Master Advanced Theoretical Perspectives for Nursing

| February 28, 2015
PLEASE WRITE A SUMMARY FOR THIS RESEARCH PAPER:Patricia Benner; From Novice to Expert
Using the Benner intuitive-humanistic decision-making model in action: A case study
Blum, Cynthia Ann . Nurse Education in Practice 10.5 (Sep 2010): 303-7.
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Nurse educators make decisions that affect students in profound ways. This decision-making process may follow an intuitive-humanistic
decision-making model. The author most connected with developing the intuitive model and the distinction between theoretical knowledge
and experiential knowledge in the discipline of nursing is Patricia Benner (Thompson, 1999). Educators use intuition in forming
judgments regarding educational planning. The educator may not be aware of subtleties that influence the decision but rely on a ‘gut’
instinct as they determine the appropriate action. Utilizing six key concepts identified by Dreyfus and Dreyfus (Benner and Tanner,
1987) this process utilizes what is known to the educator from previous situations to determine a course of action appropriate for the
given situation. This paper describes a method one nursing educator used and identifies outcomes that could impact the career path for
the student when determining if they were safe to continue in a practice based course.
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Introduction
The academically-based clinical nurse educator assigns grades and makes decisions regarding a student’s ability to perform safe
practice. In the practice setting this can be a difficult and subjective process (Walsh and Seldomridge, 2005). Prior to admittance to
the College of Nursing referred to in this paper, the student has been screened for physical health and safety concerns. Moreover,
this institution prides itself on admitting the brightest and the best students based on grade point averages and nurse entrance exam
scores. Nonetheless, this does not preclude the student from entering the program with barriers to success other than intelligence.
The college may not be aware of emotional or personal issues that affect the student’s performance. To identify these barriers the
nurse educator relies on the “sixth” sense of intuition, whereby “the intuitive decision-maker will attempt to re-experience the chain
of events that led him to see things the way he does, and at each stage he will intentionally focus upon elements not originally seen
as important to see if there is an alternative intuitive interpretation” (Benner et al., 1996, p. 268).
Nurses have valued their intuition in a variety of clinical settings (Rew and Barrow, 2007), yet intuition as a basis for faculty-
student support is noticeably absent in the literature. The aim of this paper is to weave Benner’s intuitive-humanistic decision-
making model within the context of a student clinical practice experience demonstrating the model’s usefulness in academic clinical
practice settings. After detailing the situational factors that prompted the nurse educator’s line of intuitive thinking, the paper
elaborates how the expert faculty, who serves in the capacity of both didactic instructor and clinical nurse educator, in concert with
the student, designed an individualized educational plan to recognize and identify methods of dealing with the student’s psycho-
emotional difficulties. The student has given written permission for the faculty to “tell” her story. Her name has been changed to
Jade, as chosen by the student.
Context of the situation
In the United States, the typical University baccalaureate nursing program takes four to five years to complete, with the first two
years providing pre-requisite and general education courses in the sciences, English composition, arts, and humanities. Upon
admittance to the College of Nursing, students are customarily required to provide evidence of good health, purchase health insurance
privately or through the University, and submit state- and federal-level criminal background checks to assure safety in the health
care setting. Collectively, these measures provide reasonable assurance of safeguard of patients, clinical facilities, and the
discipline of nursing as a profession.
Didactic, lecture-based nursing courses frequently have a clinical practicum co-requisite course to afford student practice
opportunities (i.e., hands-on learning) in a health care setting. The first semester that many baccalaureate undergraduate nursing
students are in the practice setting is in their junior year. Students arrive apprehensive about the expectations of the program and
those of the clinical instructor. After an initial “warming in” period students begin to find their own rhythm that is compatible with
the expectations of both the clinical practice setting and of the clinical instructor, which represents both the instructor’s own
values and those of the University.
The following account describes a student experience in a practice setting and how the student and faculty, concurrently serving as
didactic instructor and clinical instructor, collaborated for optimal outcomes.
The student: Jade
One recent semester, one particular student, Jade, was not assimilating well into the environment. Although she performed safely
(based on weekly pre-established guidelines of scope of practice for a beginning student) when paired with another student, Jade
generally remained detached from her peers. In a setting reliant on teamwork and peer support, Jade demonstrated a disconnection with
both the practice environment and with her clinical group. Concerns for Jades’ ability to work as a health care team member began to
surface. As a beginning student, Jade’s attention to patient care was acceptable although not exemplary.
In the practice setting, Jade was always kind to her patients. Jade’s patients expressed satisfaction with their nursing care. While
she was not ambitious in seeking out new experiences, the core care was given, albeit slowly for her patient assignment. The wholeness
of the patient situation was beginning to emerge in her written papers and could be coerced from Jade in conversation. Yet Jade lacked
enthusiasm, had a sad countenance, and rarely smiled. On a regular basis the faculty asked Jade how she could help her to feel more
comfortable in the practice environment. Jade said she was “fine” and still getting used to being in the hospital, expressing “feeling
where she thought she should be” at this point in her education, but the faculty continued to have concerns. A policy was in place
that when missing a practice day the students should call the instructor’s cell phone or the practice facility before the start of the
shift. This policy had been discussed with students and appears in the course syllabus. Jade missed a practice day and did not call
until that afternoon. She said she was not feeling well and had vague complaints. Jade had been late to the practice facility on other
occasions. In addition, Jade’s papers were consistently late. Jade had to be asked twice to turn in her self-evaluation at midterm and
the care plan that was due the previous week.
At midterm, the faculty expressed her concerns to Jade regarding attendance and responsibility, accountability for written
assignments, and establishing a connection with the practice environment and a support system with her peers. Jade was asked if she
felt comfortable in this setting and how the faculty could help. Jade shared that she found it difficult to get herself to the
practice site. She had a hard time getting up in the morning, a lack of motivation, and general feelings of depression. She recognized
that she was slow in completing tasks, had not related to her peers, and frequently felt detached.
Jade shared some aspects of her home life: she lived with her father and step-mother and their two young children. Jade’s mother lived
almost 200 miles north and was recently diagnosed with multiple sclerosis. Finances were difficult and Jade had minimal university-
based student health insurance to pay her own health care expenses. While this insurance is available to US students, many of these
students are self-sufficient for the first time in their lives and lack the knowledge to navigate their own health care benefits. Jade
knew she needed to seek help but did not have the motivation to do so or knowledge of the resources available to her. In tears, Jade
shared that she had always wanted to be a nurse, and was concerned with how she was going to accomplish this goal, thus expressly
identifying an inherent sense of commitment toward the profession of nursing.
The faculty encouraged Jade to make an appointment that day at the health clinic on campus. She explained that the required student
insurance was an available resource for counseling services. She told Jade she would call to see if she was successful in obtaining an
appointment. That evening when the faculty called, Jade told her she had left a message at the clinic but did not get a return call.
The faculty encouraged Jade to wait until lunchtime the next day and then to call again and she would check with her the following
evening. The second evening Jade was successful; however, she failed to show up for the scheduled appointment. Together, Jade and her
instructor planned for an appointment to be scheduled prior to her theoretical class, when she would already be on campus, increasing
the chance that she would be motivated to attend. Jade did attend, received medication, counseling, and a note that she could return
to the clinical setting.
The faculty faced the challenge of making tough decisions during this first semester about Jade’s suitability for continued patient
care: Is Jade safe in the practice setting? Could her lack of motivation impact patient care in a negative way? Would Jade be able to
be successful in this rigorous program? These are questions that make us re-examine our own understanding of a caring philosophy.
Based on the circumstances, the key question was: “Is it caring to support Jade to continue in this nursing program?” Theory and
intuition provided essential components to understanding and relating to Jade’s world.
The conceptual model and decision-making process: intuition in action
The melding of reason and intuition has been a consistent concern of our culture, highlighting the interrelation of nursing theory and
practice. According to Dreyfus and Dreyfus (1980), theory is dependent on practice and reason requires intuition. Medicine now
recognizes the connection between theory and intuition as expert diagnostic systems and their computer-based programs fail to capture
the specialist’s expertise based on intuition and judgment. Yet, attempts to quantify the nature of nursing intuition (Gobet and
Chassy, 2008) fail to appreciate the nuances of care delivered by the nurse. Nursing has the task of applying medical theory, but as a
caring practice demonstrates that intuition and clinical judgment recognizes human meaning. Use of Benner’s (1984) conceptual model is
an opportunity to bring theory and intuition to nursing practice.
Patricia Benner identifies herself as a nurse thinker (personal communication, October 18, 2008). In 1982, she described a model for
nursing based on skill acquisition. This model was originally developed by Professors Hubert and Stuart Dreyfus to identify the nature
of skill acquisition that airline pilots and chess players pass through as they develop expertise in their position (Benner et al.,
1996). In application to nursing, Benner discusses five levels of proficiency that nurses will navigate when developing their practice
(Benner, 1984): novice, advanced beginner, competent, proficient, and expert. Development through these phases is dependent on a
combination of depth and range of clinical experience, which positively compare to the length of time providing bedside nursing care
in a given area. As Benner (2004) states, “even the expert in the Dreyfus model of skill acquisition must stay attuned to the
situation and must remain open to the unexpected. In the Dreyfus model, the practitioner is assumed to dwell with increasing skill and
finesse in a meaningful, intelligible, but changing, world” (p. 198) . Not all nurses pass through each identified phase or reach a
level of expert practice.
The novice is identified as the senior level student or graduate nurse who relies on rules to direct their practice. Expert status
identifies the nurse who has had experience in one clinical area for more than five years and has developed an intuitive method of
recognizing clinical difficulties and determining the correct course of action. Benner et al. (1997, p. 16CCC) believe that: “in
narratives of connection and attunement, expert nurses focus on the needs, resourcefulness, a concern of the other, not their own
virtuosity and virtuousness in providing care” . Likewise, might clinical nursing faculty develop expertise in an organized manner
similar to the developing clinical nurse? The expert nurse faculty member has a central concern to view students as persons, respect
their dignity, care for them in ways that preserve their personhood, protect them in their vulnerability, help them feel safe in a
somewhat alien environment, and preserve the integrity of close relationships (Boykin, 1994) which parallels the descriptions by
Benner et al. (1997, p. 16DDD) of the relationship of the expert nurse and her patient. Intuitive knowing is inherent to the expert
nurse (Benner, 1982).
Benner defines intuition as “understanding without a rationale” and categorizes intuition as an art rather than as a science. Unlike
the traditional linear thinking associated with the nursing process, intuition recognizes holistic modes of thinking (McCormack,
1992). Expert human decision-makers recognize the gestalt of a situation. ‘Vague hunches’ and ‘gut feelings’ represent components of
intuition. “Intuitive judgment […] distinguishes expert human judgment from the decisions or computations […] made by the beginner
or by a machine” (Benner and Tanner, 1987, p. 23). This intuitive judgment incorporates the key aspects identified by Dreyfus and
Dreyfus: pattern recognition, similarity recognition, commonsense understanding, skilled know-how, a sense of salience, and
deliberative rationality. These aspects work in synergy to form expert intuitive judgment.
Pattern recognition
“Pattern recognition is a perceptual ability to recognize relationships without pre-specifying the components of the situation”
(Benner and Tanner, 1987, p. 24). Novices and experts differ in their capacity to recognize whole patterns–novices utilize an
analytic model to recognize a pattern from a list of features. Graduate nurses have been noted to recognize patterns of patient care
by recalling the clinical manifestations of a particular symptom (Manias et al., 2004). Jade’s pattern was thusly methodical.
Everything got done eventually, but she required patience and encouragement from her faculty to complete the components of the course.
Moreover, her pattern did not match that of her group, and she did not share the attributes to permit her to fit in. The faculty
realized her mannerisms were not that of a student who feels in touch with her environment.
Similarity recognition
Problem identification may be possible through similarity or dissimilarity recognition. Jade was dissimilar from her peers in her lack
of enthusiasm in the clinical setting. The first semester in a nursing program is frequently one of excitement when one begins to
fulfill career ambitions. Most beginning students are anxious and fearful at the same time. They are generally eager to please and
filled with wonder of how their care may impact another human. The [clinical] group initially bonds in support and encouragement. Jade
was the outsider. She did not express her feelings and when discussed, was focused on her lack of motivation. It is here that the
clinical nurse educator has an opportunity to use interpersonal attributes focused on modeling professionalism, respect, and being
approachable to the student (Hanson and Stenvig, 2008) to listen and respond to the student’s story.
Commonsense understanding
The faculty has practiced in nursing education with students in the practice environment for over 20years. This longevity as well as
diversity of both students and environments has helped the faculty to understand the struggles and complexities faced by beginning
students. The culture and language of a beginning student is well understood by the experienced faculty. Commonsense understanding
permits her to see the nuances of student behavior. The expert faculty sees their relevance in recognizing subtle trends. This
background knowledge of the students’ world provides the basis for clinical judgment about the students’ vulnerability (Benner and
Tanner, 1987). Jade just did not “fit in”. She was inwardly focused, just trying to get through the day. She demonstrated no personal
satisfaction in her student role. Jade practiced nursing alone, and did not request assistance from her peers or faculty.
Skilled know-how
Two kinds of knowledge are identified by Polanyi and Kuhn (1962): knowing how and knowing that. Knowing how is based on embodied
intelligence rather than precision. Knowing that is the theoretical knowledge that is commonly assumed to be requisite for or superior
to the practical knowledge of knowing how (Benner and Wrubel, 1982, p. 32). Skilled know-how is an aspect of expert intuition that
describes the nurse faculty as she manages a difficult student situation. Working with a student on the individual level allows one to
recognize the possibilities for each person. In this situation, the faculty intuitively recognized Jade’s need to share her personal
story. The faculty grasped Jade’s desire to have someone guide her and support her as she acknowledged her feelings and moved forward
with appropriate mental health care.
Sense of salience
A sense of salience describes events and observations that stand out as more important or less important when evaluating students.
Expert practice is characterized by increased intuitive links between seeing the salient issues in the situation and ways of
responding to them (Benner et al., 1996, p. 142). Some formal models of judgment utilize standard assessment forms and checklists as a
broad net to avoid missing what may be important signs and as a guide for beginning clinicians (Benner and Tanner, 1987). Expert
nurses utilize their sense of salience in imagining all the possibilities and determining which of these possibilities come to the
forefront in a given situation.
Jade was kind to her patients. Her patients appreciated her slow, deliberate, and unhurried delivery of care. However, her slow pace
made it difficult for Jade to complete her care and documentation in a timely manner. The faculty recognized the pace at which Jade
worked as providing a safety net to the completeness of the individual actions. As Jade gained confidence in her abilities, it was
anticipated that her pace would quicken and Jade would be able to function independently. Jade’s lack of motivation and detachment
from her peers stood out as uncharacteristic of the group behavior. Her sad countenance suggested greater meaning to the situation. In
private conversation, Jade’s tears as she described her lack of motivation confirmed the need for professional evaluation and
assistance.
Deliberative rationality
When the faculty focuses on a single aspect of student performance, they may create the error of tunnel vision. The use of
“deliberative rationality is a way to clarify one’s current perspective by considering how one’s interpretation of the situation would
change if one’s perspective were changed” (Benner and Tanner, 1987, p. 28). Likewise, recognizing shame as a manifestation in those
nursing students whose basic relational needs were not met in childhood (Bond, 2009) is an opportunity for the faculty to redirect any
tunnel vision to focusing on all aspects of the student. Consideration of the possibilities affecting Jade’s behaviors permitted the
faculty to look into Jade’s world so that together they could imagine her potential and create changes.
Intuitive judgment as a product of key aspects
The key aspects of intuitive practice identified by Dreyfus and Dreyfus (1980) cannot be separated when the expert nurse uses
intuition to guide her actions. These components work together and continually reprioritize to produce a good instinct that may lack
concrete evidence. Intuitive knowledge is based on background understanding and skilled clinical observation (Benner and Tanner, 1987)
which creates expertise as knowledge and experience become entwined in our professional being (Lyneham et al., 2008).
Western tradition has traditionally valued formal logic and mathematics and distrusted other forms of judgment. Indirect perception,
as obtained through monitors as an efficient use of time and measurement, fails to consider the “wide variety of available auditory,
visual, and tactile information that has not been pre-selected or abstracted by someone else” (Effken, 2007, p. 196). Formal logic
ignores human expertise and relies on structure with a limited set of options. Intuition permits the expert clinician to choose what
is relevant when looking at the whole and to recognize the changing nature of any situation. Rational calculations and intuitive
judgments can often work together to give a complete understanding when making complex decisions as Thompson (1999, p. 1226) states:
“an appropriate stance might be to recognize that each has something to offer and that in their theoretically ‘pure’ states they
represent ideal-typical frameworks for analysis” .
Impact of intuition in an interdisciplinary context
The impact of intuition and skill development has been observed and experimentally studied by Dreyfus and Dreyfus (1980) on chess
players, airline pilots, and automobile drivers as well as in nursing (Benner, 1984). These researchers encourage persons to apply the
key aspects of intuition to other areas to see if they fit the developed description of skill acquisition. Even with considerable
concrete experience in their domain of specialization, not all people will achieve expertise, yet the possibilities for individual
growth remain. The description of skill acquisition for nurses has relied on recollection of various learning experiences (Benner et
al., 1996).
Siler and Kleiner (2001) studied the development of novice faculty in a college of nursing. Pooled expertise among practitioners may
help to transmit clinical knowledge. The importance of mentors and research to uncover the lived meaning of the experience of novice
faculty provide insight into the development of the novice educator. Benner and Tanner (1987) utilize exemplars to document the body
of knowledge held by nursing and to demonstrate the stages of clinical expertise.
Student and faculty outcomes
This undergraduate nursing program is exemplified by students and faculty living and growing in caring. This caring relationship is
modeled by the faculty and becomes a relationship of reciprocity. Mayeroff (1971) identified factors that nurture and assist both the
faculty and students to know self as caring person. These major ingredients of caring are knowing (knowing explicitly and implicitly;
knowing that and knowing how, knowing directly and knowing indirectly), alternating rhythms (having the ability to move from wider to
narrower perspectives and to develop an honest understanding of other), trust (allowing the other to grow in his or her special way),
hope (endorsing the present as being alive with possibilities), courage (being ready to go into the unknown, to take risks, to make
decisions with the commitment of caring), humility (being willing to learn more about self and others), patience (not waiting
passively for something to happen; instead, participating with the other and giving fully of ourselves; enlarging our living space –
the space in which we think and feel), and honesty (trying to see truly). Application of these ingredients of caring by the faculty
permits positive outcomes and growth of the student as well as the faculty and as Boykin (1994, p. 15) stresses “Establishing
relationships rooted in a commitment to caring necessitates coming to know other as person expressing caring in the moment” .
Each student is accepted into the College of Nursing with the understanding that the faculty will assist them in coming to know self
as caring while supporting their growth as a professional nurse. Students utilize a variety of methods throughout the curriculum to
document their growth in nursing including journals, daily care logs, nursing care plans, concept maps, and narrative notes. This
growth is documented in the practice setting by the faculty through anecdotal notes and evaluations that reflect Roach’s (1987) caring
components. These caring components are competence, confidence, compassion, conscience, commitment, and comportment. Competence is
having the knowledge or skills to respond appropriately to one’s environment. Mutual trust and respect are critical aspects of
confidence. Confidence is the attribute that fosters trusting relationships. Compassion permits one person to participate in the
experience of another and to be sensitive to the pain of another. Conscience is a state of moral awareness that grows out of a process
of valuing self and others. The convergence of one person’s desires and obligations, what one wants to do and what one is supposed to
do, is demonstrated in commitment. Comportment describes the professionalism part of our practice. It is the dress, the timeliness,
and the preparation for nursing practice. It describes the way you carry yourself, the way you interact with others, and your level of
communication. The subjective component of evaluation is reliant on the expert faculty member’s sense of intuition to help the student
intertwine and make visible these caring components. If it is modeled well by the faculty, the student can better understand what it
means to be a professional nurse.
The student participates in their ongoing evaluation and together, with the faculty, utilizes this framework to identify and document
strengths, weaknesses, and directions for growth. Sometimes this means the faculty has to ‘bend the rules’ and allow papers to be
received late. The faculty sat with Jade to do her self-evaluation and find the words to express her difficulties. Together they
discussed the potential impact in the clinical area and designed a plan to monitor Jade’s progress weekly and to work together toward
Jade’s professional development.
The decisions the faculty faced during Jade’s first semester in the practice setting were, “Is Jade safe in the practice setting?
Could her lack of motivation impact patient care in a negative way? and, “Would Jade be able to be successful in this rigorous
program?” These are questions that make us re-examine our own understanding of a caring philosophy. With support and an intuitive
understanding that Jade would be an excellent nurse as she came to know self, Jade was counseled and supported to first, take care of
herself so that she could provide safe, compassionate nursing care. Indeed, it is caring to support Jade in this process as detailed
below.
Final thoughts
In the middle of her first semester Jade began a regular program of counseling. She was encouraged to call the faculty whenever she
wanted to talk. With many calls and much encouragement, Jade did confide in a peer, continued to seek help, took her medications, and
eventually was able to convince her mother to move to the area where they could support each other. Jade now lives with her mother
where she feels comfortable and does not have the distractions of young children and an uncomfortable parental situation. Jade has
been employed in a hospital for the last six months where she feels confident in her patient care technician role. As a senior, Jade
is precepting in the same facility and is gaining confidence in her transition to the role of registered nurse. Jade is professional
in her delivery of patient care, in her relationships with her patients and peers, and exemplifies professional comportment. Jade’s
preceptor acknowledges the competence she demonstrates as Jade delivers nursing care. The compassion modeled for Jade by her nursing
faculty is now modeled by Jade for those around her. Jade is aware of herself and conscience guides her actions. In a recent
discussion with Jade, she expresses confidence in her abilities and commitment to the profession of nursing.
Recognition by the faculty of Jade’s possible barriers to success in nursing school afforded them to co-create a plan of care to help
her become successful. The time spent by the faculty member to assist Jade was well spent, as Jade maintains her placement in this
limited access nursing program. This time, incorporated within the duties of the nurse educator, demonstrated to Jade’s peers that
each student is valued. In turn, Jade’s peers assisted her in her transition and she now functions within the group as a team member.
Had this support not been given, the student may have dropped out of nursing. Instead, the nurse educator modeled caring which
hopefully; each student will bring to their nursing practice. The faculty’s expertise supported the novice student as both lived the
caring components of competence, confidence, compassion, conscience, commitment, and comportment. The intuitive judgment of her
faculty of issues that affected Jade personally enabled her to live and grow in caring within her program of nursing. The caring
philosophy of this nursing school combined with Benner’s conceptual model and decision-making process was lived between the faculty
and the student.

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