Supervised by : Prof. Dr. Wasileh petro

Prepared by : mohammad al-naeemkhaled al-shollol

The nurse-patient relationship is not a uniform, professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life. (Benner, 1984a)Patricia BennerThe university of Jordan

OUTLINS * Objectives of presentation * Credentials and background of Patricia Benner * Theoretical Resources and Dreyfus model * Major concepts & Definitions of Benner theory * Use of empirical evidence * Major Assumptions of Benner work * Metaparadigm of Benner theory. * Logical form * acceptance by the nursing community. * Benner Work Critique * scope of utilization of beener theory * application of beener theory * Conclusion & * Reference

OBJECTIVESAt the end of my lecture, all students will be able to:

Introduce Patricia Benner and discuss Dreyfus model

- Identify the Major concepts & Definitions of theory

Identify the Major Assumptions (metaparadiam) of Benner work

describe the acceptance of theory by the nursing community

- Discuss the scope of utilization of beener theory and how we can applied it nowadays

Credentials and background of Patricia BennerLife: Patricia Benner was born in 1942 in Hampton, Virginia. And spent her childhood in California.She was married to Richard benner on 1967,they have a son and a daughter.

Professional:* Bachelor degree in nursing from Pasadena College, in 1964 .* Master in medical-surgical nursing from the University of California, San Francisco (UCSF), in 1970 .* PhD - from the University of California Berkeley , in 1982.

Benner Background (cont.)1985, Benner was inducted into the american academy of nursesBenner retired from full time teaching in 2008 as professor from university of California san Francisco (UCSF)She is currently a Distinguished Visiting Professor at Seattle University School of Nursing,

Benner Background (cont.)Published 9 books and numerous articles

Published Novice to Expert Theory in 1982 named an American Journal of NursingBook of the Year for nursing education and nursing research in 1984 .

Received Book of the Year from AJN in 1984,1989,1996, 1999.

Benner Background (cont.)Benner was appointed by carnegie foundation for preparation professions program in march 2004

this project focus on the role of nursing school In preparing nurses by addressing issues of teaching and learning Instruction, curriculum assessment and institutional context

AwardBenner received an award for outstanding contributions to the profession by national council of state boards of nursing in 2002 for her work on developing an instrument to capture the sources and nature of nursing errors .This instrument is entitled ( Taxonomy of Error ,Root Cause and Practice (TERCAP).

She recived the american association of colleges of nursing pioneering spirit award in may 2004 for her work in skill acquisition and articulationj of nursing knowledge in critical care.

Benners Books(1979): New Nurses Work Entry: A Trouble Sponsorship

(1984): Stress and Satisfaction on the Job

(1989): The Primacy of Caring: Stress and Coping in Health and Illness

(1999) : Clinical Wisdom and Interventions in Critical Care: A Thinking-In-action Approach

Benners Books (cont.)(2000): From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative

(2009) : Expertise in Nursing Practice, Caring, Clinical Judgment, and Ethics (expansion of research by Tanner and Chesla)

(2011): Clinical Wisdom and Interventions in Acute and Critical Care.

She coneptualizes in her writing about nursing skills as experience is a prerequisite for becoming an expert.

Benners Theoretical SourcesBenner studies clinical nursing practice in an attempt to discover and describe the knowledge embedded in nursing practice.( lack of charting???)

From From

Theoretical knowledge Practical knowledge = VS =Knowing that knowing howknowledgePracticeTheory

Benners Theoretical SourcesBeener belived that : ( inductive ) nurses have been lack of documentation

deprive nursing theory of uniqueness and richness of knowledge knowledge is embedded in clinical practiceKnowing that ----- lends itself to theoretical explanation ( establishe causal relationship between events ----------------------------------------------------Knowing how------ may elude precise abstract formulation( skill acquisition that defy Knowing that)

Ex: COPD . O2 therapy + CO2 ??? )

Benners Theoretical SourcesBenner and description of knowing how in practice

Benner proposed that one could gain knowledge and skills (knowing how) without ever learning the theory (knowing)

She stated that The extension of practical knowledge (know-how) through theory-based scientific investigations (know-that) is necessary for Knowledge development in a practical discipline.

Benners Theoretical SourcesBenner and description of knowing how in practice

Practical knowledge may extend theory or be developed before scientific formulas.

Clinical situation are always more varied and complicated than theoretical accounts; therefore ,clinical practice is an area of inquiry and source of knowledge development.

Theory is derived from practice and practice is altered or extended by theory. (ex: hand washing, pain score..???)

Benners Theoretical SourcesBenner work influence philosophically and ethically by:

Stuert Dreyfus and Hubert Dreyfus (1980).. Dreyfus modelRichard (1985) mentored benner in the filed of caring &stressJudith wrubel (1989) ( participant & co-author with beener)Joseph dunne (1993 )Kund logestrub (1995, 1997)Onora (1996)

Benner in 1984 adapted the dreyfus model to clinical nursing practice.

Dreyfus modelstuert Dreyfus and Hubert Dreyfus developed the skill acquisition model by studying the performance of chess master and pilots in emergency situations.

The model is situational , developmental , and describe five level of skills acquisitions . Each level build up on the pervious level.

Dreyfus modelMovement through the 5 levels(ex: school students)primary-tawjehi course

Dreyfus model (cont.)

fromtoReliance on abstract principals

Analytical rule-based thinking

Receive situation as compilation of equally relevant bits

observer, outside the situationUse of past concrete experience

Intuition

Increasingly complex whole inspite of more/less relevant parts

Fully engaged in the situation

Major concepts & Definitions

Dreyfus model (cont.)Performance level can be determined by :1- validation of Expert judges.2- Outcomes of the situation.

In applying dreyfus model to nursing , Benner noted : Experience-based skill acquisition will be safer and quicker when it rests on a sound educational base. Ex: . CPR

Benner identified 2 aspects of practice distinguishing levels from novice to expert:

1- Clinicians at different levels of practice recognize and respond to different situated needs for action .

2- Clinicians develop a sense of responsibility towardpatient (agency) > > fully participating membersof health care team.

When a familiar situation is encountered, there is embodied recognition of its meaning (Embodied intelligence).

Benner stated : skilled activity , which is made possible by our embodied intelligence , has been long regarded as lower than intellectual ,reflective activity

Person has no background experience of the situation.

Context-free rules & objective attributes must be given to guide performance.

There is difficulty discerning relevant and irrelevant aspect of a situation.

e.g.. students of nursing, or unfamiliar with a certain situation

Person can demonstrate marginally acceptable performance having coped with enough real situations to note the recurrent , meaningful components of the situation.

Have enough experience to grasp aspects of a situation.

Nurses guided by rules & are oriented by task completion, with difficulty grasping the current patient situation in terms of the larger perspective.Major concepts & Definitions Advance beginner

They view the clinical situation as a test of their abilities and the demands of the situation placed on them, rather than in term of patients needs & responses.

highly responsible for managing patient care , yet they still rely on the help of those more experienced .

E.g.. most newly graduated nurses .

Major concepts & Definitions competentConsiderable conscious & deliberate planning that determines which aspects of the current & future situations are important & which can be ignored.

Consistency, predictability, &time management are important in competent performance . And sense of mastery can be acquired, & is more realistic.

Increased level of efficiency, but the focus on the organizational satisfaction rather than on patients needs. May display hyper-responsibility for the patient.

Major concepts & Definitions competentDevises new rules & reasoning procedures for a plan while applying learned rules for action on the bases of relevant facts of that situation.

The competent stage is most pivotal in clinical learning .

Major concepts & Definitionsproficient Perceive the situation as a whole, the performance is guided by maxims , have a sense of quality, more confident in their abilities and knowledge.

Demonstrates new abilities to see changing relevance in a situation, including the recognition & implementation of skilled responses to the situation evolved.

Much more involvement with the patient & the family.

Major concepts & DefinitionsexpertThe expert performer achieved when No longer relies on analytical principle (rules, guidelines & maxim) to connect understanding of a situation to an appropriate action.

Intuitive grasp of the situation identifies the problem without losing time, considering a range of alternative diagnoses & solutions.

The expert nurse has this ability to recognize patterns on the basis of deep experiential background.

Key aspects of expert nurses practice:

Demonstrating a clinical grasp & resource-based practice.

Possessing embodied know-how.

Seeing the big picture.

Seeing the unexpected.

Video

Major Concepts & DefinitionsAspect of asituationAttributes ofa situationExemplarDomainSalienceMaximExperienceParadigmcasecomportmentCompetencyHermeneutics

1st concept:Major Concepts DefinitionsThe aspects are the recurring meaningful situational components & understood in context because the nurse has recognized as previous experience .Concept -1: Aspect of a situation

Major Concepts DefinitionsConcept -2: Attributes of a situation

Attributes are measurable properties of a situation that can be explained without previous experience in the situation.

Major Concepts DefinitionsConcept -3: Competency

An interpretively defined area of skilled performance identified & described by its intents, functions, & meanings .

Major Concepts DefinitionsConcept -4: Domain

An area of practice having a number of competencies with similar intents, functions,& meanings.

Concept -5: Exemplar

An example of clinical situation that conveys oneor more intents, functions, meanings, or outcomeseasily translated to other clinical situations.

Major Concepts DefinitionsConcept -6: Experience

Is not a mere passage of time, but an active process ofrefining & changing preconceived theories, notions,& ideas when confronted with actual situations.Concept -7: Maxim

Is a cryptic (hidden) description of skilledperformance that requires a certain level ofexperience, to recognize the implications of theInstructions (S.E) .

Major Concepts DefinitionsConcept -8: Paradigm case

Is a clinical experience (event) that stands out & altersthe way the nurse will perceive & understand futureclinical situations.

Paradigm cases Creates new clinical understanding &open new clinical perspectives & alternative.Concept -9: Salience

Perceptual stance or embodied knowledge wherebyaspects of a situation stand out as more or lessimportant.

Major Concepts DefinitionsConcept -10: comportment

A style & manner of acting and interacting, which includes gestures, posture,& stance.Concept -11: Hermeneutics . interpretive

Refers to describing & studying meaningful human phenomena in a carful & detailed manner as free as possible from prior theoretical assumptions, based instead on practical understanding .

Use of empirical evidenceFrom Novice To Expert.(1984)

Expertise In Nursing Practice.(1996)

Clinical Wisdom and intervention In Critical Care.(1999)

Use of empirical evidenceFrom novice to expertBenner was the project director of AMICAE, which led to the publication of From Novice to Expert (1984).

AMICE project was an interpretive, descriptive study.

Lead to used Dreyfus model to describe skill acquisition in clinical nursing practice.

More than 1200 nurse completed questionnaires andinterviews as a part of the AMICAE project.

AMICAE: achivement methods of intraprofessional consensus assessmen and evaluation

Use of empirical evidenceFrom novice to expertThirty-one competencies emerged.

From these competencies, seven domains were inductively derived on the bases of similarity of function and intent:

1- The helping role.

2- The teaching-coaching function.

3- The Diagnostic and patient caring function.

4- Effective management of rapidly changing situations.

5- Administering and monitoring therapeutic interventions.

6- Monitoring and ensuring quality of care practices.

7- Organizational work-role competencies.

Use of empirical evidenceExpertise in Nursing PracticeExtended from research presented in 1984 From novice to Expert.

The book was based on 6-year study of 130 hospital nurses, primarily Critical Care Nurses.

As a result of this study, there was a clearer understanding of the distinctions between engagement with a problem or situation and the requisite nursing skills of interpersonal involvement.

These nursing skills appeared to be learned overtime experientially.

The skill of involvement seems central in gaining nursing expertise.

Use of empirical evidenceClinical Wisdom In Critical care

Took place from 1996-1997 and published in 1999.

Considered phase two of the project.

Included 76 nurses (32 are APNs) from 6 hospitals

9 domains of critical care practice were identified as broad themes.

Diagnosing and managing life-sustaining physiological functions in unstable ptPreventing hazards in a technological environment . Using the skilled know-how of managing a crisis.Providing comfort measures for the acute critically ill.Caring for patients families.

Use of empirical evidenceClinical Wisdom In Critical care

9 domains of critical care practice were identified as broad themes.

6. Facing death : end of life care 7. Communication and negotiating multiple perspectives 8. Monitoring quality and managing breakdown 9. Using the skilled know-how of clinical leadership

Major Assumptions of Benner work1 - There are no interpretation- free data

the neutral science assumption : there is an independent reality whose meaning can be represented by abstract terms & concepts.

2- There are no nonreactive data .

3- People sharing a common cultural and language history have a background of common meanings , that allow for understanding & interpretation .

Major Assumptions (cont.)4- Meanings are embedded in skills, practices, intentions, expectations, & outcomes. They are taken for granted & often not recognized as knowledge and cannot be made completely explicit; but they can be interpreted by someone who shares a similar language & cultural background & can be consensually validated by the participants & relevant practitioners .

5- Humans are integrated, holistic beings.

The Nurse Theorists - Patricia Benner Video

Take a break

Metaparadigm of Benners theoryNursing is described as a caring relationship, an enabling condition of connection and concern.

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.

Benner understand Nursing practice as the care and study of the lived experience of health, illness, and disease and the relationships among the three elements.1. Nursing

Metaparadigm of Benners theoryA 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.2. PersonThe role ofTemporalityThe role ofPersonalConcernsThe role ofBodyThe role ofSituationPersonTogether, theseaspects of the personmake up the personin the world.

Metaparadigm of Benners theory Benner and Wrubel focused on the lived experience of being healthy & being ill.

Health is defined as what can be assessed, whereas well- being is a human experience of health or wholeness.

Health is not just the absence of disease & illness ; a person may have a disease but not experience him self as illness, because illness is a human experience of loss or dysfunction, but disease is what can be assessed at the physical level. (HF-RF)3. Health

Metaparadigm of Benners theory Benner use the term Situation rather than environment, because situation conveys a social environment with social definition & meaningfulness.

They use the phenomenological terms being situate & situated meaning, which are defined by the persons engaged interaction, interpretation, & understanding of the situation.

Person interpretation of the situation is bounded by the way the individual is in it4. Situation

Theoretical AssertionsSome relationship statements included in Banner's work:

1- Clinical knowledge is embedded in perceptions rather than precepts.

2- Perceptual awareness is central to good nursing judgment.

3- Formal rules are limited and discretionary judgment is needed in actual clinical situations.

4- Expertise develops when the clinician tests and refines propositions, hypotheses and principle-based expectations in actual clinical practice.

Logical FrameworkIs the Benner work is inductive or deductive ??

By following Dreyfus models logical sequence, Benner was able to identify the performance characteristics and teaching-learning needs in each level of skill by a qualitative descriptive research.

Benner claims that new knowledge and understanding are constituted by articulating meanings, skills, and knowledge that taken from clinical practice.

Acceptance by the nursingcommunity

Practice

Education

Research

Benners theory and nursing practice1- Practice

From Novice To Expert includes several examples of the application of her work in practice settings & she has been cited extensively in the literature regarding nursing practice concerns& roles of caring in such practice.

Benner approach has been used to aid in the development of clinical promotion ladders, new graduate orientation, & clinical seminars. Focusing on excellence in nursing practice have been held for staff development, recognition & reward.

Benners theory and nursing practice(Sliver 1986) ,used benner works as a basis for differentiating clinical knowledge development & career progression in nursing.

(Neverveld 1990) ,used benners rational and format in the development of basic & advanced preceptor workshops.

Benner continue to advance understanding of the knowledge embedded in clinical situation through publications (1985 1987 1996 1999 )

Benners theory and nursing practice(Crissman 1990) ,applied Benners finding in developing a cross-training program to address staffing imbalances.

Benners theory and nursing Education2- Education

She stated that competency-based testing seems limited to the less situational , less interaction areas of the patient care .

She validated the CNS clinical nursing specilaist competencies in AMICAE project.

By using Benner theory, nurse educator realized that the learning needs at the early stages of clinical knowledge development are different from those required at late stage.

Benners theory and nursing Education2- Education (cont.)

Benner theory guide nursing curricula world wide Emphasized the importance of learning the skill of involvement and caring through practical experience (Articulation of knowledge with practice).

Place novice or advance beginner with competent nurse preceptor is more suitable than expert nurse whose intuitive knowledge may elude beginners.

Benners theory and nursing Research3. Research

In AMICAE project, they concluded that formal models may serve as maps that direct care, substitute knowledge, & result in conformity. But the misuse of those models according to Gordon occurs when:nurses apply models without using judgment, when they use them to exert control (apply control), when they use language from models that may cover-up meanings, when they do not understand the meaning of the models

Benners theory and nursing Research3. Research (cont.)

SO, formal models should be used discretionsas tools & should not eclipse (cover) the relational, holistic, intuitive aspects of nursing.

Further DevelopmentBenner has taken a hermeneutical form to uncover the knowledge embedded in clinical nursing practice.

As she does this, she is also uncovering the nursing- caring with which it is deeply intertwined

It doesnt provide us with any universal truths aboutcaring in general or about nursing-caring in particular Dunlop (1986).

Scope of utilization of beener theory

application of Beener theoryNursing applies Benners Theory through:

Nursing school curriculumBuilding clinical ladders for nurses (Frisch, 2009)Developing mentorship programsPreceptors for student nursesMentors for newly graduated nurses (Dracup and Bryan- Brown, 2004)Development of the Clinical Simulation Protocol (Larew et al., 2006)

Example of Benner applicationIcu + ccu ---- ACLS \ BLS

application of Beener theoryModification on Benner theorysituation --- controlled situation good enverinment help to develop of nurses in dreyfus modle

External factor that effect situation may be motivate the nurse to becom as expert OR frastrate to develop.

Inter-ward compatancy exam (3 times\ year) reward for expert improve weakness from other + training

Exam50% clinical50% knowldge

50-60% 60-70% 70-80% 80-90% 90-100%Novice adv. Begginer competant proficient expert

Modification on Benner theory patient outcome & manager satisfaction 1- through satisfaction quastinnare about nursing) positive feedback -- reward 2- if there is a harm on patient . Modified nursing skill through (skill training + course training)

Reset counter (when you are a manger)1- Do not judge on any one untill you interfere with him2- Avoid first impression before you see \ observe them3- Ehical moral aspectapplication of Beener theory

Real examples from our nursing field that show how the benner theory applicable untill nowadays:

From Eductional field

From bedside clincal field

application of Beener theory

Conclusions1. Strength of the theory:

2. Limitation of theory

Benner Work CritiqueBenner Work CritiqueDerivableConsequencesGeneralityEmpiricalPrecisionSimplicityHow clear is theoryHow simple is theory?How general is this theory?

How accessibleIs this theory ?

How importantIs this theory ?

Benner Work CritiqueSimplicityThe model is relatively simple in regard to the five stages of skill acquisition , and it provides a comparative guide for identifying levels of nursing practice.

Description of novice level of performance would bepossible but expert description would be difficult if not impossible and limited to its usefulness.

A degree of complexity is encountered in subconcepts for differentiation among the levels of competency and the need to identify meanings and intentions.

Benner Work CritiqueGeneralityThe model has universal characteristics; it is not restricted by age, illness, health, or location of nursing practice.

has the potential for universal application as a framework, but the descriptions are limited by dependence on the actual clinical nursing situations from which they must be derived.

Benner Work CritiqueGenerality

Finally , clinical knowledge is relational and contextual and involves local , specific , historical issues. It is generealizable in terms of the translation of meaning to similar situation.

Benner Work CritiqueEmpirical PrecisionBenner theory is researchable, and qualitative research has been the primary paradigms to discover embedded knowledge of clinical practice.

Quantitative attempt have been made to design and validate nurse competence scale.

Her work can be considered as hypothesis generating rather than hypothesis testing .

So it is an inductive theory .

Benner Work CritiqueDerivable ConsequencesThe strength of the Beener model is that data base research contribute to the science of nursing as practice discipline

The significant of beener research finding lays in her conclusion that a nurses clinical knowledge is relevant to the extent to which it is manifestation in nursing skills making a difference in patient care and patient outcomes.

ReferencesReferences

Tomey, A. M. and Alligood, M.R. (2006). Nursing theorists and their work.

http://www.jointcommissioninternational.org/improve/get-accredited-academic-medical-center-hospitals/

http://www.jnc.gov.jo/arabic/Nursing%20Polices.htm

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Reading, MA: Addison-Wesley.

Dreyfus, H. L., & Dreyfus, S. E. (1986). Mind over machine: The power of human intuition and expertise in the era of the computer.

Meleis, A. (2007). Theoretical nursing. New York: Lippincott.Patricia Benners Nursing Theories,accessed at http://~kmckee/utilization.html on 5 April 2004.

Thank You !!

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