Theoretical Foundation of Nursing

Patricia Benner’s
Stages of Nursing Expertise
History and Background

∙ Patricia Sawyer Benner was born August 31,

1942 in Hampton, Virginia and spent her
childhood in California. She finished her BSN
from Pasadena College, her master’s degree in
medical-surgical nursing from the University of
California, San Francisco, and the Ph.D. from
the University of California, Berkeley, in Stress
and Coping and Health under the direction of
Hubert Dreyfus and Richard Lazarus.
Benner’s Theoretical Sources for Theory
Development
∙ Her thinking was influenced greatly by Virginia Henderson.
∙ She argues that knowledge accrues over time in a practice
discipline and is developed through experiential learning,
situated thinking, and reflection in particular practice
situations. She refers to this work as articulation research.
∙ Benner applied in her work the Dreyfus Model of Skill
Acquisition (Dreyfus and Dreyfus, 1980, 1986). In applying
the model to nursing, Benner noted that
“experience-based skill acquisition is safer and quicker
when it rests upon a sound educational base”.
∙ Lazarus’ theory on stress and coping which believes that
stress is the disruption of meanings and coping is what the
person does about the disruption is another great
influence in Benner’s concept to clinical nursing practice.
 Major Concepts and Definition of
Benner’s Theory
1. Novice
In the Novice stage of skill acquisition in the
Dreyfus model, the person has no background
experience of the situation. Context-free rules and
objective attributes must be given to guide
performance. There is difficulty discerning
between relevant and irrelevant aspects of a
situation. Nursing students are under this level,
including registered nurses assigned in a
particular area but will be transferred to an area
or situation completely new to them.
2. Advanced Beginner
The Advanced Beginner stage is developed
when the person can demonstrate marginally
acceptable performance, having coped with
enough real situations to note, or to have pointed
out by a mentor, the recurring meaningful
components of the situation. Nurses functioning
at this level are guided by rules and oriented by
task completion. They have difficulty grasping the
current situation in terms of the larger
perspective.
• Examples of advanced beginners are newly
registered professional nurses.
3. Competent
The competent stage of the Dreyfus model is
typified by conscious and deliberate planning that
determines which aspects of current and future
situations are important and which can be ignored.
A competent nurse must exhibit sense of mastery,
increased level of efficiency, consistency,
predictability, and time management.
The most important task of a competent nurse
before she progresses to the next level is active
teaching and learning.
4. Proficient
The proficient nurse already has a holistic view
of a particular situation. The nurse’s performance is
guided by maxims by this stage. The nurse can
already show an intuitive grasp of the situation
based on background understanding. She now can
see changing relevance in a given situation
including recognition and implementation of skilled
responses to the situation as it evolves. At the
proficient stage, there is much more involvement
with the patient and family. The proficient stage is
a transition into expertise.
5. Expert
The last stage is achieved when “the expert
performer no longer relies on analytical principle
of rule, guideline, and maxim to connect an
understanding of the situation to an appropriate
action.” Benner described the expert nurse as
having the intuitive grasp of the situation and as
being able to identify the region of the problem
without losing time considering a range of
alternative diagnoses, and solutions. There is a
qualitative change as the expert performer “knows
the patient”, meaning knowing typical patterns of
response and knowing the patient as a person.
 The exert nurse is characterized by the following:

1. Demonstrating a clinical grasp and

resource-based practice
2. Possessing embodied know-how
3. Seeing the big picture
4. Seeing the unexpected
 Benner’s Seven Domains of Nursing Practice
1. The helping role.
2. The Diagnostic & Patient-Monitoring Function
3. The Effective Management of Rapidly Changing
Situations.
4. The Administration and Monitoring Therapeutic
Interventions and Regimens
5. The Monitoring and Ensuring the Quality of
Health Care Practice
6. The Organizational & Work-Role Competencies
 Four Major Concepts

∙ Nursing:
Nursing is described as a caring relationship, an
“enabling condition of connection and concern”.
“Caring is primary because sets up the possibility of
giving help and receiving help”. “Nursing is viewed
as a caring practice whose science is guided by the
moral art and ethics of care and responsibility”.
∙ Person: “A person is s self-interpreting being,
that is, the person does not come into the world
predefined but gets defined in the course of
living a life. A person also has an effortless and
non-reflective understanding of the self in the
world”.
∙ A person is embodied with four major aspects of
understanding that the person must deal with:
1.The role of situation
2.The role of the body
3.The role of personal concerns
4.The role of temporality
Five dimension of the body
1. The unborn complex
2. The habitual skilled body
3. The projective body
4. The actual projected body
5. The phenomenal body
∙ Health:
Benner and Wrubel focus “on lived experience of
being healthy and being ill”. Health is defined as
what can be assessed, whereas well-being is the
human experience of health or wholeness.

Situation (Environment): Benner and Wrubel use

the term situation rather than environment,
because situation conveys a social environment
with definition and meaningfulness.