CHAPTER 9 “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” (Benner, 1984a). 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 University of California, Berkeley, and her dissertation was published in 1984 (Benner, 1984b). Benner has a wide range of clinical experience, including acute medical-surgical, critical care, and home health care. She has held staff and head nurse positions. Benner acknowledges that her thinking in nursing has been influenced greatly by Virginia Henderson. Henderson (1989) commented that Benner’s From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984a) had the potential to materially affect the practice and preparation of nurses for practice. The Institute for Nursing Healthcare Leadership commemorated the impact of this landmark book on nursing practice with a celebration 20 years after its publication, at the conference “Charting the Course: The Power of Expert Nurses to Define the Future,” which was held in Boston in September of 2003. In the Foreword to Benner’s work, The Primacy of Caring: Stress and Coping in Health and Illness (Benner & Wrubel, 1989), Henderson made the following comment regarding the publication: The research described in the book by Benner, Tanner, and Chesla (1996), Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics, is a continuation and expansion of the research described in From Novice to Expert. In the Foreword to the 1996 book, Barbara Stevens Barnum wrote the following: Clinical Wisdom in Critical Care: A Thinkingin-Action Approach, by Benner, Hooper-Kyriakidis, and Stannard (1999), constitutes phase two of the articulation research of critical care nursing practice begun in Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. Articulation refers to “describing, illustrating, and giving language to taken-for-granted areas of practical wisdom, skilled know-how, and notions of good practice” (Benner et al., 1999, p. 5). In the first Foreword to this book, Joan Lynaugh wrote the following: Perhaps the most important accomplishment of this text is its insistence on incorporating all the elements of critical care: clinical thinking and thinking ahead, caregiving to patients and families, ethical and moral issues, dealing with breakdown and technological hazard, communication and negotiation among all participants, teaching and coaching, and understanding the linkages between the larger systems and the individual patient (Benner et al., 1999, p. vi). In the second Foreword, Joyce Clifford wrote the following of the work: …provides the nurse administrator a wonderful understanding of the way organizational design can facilitate the caregiving process of clinical experts…[and] also provides guidance to those entrusted with the development of practice environments that promote the clinical learning and advancement of those just entering the profession (Benner et al., 1999, p. vii). Benner has published extensively and has been the recipient of numerous honors and awards, including the 1984, 1989, 1996, and 1999 American Journal of Nursing (AJN) 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 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. Several of her articles also have been translated and read worldwide. Benner received the AJN 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). Benner received an award for outstanding contributions to the profession from the National Council of State Boards of Nursing in 2002, for her work on developing an instrument to capture the sources and nature of nursing errors. The instrument Taxonomy of Error, Root Cause and Practice (TERCAP) is an electronic data collection tool that can be used to examine practice breakdown (Benner et al., 2002; Benner & Malloch, 2010). In 2003, Benner received an award for 20 years of collecting and extending clinical wisdom, experiential learning, and caring practices from the Institute for Nursing Health Care Leadership. She received the American Association of Colleges of Nursing 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. She is invited worldwide to lecture and lead workshops on health, stress and coping, skill acquisition, and ethics. Patricia Benner and her husband and colleague, Richard Benner, consults with nurses in hospitals around the world regarding their approach to 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. This is a nationwide study that is part of a series of studies on professional education that focus on the shift from technical professionalism to civic professionalism. According to this perspective, teachers are engaged as mentors in apprenticeships with learners to promote learning to see and think like professional practitioners—in this case, nurses (www.nursing.ubc.ca). 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 dialogue in relationship and situational contexts. She refers to this work as articulation research, as was noted earlier. One of the first philosophical distinctions that Benner made was to differentiate between practical and theoretical knowledge. Benner 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). She 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). Benner has contributed extensively 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. Knowing how is skill acquisition that may defy knowing that, that is, an individual may know how before a theoretical explanation is developed. Benner (1984a) maintains that practical knowledge may extend theory or may be developed before scientific formulations. 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. Clinical practice embodies the notion of excellence. By studying practice, nurses can uncover new knowledge. Nursing must develop the knowledge base of its practice (know-how), and, through scientific investigation and observation, it must begin to record and develop the know-how of clinical expertise. Ideally, practice and theory set up a dialogue that creates new possibilities. Theory is derived from practice, and practice is altered or 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. 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). This 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 as follows: (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 et al., 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 healthcare team. 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. Persons come to situations with an understanding of the self in the world. Heidegger (1962) termed practical knowledge as the kind of knowing that occurs when an individual is involved in the situation. Persons share background meanings, skills, and habits derived from their cultural practices. 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 other nurses who have not seen it before. Benner and Wrubel (1989) stated, “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 development of stress and coping theory. As part of Lazarus’ larger study, Benner conducted a study of midcareer males’ meaning of work and coping, which was published as Stress and Satisfaction on the Job: Work Meanings and Coping of Mid-Career Men (1984b). In this study, coping is defined as a form of practical knowledge, and it was determined that work meanings influence what is experienced as stress and what coping options are available to the individual. 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 described as the disruption of meanings, and coping is what the person does about the disruption. Both doing something and refraining from doing something about the stressful situation are ways of coping. Coping is bound by the meanings inherent in what the person interprets as stressful. The person must be understood as a “participant self” in a situation that is shaped by reflective and nonreflective meanings and concerns (Benner & Wrubel, 1989, p. 63). Different possibilities arise from the way the person is in the situation. Benner uses this key concept to describe clinical nursing practice in terms of nurses making a positive difference by being in the situation in a caring way. Benner’s approach to knowledge development that began with From Novice to Expert (1984a) constitutes the commencement of a growing, living tradition for learning from clinical nursing practice through collection and interpretation of exemplars (Benner, 1994; Benner & Benner, 1999; Benner, et al., 1996; Benner, et al., 1999). Benner and Benner 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 (Benner & Benner, 1999, pp. 23-24). Benner expresses that nursing is a cultural paradox in a highly technical society that is slow to value and articulate caring practices. She feels that the value of extreme individualism makes it difficult to perceive the brilliance of caring in expert nursing practice. Benner (2003) calls for a relational ethic that is based on practice to balance the dominant focus on rights and justice. 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 a 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). The advanced 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 who are in the advanced beginner stage as a test of their abilities and the demands of the situation placed on them rather than in terms of 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 who are more experienced (Benner et al., 1992). Benner places most newly graduated nurses at this level. 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 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). The level of efficiency is increased, but “the focus is on time management and the nurse’s organization of the task world rather than on timing in relation to the patient’s 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 that situation. To become proficient, the competent performer must allow the situation to guide responses (Dreyfus & Dreyfus, 1996). Studies point to the importance of active teaching and learning in the competent stage to coach nurses who are making the transition from competency to proficiency (Benner et al., 1996; Benner et al., 1999). 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 recognition and implementation of skilled responses to the situation as it evolves. They no longer rely on preset goals for organization, and they demonstrate 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 (see the Case Study). The proficient stage is a transition into expertise (Benner et al., 1996). The fifth stage of the Dreyfus model is achieved when “the expert performer no longer 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 described 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 is a qualitative change as the expert performer “knows the patient,” meaning knowing typical patterns of responses and knowing the patient as a person. Key aspects of the expert nurse’s practice are as follows (Benner et al., 1996): The expert nurse has this ability to recognize patterns on the basis of deep experiential background. For the expert nurse, meeting the patient’s actual concerns and needs is of utmost 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 (Benner et al., 1992). The aspects are the recurring meaningful situational components recognized and understood in context because the nurse has previous experience (Benner, 1984a). The attributes are measurable properties of a situation that can be explained without previous experience in the situation (Benner, 1984a). Competency is “an interpretively defined area of skilled performance identified and described by its intent, functions, and meanings” (Benner, 1984a, p. 292). This term is unrelated to the competent stage of the Dreyfus model. This is an area of practice having a number of competencies with similar intents, functions, and meanings (Benner, 1984a). An exemplar is an example of a clinical situation that conveys one or more intents, meanings, functions, or outcomes easily translated to other clinical situations (Benner, 1984a). Experience is not a mere passage of time, but an active process of refining and changing preconceived theories, notions, and ideas when confronted with actual situations; it implies there is a dialogue between what is found in practice and what is expected (Benner & Wrubel, 1982). This is a cryptic description of skilled performance that requires a certain level of experience to recognize the implications of the instructions (Benner, 1984a). A paradigm case is a clinical experience that stands out and alters the way the nurse will perceive and understand future clinical situations (Benner, 1984a). Paradigm cases create new clinical understanding and open new clinical perspectives and alternatives. Salience describes a perceptual stance or embodied knowledge whereby aspects of a situation stand out as more or less important (Benner, 1984a). Good conduct born out of an individualized relationship with the patient which involves engagement in a particular situation and entails a sense of membership in the relevant professional group. It is socially embedded, lived and embodied in practices, ways of being, and responding to a clinical situation that promote the well being of the patient (Day & Benner, 2002). “Clinical and ethical judgments are inseparable and must be guided by being with and understanding the human concerns and possibilities in concrete situations” (Benner, 2000, p. 305). Hermeneutics means “interpretive.” The term derives from biblical and judicial exegesis. As used in research, hermeneutics refers to describing and studying “meaningful human phenomena in a careful and detailed manner as free as possible from prior theoretical assumptions, based instead on practical understanding” (Packer, 1985, pp. 1081-1082). Benner’s early work focused on the anticipatory socialization of nurses. Benner and Kramer (1972) studied the differences between nurses who worked in special care units and those who worked in regular hospital units. Benner was a research consultant for a nursing activity study conducted in 1974 and 1975 to determine the use and productivity of nursing personnel. Concurrently, she was a consultant on a study of new nurse-work entry. Benner and Benner (1979) conducted a systematic evaluation of the competencies, the job finding, and the work-entry problems of new graduate nurses. Benner also studied methods of increasing teacher competencies through the use of a mobile microteaching laboratory. 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) and numerous articles. 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. In describing the interpretive approach, Benner (1984a) explains that it seeks a rich description of nursing practice from observation and narrative accounts of actual nursing practice to provide the 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 healthcare 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, et al., 1996; Silver, 1986a, 1986b). The domains and competencies have 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 their 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). 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 et al., 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. 1. Diagnosing and managing life-sustaining physiological functions in unstable patients 2. Using the skilled know-how of managing a crisis 3. Providing comfort measures for the 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 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 et al., 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 et al., 1999, p. 317). She 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 et al., 1999, p. 317). Benner incorporates the following assumptions (as delineated in Brykczynski’s 1985 dissertation; see also Benner 1984a) in her ongoing articulation research:
Caring, Clinical Wisdom, and Ethics in Nursing Practice
CREDENTIALS AND BACKGROUND OF THE PHILOSOPHER
PHILOSOPHICAL SOURCES
USE OF EMPIRICAL EVIDENCE
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.
MAJOR ASSUMPTIONS
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 allows 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).
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