Caring, clinical wisdom, and ethics in nursing practice
Karen A. Brykczynski
“The nurse-patient relationship is not a uniform, professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life.”
Patricia Benner
Credentials and background of the philosopher
Patricia Benner was born in Hampton, Virginia, and spent her childhood in California, where she received her early and professional education. Majoring in nursing, she obtained a baccalaureate of arts degree from Pasadena College in 1964. In 1970, she earned a master’s degree in nursing, with major emphasis in medical-surgical nursing, from the University of California, San Francisco (UCSF) School of Nursing. Her PhD in stress, coping, and health was conferred in 1982 at the University of California, Berkeley, and her dissertation was published in 1984 (Benner, 1984b). Benner has a wide range of clinical experience, including positions in acute medical-surgical, critical care, and home health care.
Benner has a rich background in research and began this part of her career in 1970 as a postgraduate nurse researcher in the School of Nursing at UCSF. Upon completion of her doctorate in 1982, Benner achieved the position of associate professor at the Department of Physiological Nursing at UCSF and tenured professor in 1989. In 2002, she moved to the Department of Social and Behavioral Sciences at UCSF, where she was the first occupant of the Thelma Shobe Cook Endowed Chair in Ethics and Spirituality. She taught at the doctoral and master’s levels and served on three to four dissertation committees per year. Benner retired from full-time teaching in 2008 as professor emerita from UCSF, but continues to be involved in presentations and consultation, as well as writing and research projects. She is currently a Distinguished Visiting Professor at Seattle University School of Nursing, assisting them with a transformation of their undergraduate and graduate curricula.
Benner has published extensively and has been the recipient of numerous honors and awards, the most recent being induction into the Danish Nursing Society as an Honorary Member, and the Sigma Theta Tau International Book Author award shared with her co-editors for Interpretive Phenomenology in Health Care Research (Chan, Brykczynski, Malone, & Benner, 2010). She was honored with 1984, 1989, 1996, and 1999 American Journal of Nursing Book of the Year awards for From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984a), The Primacy of Caring: Stress and Coping in Health and Illness (1989, with Wrubel), Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (1996, with Tanner and Chesla), and Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach (1999, with Hooper-Kyriakidis & Stannard), respectively. The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions (1994), edited by Susan S. Phillips and Patricia Benner, was selected for the CHOICE list of Outstanding Academic Books for 1995. Benner’s books have been translated into 10 languages as well as several of her articles. Benner received the American Journal of Nursing media CD-ROM of the year award for Clinical Wisdom and Interventions in Critical Care: A Thinking-in-Action Approach (2001, with Hooper-Kyriakidis & Stannard).
In 1985, Benner was inducted into the American Academy of Nursing. She received the National League for Nursing’s Linda Richards Award for leadership in education in 1989 and both the NLN Excellence in Leadership Award for Nursing Education and the NLN President’s Award for Creativity and Innovation in Nursing Education in 2010. In 1990, she received the Excellence in Nursing Research and Excellence in Nursing Education Award from the California Organization of Nurse Executives. She also received the Alumnus of the Year Award from Point Loma Nazarene College (formerly Pasadena College) in 1993. In 1994, Benner became an Honorary Fellow in the Royal College of Nursing, United Kingdom. In 1995, she received the Helen Nahm Research Lecture Award from the faculty at UCSF for her contribution to nursing science and research. Benner received an award for outstanding contributions to the profession from the National Council of State Boards of Nursing in 2002, for developing an instrument, Taxonomy of Error, Root Cause and Practice (TERCAP) an electronic data collection tool to capture the sources and nature of nursing errors (Benner, Sheets, Uris, et al., 2002).
In 2002, The Institute for Nursing Healthcare Leadership commemorated the impact of the landmark book From Novice to Expert (1984a) with an award acknowledging 20 years of collecting and extending clinical wisdom, experiential learning, and caring practices and a celebration at the conference “Charting the Course: The Power of Expert Nurses to Define the Future.” Benner received the American Association of Critical Care Nurses Pioneering Spirit Award in May 2004 for her work on skill acquisition and articulating nursing knowledge in critical care. In 2007, she was selected for the UCSF School of Nursing’s Centennial Wall of Fame and was a visiting professor at the University of Pennsylvania School of Nursing in 2009. Along with her husband and colleague, Richard Benner, Patricia Benner consults around the world regarding clinical practice development models (CPDMs) (Benner & Benner, 1999). Benner was appointed Nursing Education Study Director for the Carnegie Foundation’s Preparation for the Professions Program (PPP) in March 2004. The book published from The Carnegie Foundation for the Advancement of Teaching National Nursing Education Study, Educating Nurses: A Call for Radical Transformation was awarded the American Journal of Nursing Book of the Year Award for 2010, and the Prose Award for Scholarly Writing. This nationwide study was a study of professional education and the shift from technical professionalism to civic professionalism. In 2011, the American Academy of Nursing honored Patricia Benner as a Living Legend.
Philosophical sources
Benner acknowledges that her thinking in nursing has been influenced greatly by Virginia Henderson. Benner studies clinical nursing practice in an attempt to discover and describe the knowledge embedded in nursing practice. She maintains that knowledge accrues over time in a practice discipline and is developed through experiential learning and situated thinking and reflection on practice in particular practice situations. She refers to this work as articulation research, defined as: “describing, illustrating, and giving language to taken-for-granted areas of practical wisdom, skilled know-how, and notions of good practice” (Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 5). One of Benner’s first philosophical distinctions was to differentiate between practical and theoretical knowledge. She stated that knowledge development in a practice discipline “consists of extending practical knowledge (know-how) through theory-based scientific investigations and through the charting of the existent ‘know-how’ developed through clinical experience in the practice of that discipline” (1984a, p. 3). Benner believes that nurses have been delinquent in documenting their clinical learning, and “this lack of charting of our practices and clinical observations deprives nursing theory of the uniqueness and richness of the knowledge embedded in expert clinical practice” (Benner, 1983, p. 36). She has contributed to the description of the know-how of nursing practice.
Citing Kuhn (1970) and Polanyi (1958), philosophers of science, Benner (1984a) emphasizes the difference between “knowing how,” a practical knowledge that may elude precise abstract formulations, and “knowing that,” which lends itself to theoretical explanations. Knowing that is the way an individual comes to know by establishing causal relationships between events. Clinical situations are always more varied and complicated than theoretical accounts; therefore, clinical practice is an area of inquiry and a source of knowledge development. By studying practice, nurses can uncover new knowledge. Nurses must develop the knowledge base of practice (know-how), and, through investigation and observation, begin to record and develop the know-how of clinical expertise. Ideally, practice and theory dialog creates new possibilities. Theory is derived from practice, and practice is extended by theory.
Hubert Dreyfus introduced Benner to phenomenology. Stuart Dreyfus, in operations research, and Hubert Dreyfus, in philosophy, both professors at the University of California at Berkeley, developed the Dreyfus Model of Skill Acquisition (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986), which Benner applied in her work, From Novice to Expert (1984a). She credits Jane Rubin’s (1984) scholarship, teaching, and colleagueship as sources of inspiration and influence, especially in relation to the works of Heidegger (1962) and Kierkegaard (1962). Richard Lazarus (Lazarus & Folkman, 1984; Lazarus, 1985) mentored her in the field of stress and coping. Judith Wrubel has been a participant and co-author with Benner for years, collaborating on the ontology of caring and caring practices (Benner & Wrubel, 1989). Additional philosophical and ethical influences on Benner’s work include Joseph Dunne (1993), Knud Løgstrup (1995a, 1995b, 1997), Alistair MacIntyre (1981, 1999), Kari Martinsen (Alvsvåg, 2010), Maurice Merleau-Ponty (1962), Onora O’Neill (1996), and Charles Taylor (1971, 1982, 1989, 1991, 1993, 1994).
Benner (1984a) 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 (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986). Benner’s model is situational and describes five levels of skill acquisition and development: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert. The model posits that changes in four aspects of performance occur in movement through the levels of skill acquisition: (1) movement from a reliance on abstract principles and rules to the use of past, concrete experience, (2) shift from reliance on analytical, rule-based thinking to intuition, (3) change in the learner’s 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 (Benner, Tanner, & Chesla, 1992).
Because the model is situation-based and is not trait-based, the level of performance is not an individual characteristic of an individual performer, but instead is a function of a given nurse’s familiarity with a particular situation in combination with her or his educational background. The performance level can be determined only by consensual validation of expert judges and by assessment of the outcomes of the situation (Benner, 1984a). 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” (1984a, p. xix). Benner (1984a) defines skill and skilled practice to mean implementing skilled nursing interventions and clinical judgment skills in actual clinical situations. In no case does this refer to context-free psychomotor skills or other demonstrable enabling skills outside the context of nursing practice.
In subsequent research undertaken to further explicate the Dreyfus model, Benner identified two interrelated aspects of practice that also distinguish the levels of practice from advanced beginner to expert (Benner, Tanner, & Chesla, 1992; 1996). First, clinicians at different levels of practice live in different clinical worlds, recognizing and responding to different situated needs for action. Second, clinicians develop what Benner terms agency, or the sense of responsibility toward the patient, and evolve into fully participating members of the health care team. The skills acquired through nursing experience and the perceptual awareness that expert nurses develop as decision makers from the “gestalt of the situation” lead them to follow their hunches as they search for evidence to confirm the subtle changes they observe in patients (1984a, p. xviii).
The concept that experience is defined as the outcome when preconceived notions are challenged, refined, or refuted in actual situations is based on the works of Heidegger (1962) and Gadamer (1970). As the nurse gains experience, clinical knowledge becomes a blend of practical and theoretical knowledge. Expertise develops as the clinician tests and modifies principle-based expectations in the actual situation. Heidegger’s influence is evident in this and in Benner’s subsequent writings on the primacy of caring. Benner refutes the dualistic Cartesian descriptions of mind-body person and espouses Heidegger’s phenomenological description of person as a self-interpreting being who is defined by concerns, practices, and life experiences. Persons are always situated, that is, they are engaged meaningfully in the context of where they are. Heidegger (1962) termed practical knowledge as the kind of knowing that occurs when an individual is involved in the situation. By virtue of being humans, we have embodied intelligence, meaning that we come to know things by being in situations. When a familiar situation is encountered, there is embodied recognition of its meaning. For example, having previously witnessed someone developing a pulmonary embolus, a nurse notices qualitative nuances and has recognition ability for observing it before those nurses who have never seen it. Benner and Wrubel (1989) state, “Skilled activity, which is made possible by our embodied intelligence, has been long regarded as ‘lower’ than intellectual, reflective activity” but argue that intellectual, reflective capacities are dependent on embodied knowing (p. 43). Embodied knowing and the meaning of being are premises for the capacity to care; things matter and “cause us to be involved in and defined by our concerns” (p. 42).
While doing her doctoral studies at Berkeley, Benner was a research assistant to Richard S. Lazarus (Lazarus, 1985; Lazarus & Folkman, 1984), who is known for his stress and coping theory. As part of Lazarus’ larger study, Benner studied midcareer males’ meaning of work and coping that was published as Stress and Satisfaction on the Job: Work Meanings and Coping of Mid-Career Men (1984b). Lazarus’ Theory of Stress and Coping is described as phenomenological, that is, the person is understood to constitute and be constituted by meanings. Stress is the disruption of meanings, and coping is what the person does about the disruption. Both doing something and refraining from doing something are ways of coping. Coping is bound by the meanings inherent in what the person interprets as stressful. Different possibilities arise from the way the person is in the situation. Benner used this concept to describe clinical nursing practice in terms of nurses making a difference by being in a situation in a caring way.
Benner’s approach to knowledge development that began with From Novice to Expert (1984a) began a growing, living tradition for learning from clinical nursing practice through collection and interpretation of exemplars (Benner, 1994; Benner & Benner, 1999; Benner, Tanner & Chesla, 1996; Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner and Benner (1999) stated the following:
Effective delivery of patient/family care requires collective attentiveness and mutual support of good practice embedded in a moral community of practitioners seeking to create and sustain good practice… This vision of practice is taken from the Aristotelian tradition in ethics (Aristotle, 1985) and the more recent articulation of this tradition by Alasdair MacIntyre (1981), where practice is defined as a collective endeavor that has notions of good internal to the practice… However, such collective endeavors must be comprised of individual practitioners who have skilled know how, craft, science, and moral imagination, who continue to create and instantiate good practice (pp. 23-24).
Use of empirical evidence
From 1978 to 1981, Benner was the author and project director of a federally funded grant, Achieving Methods of Intraprofessional Consensus, Assessment and Evaluation, known as the AMICAE project. This research led to the publication of From Novice to Expert (1984a). Benner directed the AMICAE project to develop 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. Benner (1984a) explains that the interpretive approach seeks a rich description of nursing practice from observation and narrative accounts of actual nursing practice to provide text for interpretation (hermeneutics).
Nurses’ descriptions of patient care situations in which they made a positive difference “present the uniqueness of nursing as a discipline and an art” (Benner, 1984a, p. xxvi). More than 1200 nurse participants completed questionnaires and interviews as part of the AMICAE project. Paired interviews with preceptors and preceptees were “aimed at discovering if there were distinguishable, characteristic differences in the novice’s and expert’s descriptions of the same clinical incident” (Benner, 1984a, p. 14). Additional interviews and participant observations were conducted with 51 nurse-clinicians and other newly graduated nurses and senior nursing students to “describe characteristics of nurse performance at different stages of skill acquisition” (Benner, 1984a, p. 15). The purpose “of the inquiry has been to uncover meanings and knowledge embedded in skilled practice. By bringing these meanings, skills, and knowledge into public discourse, new knowledge and understandings are constituted” (Benner, 1984a, p. 218).
Thirty-one competencies emerged from the analysis of transcripts of interviews about nurses’ detailed descriptions of patient care episodes that included their intentions and interpretations of events. From these competencies, which were identified from actual practice situations, the following seven domains were derived inductively on the basis of similarity of function and intent (Benner, 1984a):
2. The teaching-coaching function
3. The diagnostic and patient monitoring function
4. Effective management of rapidly changing situations
5. Administering and monitoring therapeutic interventions and regimens
6. Monitoring and ensuring the quality of health care practices
Each domain was developed using the related competencies from actual practice situation descriptions. Benner presented the domains and competencies of nursing practice as an open-ended interpretive framework for enhancing the understanding of the knowledge embedded in nursing practice. As a result of the socially embedded, relational, and dialogical nature of clinical knowledge, domains and competencies should be adapted for use in each institution through the study of clinical practice at each specific locale (Benner & Benner, 1999). Such adaptations have been implemented in many institutions for nursing staff in hospitals around the world (Alberti, 1991; Balasco & Black, 1988; Brykczynski, 1998; Dolan, 1984; Gaston, 1989; Gordon, 1986; Hamric, Whitworth, & Greenfield, 1993; Lock & Gordon, 1989; Nuccio, Lingen, Burke, et al., 1996; Silver, 1986a, 1986b). The domains and competencies have also been useful for ongoing articulation of the knowledge embedded in advanced practice nursing (Brykczynski, 1999; Fenton, 1985; Fenton & Brykczynski, 1993; Lindeke, Canedy, & Kay, 1997; Martin, 1996).
Benner and Wrubel (1989) have further explained and developed the background to the ongoing study of the knowledge embedded in nursing practice in The Primacy of Caring: Stress and Coping in Health and Illness. They note that the primacy of caring is three-pronged “as the producer of both stress and coping in the lived experience of health and illness …. as the enabling condition of nursing practice (indeed any practice), and the ways that nursing practice based in such caring can positively affect the outcome of an illness” (1989, p. 7).
Benner extended the research presented in From Novice to Expert (1984a) and features this work in Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics (Benner, Tanner, & Chesla, 1996; 2009). This book is based on a 6-year study of 130 hospital nurses, primarily critical care nurses, examining the acquisition of clinical expertise and the nature of clinical knowledge, clinical inquiry, clinical judgment, and expert ethical comportment. The key aims of the extension of this research were as follows:
• Delineate the practical knowledge embedded in expert practice.
• Describe the nature of skill acquisition in critical care nursing practice.
• Begin to identify educational strategies that encourage the development of expertise.
In the introduction to the 1996 work, Benner stated, “In the study we found that examining the nature of the nurse’s agency, by which we mean the sense and possibilities for acting in particular clinical situations, gave new insights about how perception and action are both shaped by a practice community” (Benner, Tanner, & Chesla, 1996, p. xiii). This study resulted in a clearer understanding of the distinctions between engagement with a problem or situation and the requisite nursing skills of interpersonal involvement. It appears that these nursing skills are learned over time experientially. The skill of involvement seems central in gaining nursing expertise. Understanding of the interlinkage of clinical and ethical decision making (i.e., how an individual’s notions of good and poor outcomes and visions of excellence shape clinical judgments and actions) was enhanced by this research. This study represents phase one of the articulation project designed to describe the nature of critical care nursing practice.
Phase two took place from 1996 to 1997 and included 76 nurses (32 of them advanced practice nurses) from six different hospitals. This work is presented in Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach,which was published in 1999 and updated and enlarged in 2011 by Benner, Hooper-Kyriakidis, and Stannard.The following nine domains of critical care nursing practice were identified as broad themes in this work:
1. Diagnosing and managing life-sustaining physiological functions in acute and unstable patients
2. Using the skilled know-how of managing a crisis
3. Providing comfort measures for the acute critically ill
4. Caring for patients’ families
5. Preventing hazards in a technological environment
6. Facing death: end-of-life care and decision making
7. Communicating and negotiating multiple perspectives
8. Monitoring quality and managing breakdown
9. Using the skilled know-how of clinical leadership and the coaching and mentoring of others
These nine domains of critical care nursing practice were used as broad themes to interpret the data and incorporate descriptions of the following nine aspects of clinical judgment and skillful comportment:
1. Developing a sense of salience
2. Situated learning and integration of knowledge acquisition and knowledge use
3. Engaged reasoning-in-transition
6. Agency
7. Perceptual acuity and interpersonal engagement with patients
8. Integrating clinical and ethical reasoning
Identification of clinical grasp and clinical forethought (two pervasive habits of thought linked with action in nursing practice in phase two of this articulation project) enriched the understanding of clinical judgment (Benner, Hooper-Kyriakidis, & Stannard, 1999). Benner explained that clinical grasp is as follows:
“…. clinical inquiry in action that includes problem identification and clinical judgment across time about the particular transitions of particular patients and families. It has four components: making qualitative distinctions, engaging in detective work, recognizing changing clinical relevance, and developing clinical knowledge in specific patient populations.”
(Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 317)
Benner added that clinical forethought, although it plays a role in clinical grasp, “also plays an essential role in structuring the practical logic of clinicians. Clinical forethought refers to at least four habits of thought and action: future think, clinical forethought about specific diagnoses and injuries, anticipation of risks for particular patients, and seeing the unexpected” (Benner, Hooper-Kyriakidis, & Stannard, 1999, p. 317).
Major assumptions
Benner incorporates the following assumptions (as delineated in Brykczynski’s 1985 dissertation; see also Benner 1984a) in her ongoing articulation research:
• There are no interpretation-free data. This abandons the assumption from natural science that there is an independent reality whose meaning can be represented by abstract terms or concepts (Taylor, 1982).
• There are no nonreactive data. This abandons the false belief from natural science that one can neutrally observe brute data (Taylor, 1982).
• Meanings are embedded in skills, practices, intentions, expectations, and outcomes. They are taken for granted and often are not recognized as knowledge. According to Polanyi (1958), a context possesses existential meaning, and this distinguishes it from “denotative or, more generally, representative meaning” (p. 58). He claims that transposing a significant whole in terms of its constituent parts deprives it of any purpose or meaning.
• People who share a common cultural and language history have a background of common meanings that allow for understanding and interpretation. Heidegger (1962) refers to this as primordial understanding, after the writings of Dilthey (1976) in the late 1800s and early 1900s, asserting that cultural organization and meanings precede and influence individual understanding.
• The meanings embedded in skills, practices, intentions, expectations, and outcomes cannot be made completely explicit; however, they can be interpreted by someone who shares a similar language and cultural background and can be validated consensually by participants and relevant practitioners. Humans are self-interpreting beings (Heidegger, 1962). Hermeneutics is the interpretation of cultural contexts and meaningful human action.
• Humans are integrated, holistic beings. The mind-body split is abandoned. Embodied intelligence enables skilled activity that is transformed through experience and mastery (Dreyfus & Dreyfus, 1980; Dreyfus & Dreyfus, 1986). Benner stated, “This model assumes that all practical situations are far more complex than can be described by formal models, theories and textbook descriptions” (1984a, p. 178). The hierarchical elevation of intellectual, reflective activity above embodied skilled activity ignores the point that skilled action is a way of knowing and that the skilled body may be essential for the more highly esteemed levels of human intelligence (Dreyfus, 1979).
Benner and her collaborators explicated the themes of nursing, person, situation, and health in their publications.
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 Heidegger’s phenomenological description of person, which they 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 nonreflective 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) conceptualized the following four major aspects of understanding that the person must deal with:
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 (1979, 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. Based on the work of Merleau-Ponty (1962), Dreyfus (1979, 1991), and Dreyfus and Dreyfus (1986), they outline the following five dimensions of the body (Benner & 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)
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