Holistic Nursing

From Novice to Expert: Benner's application of the Dreyfus model of skill acquistion

Teresa L. Frisch, RN, Reiki Master / Teacher 3.29.09

The nursing profession is fortunate that time and circumstances found Patricia Benner and Hubert Dreyfus together at the University of California, Berkeley in the late 1970s and early 1980s. While there, Ms. Benner received her Ph.D. “in Stress and Coping and Health under the direction of Hubert Dreyfus and Richard Lazarus” (“Patricia Benner, R.N.”).

Collecting data, she then applied the Dreyfus Model of Skill Acquisition to nursing, and in 1984 published her landmark work, From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Considered a gold standard in nursing, Benner introduced the concept that nursing intuition exists, and became the impetus for further research and study of this elusive skill characteristic that nurses come to recognize but cannot measure, define or describe

I hope that you enjoy this introduction to Benner’s “Stages of Clinical Competence.” It is an honor for me to introduce you to it, and I can only hope that I have done so in a way that clarifies our nursing practice for anyone unfamiliar with it

February, 1980.

Drefus & Dreyfus: A Five-Stage Model of the Mental Activities Involved in Direct Skill Acquisition

Contracted by the Air Force Office of Scientific Research (AFSC), USAF, Stuart and Hubert Dreyfus, working at the University of California, Berkeley, publish their landmark research, “A Five-Stage Model of the Mental Activities Involved in Direct Skill Acquisition.” Their goal was to acquire an understanding of the stages of learning to facilitate training programs and “high order skills.” This joint effort between the two brothers crossed scientific disciplines to study three groups: foreign language acquisition, chess learners and flight instruction. (Read article)

Moving from initial, rule-driven situations each group gained experience in their environments. As their comfort zones increased, they depended less on rules and perceived situations holistically, eventually achieving an intuitive mastery and while aware of the rules, were not dependent upon them. Taken from the article, the following table with the relevant narrative below demonstrates each stage.

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Drefus and Dreyfus: A Five-Stage Model of the Mental Activities Involved in Direct Skill Acquisition

Benner: From Novice to Expert – Excellence and Power in Clinical Nursing Practice
Patricia Benner, R.N., Ph.D., University of California School of Nursing, Department of Psychological Nursing, applies the Dreyfus Model of Skill Acquisition to nursing and publishes her ground-breaking research From Novice to Expert – Excellence and Power in Clinical Nursing Practice. Collecting narratives of situational experiences from nurses enabled her to delineate and define skill levels, in Stages One through Five, and formulate recommended best practice learning techniques for each. Benner’s work is considered the gold standard, and incorporated into most nursing core curriculums and practicing clinical ladders today.

I have paraphrased Ms. Benner’s stages of Novice through Expert below, with some additional, definitive descriptions. I have done so in an attempt to further explain and clarify language and situations for the non-nursing audience as Ms. Benner moves us through the five stages, from rule-oriented novice into the role of the expert.

Stage 1: Novice
Whether a beginner entering the profession, or a seasoned nurse changing specialties within it, these nurses will be expected to function in situations with no prior experience to guide them. To provide patient care they are given attributes: objective, measurable parameters and rigid textbook context-free rules for guidance. As they gain experience by moving through real-life patient care and utilize the tools available to them, they begin to develop the pivotal skills necessary to function in real life situations instead of the classroom.

Stage 2: Advanced Beginner
Advanced beginners have gained enough real-life experience that they can gather and interpret information in both objective and subjective manners. They begin to move solely from rote application of attributes to recognizing aspects of a situation, but are often not able to discern, differentiate or prioritize between the two types of information. Mentors assist the advanced beginner, initiating integrative thinking regarding the two types. Principles, or guidelines based on the integrative information are shaped into individualized, patient-centered action plans.

Stage 3: Competent
The competent nurse has been in the same or similar role for two or three years and consciously establishes long-range goals and plans. The plan of care integrates considerable amounts of conscious and abstract information, leading to analytic contemplation of the situation or problem. This conscious planning, or awareness, is a key element, giving the nurse a sense of mastery and establishing a perspective. This perspective facilitates increased efficiency, organization and time management skills. While able to cope and manage contingencies, the competent nurse remains slower, less flexible, and less able to recognize which aspects are the most salient in a given situation than the proficient nurse.

Stage 4: Proficient
The proficient nurse has worked in the same or similar situation for three to five years. At this level, the nurse perceives situations holistically and action plans are based on maxims instead of aspects of the given situation. The perspective is not consciously thought out, but presents itself holistically based on past experiences and events. This nurse has a deep understanding of situations and, as such, posseses an increased level of critical thinking and decision-making skills. Past learning of expected “normal” outcomes to given situations empowers and enables the proficient nurse to modify action plans accordingly. Maxims facilitate a rapid, focused, patient-centered action plan, reflecting nuances, or variables unique to each situation. As a direct result of their variability, these nuances are lost on the less experienced nurse.

Stage 5: The Expert
The expert has built an enormous background of experience and will use it when necessary, but no longer relies solely upon the previous analytic principles of rules, guidelines or maxims. An intuitive grasp of the current situation immediately hones the focus and eliminates the need for wading through alternative diagnoses or situations. Operating from a deep holistic grasp of the total situation makes it difficult for the expert performer to describe why or how a particular plan was formed or executed. Experts speak with certainty, based on perceptual recognition and several years of experience. Benner gives voice to the question of whether or not this certainty is “empirically borne out, and which nurses have it, and under what circumstances (33).”