Patricia Sawyer Benner

Theory of Skill Acquisition in Nursing or The from Novice to Expert model

Viel Q. Vizcarra

Bibliography Dr. Patricia Sawyer Benner is a very accomplished nursing theorist. She was born on May 10, 1955 to parents Ethel and Donald Brushett in Hampton, Virginia. She went to Pasadena College and received her BSN in 1964. She then received her Masters Degree in Medical Surgical Nursing from the University of California, San Francisco in 1970 and went to get her Ph.D. in Stress, Coping and Health from the University of California, Berkeley in 1982. Dr. Benner is currently a professor of nursing in the Department of Social and Behavioral Nursing at the University of California, San Francisco. She is an internationally known researcher and lecturer on health, stress and coping, skill acquisition and ethics and has had great influence on the world of nursing. She is the author of nine books including, From Novice to Expert: Excellence and Power in Clinical Nursing Practice in 1982. In this book, Dr. Benner outlined her own theory as to how a nurse transitions from a beginner to an expert in the nursing profession. From 1978 to 1981, Benner was the author and project director of a federally funded grant, Achieving Method of Intraprofessional Consensus, Assessment and Evaluation, known as the AMICAE project. This led to the publication of From Novice to Expert (1984a) and numerous articles. Benner directed the AMICAE project to evaluation methods for participating schools of nursing and hospitals in the San Francisco area. It was an interpretive, descriptive study that led to the use of Dreyfus five levels of competency to describe skill acquisition in clinical nursing practice.

Introduction of the Theory Dr. Benner introduced the theory that expert nurses develop skills and understanding of patient care over time through a sound educational base and a multitude of experiences. The premise of this theory is that the development of knowledge on applied disciplines such as medicine and nursing is composed of the extension of practical knowledge through research and understanding the know-how of clinical experience. It states that nursing requires procedural or scientific knowledge, technique, and the advancement of knowledge through practice and

experience. Before the publication of her most widely known book From Novice to Expert: Excellence and Power in Clinical Nursing Practice, there was no real characterization of the learning process of nurses Benner adapted the Dreyfus model to clinical nursing practice. The Dreyfus brothers developed the skill acquisition model by studying the performance of chess masters and pilots in emergency situations. The model is situational and describes five levels of skill acquisition and development: 1: novice, 2: advanced beginner, 3: competent, 4: proficient, 5: expert. The model posits that changes in four aspects of performance occur in movement through the levels of skill acquisition as follows: 1: movement from a reliance of abstract principles and rules to use of past, concrete experience, 2: shift from reliance on analytical, rule-based thinking to intuition, 3: change in the learners perception of the situation from viewing it as a compilation of equally relevant bits to viewing it as an increasingly complex whole in which certain parts stand out as more or less relevant, and 4: passage from a detached observer, standing outside the situation, to one of a position of involvement, fully engaged in the situation.

Theoretical Assertions of Theory Benner stated that there is always more to any situation than theory predicts. The skilled practice of nursing exceeds the bounds of formal theory. Concrete experience provides learning about the exceptions and shades of meaning in a situation. The knowledge embedded in practice can lead to discovering and interpreting theory, precedes and extends theory, synthesizes and adapts theory in caring nursing practice. Some of the relationship statements included in Benners works follow: Discovering assumptions, expectations, and sets can uncover an unexamined area of practical knowledge that can then be systematically studied and extended or refuted (Benner, 1948a, p.8). Clinical knowledge is embedded in perceptions rather than percepts. Perceptual awareness is central to good nursing judgment and. (for expert) begins with vague hunches and global assessments that initially bypass critical analysis; conceptual clarity follows more often than it precedes (Benner, 1948a, p. xviii). Formal rules are limited and discretionary judgment is needed in actual clinical situations. Clinical knowledge develops over time, and each clinician develops a personal repertoire of practice knowledge that can be shared in dialogue with other clinicians. Expertise develops when the clinician tests and refines propositions, hypotheses, and principle-based expectations in actual practice situations (Benner, 1984a, p.3)

The Nursing Metaparadigm Nursing Nursing is described as a caring relationship, an enabling condition of connection and concern (Benner & Wrubel, 1989, p.4). Caring is primary because caring sets up the possibility of giving help and receiving help (Benner & Wrubel, 1989, p.4). Nursing is viewed as a caring practice whose science is guided by the moral art and ethics of care and responsibility (Benner & Wrubel, 1989, p.xi). Benner and Wrubel (1989) understand nursing practice as the care and study of the lived experience of health, illness, and disease and the relationships among these three elements. Person Benner and Wrubel (1989) use Heideggers phenomenological description of person, which they are describe as A person is a 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 no reflective understanding of the self in the world (p.41). The person is viewed as a participant in common meanings(Benner & Wrubel, 1989, p.23). Finally, the person is embodied Benner and Wrubel (1989) have conceptualized the following four major aspects of understanding that the person must deal with: 1. The role of the situation 2. The role of the body 3. The role of personal concerns 4. The role of temporality

Together, these aspects of the person make up the person in the world. This view of the person is based on the works of Heidegger (1962), Merleau-Ponty (1962), and Dreyfus (1971, 1991). Their goal is to overcome Cartesian dualism, the view that the mind and body are distinct, separate entities (Visintainer, 1988). Benner and Wrubel (1989) define embodiment as the capacity of the body to respond to meaningful situations. On the basis of the work of Merleau-Ponty (1962), Dreyfus (1979, 1991), and Dreyfus (1962), they outline the following five dimensions of the body Benner and Wrubel (1989): 1. The unborn complex, unacculturated body of the fetus and newborn baby 2. The habitual skilled body complete with socially learned postures, gestures, customs, and skills evident in bodily skills such as sense perception and body language that are learned over time through identification, imitation, and trial and error (Benner & Wrubel, 1989, p.71). 3. The projective body that is set (predisposed) to act in specific situations (for example, opening a door or walking) 4. The actual projective body indicating an individuals current bodily orientation or projection in a situation that is flexible and varied to fit the situation, such as when an individual is skillful in using a computer. 5. The phenomenal body, the body aware of itself with the ability to imagine and describe kinesthetic sensations. They point out that nurses attend to all these dimensions of the body and seek to understand the role of embodiment in particular situations of health, illness, and recovery.

Health On the basis of the work of Heidegger (1962) and Merleau-Ponty (1962), Benner and Wrubel focus on the lived experience of being healthy and being ill (1989, p.7). Health is defined as what can be assessed, whereas well-being is the human experience of health or wholeness. Well-being and being ill are understood as distinct ways of being in the world. Health is described is described as not just the absence of disease or illness. Also, on the basis of the work of Kleinman, Eisenberg, and Good (1978) a person may have a disease and not experience illness, because illness is the human experience of loss or dysfunction, whereas disease is what can be assessed at the physical level (Benner &Wrubel, 1989). Situation (Environment) Benner and Wrubel (1989) use the term situation rather that environment, because situation conveys a social environment with social definition and meaningfulness. They use the phenomenological terms being situated and situated meaning, which are defined by the persons engaged interaction, interpretation, and understanding of the situation. Personal interpretation of the situation is bounded by the way the individual is in it (Benner &Wrubel, 1989, p.84). This means that each persons past, present, and future, which include their own personal meanings, habits, and perspectives, influence the current situation.

Model of Theory or Conceptual Design

Patricia Benner described 5 levels of nursing experience as;

1. Novice 2. Advanced beginner 3. Competent 4. Proficient 5. Expert

Stage 1: NOVICE In the novice stage of skill acquisition in the Dreyfus model, the person has no background experience of the situation in which he or she is involved. Context-free rules and objective attributes must be given to guide performance. There is difficulty discerning between relevant and irrelevant aspects of situation. Generally, this level applies to students of nursing, but Benner has suggested that nurses at higher levels of skill in one area of practice could be classified at the novice level if placed in an area or situation unfamiliar to them (Benner, 1984a).

Stage 2: ADVANCED BEGINNER The advance beginner stage in the Dreyfus model develops 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. The advanced beginner has enough experience to grasp aspects of the situation (Benner, 1984a). Unlike attributes and features, aspects cannot be objectified completely because they require experience based on recognition in the context of the situation. Nurses functioning at this level are guided by rules and are oriented by task completion. They have difficulty grasping the current patient situation in terms of the larger perspective. However, Dreyfus and Dreyfus (1996) state the following: Through practical experience in concrete situations with meaningful elements which neither the instructor nor student can define in terms of objective features, the advanced beginner starts intuitively to recognize these elements when they are present. We call these newly recognized elements situational to distinguish them from the objective elements of the skill domain that the beginner can recognize prior to seeing concrete examples. (p.38) Clinical situations are viewed by nurses at the advanced beginner stage as a test of their abilities and the demands of the situation placed on them rather than in terms of the patient needs and responses (Benner et al., 1992). Advanced beginners feel highly responsible for managing patient care, yet they still rely on the help of those more experienced (Benner et al., 1992). Benner places most newly graduated nurses at this level.

Stage 3: COMPETENT Through learning from actual practice situations and by following the actions of others, the advanced beginner moves to the competent level (Benner et al., 1992). The competent stage of the Dreyfus model is typified by considerable conscious and deliberate planning that determines which aspects of the current and future situations are important and which can be ignored Benner, 1984a). Consistency, predictability, and time management are important in competent performance. A sense of mastery is acquired through planning and predictability Benner et al., 1992). There is an increased level of efficiency, but the focus is on time management and the nurses organization of the task world rather than on timing in relation to the patients needs Benner et al., 1992, p.20). the competent nurse may display hyperresponsibility for the patient, often more than is realistic, and may exhibit an ever-present and critical view of the self Benner et al., 1992). The competent stage is most pivotal in clinical learning, because the learner must begin to recognize patterns and determine which elements of the situation warrant attention and which can be ignored. The competent nurse devises new rules and reasoning procedures for a plan while applying learned rules for action on the basis of relevant facts of the situation.to become proficient, the competent performer must allow the situation to guide responses (Dreyfus and Dreyfus, 1996). Studies point to the importance of active teaching and learning in the competent stage to coach nurses making the transition from competency to proficiency (Benner et al., 1996; Benner et al., 1999).

Stage 4: PROFICIENT At the proficient stage of the Dreyfus model, the performer perceives the situation as a whole (the total picture) rather than in terms of aspects, and the performance is guided by maxims. The proficient level is a qualitative leap beyond the competent. Now, the performer recognizes the most salient aspects and has an intuitive grasp of the situation based on background understanding (Benner, 1984a). Nurses at this level demonstrate a new ability to see changing relevance in a situation, including the recognition and the implementation of skilled responses to the situation as it evolves. They no longer rely on preset goals for organization, and they demonstrate an increased confidence in their knowledge and abilities (Benner et al., 1992). At the proficient stage, there is much more involvement with the patient and family. The proficient stage is a transition into expertise (Benner et al., 1996). Stage 5: EXPERT The fifth stage of the Dreyfus model is achieved when the expert performer no longer the relies on analytical principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action" (Benner, 1984a, p. 31). Benner describe the expert nurse as having an 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 qualitative change as the expert performer knows the patient, meaning knowing typical patterns of responses and knowing the patient as a person. Key aspect of the expert nurses practice are follows (Benner et al., 1996): Demonstrating a clinical grasp and resource-based practice

Possessing embodied know-how Seeing the big picture Seeing the unexpected The expert nurse has this ability to recognize patterns on the basis of deep experiential

background. For the expert nurse, meeting the patients actual concerns and needs is of outmost importance, even if it means planning and negotiating for a change in the plan of care there is almost a transparent view of the self (Banner et al., 1992).

Critique of the Theory Personal There have been many articles, editorials, and scholarly works written about Dr. Benners work. Some of them address whether her work is a theory or a concept. Several articles have called attention to her incorporation of intuition into the process of becoming an expert. I suspect this is because intuition is not tangible and very hard to measure. Benner describes the expert nurse as having An intuitive grasp of the situation (Benner 1982). The seasoned nurses well-honored sixth sense enables her to make lifesaving decisions (Benner, & Tanner 1987). Tabers medical dictionary defines intuition as Assumed knowledge; guesswork; a hunch (Venes 2005). While intuition may involve some guesswork, it is based on the

knowledge and experience of the clinician, which cannot be taught in a textbook. Expert intuition demonstrates acute awareness on the part of the clinician and often times precedes clear evidence of clinical changes in the patient. Ian English wrote an article in reference to Benners Novice to Expert model that was published in the Journal of Advanced Nursing. He concluded

that Benner needed to accurately define the term expert. English feels that nursing experts need to be objectively quantified so that they can be measured. (English 1993). While scientist often use objective, empirical data to compare statistics and make theory based findings, some things in life just cannot be quantified. Intuition is one of these elements. The fact the intuition cannot be objectively measured, does not, in my opinion, diminish its significance in the clinical setting. I believe that Dr. Benner has accurately enunciated the learning curve that clinicians must transcend to become an expert in their profession. Her steps to becoming an expert in the field of nursing are logical and evidence based. One can compare her steps to a first year resident medical doctor, who has been highly educated in medical theory, but who lacks the experience of an expert. At this point in his or her career, the resident is simply a novice, highly educated, but with little Real world clinical experience. The progression from novice to expert is highly correlated to work experience, as it should be. Benners theory made me realized that book knowledge is important, but it is only a beginning, and by no means, regardless of your educational level, makes one an expert. From Other People Meleis (1991) describes a method for critiquing a theory suggesting the following areas be assessed. Clarity, consistency, simplicity and visual representation. Although Benners model most closely fits the definition of a philosophy, certain aspects can be critiqued as if it were a theory. Clarity Clarity denotes precision of boundaries, a communication of a sense of orderliness, vividness of meaning and consistency throughout the theory. Benner provides theoretical

definitions for all major concepts, but not the operational definitions necessary for empirical measurement. She follows the logical sequence developed by Dreyfus, does not deviate by introducing other concepts and states her philosophy simply and briefly. Benners philosophy is general, yet situation dependent; it encompasses many aspects of nursing from students through expert practitioners and espouses a broad range of applications within nursing such as in administration and research. Thus, the theory of Benner is not that much clear. Consistency Consistency is determined by evaluating the congruency between each component of a theory. Benners model contains concepts which are consistent with each other and are consistently utilized. Since first proposing the philosophy, Benner has continued to research the phenomena and has not changed her concepts. This is difficult to quantify, however, since specific operational definitions have not been articulated. Simplicity vs. Complexity It relates to the number of phenomena the theory considers and the relationships which could develop. Depending on the purpose of the theory, either simplicity or complexity could be preferred. The model is relatively simple in regard to the five stages of skill acquisition and it provides a comparative guide for identifying levels of nursing practice from individual nurse descriptions and observations of actual nursing practice. The essence of the model is easy to grasp and explain. Visual Representation

Visual representations of the theory may further enhance its clarity. Benner does not present a visual representation, but the stages can be referred to as being along a continuum. Progress along this continuum is sequential from novice to expert, but may include regression when the nurse is in an unfamiliar situation. Contagiousness Contagiousness is whether or not it is adopted by others and must look at the geographical location and type of intuition which adopted the theory. This theory has been adopted in many countries and by many different types of institutions. This is evident, in a simple form, by reviewing the literature, noting articles from different countries and relating to different uses of the philosophy. Usefulness Assessing the usefulness of a theory includes its usefulness in practice, research, education, and administration. Benners model has been utilized in all areas to be assessed. Benners model has become the foundation for preceptor programs for students and new graduate nurses (Myrick & Barrett, 1992), as well as continuing education programs. Many research studies have been conducted based on the concepts proposed by Benner. Many schools of nursing adopted this model as a basis for providing education, as noted by English (1993). Nursing administration has utilized this model to develop career ladders, staff development and recognition and rewards programs (Nelson & McGillion2004). Values

Values include those of the theorist and the critic, other professions and society. Values are not explicitly identified in this theory. This theory was borrowed from another profession which demonstrates congruence. Social Significance Finally, the social significance must be assessed because in our attempt to enhance nursing science and articulate the discipline of nursing we must not neglect the significance of its practice to humanity and society (Meleis 1991, p.237). This model is proposed as a method for determining the expert practitioners and developing more expertise in practitioners. This has social ramifications as it is optimal to have the best, most knowledgeable, practitioners providing care. Benners model has been criticized for not being quantitative; her research used a qualitative approach. The philosophical basis of Benners work challenges the traditional notion of objective science. The study conducted by Benner included small number of participant, so the theory developed by such study might contain bias.

Implications of the Theory Nursing Education Benner (1982) has critiqued the concept of competency-based testing by contrasting it with the complexity of the proficiency and expert stages described in the Dreyfus Model of Skill Acquisition and the 31 competencies described in the Achieving Method of Intraprofessional Consensus, Assessment and Evaluation (AMICAE) project (Benner, 1984a). In summary, she stated, Competency-based testing seems limited to the less situational, less interactional areas of

patient care where the behavior can be well defined and patient and nurse variations do not alter the performance criteria (1982, p.309). Fenton (1984, 1985) described the application of the domains of clinical nursing practice as the basis for studying the skilled performance of clinical nurse specialists (CNSs). Her analysis validated that the CNSs studied demonstrated competencies in common with those skills of expert nurses reported in the AMICAE project. She also identified additional areas of skilled performance for the CNSs including the consulting role, and she delineated five preliminary categories relevant for curriculum evaluation in the graduate program. Ethical, clinical, and political dilemmas, positions or stances that promote success or failure, and new knowledge that blends the empirical and theoretical were among these categories. According to Barnum (1990), it was not Benners development of the seven domain of nursing practice that has had the greatest impact on nursing education , but the appreciation of the utility of the Dreyfus model in describing learning and thinking in our discipline (p.170). As a result of Benners application of the Dreyfus Model, nursing educators have realized that learning needs at the early stages of clinical knowledge development are different from those required at later stages. These differences need to be acknowledged and valued in developing, nursing education programs appropriate for the background experience of the students. Some in nursing have come to appreciate that knowledge does develop in practice and that practice is more complex than any one theory can encompass, but the platonic quest for application of abstract theories continues to be a strong thrust in academia. In Expertise in Nursing Practice, Benner and colleagues (1996) emphasized the importance of learning the skill of involvement and caring through practical experience, the

articulation of knowledge with practice, and the use of narratives in undergraduate education. This work provides further support for the thesis that it may be better to place a new graduate with a competent nurse preceptor who can explain nursing practice in ways that the beginner comprehends than with the expert, whose intuitive knowledge may elude beginners who do not have the experienced know-how to grasp the situation. In Clinical Wisdom in Critical Care, Benner and colleagues (1999) urged greater attention to experiential learning and presented the work as a guide to teaching. They designed a highly interactive CD-ROM to accompany the book (Benner et al; 2001). Nursing Practice Banner describes clinical nursing practice by using an interpretive phenomenological approach. From Novice to Expert (1984a) includes several examples of the application of her work in practice settings (Dolan, 1984; Huntsman, Lederer, & Peterman, 1984; Ullery, 1984). As noted earlier, Benners approach has been used to aid in the development of clinical promotion ladders, new graduate orientation programs, and clinical knowledge development seminars. Symposia focusing on excellence in nursing practice have been held for staff development, recognition, and reward and as a way to demonstrate clinical knowledge development in practice (Dolan, 1984). Fenton (1984) reported the use of Benners approach in an ethnographic study of the performance of clinical nurse-specialists. Her findings included identification and description of competencies of nurses functioning at an advanced level of preparation. Balasco and Black (1988) and Silver (1986a, 1986b) used Benners work as a basis for differentiating clinical knowledge development and career progression in nursing.

Neverveld (1990) used Benners rationale and format in her development of basic and advanced preceptor workshops. Farrell and Bramadat (1990) used Benners paradigm case analysis in a collaborative educational project between a university school of nursing and a tertiary care teaching hospital to better understand the development of clinical reasoning skills in actual practice situations. Crissman and Jelsman (1990) applied Benners findings in developing a cross-training program to address staffing imbalances. They delineated specific cross-training performance objectives for novice nurses, but also provided support for the experiential judgment needed to function in unfamiliar settings by designating a preceptor in the clinical area. The aim is for the novice to be able to perform more like an advanced beginner with an experienced nurse available as a resource. Benner has been cited extensively in nursing literature regarding nursing practice concerns and the role of caring in such practice. She continues to advance understanding of the knowledge embedded in clinical situations through publications (Benner 1985a, 1985b, 1987; Benner & Tanner, 1987; Benner, et al., 1996; Benner et al., 1999). Benner edited a clinical exemplar series in the American Journal of Nursing during the 1980s. In 2001, she began editing a series called Current Controversies in Critical Care in the American Journal of Critical Care. Nursing Research The preceding example by Fenton (1984, 1985) presented an application of educational research. Lock and Gordon (1989), medical anthropologists who had been research assistants on the AMICAE project, extended the inquiry to study the formal models used in nursing practice and medicine. They concluded that formal models may serve as maps that direct care, substitute knowledge and result in conformity. Gordon (1984) cautions that a misuse of formal models

occurs when nurses apply models without using judgment, when they use models to exert control, when they use language from model that may cover up meanings, or when they do not understand the meaning of the models. And finally, formal models should be used with discretion as tools and should not eclipse the relational, holistic, intuitive aspects of nursing (p.242)

Application of the Theory Using the 11 Core Competencies 1. Safe and Quality Nursing Care One important factor that contributes to nursing quality is the nurse's years of experience in nursing (Aiken, Havens, & Sloane, 2009; Dunton, 2007). Multiple experiences of observing cues, and recognizing patterns related to patient status that need to be acted on in specific ways, lead to higher levels of clinical performance (Burritt & Steckel, 2009). An experienced nurse may assess the same patient as an inexperienced nurse but respond differently based subtle changes (cues) that serve as a forewarning of significant, underlying issues. Daley (1999) has reported that novice nurses tend to learn through formal training, such as review of policies and procedures and attendance at educational offerings. In contrast expert practitioners supplement formal learning with a mature knowledge base that they have developed over a period of years.

2.

Management of Resources and Environment The work environment for the practice of nursing has long been cited as one of the most

demanding across all types of work settings. Nurses provide the vast majority of patient care in hospitals, nursing homes, ambulatory care sites, and other health care settings (AONE, 2000). The first objective of the professional practice environment for nurses is to put the patient first. Nurses and health care organizations must focus on patient safety and care quality and always ask the question, "What is best for our patients?" One must identifies tasks or activities that need to be accomplished, plans the performance of tasks or activities based on priorities and verifies the competency of the staff prior to delegating tasks In Benners theory, the expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation on the accurate region of the problem without any wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions, thus, can do all the above task. 3. Health Education Education influences expertise by providing a theoretical and practical knowledge base that can be tested and refined in actual situations (Dreyfus & Dreyfus, 1996). Didactic learning alone cannot generate clinical expertise, and one distinguishing aspect of nursing education is a focus on clinical learning. Benner (2004) suggested that hands-on learning is at the heart of good clinical judgment. Mentored clinical learning situations in both classrooms and practice sites offer critical opportunities for nurses to apply and integrate theoretical knowledge with actual events (Field, 2004). A sound educational foundation expedites the acquisition of skills through

experience (Benner, 1984). Without background knowledge, nurses risk using poor judgment and lack the tools necessary to learn from experience. Theory and principles enable nurses to ask the right questions to hone in on patient problems to provide safe care and make good clinical decisions. Bonner's (2003) research on nephrology nurses showed expert and non-expert nurses differed based on types of learning opportunities (both formal and informal) rather than years of experience. In a literature review on the relationship between nursing education and practice, Kovner and Schore (1998) reported mixed findings regarding whether and in what ways bachelor of science in nursing (BSN) prepared nurses' skills and abilities differ from those of associate degree and diploma-prepared nurses. 4. Legal Responsibility The ANA Code of Ethics notes it is the responsibility of both individual staff nurses and nursing management to facilitate an environment of respect. Provision 6 of the Code notes that managers and administrators are responsible for setting standards and managing the environment of care to assure that each employee is treated fairly and is able to practice in an environment conducive to the provision of quality health care consistent with the values of the profession (ANA, 2001). Whether you are a novice or an expert, one must practice the core competencies included in this area of responsibility. 5. Ethico-moral Responsibility James Rests (1983; Narvaez & Rest, 1995) Four Component Model describes the psychological that comprise an ethical or moral action. The model has been used for educational design and intervention for several decades (see Rest & Narvaez, 1994). The model has been

used to identify skills that can be taught based on a novice-to-expert pedagogy (Narvaez et al., 2004; Narvaez, 2006). This document offers a way to assess skills related to each component. The Four Component Model allows us to view moral behavior as a set of responses to particular situational features. Experts in the skills of Moral Sensitivity are better at quickly and accurately reading a moral situation and determining what role they might play. Experts in the skills of Moral Judgment have many tools for solving complex moral problems. Experts in the skills of Moral Self/Identity cultivate an ethical identity that leads them to prioritize ethical goals. Experts in the skills of Moral Striving know how to keep their eye on the prize, enabling them to stay on task and take the necessary steps to get the ethical job done. 6. Personal and Professional Development Nursing is a unique profession in which the experience of the practitioner is the most significant attribute to professional growth and knowledge development. Patricia Benners theory, novice to expert, and the concept of reflective practice both validate this idea. Benner utilized reflection within her study of the nursing profession in order to depict the unique characteristics and knowledge embedded in the experience of the nurse. Both the theory and the concept have been employed to enhance knowledge development, professional growth and innovative changes within the nursing profession. 7. Quality Improvement Continuous quality improvement is a concept which includes: Quality assurance--the provision of services that meet an appropriate standard. Problem resolution--including all departments involved in the issue at hand. Quality improvement--a continuous process involving all levels of the organization working together across departmental lines to produce better

services for health care clients. Deming (1982b) and others have espoused total system reform to achieve quality improvement--not merely altering the current system, but radically changing it. It must be assumed that those who provide services at the staff level are acting in good faith and are not willfully failing to do what is correct (Berwick, 1991). Those who perform direct services are in an excellent position to identify the need for change in service delivery processes. 8. Research Research without practice is folly, but practice without research is blind. There have been several rather counterintuitive phenomena observed in different fields of research that compared the performance of experts and novices. For example, studies of medical expertise demonstrated that less experienced medical students may in some situations outperform seasoned medical practitioners on recall of specific cases. Studies of cognitive load aspects of complex skill acquisition in technical and academic domains demonstrated that more experienced technical trainees or students may learn less than expected from instructions that are very effective for novices. Apparently, in each of those phenomena, there is a mechanism that disrupted successful expert performance while, at the same time, enhanced performance of less experienced individuals. 9. Record Management The records management key area includes core competencies of maintaining appropriate documentation using the appropriate system and staying within legal boundaries in the area of patient privacy. Wherever you are in Benners 5 levels of skill acquisition, nurses are held responsible as to the proper documentation of the total care or interventions that were done for the patient. We

should ensure that the entries in the patient chart are accurate for we are aware of the legal issues that will require the involvement of these records. We should also facilitate the maintenance of the confidentiality of these records in respect to our pledge of confidentiality to our patient. 10. Communication

Our initial responsibility as to the establishment of a strong foundation for communication and cooperation is the establishment of trust or rapport with our patient and the significant others. In as much as possible, we should make ourselves available to them to facilitate interaction and listen to their concerns related to the disease process or to the interventions that are or will be suggested. We should also be sensitive enough as to communicating within the knowledge or level of understanding of our patient. Identifying barriers that may hinder effective communication, like language, beliefs/ culture, misconceptions, is also vital. Communication skills must be present in all the 5 levels of Benners skill acquisition. 11. Collaboration and Teamwork The current healthcare climate requires health professionals to incorporate evidencebased scientific knowledge and perform competent skills while participating as team members. In particular, members of a rural healthcare team are expected to provide safe and quality patient care through interprofessional collaboration, communication, and coordination.

Interprofessional teamwork is a core competency which is seen important for effective rural practice. Interprofessional collaborative practice should be promoted as it provides good role modeling for students and new graduates of any discipline.

In novice, some team members demonstrate limited awareness of each others professional, legal and ethical frameworks for scope of practice. Some language used is Advanced

profession-specific. There is some confusion and ambiguity relating to tasks.

beginners demonstrate only superficial awareness of each others professional, legal and ethical frameworks for scope of practice. Task allocation was hierarchical and structured with little negotiation. Competent are aware of and/or communicate to each other their role and scope of practice which relate to the situation. Team appears comfortable with interacting with each other. Task allocation was negotiated with clear recognition of mutuality. In proficient, the team is aware of each others scope of practice to undertake specific complementary skills and these are appropriate to the situation. The team interacts well and there is open communication and mutual respect demonstrated regarding roles and role limitations. And experts are clearly aware of each others scope of practice to undertake specific complementary skills and opportunities learn are extended appropriate to the acuity of the clinical situation. There is a high level of interaction, open communication and mutual respect within the team.

Bibliography Biography of Patricia Benner, Available on http://home.earthlink.net/bennerassoc/patricia.html Cited on 26th of June 2013 Dreyfus model of skill acquisition Available on http://en.wikipedia.org.wiki/Dreyfus_model_of_skill_acquisition, Cited on 26th of June 2013 Understanding Clinical Expertise: Nurse Education, Experience, and the Hospital Context, Available on http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998339/, Cited on 27th of June 2013 Educational implications of expertise reversal effects in learning and performance of complex cognitive and sensorimotor skills Available on http://ro.uow.edu.au/edupapers/1066/ Cited on 27th of June 2013 Seminar on Nursing Practice Expertise Available on file:///C:/Users/jungle/Desktop/Nursing%20theory,%20expertise%20model.htm Cited on 27th of June 2013 Alligood & Marriner Tomey (2009). Nursing Theory: Utilization and Application (4th ed.) St. Louis: Mosby