The Background of Nursing Practice

Before the industrial revolution most people had the capability to evaluate quality of services that were given to them. The communities were usually small and almost all people knew each other, but the basic needs were made by each family and any person could call herself a nurse. The first registration law for nursing was enacted in North Carolina in 1903, with the aim of protecting title of nurses and enhancing the practice related to nursing (Buer, 2013). The profession of advanced practice nurses can be linked with the civil war when nurses were involved in a system anesthesia services during surgeries. The essay will elaborate on the theory proposed by a nursing theories started and academic, Patricia Sawyer Benner and  will also discuss different journal articles that emphasize on the implications of this theory in nursing practice.

Benner Was born in Hampton, Virginia and is well known for one her book ‘From Novice to Expert: Excellence and Power in Clinical Nursing Practice’, where she described the different stages of skill acquisition and learning, across the entire career of nurses and also applied the Dreyfus model of skill acquisition to the profession of nursing. Besides having a strong foundation in their educational background, the novice to expert transition has been defined as a primary skill acquisition (Alligood, 2017). It was also backed by the Dreyfus model of skill acquisition that acted as the basic foundation for the theory proposed by Benner.  Benner’s theory does not just place an emphasis on how to be a nurse, rather it illustrates the process by which one could gain a set of skills and knowledge (“knowing-how”), without “knowing that” (Lyon, 2015). The Dreyfus model of skill acquisition as described by the brothers Hubert and Stuart Dreyfus is usually explained as a model that was based on observations of different chess players, army commanders, air force pilots, and tank drivers. It was believed by the brothers that learning through experience and simulation was essential for the transition of any student from novice to expert, and each of them had to pass through five very discrete stages of learning. Parallels were found by Benner in nursing where she elaborated on the fact that improved nursing practice largely depended on science and experience, and the development of skills related to nursing was a progressive and long process. Benner found that in situations where the nurses were engaged in different circumstances, they learnt from their experiences and generated skills of involvement with the family members of their patients are clients. In the words of Weidman (2013) this model has been found relevant for the ethical development of nursing practice, owing to the fact that ethical perception is highly dependent on the level of expertise that is demonstrated by nurses. Nursing in acute care settings has gradually grown into a complex and multifaceted domain that it becomes almost impossible to routinize, standardize, and delegate the work that is performed by a nurse. In the past decades, systematization of nursing care and replacement nursing personnel were regarded as the easy solution to high rates of nursing turnover (Spiva et al., 2013).

Benner’s Theory of Novice to Expert

The voluntary responsibility of nursing care for welfare of the patients was often ignored, and less attention was paid to giving rewards and incentives to nurses for their long-term careers in hospitals. However, the theory proposed by Benner recognises the need for increase in acuity level of service users, decreasing length of stay at hospitals, proliferation of different specialisations and healthcare technology, all of which require highly experienced and expert nurses in the healthcare settings. According to DaRosa et al. (2013) Dreyfus model of skill acquisition primarily focused on the ways by which learners acquired a range of different skills through practicing and formal instruction and was particularly used in fields of operation research and education. Nonetheless, Benner stated that the model of skill acquisition could be generalized in a simple format in the nursing profession that would take into account skilled performance, increment based on experiences of nurses, as well as their educational background. This resulted in placing more emphasis on development of clinical knowledge and progression in career in clinical nursing.

All nurses have to pass through the five levels of proficiency in their clinical practice environment, during acquisition and enhancement of nursing skills. According to Benner (1982) stage 1 refers to the ‘Novice’ where a beginner or novice nurse has no experience in the clinical situations that they are expected to perform. They often have lack confidence to deliver and demonstrate safe clinical practice and are in continuous requirement of physical and verbal cues from their seniors or mentors. Practice occurs within a prolonged time frame and makes the nurses unable to use discretionary judgement power. Marañón and Pera (2015) conducted a qualitative study and suggested that the nursing students believe that both practical and theoretical trainings were indispensable to their work. However, Butts and Rich (2013) stated that clinical placements were considered imperative for conferring a sense to the nursing theory of Benner and to shape identity of the students. This in turn help the nurses to experience the professional reality that lies in store for them in future and to draw a comparison of the reality, with what they had experienced in their academic and theoretical classes (Sharpnack et al., 2013). The role of clinical mentors has also been identified crucial for skill acquisition of novice nurses that provide them confidence for approaching new situations and daily problems.

Benner (1982) stated that stage 2 is that of an ‘Advanced Beginner’ where they are able to marginally demonstrate acceptable nursing performance, in relation to their previous experience in similar actual situations. The nurses become skillful and efficient in different parts of their practice area.  However, they might occasionally require supportive cues (Hayes et al., 2015).  This phase is primarily supported by development of clinical knowledge. Stage 3 is that of a ‘Competent’ nurse demonstrated by those who have been on their job in similar situation for at least 2-3 years.  The nurses are now able to demonstrate enhanced efficiency in their work, have confidence in their actions and are able to care for the patients in a coordinated manner. A plan is also established, in relation to perspective of the nurses and analytic compilation of all the problems that they face.  At this particular state the nurses are able to formulate a deliberate planning that is characteristic of the levels of skill that they have acquired, and helps them in completing care of patients within a suitable time span, without additional support or cues (Gohery & Meaney, 2013).

The Stages of Skill Acquisition in Nursing

This in turn was supported by Garside and Nhemachena (2013) in an article that identified competence as an essential aspect for healthcare practitioners. It was stated that a successful completion of nurse education and acquiring professional registration marks the formal ‘learning’ phase of a nurse’s career. Registration marks a momentous decline in learning time, but should not signify break in the process of learning. Competence assessment by holistic approach relies on direct observation of performance. Thus, it depends on achieving a satisfactory performance level in each element of a defined task. Simulation has also been identified as an effective training method for practicing nurses for new communication processes, procedures, and skill or non-skill techniques.

In the words of Benner (1982) stage 4 is that of ‘Proficient’ nurses who are accountable for perceiving situations as a whole and establish the circumstances in terms of long term goal. Proficient nurses are able to learn from their experiences, related to typical events and how they should modified plants in response to such incidents.  Holistic understanding of the clinical situation allows proficient nurses to engage in effective decision making, and enhance the health and wellbeing of their patients. Stage 5 is that of an ‘Expert’ who has a grasp of every situation that might occur in the clinical scenario and are able to exactly identify the accurate problem, without consideration of any alternative for unfruitful solutions and diagnosis.  Performance of an expert nurse usually becomes flexible proficient and fluid with time, and demonstrate high skilled analytical reasoning power event for situations where the nurse have had no previous experiences. Simulation was identified as an essential mechanism for enhancing competency in a certain area of nursing (Aebersold & Tschannen, 2013). Rushton (2015) also on the fact that nursing students of and lack confidence and knowledge in relation to critical care nursing and were found to be apprehensive about their placements in those areas. High fidelity simulation made the students feel more confident about clearing corporations in Coronary Care Unit (CCU) and also enhance their clinical competence.

Conclusion

The nursing profession within the health care sector emphasizes on care of families individuals and communities to allow them maintain recover and attain optimal health, wellbeing and quality of life. Benner applied Dreyfus’ theory to the nursing profession by outlining different stages and levels of clinical competency namely, (1) novice, (2) advanced, (3) competent, (4) proficient, and (5) expert. The novice to expert theory proposed that all expert nurses must enhance their knowledge, related to patient care and extensive skills by acquiring experiences that are collected over the course of their lifetime. To conclude, the five stages of nursing career helps in the smooth transition of nursing staff from their novice stage to that of an expert, thus allowing them to care for their service users in a more enhanced manner.

References

Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing, 18(2).

Alligood, M. R. (2017). Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.

Benner, P. (1982). From novice to expert. AJN The American Journal of Nursing, 82(3), 402-407.

Buer, M. C. (2013). Health, wealth and population in the early days of the industrial revolution. Routledge.

Butts, J. B., & Rich, K. L. (2013). Philosophies and theories for advanced nursing practice. Jones & Bartlett Publishers.

DaRosa, D. A., Zwischenberger, J. B., Meyerson, S. L., George, B. C., Teitelbaum, E. N., Soper, N. J., & Fryer, J. P. (2013). A theory-based model for teaching and assessing residents in the operating room. Journal of surgical education, 70(1), 24-30.

Garside, J. R., & Nhemachena, J. Z. (2013). A concept analysis of competence and its transition in nursing. Nurse Education Today, 33(5), 541-545.

Gohery, P., & Meaney, T. (2013). Nurses’ role transition from the clinical ward environment to the critical care environment. Intensive and Critical Care Nursing, 29(6), 321-328.

Hayes, C., Power, T., Davidson, P. M., Daly, J., & Jackson, D. (2015). Nurse interrupted: Development of a realistic medication administration simulation for undergraduate nurses. Nurse education today, 35(9), 981-986.

Lyon, L. J. (2015). Development of teaching expertise viewed through the Dreyfus model of skill acquisition. Journal of the Scholarship of Teaching and Learning, 88-105.

Marañón, A. A., & Pera, M. P. I. (2015). Theory and practice in the construction of professional identity in nursing students: a qualitative study. Nurse Education Today, 35(7), 859-863.

Rushton, M. (2015). Simulation and the student pathway to critical care. British Journal of Cardiac Nursing, 10(2), 93-98.

Sharpnack, P. A., Goliat, L., Baker, J. R., Rogers, K., & Shockey, P. (2013). Thinking like a nurse: using video simulation to rehearse for professional practice. Clinical Simulation in Nursing, 9(12), e571-e577.

Spiva, L., Hart, P. L., Pruner, L., Johnson, D., Martin, K., Brakovich, B., … & Mendoza, S. G. (2013). Hearing the Voices of Newly Licensed RNs The Transition to Practice. AJN The American Journal of Nursing, 113(11), 24-32.

Weidman, N. A. (2013). The lived experience of the transition of the clinical nurse expert to the novice nurse educator. Teaching and Learning in Nursing, 8(3), 102-109.