enner, 1984) were identified and described inductively from clinical situation interviews and observations of novice and expert staff nurses in actual practice.
This interpretive phenomenological study used a situational approach to the study of the knowledge and meanings embedded in the everyday practice of nurses. “The strength of this method lies in identifying competencies from ac-tual practice situations rather than having experts generate competencies from models or hypothetical situations” (Benner, 1984, p. 44). A holistic perspective such as this provides details of the situational contexts that guide interpreta-tion. Thirty-one interpretively defined competencies were identified and de-scribed from the narrative data. These competencies were grouped according to similarities of function, intent, and meaning to form seven domains of nursing practice (Box 7-1).
The helping role domain includes competencies related to establishing a healing relationship, providing comfort measures, and inviting active patient participation and control in care. Timing, readying patients for learning, moti-vating change, assisting with lifestyle alterations, and negotiating agreement on
BOX 7-1
Benner’s Domains of Nursing Practice
• 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 and work-role competencies
From Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, with permission from Pearson Education.
goals are competencies in the teaching-coaching function domain. The diagnostic and patient-monitoring function domain refers to competencies in ongoing as-sessment and anticipation of outcomes. Competencies in the effective manage-ment of rapidly changing situations domain include the ability to contingently match demands with resources and to assess and manage care during crisis situ-ations. The domain administering and monitoring therapeutic interventions and regimens incorporates competencies related to preventing complications during drug therapy, wound management, and hospitalization. Monitoring and ensur-ing the quality of health care practices domain includes competencies concerned with maintenance of safety, continuous quality improvement, collaboration and consultation with physicians, self-evaluation, and management of technology.
The organizational and work-role competencies domain refers to competencies in priority setting, team building, coordinating, and providing for continuity of care.
The domains and competencies of nursing practice are nonlinear, with no precise beginning or endpoint. Instead, the nurse enters the hermeneutic circle of caring for the patient by way of whichever competency is needed at the time. One competency in one domain may be more prominent at a particular point in time, but all seven domains and numerous competencies (some not yet identified) will perhaps overlap and come into play at various times in the transitional (ongoing) process of caring for a patient.
The domains and competencies of nursing practice (Benner, 1984) were ini-tially presented as an open-ended interpretive framework for enhancing under-standing of the knowledge embedded in nursing practice. The expectation was that they be interpreted in the context of the situations from which they arise along with articulation of ideas of the good or ends of nursing practice. Narrative text must accompany the identification and description of domains and competencies. They are not mutually exclusive, jointly exhaustive categories that can be abstracted from their narrative sources. Because of the socially embedded, relational, and dialogical nature of clinical knowledge, the domains and competencies need to be adapted for each institution. This is achieved through study of clinical practice at each specific locale by systematically collecting 50 to 100 clinical narratives that are then in-terpreted to identify strengths, challenges, or silences in that practice community.
A CPDM can then be designed specifically for the particular setting (Benner &
Benner, 1999).
Benner’s work focuses on developing understanding of perceptual acuity, clinical judgment, skilled know-how, ethical comportment, and ongoing experi-ential learning. Benner’s proposal (1994b) that narrative data be interpreted as text rather than being coded with formal criteria is useful for understanding her work, specifically with regard to expertise, practical knowledge, and intuition. When these terms are considered as formal, explicit criteria (Cash, 1995; Edwards, 2001;
English, 1993; Gobet & Chassy, 2008), erroneous interpretations of conservatism, traditionalism, or mysticism may arise. Therefore, each term is discussed in detail in the following sections.
The Dreyfus (Dreyfus & Dreyfus, 1986) model of skill acquisition maintains that expert practice is holistic and situational. Qualitative distinctions between
122 PART 2 Application
the levels of competence, from the novice to expert skill acquisition model (Benner, et al., 1996), reflect “the situational and relational nature of common-sense understanding and developing expert practice” (Darbyshire, 1994, p. 757).
According to this model, which Benner (1984) validated for nursing, expert practice develops over time through committed, involved transactions with per-sons in situations.
Clinical nursing expertise is embodied—that is, the body takes over the skill.
Embodied expertise means that as human beings, we know things with our feelings and bodily senses (sight, sound, touch, smell, intuition), rather than just our ratio-nal minds. According to Brykczynski (1998):
To say that expertise is embodied is to say that, through experience, skilled per-formance is transformed from the halting, stepwise perper-formance of the begin-ner—whose whole being is focused on and absorbed in the skilled practice at hand—to the smooth, intuitive performance of the expert. The expert performs so deftly and effortlessly that the rational mind, feelings, and perceptions are available to notice the patient and others in the situation and to perceive salient aspects of the situational context (p. 352).
Because expertise in this model is situational rather than defined as a trait or talent, one is not expert in all situations. When a novel situation arises or the usually expert nurse incorrectly grasps a situation, his or her performance in that particular situation relates more to competent or proficient levels. This experience then becomes part of the nurse’s repertoire of background experi-ences. In future encounters this nurse will approach a similar situation more expertly. This variable nature of expertise is very troublesome for those seeking abstract, objective, mutually exclusive, jointly exhaustive categories. However, it is quite compatible with the holistic, interpretive phenomenological approach.
Experts functioning according to this perspective maintain a flexible and proac-tive stance with regard to possibly forming an incorrect grasp of the particular situation. For example, the intensive care unit (ICU) nurse described in FNE (Benner, 1984) who negotiated for more time for a patient to relax and stop re-sisting ventilator assistance before administration of additional sedation based her actions on the premise of a concern that she might be wrong. This model of expertise is open to possibilities in the particular situation, which fosters innova-tive interventions that maximize patient, staff, and other resources and supports to achieve an optimal outcome.
Next, an understanding of distinctions between practical and theoretical knowledge is essential for grasping this perspective (Kuhn, 1970; Polanyi, 1958).
Embodied knowledge is the kind of global integration of knowledge that develops when theoretical concepts and practical know-how are refined through experience in actual situations (Benner, 1984). The more tacit knowledge of experienced clini-cians is uniquely human. It is the kind of knowledge that computers do not have (Dreyfus, 1992). It requires a living person, actively involved in a situation with the complexity of background and context. The following distinction between human and computer capabilities clarifies aspects of the theory-practice gap so widely dis-cussed in practice disciplines:
All of knowledge is not necessarily explicit. We have embodied ways of knowing that show up in our skills, our perceptions, our sensory knowledge, our ways of organizing the perceptual field. These bodily perceptual skills, instead of being primitive and lower on the hierarchy, are essential to expert human problem-solving which relies on recognition of the whole (Benner, 1985b, p. 2).
Theoretical knowledge may be acquired as an abstraction through reading, ob-serving, or discussing, whereas the development of practical knowledge requires experience in an actual situation because it is contextual and transactional. Clinical nursing requires both types of knowledge. Table 7-1 provides definitions and ex-amples of aspects of practical knowledge based on Benner (1984).
The examples of aspects of practical knowledge described in Table 7-1 are self-explanatory. However, maxims require explanation. The maxim “When you hear hoofbeats in Kansas, think horses, not zebras” reminds clinicians that for most common conditions time-consuming, extensive searches for rare conditions are usually not warranted. The maxim “Follow the body’s lead” relates to the percep-tual acuity developed by nurses to intuitively sense the meaning of a patient’s bodily responses. It appears, for example, in situations in which patients are being assessed for readiness to be weaned from ventilator assistance and when nurses evaluate comfortable positions preferred by a particular infant.
In the interpretive phenomenological perspective, the body is indispensable for intelligent behavior rather than interfering with thinking and reasoning. According to Dreyfus (1992), the following three areas underlie all intelligent behavior:
1. The role of the body in organizing and unifying our experience of objects 2. The role of the situation in providing a background against which
behav-ior can be orderly without being rule-like
3. The role of human purposes and needs in organizing the situation so that objects are recognized as relevant and accessible
Finally, intuition, rather than mystical, is defined as immediate situation rec-ognition (Dreyfus & Dreyfus, 1986). This definition is based on Merleau-Ponty’s (1962) ideas that “the body allows for attunement, fuzzy recognition of problems, and for moving in skillful, agentic, embodied ways” (Benner, 1995, p. 31). Intuition functions on a background understanding of prior similar and dissimilar situations and depends on the performer’s capacity to be confident in and trust his or her perceptual awareness. This ability is similar to the ability to recognize family resem-blances in faces of relatives whose objective features may be quite different. Benner (1996) argues that “[c]linical reasoning is necessarily reasoning in transition, and the intuitive powers of understanding and recognition only set up the condition of possibility for confirmatory testing or a rapid response to a rapidly changing clini-cal situation” (p. 673).
Interfacing with Practice
Practice and theory are seen as interrelated and interdependent. An ongoing dia-logue between practice and theory creates new possibilities (Benner & Wrubel, 1989). In Benner’s work, practice is viewed as a way of knowing in its own right
124 PART 2 Application
TABLE 7-1 Aspects of Practical Knowledge
Aspect Definition Examples
Qualitative distinctions
Perceptual, recognitional clinical judgment that refers to accurate detection of subtle alterations that cannot be quantified and that are often context dependent
Discrete alterations in skin color Significance of changes in mood Different manifestations of anxiety
Maxims Cryptic statements that guide action and require deep situational understanding to make sense
When you hear hoofbeats in Kansas, think horses, not zebras.
Follow the body’s lead.
Assumptions, expectations, and sets
Knowledge from past experience that helps orient and provide a frame of reference for anticipatory guidance along the typical trajectory
Assumptions are beliefs that something is true; expectations are outcomes that can be reasonably anticipated following a certain scenario; sets are inclinations or tendencies to respond to anticipated situations
Assumptions include the ability to maintain and communicate hope in situations based on possibilities learned from previous similar situations.
It is expected that an obese person with essential hypertension who loses weight and engages in aerobic exercise 3 times a week will experience a decrease in blood pressure.
A set can be illustrated by thinking about the difference in the way a nurse would approach a woman in labor for whom everything seemed to be going normally and the way a nurse would approach the woman if there was a known fetal demise.
Common meanings
Shared, taken for granted, background knowledge of a cultural group that is transmitted in implicit ways
It is often better to know even bad news than not to know.
The need to advocate for the vulnerable and voiceless
Paradigm cases Clinical experiences that stand out in one’s memory as having made a significant impact on the nurse’s future practice and profoundly alter perceptions and future understanding
The first patient a nurse worked with who stops smoking
The first patient with a breast lump who a nurse refers for evaluation
Exemplars Robust clinical examples that convey more than one intent, meaning, or outcome and can be readily translated to other clinical situations that may be quite different An exemplar might constitute a
paradigm case for a nurse depending on its impact on personal knowledge and future practice
Helping a patient/family to experience a peaceful death
Teaching/coaching a patient/family to live with a chronic illness
Unplanned practices
Knowledge that develops as the practice of nursing expands into new areas
Experience gained with available alternative therapies and patient responses to them
Developed from Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA:
Addison-Wesley.
(Benner, 1999). As noted earlier, Benner’s approach to articulating nursing practice is inductive, developmental, and interpretive. She locates it in “the feminist tradition of consciousness raising that seeks to name silences and to bring into public dis-course poorly articulated areas of knowledge, skill, and self-interpretations in clini-cal nursing practice” (Benner, 1996, p. 670).
Articulation is defined as “describing, illustrating, and giving language to taken-for-granted areas of practical wisdom, skilled know-how, and notions of good practice” (Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 5). Since the publication of FNE in 1984, which involved staff nurses from various clini-cal areas, Benner and colleagues have focused on articulating skill acquisition processes and competencies of nurses in acute and critical care areas (Benner, et al., 1996, 2009; Benner, et al., 1999, 2011). Domains and competencies have also been useful for articulation of knowledge embedded in advanced nursing practice (Brykczynski, 1999; Fenton, 1985; Fenton & Brykczynski, 1993; Lindeke, Canedy, & Kay, 1997; Martin, 1996).
Selected studies illustrate applications of Benner’s work and continued ar-ticulation of the competencies of advanced nursing practice. Fenton’s (1985) study indicated that the original domains were present in the practice of clini-cal nurse specialists (CNSs). She identified additional competencies for three of Benner’s original domains and described one additional domain, the consulting role of the nurse (Figure 7-1). Fenton described the competency making the bu-reaucracy respond in her study of CNSs. This involved knowing how and when to work around bureaucratic roadblocks in the system so patients and families could receive needed care.
Brykczynski (1985) developed an additional domain from her study of out-patient nurse practitioner (NP) practice. The new domain consolidated two of Benner’s domains that were typical of inpatient nursing practice—diagnostic and patient monitoring function and administering and monitoring therapeutic interven-tions and regimens (see Figure 7-1)—and replaced it with management of patient health/illness status in ambulatory care settings. The remaining five of Benner’s seven domains were interpreted as valid for the practice of the NPs studied. The cumulative nature of qualitative research is demonstrated by Brykczynski’s (1985) identification of managing the system as a competency in her NP study. Further in-terpretation revealed that this competency was identical to making the bureaucracy respond described by Fenton with CNSs. This competency involves negotiating and interpreting policies and procedures for patients so that they can fit into the sys-tem and get what they need. It demands flexibility in the nurse’s stance toward the system and requires not getting caught up in unproductive interpersonal conflicts;
instead, the nurse uses knowledge of the bureaucracy and interpersonal communi-cation skills to provide care for patient needs.
Later Fenton and Brykczynski compared the findings of their studies to dis-cover commonalties and distinctions between the practice of NPs and CNSs. The comparative analysis indicated “a shared core of advanced practice competencies as well as distinct differences between the practice roles” (Fenton & Brykczynski, 1993, p. 313). As noted, making the bureaucracy respond was shared by both groups;
however, the organizational and work-role competencies were more prominent in
126PART 2Application
Management of patient health/
illness status in ambulatory care
settings Diagnostic/
patient-monitoring
function
Organization and work-role competencies
Teaching/
coaching function
Effective management of rapidly changing
situations Helping role
of the nurse The consulting
role of the nurse Administering/
monitoring therapeutic interventions and regimens
Interpreting the role of nursing to others:
role-modeling Providing consultation to MDs and other staff on patient management
Providing patient advocacy
by sensitizing staff to dilemmas faced by patients Making health
and illness approachable/
understandable
Negotiation when patient/
provider priorities conflict
Domain identified by Benner CNS domain identified by Fenton CNS competency identified by Fenton NP competency identified by Brykczynski NP domain identified by Brykczynski Grooming
staff to see their roles as
part of the organization
Providing support for nursing staff
Making the bureaucracy
respond to patient/family
needs Obtaining specialist care while remaining
the primary care provider
Coping with staff and organizational
resistance to change Assessment/
monitoring/
coordination/
management of patient care
over time Detecting acute/chronic disease while attending
to illness Scheduling
follow-up patient visits
to monitor care Selecting/
recommending diagnostic/
therapeutic interventions
Monitoring/
ensuring the quality of healthcare
practices Recognition of recurring generic problem
resolvable by policy change Developing strategies for dealing with concerns over
consultation Self-monitoring
and seeking consultation as
necessary Using physician consultation
effectively Giving constructive feedback to ensure safe care
practice
Providing emotional/
informational support to
patients’
families
Healthcare needs and capacities:
teaching for self-care
FIGURE 7-1
the practice of the CNSs. NPs practiced more as direct providers of care, whereas CNSs functioned more as facilitators of care. The new domain, the consulting role of the nurse, was evidenced in the practice of both CNSs and NPs. Competencies in this domain represent the initial articulation of skills and knowledge specific for advanced nursing practice.
Lindeke, Canedy, and Kay (1997) followed this work with a study of similari-ties and differences between CNS and NP roles among CNSs who completed a post-master’s NP program. They found that although practice domains were simi-lar, there was distinct expression of the domains in each advanced practice nurse (APN) role. The post-master’s participants stated that they “experienced significant role change in the transition from CNS to NP roles” (Lindeke, et al., 1997, p. 287);
important advanced practice role findings for curriculum planning.