From Novice to Expert Author(s): Patricia Benner Source: The American Journal of Nursing, Vol. 82, No. 3 (Mar., 1982), pp. 402-407 Published by: Lippincott Williams & Wilkins Stable URL: https://www.jstor.org/stable/3462928 Accessed: 11-11-2018 07:55 UTC JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms Lippincott Williams & Wilkins is collaborating with JSTOR to digitize, preserve and extend access to The American Journal of Nursing This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms .i i; ~f~-r~s ,? -f r ;. 1. i41-5~-i~~jiS' ,-.. us r "' ,Ti-.~??, ?Z-? ?ri???? --,, *. ???r ;:i Y1?h" :i- I. .:i~t. y, ~Zt~T:,. 'i- ...?h--~ ~? -h i' ~? t *? ~: * ?~ : ?. '. . - -i i..?r? d~' ~?) r;- ?; -I?;? ."(.. 7~ ~~ .I?. "";~4~4 ~i~s~~l~ r-u .:YJ ~ ;Ji~ria-I r :~? -i~?F .-,*c?~i? i~l~?. e ;r. :.? dr; long-term and ongoing career de- opment of a skill, one passes through velopment. This, in turn, requires five levels of proficiency: * novice an understanding Nursing in acute-care settings hasof the differences * advanced beginner experienced nurse and grown so complex that itbetween is no the longthe routinize, novice. * competent er possible to standardize, By Patricia Benner The Dreyfus and delegate much of what theModel of Skill Ac- nurse does. quisition offers a useful tool for doing this. of This model was inducIn the past, formalization tively derived by two University of nursing care and interchangeability of nursing personnel were considCalifornia, Berkeley, professors-- * proficient * expert The levels reflect changes in two general aspects of skilled per- formance. One is a movement from Stuart Dreyfus, a mathematician ered easy answers to nurse turnover. and systemsof analyst, and Hubert The discretionary responsibility Dreyfus, a philosopher-from their nursing care for patient welfare was reliance on abstract principles to the lots(1,2).and repaid to providing incentives myclinistudies, I have found wards for long-term careersInin thatThis the model be generalized to cal nursing in hospitals. iscan no nursing. It takes into account increlonger tenable. ments of in skilled performance based Increased acuity levels patients, decreased length of upon hospitaliexperience as well as education. It also provides zation, and the proliferation ofa basis for clinical knowledge development and health care technology and specialization have increased the need for career progression in clinical nurs- of a demand situation so that the sit- study of was chess players and piignored, and little attention highly experienced nurses. The complexity and responsibility of use of past, concrete experience as paradigms. The other is a change in the perception and understanding uation is seen less as a compilation of equally relevant bits and more as a complete whole in which only certain parts are relevant(2). To evaluate the practicality of applying the Dreyfus model to nursing and to clarify the characteristics of nurse performance at different stages of skill acquisition, interviews ing. Briefly, the Dreyfus model pos- nursing practice today requires its that, in the acquisition and devel- and participant observations were conducted with 51 experienced 402 American Journal of Nursing/March 1982 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms aA-l~ a Jr,-: ~:~t~9 ;.j -- ldi;;4"-'~"~?; ii.- ~%?Pr' ?-:i ~~'"-?:?: i; -?i :~;~?- .p ? b~?;-:~~~ af~~Y~S~c~ ~?S: ~p~`i ~,li *Y*xlx' ~tr~i p":r;- . :.. ? ~3i t~~P`~ -;? ~ -;; ;?--- )-~42 ~,. ; "" ;c, 3-~?',~at; -jc+T~a~ ?' IV1-4;:6-5i-."~-~E*?~;~b ~?.*?C-P'~"~t~Aj~,~;= ; r-?t;:'f~?~-~;? h~~g; ?frr2j? ~S~T, ~ ".P a, t= .- :~ .;. L; J ~:'~: _ a r~? -I i: ": I.. -;-~"^";? rr~ ?-x;e ; ir2~~ ~~~~~f~LI~: 1? -- .I:._: ~ ~~~5" .-_-:.~ BFZ~JT~ ';i~::? :~L;. 17X L;~ 7* .. -j~?::i~?- ~~J;-a ~?. iv : .,- ~ , cts-: 9",~~ ~?` .? ":' .~i ~13~e ?i?~i?~-I " ;I ~t~;~*ai~ . i~-P -i.:. -* "o' e --=-;r:i- 4-)3C~ a~ frX ?',P~?'g~`l ~j~ :P ICI~ a~_ ?? '?"ill;jtAl;"~Xf~:`-^ ; -.? ~t)d~I ~,~fY--~~~p),tr;;c~~ a-7~~ ';;t~u~E pi3bL"P~a~,~ -. i i ;.yl....~---j~lli?~fl~ 4 , ;I*~Lp ~::::: ~gi?:?c~rk~ i Gr: s:~ ., ~_ ?:Z, ::I8~:6t~~~fr-l;% I8:C~R~T~-iX~SBPII S ;: :.L~*~:L I' ~XP~ x94 .."t~t~f ~1-~fF~.~ ? C .?9,-~ . r? ct~~ ~-~s-~-~~ii~i %~-?~i7~~t~ in ? ? -~---lt "., ~~ L~C~~ ?~I~? -?-9f: r; :'a~~~ ~o~ :~e r ~i~(~?J?-~~~S~J?~I~FI1 ..r :*~ ~;t :r-e? ~j~ . *c? ~- ?1?~ t?-~t-:? I -?:?:::?:~, -,c-~~ _:sr ::" ,~~~d~:t S `~.?? P ~"~4~?~":'~ krc~s: -o".-'~ r'.,rss;r i~,q=??t--~ r. ,ic`i~?~c-; ? ~- r -?id ?` ?-, ..e ~-r=J~~~~,?-? ~~??,g ~: ?" m: '' .?:c-~-i --i ?_::"f__L-~?;~ iSz'~: : ? ~~ ~~?-" t.. .::1? ? -" ~J~t~t-" ii- i-, B ;$r f5: PiY~i? : i?ir: r' )? >~-_^;" i;+,driuii;?Spl~e~~~ d~ .' .~Yd~` -~?-~ ;?i~t ,7~h?""~;~~~+"~P~ZR~rgrsm;c~,~;~ r-7~.~-,PU-.~bd:.'?. ,._ L -~kil~----~ . = i; i_ 3~t"i`~~ I-: ;::??I,.e a;`-Lb~k~c~ ~t~53~;Y6;L~4t?3~z~i3~~s~~i- 2~;~?5~~ ?i~it~m~ '" Lh-'j~L~I i ?iV) _1 nurse ?:. i iS~T- f?;.R L: :c:~ c:-:T "'--.~-- ? ?"-~:I ? :fi ?-lsT-:_l 2- , ?:_.ill.i: ~7~:] i ---;; and output, temperature, blooding graduate clinicians, 11 new rules legislates against successful pulse, and other such ob- task performance and 5pressure, senior nursing students because no rule tasks are different hospitals-two prijectifiable, measurable parameterscan tell a novice which nurses, in six mosttwo relevant in a comreal situation or vate community of the patient's hospitals, condition. when an exception to the rule is in Novice practitioners are also munity teaching hospitals, one university medical taught rules center, to guide actionand in order. one inrespect to different attributes. The ner-city general teaching hospital. Much confirming following is an example and of suchno aLevel II: disconAdvanced Beginner context-free rule: firming evidence was found for use of the Dreyfus Skill AcquiThe advanced beginner is one To Model determine fluidof balance, sition tice(3,4). Level I: Novice in check the patient'snursing morning clinical pracwho can demonstrate marginally weights and daily intake and out- put for the past three days. Weight gain in addition to an intake that is consistently greater than 500 cc Beginners have no experiencecould indicate water retention; in with the situations in which they are that case, fluid restriction should be started until the cause of the expected to perform tasks. In order imbalance can be determined. to give them entry to these situa- acceptable performance. This person is one who has coped with enough real situations to note (or to have them pointed out by a mentor) the recurrent meaningful situational components, called aspects. In the Dreyfus model, the term "aspects" has a very specific mean- The heart of the difficulty that ing. Unlike the measurable, contexttions, they are taught about them in terms of objective attributes. Thesethe novice faces is the inability to free attributes of features that the attributes are features of the task use discretionary judgment. Since inexperienced novice uses, aspects that can be recognized without situ- novices have no experience with the are overall, global characteristics ational experience. situation they face, they must usethat require prior experience in acCommon attributes accessible these context-free rules to guide tual situations for recognition. to the novice include weight, intake their task performance. But followFor example, assessing a pa- American Journal of Nursing/March 1982 403 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms The advanced beginner, or inindicative of pulmonary edema and structor of the advanced beginner,those indicative of pneumonia. But similar situations and similar teachcan formulate guidelines for actions in practice areas, where the cliniing-learning needs. An expert clini- in terms of attributes and aspects. cian has already attained competencian describes her assessment of a These action guidelines integrate ascy, aspect recognition will probably patient's readiness to learn about his many attributes and aspects as possibe redundant; the competent clinician will focus on the more adcontinent ileostomy this way: ble, but they tend to ignore the difEarlier, I thought he was feel- ferential importance. In other vanced clinical skill of judging the relative importance of different aspects of the situation. The major implication for both tient's readiness to learn depends on experience with previous patients in "Novices and advanced beginners can take in little of the situation-it is too new, too strange." preservice and inservice education is that the advanced beginner needs support in the clinical setting. Ad- vanced beginners need help in setting priorities since they operate on general guidelines and are only being helpless about the operation he had just had. He looked as though he felt crummy-physically, sort of stressed-looking, nervous-looking. Furthermore, he was treating the wound physically very gingerly. He didn't need to be that gentle with it. But, on this morning, it was different, he began to ask questions. An instructor or mentor can words, they treat all attributes and aspects as equally important. The ginning to perceive recurrent meaningful patterns in their clinical prac- following comment about advanced beginners in an intensive care nursery illustrates this. nurses to ensure that important pa- tice. Their patient care must be backed up by competent level I give very detailed and expli- tient needs do not go unattended cit instructions to the new grad- because the advanced beginner canuate: When you come in and first not yet sort out what is most imporsee the baby, take the vital signs tant. and make the physical examina- provide guidelines for recognizingtion. Then, check the IV sites, such aspects as readiness to learn; check the standby ventilator and Level III: Competent for example, "Notice whether or not make sure that it works, and check the patient asks questions about the the monitors and alarms. When I Competency, typified by the nurse who has been on the job two surgery or the dressing change."say this to new graduates, they do to three years, develops when the "Observe whether or not the patient exactly what I tell them to do, no nurse begins to see his or her actions looks at or handles the wound." But matter what else is going on.... in terms of long-range goals or the guidelines are dependent onThey can't choose one to leave out. plans. The nurse is consciously knowing what these aspects soundThey can't choose which is more aware of these plans, and the goal or like and look like in a patient careimportant.... They can't do for plan dictates which attributes and situation. one baby the things that are most aspects of the current and contem- While aspects may be made important, then go to the next baby explicit, they cannot be made com- and do the things that are most pletely objective. It makes a differ- important and leave out the things ence in the way that the patient asks that can be left until later. plated future situation are to be con- about the surgery or the dressing tive, and the plan is based on consid- Novices and advanced begin- change. You have to have some ners can take in little of the situa- experience with prior situations be- tion-it is too new, too strange. Aspect recognition is dependent on prior experience. remembering the rules they have fore you can use the guidelines. Besides, they have to concentrate on PATRIC(:IA BENNER, RN. MS, has been involved in studies to identify the competencies of new graduates for over 10 years. When this was prepared, Ms. Benner was director of the Achieving Methods of Intraprofessional Con- sensus, Assessment, and Evaluation (AMI- CAE) Project at the University of San Francisco. This article is based on material to be published by the National Commission on Nursing of the American Hospital Associa- tion in a monograph, From' Novice to Expert: Promoting Excellence and Career Develop- ment in Clinical Nursing Practice. The study reported in the monograph was sup- ported by a Department of Health and Human Services Division of Nursing grant. sidered most important and which can be ignored. For the competent nurse, a plan establishes a perspecerable conscious, abstract, analytic contemplation of the problem. A preceptor describes her own evolu- tion to the stage of competent, been taught. As the expert clinician planned nursing from her earlier quoted above adds, If I say, you have to do these stimulus-response level of nursing: eight things, they do those things. They don't stop if another baby is I had four patients. One needed colostomy teaching, the others needed a lot of other things. Instead of thinking before I went into the room, I got caught up.... Someone's IV would stop, and I'd needs attention, they're like mules work on that. Then I'd forget to between two piles of hay. Much time is spent by precep- give someone their meds, and so would have to rush around and do tors and new graduates on aspect that. And then someone would feel recognition. For example, in mak- screaming its head off. When they do realize that the other child ing physical assessments, aspect rec-nauseated and I'd try to make them feel better while they were ognition is an appropriate learning goal. The nurse will practice dis-sick. And then the colostomy bag criminating between breath soundswould fall off when I wanted to 404 American Journal of Nursing/March 1982 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms start teaching. And, all of a sudden the morning was gone, and no one had a bed bath. Now I come out of report and I know I have a couple of things that I have to do. Before I go in the room, I write down the meds I'm supposed to give for that day, and then walk in there and make sure terms of aspects, and performance situation. is They can mean one thing at one time and quite another at guided by maxims. another time. But once one has a Experience teaches the profi- cient nurse what typical events deep to understanding of the situation, the maxim provides directions as to expect in a given situation and how what is important to take into conto modify plans in response to these sideration. This is revealed in the events. There is a web of perspectives, and as Dreyfus notes, experienced nurse clinicians's ac- Except in unusual circum-count of how she weans a patient that everybody's IV is fine.... I stances, the performer will be expefrom a respirator: know what I have to do, and I am much more organized. Competence is evidenced by the fact that the nurse begins to see his or her actions in terms of longrange goals or plans. The competent nurse lacks the speed and flexibility riencing his current situation as Well, you look at vital signs to similar to some brain-stored, expesee if there is anything significant there. But even here you need to do rience-created, typical situation little guessing. You have to decide (complete with its saliences) due ato recent past history of events.... if the patient is just anxious be- cause he's so used to the machine Hence the person will experience breathing for him. And if he does of the nurse who has reached the through a perspective, but ratherget anxious, you don't really want proficient level, but the competencythan consciously calculating this to medicate him, because you're stage is characterized by a feeling ofperspective or plan, it will simply afraid he will quit breathing. But mastery and the ability to cope withpresent itself to him or her(5). on the other hand, he may really and manage the many contingenBecause of the experience- need to calm down a bit. It just his or her situation at all times cies of clinical nursing. The compe- based ability to recognize whole sit-depends on the situation.... You tent nurse's conscious, deliberateuations, the proficient nurse canhave your groundwork from what planning helps achieve a level of now recognize when the expectedyou have done in the past, and you efficiency and organization. Nurses normal picture does not present know when you are going to get at this stage can benefit from deci-itself-that is, when the normal is sion-making games and simulations absent. The holistic understanding that give them practice in planningof the proficient nurse improves his and coordinating multiple, com- or her decision making. Decision plex, patient care demands. making is now less labored since the The competent level is sup-nurse has a perspective about which ported and reinforced institutional-of the many attributes and aspects ly, and many nurses may stay at thispresent are the important ones. level because it is perceived as the Whereas the competent person ideal by their supervisors. The stan-does not yet have enough experidardization and routinization of ence to recognize a situation in into trouble. Proficient performers are best taught by use of case studies where their ability to grasp the situation is solicited and taxed. Providing proficient performers with context-free principles and rules will leave them somewhat frustrated and will usually stimulate them to give examples of situations where, clearly, the principle or rule would be contra- procedures, geared to manage the terms of an overall picture or in dicted, high turnover in nursing, most often terms of which aspects are most salireflect the competent level of perent and most important, the profi- Level V: Expert "Experience teaches the proficient nurse what typical events to expect in a given situation and how to modify plans in response to these events." formance. Most inservice education cient performer now considers few- is aimed at the competent level of er options and hones in on an accuachievement; few inservice offer- rate region of the problem. Aspects ings are aimed at the proficient or stand out to the proficient nurse as expert level of performance. Level IV: Proficient With continued practice, the competent performer moves to the proficient stage. Characteristically, the proficient performer perceives situations as wholes, rather than in being more or less important to the situation at hand. Maxims are used to guide the proficient performer, but a deep understanding of the situation is required before a maxim can be used. At the expert level, the performer no longer relies on an analy- tical principle (rule, guideline, maxim) to connect her/his under- standing of the situation to an appropriate action. The expert nurse, with her/his enormous background of experience, has an intuitive grasp of the situation and zeros in on the accurate region of the problem without wasteful consideration of a large range of unfruitful possible problem situations. It is very frustrating to try to capture verbal descriptions of expert performance because the expert operates from a deep under- standing of the situation, much like the chess master who, when asked Maxims reflect what would appear why he made a particularly masterto the competent or novice perform- ful move, will just say, "Because it er as unintelligible nuances of the felt right. It looked good." American Journal of Nursing/March 1982 405 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms The problem experts have telling all they know is evident in the following excerpt from an interview with an expert psychiatric nurse clinician. She has worked in psychiatry for 15 years and is highly respected by both nurse and physician colleagues for her clinical judgment and ability. When I say to a doctor, "The patient is psychotic," I don't always know how to legitimize that statement. But I am never wrong because I know psychosis from the inside out. And I feel that, and I know it, and I trust it. This nurse went on to describe a specific situation in which she knew that a patient was being mis- diagnosed as psychotic when the patient was extremely angry. The physician was convinced that the embedded in the expert's practice clinical situation in the same way. It is not that proficient nurses have becomes visible. This is not to say that the internalized the rules and formulas expert never uses analytical tools. learned during the earlier stages of Highly skilled analytical ability is skill acquisition; they are no longer necessary for novel or new situa- using rules and formulas to guide tions. Analytical tools are also neces- their practice. They are now using sary when the expert gets a wrong take or a wrong grasp of the situation and finds that events and be- past concrete experiences much like the researcher uses paradigms. haviors are not occurringaccording the expert intended to accomplish and what the outcomes were. Also, it is possible to get a description to expectations. When alternative What can be described is what perspectives are not available to the experienced clinician, the only way out of the wrong grasp of the problem is analytical problem solving. from the patient and it is possible to systematically observe and describe expert practice. But it is not possible Describing Expert Practice to recapture from the expert in explicit, formal steps the mental We have much to learn from processes or all the elements that go into his or her expert recognitional the expert nurse clinicians, but tocapacity in making rapid patient describe or document expert nurseassessments. So, although you canpatient was psychotic and said, performance, a new strategy fornot recapture elemental steps in the "We'll do an MMPI to see who's identifying and describing nursing process, you can observe and deright." This nurse responded, "I am competencies is needed. If, as thescribe in narrative interpretive form sure that I am right regardless of Dreyfus Model of Skill Acquisitionthe accomplishments and characterwhat the MMPI says." The results posits, the expert nurse's perfor-istics of expert nurse performance. mance is holistic rather than fracbacked up the nurse's assessment, Such a narrative, interpretive and, based on her assessment, this tionated, procedural, and based approach to describe expert nurse nurse began what was a very sucupon incremental steps, then the performance is illustrated in the folcessful intervention for the patient. strategy for describing expert nurs- lowing example which describes the By studying proficient and exing performance must be holistic as coaching function of nursing. pert performance, it is possible well. to Illness, pain, disfigurement, obtain a rich description of the Currently, the language used death, and even birth are, by and kinds of goals and patient outcomes to talk about nursing practice is too large, segregated, isolated experiences. It makes little sense for the that are possible in excellent nursing simple, formal, and context-free to practice. This knowledge of goals capture the essence and complexity lay person to personally prepare in and possible outcomes can be useful of expert nursing. At best, formal advance for the many possible illness experiences. Nurses, in contrast, through their education and experience, develop and observe many ways to "A competent nurse and a proficient understand and cope with illness, as nurse will not approach or solve a well as many ways of experiencing illness, suffering pain, death, and clinical situation in the same way." birth. Nurses offer avenues of un- derstanding, increased control, acceptance, and even triumph in the in expanding the scope of practicemodels recognize and capture areas midst of what, for the patient, is a of nurses who are less proficient. In of performance typical of the nov- foreign, uncharted experience. fact, a vision of what is possible is ice, advanced-beginner, or compe- Experience, in addition to formal education preparation, is reone of the characteristics that sepa-tent nurse. But since most formal rates competent performance frommodels focus on structure or pro-quired to develop this competency proficient and expert performance.cess, the content and relational as-since it is impossible to learn ways of Exemplars and descriptions of ex-pects of nursing practice in even thebeing and coping with an illness solely by concept or theorem. A cellence from expert nurse clini-beginning levels go undescribed. It is important to underline the deep understanding of the situation cians can raise the sights of the competent nurse, and perhaps facil-claim of the Dreyfus model that is required before one acquires a itate his or her movement to the there is a transformation, a qualita-repertoire of ways of being and copproficient stage. By assisting the ex- tive leap, from the competent toing with a particular illness experipert to describe clinical situations proficient levels of performance. A ence. Often, these ways of being where his or her interventions made competent nurse and a proficientand ways of coping are transmitted a difference, some of the knowledge nurse will not approach or solve anonverbally by demonstration, by 406 American Journal of Nursing/March 1982 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms attitudes, and by reactions as in the a little smoother for those who had realities than can be captured by to travel it. With that, he hugged theory alone. Theory, however, me, said thank you, and turned guides clinicians and enables them young man close to her own age away nodding his head, with tears to ask the right questions. following example. A nurse clini- cian described an encounter with a Theory and research are generwho was visiting his father who was in his eyes. There were tears in my ated from the practical world, from dying. There was a rather sudden eyes too. deterioration in the father, and the In translating for the son how the practices of the experts in a family was extremely distraught. the culturally avoided had become field. Only from the assumptions and expectations of the clinical practice of experts are questions . *. . experience is not the mere passage of time or longevity . . " The son stopped the nurse in the understandable and approachable to her, the nurse widened this young hall and asked how long his father would live. The nurse answered that man's perspective and acceptance. she really didn't know, that it could be minutes, hours, days, or weeks. There was no way to tell. He then asked if there were other patients dying on the floor. The nurse re- This is what is meant by the coaching function of nursing, nurses who have come to grips with the cultur- ally avoided or uncharted and can open ways of being and ways of sponded, "Yes." Then, as she re- coping for the patient and the counts the incident, there was a long pause, followed by a barrage of questions: How could I work here? How family. I have collected many examples of this particular skilled prac- generated for scientific testing and theory building. Recognition, reward, and retention of the experienced nurse in positions of direct clinical practice-along with the documention and adequate description of their practice-are the first steps in improving the quality of patient care. The Dreyfus Model of Skill Acquisi- tion, applied to nursing and combined with an interpretive approach to describing nursing practices, of- fers guidelines for career and for knowledge development in clinical nursing practice. It also indicates the importance of career ladders within clinical nursing practice and adds to our can I go home and sleep at night? case the nurse did not offer the understanding of the need for and How could I do what I do? patient precepts or platitudes that acceptance of the emergence of No one had ever been so direct might sound like, "Even in the clinicians and clinical specialists in tice and am impressed that in each with such questions as these before, midst of great handicap and impos-the patient-care setting. and their bluntness threw me off sibility, I think it is possible to make balance. But he was sincere and the most of it." This would be an was waiting for my answer, and soexample of inflexible teaching by I told him how I had resolved theseprecept. same questions within myself. It Nurses, in their practice, by the was not quite a monologue, but forway they approach a wound or the 10 plus minutes he listened intent-way they talk about recovery from a ly as I described to him my feelsurgery, offer ways of understand- ings. I told him my philosophy ing and avenues of acceptance. about life and about dying and Through the nurse's own ability to about nursing. face and cope with the problem, I told him how gradually I hadsuch as a difficult, draining wound, settled into the medical floor inthe patient can come to sense that stead of using it as a stepping stone the problem is approachable and to a surgical floor-which was my manageable. first intention. I told him how it Experience, as it is understood was difficult, and how it was emo-and used in the acquisition of expertionally draining, and how it some-tise, has a particular definition that should be clarified. As it is described times was difficult to sleep at night. I told him how there was great satisfaction in helping a patient through the particular passage known as death and how I felt I was able to help the family also through the pain of that passage. I told him the gratification, the in this model, experience is not the mere passage of time or longevity; it is the refinement of preconceived notions and theory by encountering many actual practical situations that add nuances or shades of differences to theory(6,7). Theory offers what can be thing that kept me here, was in knowing that maybe somehow, I made explicit and formalized, but had made this particular rocky road complex and presents many more clinical practice is always more References 1. Dreyfus, H. L. What Computers Can't Do: A Critique of Artificial Reason. New York, Harp- er & Row. 1972. (Paperback edition, 1979) 2. Dreyfus, Stuart, and Dreyfus, Hubert. A FiveStage Model of the Mental Activities Involved in Directed Skill Acquisition. (Supported by the U.S. Air Force, Office of Scientific Research (AFSC) under contract F49620-C-0063 with the University of California) Berkeley, February, 1980. (Unpublished study) 3. Benner, Patricia, and Benner, R. V. The New Nurse's Work Entry: A Troubled Sponsorship. New York, Tiresias Press, 1979. 4. Benner, P., and others. From Novice to Expert: A Community View of Preparing for and Rewarding Excellence in Clinical Nursing Practice. (AMICAE Project Grant # 7 D20NU 29104) San Francisco, University of San Francisco, 1981. (Unpublished study) 5. Dreyfus, Stuart. Formal Models vs. Human Situational Understanding: Inherent Limitations on the Modeling of Business Expertise. (Supported by the U.S. Air Force, Office of Scientific Research (AFSC), under contract F49620-79-C-006x with the University of Cali- fornia) Berkeley, Feb. 1981, p. 19. (Unpub- lished report. Copies, for $5 each to cover the cost of duplicating and mailing, are available from Stuart Dreyfus, Director of Operations Research Center, Univ. of Calif., Berkeley, Calif. 94720). 6. Cadamer, H.G. Truth and Method. London, Sheet and Ward, 1970. 7. Benner, Patricia, and Wrubel, Judith. Clinical knowledge development: a neglected staff development and clinical function. (Submitted for publication to Nurse Educ 1981) American Journal of Nursing/March 1982 407 This content downloaded from 204.17.31.62 on Sun, 11 Nov 2018 07:55:58 UTC All use subject to https://about.jstor.org/terms
Purchase answer to see full attachment